Surgery Ctr. of Viera, LLC v. UnitedHealthcare, Inc.

• Decision Date: 08 June 2020
• Docket Number: Case No. 6:20-cv-24-Orl-22EJK
• Citation: 465 F.Supp.3d 1211
• Parties: SURGERY CENTER OF VIERA, LLC, Plaintiff, v. UNITEDHEALTHCARE, INC., Defendant.
• Court: U.S. District Court — Middle District of Florida

465 F.Supp.3d 1211

SURGERY CENTER OF VIERA, LLC, Plaintiff,

v.UNITEDHEALTHCARE, INC., Defendant.

Case No. 6:20-cv-24-Orl-22EJK

United States District Court, M.D. Florida, Orlando Division.

Signed June 8, 2020

Ivan J. Tarasuk, Jeffrey Lewis Greyber, Callagy Law, PC, Boca Raton, FL, for Plaintiff.

Edward Ugochukwu Ibeh, Akerman LLP, Miami, FL, Gera R. Peoples, Akerman LLP, Irene Bassel Frick, Akerman LLP, Tampa, FL, for Defendant.

ORDER

ANNE C. CONWAY, United States District Judge

This cause comes before the Court on DefendantUnitedHealthcare, Inc.’s Motion to Dismiss(Doc. 31) the Amended Complaint of Plaintiff Surgery Center of Viera's ("Surgery Center").(Doc. 29).Surgery Center filed a Response in Opposition.(Doc. 34).For the reasons below, the Motion will be granted in part and denied in part.

I.BACKGROUND¹

The dispute in this case arises out of medical services provided to Patient C.R. for treatment of "chronic debilitating neck pain and radiculopathy" for whom alterative, conservative treatment did not resolve his pain.(Doc. 29 ¶ 7).Patient C.R. is covered by UnitedHealthcare Insurance Company's ("United") Group Plan 909155 for employees of Merritt Island Boat Works Inc.(the "Plan").²(Id.).For coverage under the Plan, a Boat Works employee "must see a Network Physician in order to obtain Benefits.Except as specifically described in th[e] Schedule of Benefits, ... [b]enefits are not available for services provided by non-Network providers" with certain exceptions specifically described in the Plan.(Doc. 29-2at 10).

On January 9, 2018, medical personnel at Surgery Center of Viera operated on Patient C.R., after he had received a letter from United on January 4, 2018, stating that the surgical procedure was deemed "medically necessary" and would be covered at the network level because "there was not a doctor, health care professional, or facility in C.R.’s area to provide the services"; Surgery Center construes this communication from United as treating the procedure as "in-network."(Doc. 29 ¶¶ 14, 17).Surgery Center subsequently billed the charges for Patient C.R.’s surgery and medical care to United in the amount of $418,133.(Id.¶ 9).

Three months later, on April 5, 2018, United paid a claim for these medical services of only $44,814.06, just over ten percent of the balance due.(Id.at ¶ 12).Surgery Center was not a provider or facility with a formal "in-network provider" agreement with United.³However, Surgery Center was "in agreement" with United as part of a "re-pricing contract" with Preferred Medical Claim Solutions ("PMCS") who negotiated as United's affiliate and/or subcontractor to secure discounted rates from providers including Surgery Center; the "re-pricing contract" provided that Surgery Center would receive 80% of its billed charges less the charges for which patients were responsible, with 100% reimbursement for hard costs such as prosthetics and implants.(Id.¶¶ 10-11).In keeping with the PMCS re-pricing contract, Surgery Center sought reimbursement for 80% of the full amount of the charges of $418,133—in the amount of $351,230.20—less co-pays, deductibles, and co-insurance to be paid by the patient.(Id.at ¶¶ 11, 28).Deducting the amount previously paid by United of $44,814.06, Surgery Center sought the outstanding balance to which it was entitled, calculated at 80%, of $306,416.14.(Id.).United declined to pay the amount sought for various reasons, including because Surgery Center was an "out-of-network" provider, and because certain amounts were in excess of allowable charges particularly in light of the "data isight" figures for comparable available facilities.(Id.¶¶ 15-16).Following United's denials, Surgery Center appealed United's decision to only pay part of the claim and sought the full claims file for Patient C.R. (Id.¶¶ 19-27).

Nearly two years after the surgery, on January 7, 2020, Surgery Center brought a five-count Complaint against United, seeking to compel production of the administrative record under the Employee Retirement Income Security Act("ERISA")(Count I); seeking to recover damages for breach of contract (Count II); unjust enrichment (Count III); quantum meruit (Count IV), and statutory violations (Count V) for United's failure to pay the full amount Surgery Center argues it is owed for the medical services it provided to Patient C.R. (Doc. 1).Surgery Center alleges jurisdiction under 28 U.S.C. § 1332, based on an amount in controversy in excess of $75,000.00 and diversity of citizenship of the parties, since Surgery Center of Viera, LLC, is a citizen of Florida and UnitedHealthcare, Inc., is a citizen of Minnesota.(Doc. 29 ¶¶ 2-3).⁴

On March 6, 2020, United filed its Motion to Dismiss Surgery Center's Complaint.(Doc. 24).In lieu of filing a response to United's Motion to Dismiss, on March 30, 2020, Surgery Center filed its Amended Complaint with one significant substantive change – it recast its ERISA claim in Count I as a claim for United's "breach of contract" of an obligation under the Plan to produce the entire claim file.(Doc. 29 ¶¶ 31-37).The remainder of the Counts in the Amended Complaint remained unchanged.United filed its Motion to Dismiss the Amended Complaint on April 13, 2020(Doc. 31) and Surgery Center responded in opposition on April 27, 2020.(Doc. 34).The matter is ripe for decision.

II.LEGAL STANDARD

When deciding a motion to dismiss based on failure to state a claim upon which relief can be granted, the court must accept as true the factual allegations in the complaint and draw all inferences derived from those facts in the light most favorable to the plaintiff.Randall v. Scott , 610 F.3d 701, 705(11th Cir.2010)."Generally, under the Federal Rules of Civil Procedure, a complaint need only contain ‘a short and plain statement of the claim showing that the pleader is entitled to relief.’ "Id.(quotingFed. R. Civ. P. 8(a)(2) ).However, the plaintiff's complaint must provide "enough facts to state a claim to relief that is plausible on its face."Bell Atl. Corp. v. Twombly , 550 U.S. 544, 570, 127 S. Ct. 1955, 167 L. Ed. 2d 929(2007)."A claim has facial plausibility when the plaintiff pleads factual content that allows the court to draw the reasonable inference that the defendant is liable for the misconduct alleged."Ashcroft v. Iqbal , 556 U.S. 662, 678, 129 S.Ct. 1937, 173 L.Ed.2d 868(2009)(citingTwombly , 550 U.S. at 556, 127 S.Ct. 1955 ).Thus, the Court is not required to accept as true a legal conclusion merely because it is labeled a "factual allegation" in the complaint; it must also meet the threshold inquiry of facial plausibility.Id.

III.ANALYSIS

United moves to dismiss all of the counts of Surgery Center's Amended Complaint, arguing that the claim for failure to produce the requested Plan documents and for breach of contract, unjust enrichment, and quantum meruit fail because these claims are preempted by ERISA, and Surgery Center is not a party to the Plan that covered Patient C.R. United further argues that Surgery Center's fifth claim, for violation of Florida statutes governing healthcare reimbursements, must be dismissed because Surgery Center does not meet the statutory criteria.

A.Count I

United moves to dismiss Count I, arguing that Surgery Center was not a beneficiary or participant under the Plan and, thus, it lacks standing to seek enforcement of provisions of the Plan to produce the administrative record.Although Surgery Center alleged a claim under ERISA in the original Complaint for failure to produce the administrative record pursuant to 29 U.S.C. § 1132(c)(1), following United's first Motion to Dismiss, Surgery Center filed an Amended Complaint recasting this claim as one allegedly for "breach of an insurance contract,"i.e. , the Plan, for United's refusal to provide the requested Plan documents and claims file.(Doc. 29 ¶¶ 31-32)("[United] provided health insurance to C.R. under the insurance policy, which is a binding and enforceable insurance contract....The insurance contract required Defendant's production of the germane documentation/information requested by [Surgery Center].")Thus, Count I is nothing more than Surgery Center's original claim under ERISA to enforce a term in the Plan for copies of administrative documents.(Doc. 31)(contending that Plaintiff has no standing to seek enforcement of Plan terms that reiterate ERISA rights under 29 C.F.R. § 2560.503-1(h)(2) ).United argues that Surgery Center lacks standing to enforce any ERISA statutory provisions or Plan rights—even under the guise of calling it a "breach of contract" claim—based on a putative (but unfiled)"assignment of benefits" from Patient C.R.Simply recasting Surgery Center's claim as one for "breach of a health insurance contract/plan" as the assignee, when the right to be exercised "under the contract" is nothing other than an attempt to obtain documents pursuant to ERISA, will not allow Surgery Center to avoid the ERISA standing issue.

ERISA permits a plan participant or beneficiary to bring a civil action "to recover benefits due to him under the terms of his plan."29 U.S.C. § 1132(a)(1)(B)."Two categories of persons may sue for benefits under an ERISA plan: plan beneficiaries and plan participants."Griffin v. Suntrust Bank, Inc. , 648 F. App'x 962, 967(11th Cir.2016)(unpublished).⁵"Healthcare providers are typically not ‘participants’ or ‘beneficiaries,’ so they lack independent standing, but they may obtain derivative standing through a written assignment from a beneficiary or participant."Id.

A healthcare provider such as Surgery Center generally "acquire[s] derivative standing to sue under ERISA by obtaining a written assignment" from its patient of the right to payment of medical benefits.⁶Seeid.(quotingConn. State Dental Ass'n v. Anthem Health Plans, Inc. , 591 F.3d 1337, 1347(11th Cir.2009) ).In this case, Surgery Center is relying on its "assignment of benefits" to...