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IHC Health Service, Inc. v. Central States Southeast and Southwest Areas Health and Welfare Fund

United States District Court, D. Utah

March 15, 2019




         Before the court is Defendant Central States, Southeast and Southwest Areas Health and Welfare Fund's (“Central States”) Motion to Dismiss Plaintiff's First Amended Complaint for Failure to State a Claim (“Motion”) (ECF No. 35), filed August 8, 2018. For the reasons below, the motion is granted in part and denied in part.

         I. BACKGROUND

         Plaintiff IHC Health Services, Inc. (“IHC”) operates several hospitals in the mountain west, including the McKay-Dee Hospital in Ogden, Utah. On December 29, 2014, IHC provided unspecified medical treatment to a patient, “K.N., ” at the McKay-Dee Hospital. K.N. was a participant in a health insurance plan funded by Central States (the “Plan”). However, the procedure was considered “out of network” under the Plan.

         On November 26, 2014, Central States sent K.N. an exemption letter permitting him to receive treatment at an out-of-network provider. It appears the letter was in response to a request from the patient, who wished to receive treatment from a doctor he had seen previously. The exemption letter from Central States stated that the out-of-network treatment would be paid at “85% of the reasonable and customary” fees.

         K.N. received treatment on December 29, 2014, approximately one month after receiving the exemption letter. Billed charges for the treatment totaled $27, 589.48. The patient assigned the associated claim to IHC at the time of treatment. Initially, Central States denied the claim because “treatment was provided out of network and Billed Charges exceeded usual, customary, and reasonable costs.” However, Central States eventually issued a payment for $9, 991.95-or approximately thirty-six percent of the total amount billed for the treatment. In the Explanation of Benefits provided to K.N., Central States asserted that $9, 991.95 is eighty-five percent of the “reasonable & customary amount” calculated by Central States pursuant to plan section 11.09 and is therefore the maximum benefit allowable under the Plan.

         IHC, as the assignee of K.N.'s claim, appealed this “partial denial of benefits” twice, seeking the remaining $16, 047.53 billed. Central States denied both appeals. Central States explained that, according to its pricing agency, Data iSight, $9, 991.95 was the maximum benefit allowable for the services rendered because it was eighty-five percent of the “Reasonable and Customary charge” for the services. In denying the second appeal, Central States further explained that the amount paid represented the maximum benefit allowable because IHC was unwilling to negotiate claim adjustments with Data iSight. On December 29, 2017, IHC filed its complaint.

         IHC initially brought three claims under the Employment Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1001 et seq.: (1) recovery of plan benefits, (2) breach of fiduciary duties, and (3) failure to produce plan documents upon written request. On February 14, 2018, Central States moved to dismiss all three claims. On August 8, 2018, this court dismissed the first claim without prejudice and the second and third claims with prejudice. Or. Mot. Dismiss, ECF No. 33.

         On August 15, 2018, IHC filed its First Amended Complaint (“Amended Complaint”) containing a single claim for recovery of plan benefits under 29 U.S.C. § 1132(a)(1)(B).

         II. ANALYSIS

         Central States moves to dismiss IHC's Amended Complaint for failure to state a claim under Rule 12(b)(6). Specifically, Central States argues that the Amended Complaint should be dismissed because 1) IHC failed to bring a claim for equitable estoppel as invited by the court, 2) its restated claim for recovery of plan benefits is still deficient, and 3) IHC failed to allege its authority to seek relief against Central States under a purported assignment of benefits.

         A. Standard of Review

          A defendant may move to dismiss a claim under Rule 12(b)(6) of the Federal Rules of Civil Procedure when the plaintiff has failed to state a claim upon which relief can be granted. In resolving a Rule 12(b)(6) motion, the court does not weigh potential evidence that the parties might present at trial. Rather, it must “assess whether the plaintiff's complaint alone is legally sufficient to state a claim for which relief may be granted.” Dubbs v. Head Start, Inc., 336 F.3d 1194, 1201 (10th Cir. 2003) (quoting Miller v. Glanz, 948 F.2d 1562, 1565 (10th Cir.1991)).

         “A court reviewing the sufficiency of a complaint presumes all of [the] plaintiff's factual allegations are true and construes them in the light most favorable to the plaintiff.” Hall v. Bellmon, 935 F.2d 1106, 1109 (10th Cir. 1991). Legal conclusions “are not entitled to the assumption of truth” but “must be supported by factual allegations.” Ashcroft v. Iqbal, 556 U.S. 662, 679 (2009). Although detailed factual allegations are not required, “a complaint must contain sufficient factual matter, accepted as true, to ‘state a claim to relief that is plausible on its face.'” Id. at 678 (quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007)). A claim ...

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