By the statute’s terms, only a “participant or beneficiary” may bring a claim. Pascack Valley Hosp. v. Local 464A UFCW Welfare Reimbursement Plan, 388 F.3d 393, 400 (3d Cir. 2004). Nonetheless, a healthcare provider may bring claims if it has a valid assignment of benefits from a plan participant. CardioNet, Inc. v. Cigna Health Corp., 751 F.3d 165, 176 n.10 (3d Cir. 2014).
Open MRI & Imaging of RP Vestibular Diagnostics, P.A. v. Cigna Health & Life Ins. Co. (D. N.J. 2021)
Since a claim for benefits must be asserted by a participant or beneficiary, a health care provider needs a valid assignment of a patient’s claims to pursue an insurer or other payer. Cigna argued that the provider had not alleged a valid assignment and moved to dismiss the complaint. As the court noted, the provider would be the most likely party to possess the assignments.
Instead, the provider submitted EOB’s and argued that Cigna’s failure to state the lack of assignments as a cause for claims denial led to an inference the assignments existed. The court refused to do this –
“The Twombly/Iqbal standard does not require the Court to engage in such gymnastics for plaintiff’s benefit. If Smith files a negligence suit for damages because Jones was injured in a car accident, Smith has not (yet) stated a claim. Open MRI objects that it is not yet required to prove that such assignments exist, and to that extent it is correct. The trouble is that Open MRI has not so much as alleged that such assignments exist. If Open MRI possesses a valid assignment, that fact should be readily ascertainable and easily alleged. Indeed, MRI, not Cigna, is the party which naturally would possess such assignments, if they exist. Given that an assignment is the very basis of its entitlement to sue, Open MRI may reasonably be asked to at least allege its existence. See MedWell, 2020 WL 7090745, at *3.“