Through this matter, Plaintiffs are attempting to stop Defendants allegedly improper practice of underbilling for chiropractic services that Plaintiffs provided to their patients. Presently before the Court are motions to dismiss the First Amended Complaint filed by the . . . Defendants. Plaintiffs allege that the Cigna and Aetna Defendants hired the Vendor Defendants to reprice insurance reimbursements made to Plaintiffs. Plaintiffs further allege that because of the repricing, they have been underpaid by the Cigna and Aetna Defendants for provided medical services, in contravention of ERISA plan documents.
Association of New Jersey Chiropractors v. Data ISight et al, Civil Action No. 19-21973 (D. NJ. 2021)
The plaintiffs, two chiropractors, and the Association of New Jersey Chiropractors, Inc. (“ANJC”), sued the defendants “to stop Defendants allegedly improper practice of underbilling for chiropractic services that Plaintiffs provided to their patients.” The plaintiffs sought a declaratory judgment stating that Defendants’ repricing scheme constituted a breach of fiduciary duties under ERISA.
[A]n association may assert claims on its members’ behalf “when: (a) its members would otherwise have standing to sue in their own right; (b) the interests it seeks to protect are germane to the organization’s purpose; and (c) neither the claim asserted nor the relief requested requires the participation of individual members in the lawsuit.” Franco v. Conn. Gen. Life Ins. Co., 647 F. App’x 76, 82 (3d Cir. 2016). The court found that the ANJC could not show associational standing and therefore dismissed this plaintiff.
Individual Chiropractor Plaintiffs
Generally, only a participant or beneficiary under a plan has standing to bring an ERISA claim. 29 U.S.C. § 1132(a)(1). If a provider has a valid assignment of benefits, however, the provider may assert an ERISA claim under this provision.
The plaintiffs ran into standing problems as well since they “fail[ed] to allege sufficient facts demonstrating that either Individual Plaintiff had an AOB from a patient with an Aetna plan or that Loewrigkeit had an AOB from a patient with a Cigna plan. Scordilis has not established his standing to bring claims as to Aetna, and Loewrigkeit’s has not shown that he has standing to bring claims as to Aetna or Cigna. Aetna and Cigna’s motions, therefore, are also granted on these grounds.”
“Vendor” Defendants as Functional Fiduciaries
The plaintiffs sought to place Multiplan in a fiduciary role by virtue of an alleged functional role in plan administration.
ERISA defines a fiduciary “in functional terms of control and authority over the plan,” or in other words, in terms of who performs particular functions. Edmonson v.Lincoln Nat’l Life Ins. Co., 725 F.3d 406, 413 (3d Cir. 2013). Further, “[t]he definition of a fiduciary under ERISA is to be broadly construed.”
On the other hand,
“[P]ersons who perform purely ministerial tasks, such as claims processing and calculations, cannot be fiduciaries because they do not have discretionary roles.” Confer v. Custom Eng’g, 952 F.2d 34, 39 (3d Cir. 1991); see also 29 C.F.R. § 2509.75-8 (listing examples of ministerial functions that do not amount to a fiduciary role, including calculation of benefits and processing claims).
The court held that the plaintiffs had failed to allege any role that exceeded that of ministerial duties. Thus, the ERISA claim as to these defendants failed.
Because Cigna and the Vendor Defendants did not challenge Scordilis’s standing to assert claims as to them. First, the court declined to dismiss the 502(a)(3) claims as duplicative.
Although some courts dismiss Section 502(a)(3) claims that are duplicative of a Section 502(a)(1)(B) claim at the motion to dismiss stage, see, e.g., id., the Court will not do so at this time. See Shah v. Aetna, No. 17-195, 2017 WL 2918943, at *2 (D.N.J. July 6, 2017) (concluding that dismissing Section 502(a)(3) claims as duplicative “is not appropriate at this early procedural stage”). Cigna’s motion is denied on these grounds.
The court granted CIGNA’s motion to dismiss plaintiff’s claims concerning ERISA Section 503, agreeing with the defendant that Section 503 affords no privated cause of action. The proper remedy would be remand.
Here, Plaintiffs largely seek declaratory and injunctive relief but do not ask for any claim to be remanded for full review. Accordingly, because
Plaintiffs fail to seek the only relief that is permissible under Section 503, Count One is dismissed to the extent it is premised on a violation of Section 503. See Shah, 2017 WL 2918943, at *3 (“Dr. Shah’s requested relief, equitable though it may be, is not available for a violation of [§ 503’s regulations].”). Cigna’s motion is granted on these grounds.
Note – The claim for statutory penalties under 29 U.S.C. § 1132(c)(2) was denied since CIGNA was not the plan administrator.
“only the Plan Administrator can be liable for statutory penalties for failing to provide the Plan Documents.” Malishka v. MetLife, 639 F. App’x 788, 791 (3d Cir. 2015). An administrator includes “the person specifically so designated by the terms of the instrument under which the plan is operated.” 29 U.S.C. § 1002(16)(A). Cigna, however, is not a Plan Administrator under any of the plans for which Plaintiffs claim that they sought documents.
The opinion is attached.