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Ciampa v. Oxford Health Insurance, Inc.

United States District Court, Eastern District of New York

May 13, 2015

ALEXANDRA CIAMPA, Plaintiff,
v.
OXFORD HEALTH INSURANCE, INC., Defendant.

EDWARD J BOYLE Attorneys for Plaintiff By: Edward Joseph Boyle, Esq.

SEDGWICK LLP Attorneys for Defendant By: Michael Bernstein, Esq.

MEMORANDUM AND ORDER

Denis R. Hurley Unites States District Judge

Plaintiff Alexandra Ciampa (“plaintiff” or “Ciampa”) brings this action against defendant Oxford Health Insurance, Inc. (“defendant” or “Oxford”), pursuant to the Employment Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001, et seq. Although plaintiff claims that her Complaint is brought “under 29 U.S.C. § 1132(a)(1)(B) and (a)(3) of ERISA, ” (Compl. ¶ 4), she specifically enumerates only claims of breach of contract, negligence, and breach of fiduciary duty pursuant to 29 U.S.C. § 1104. Presently before the Court is defendant’s motion to dismiss these claims pursuant to Federal Rule of Civil Procedure (“Rule”) 12(b)(6) for failure to state a claim upon which relief may be granted. For the reasons set forth below, defendant’s motion is granted.

BACKGROUND

The following facts are taken from plaintiff’s Complaint and are presumed to be true for purposes of defendant’s present Motion.[1]

At all relevant times, Ciampa was insured by Oxford through Ciampa Management Corporation, her husband’s employer. In 2012, it became apparent that plaintiff required back surgery. Plaintiff retained Dr. Patrick O’Leary, an “out of network” physician, to perform the surgery. Plaintiff applied for pre-approval from Oxford for the surgery. In a letter dated November 28, 2012, Oxford sent plaintiff a letter in which it reviewed the proposed surgery and approved certain procedures.

After the surgery, plaintiff received a $59, 000 bill from the surgeon and a $9, 545 bill from the anesthesiologist, totaling $68, 545. To date, Oxford has paid $5, 645.19 of this amount. There is no dispute that the Certificate of Coverage for plaintiff’s plan states that “the out-of-network reimbursement amount is based on 140% of Medicare, a gap methodology or 50% of the billed changes” and states that “Payment Determination Will Be Made Upon Receipt of a Claim.” (Compl. ¶ 12.) Ciampa claims, however, that “since Ciampa Management Corporation was paying the $4, 100 a month premiums for family medical coverage and since Plaintiff received pre-approval for this sophisticated surgery, there was no basis for Ciampa to interpret [Oxford’s] communications or its [Summary Plan Description] in any manner to prepare her for a reimbursement of only $5, 645.19, leaving her with personal responsibility for nearly $63, 000.” (Id. ¶ 18.)

Following receipt of the reimbursement, Ciampa exhausted all administrative remedies with Oxford. In the decision on Ciampa’s second and final appeal, Oxford denied Ciampa’s appeal determining that her claim “was correctly paid in accordance with [Ciampa’s] out-of-network benefits and no additional reimbursement [would] be made.” (Letter from Oxford dated Jan 17, 2014, Ex. B to Compl. at 1.) Moreover, Oxford explained that it reimbursed her “using 140% of [the] Medicare” rate of reimbursement. (Id. at 2.)

DISCUSSION

I. Standard of Review for Motion to Dismiss

Rule 8(a) provides that a pleading shall contain “a short and plain statement of the claim showing that the pleader is entitled to relief.” Fed.R.Civ.P. 8(a)(2). In recent years, the Supreme Court has clarified the pleading standard applicable in evaluating a motion to dismiss under Rule 12(b)(6).

First, in Bell Atl. Corp. v. Twombly, 550 U.S. 544 (2007), the Court disavowed the well-known statement in Conley v. Gibson, 355 U.S. 41, 45–46 (1957) that “a complaint should not be dismissed for failure to state a claim unless it appears beyond doubt that the plaintiff can prove no set of facts in support of his claim which would entitle him to relief.” Twombly, 550 U.S. at 561. Instead, to survive a motion to dismiss under Twombly, a plaintiff must allege “only enough facts to state a claim to relief that is plausible on its face.” Id. at 570.

While a complaint attacked by a Rule 12(b)(6) motion to dismiss does not need detailed factual allegations, a plaintiff’s obligation to provide the grounds of his entitlement to relief requires more than labels and conclusions, and a formulaic recitation of the elements of a cause of action will not do. Factual allegations must be enough to raise a right to relief above the speculative ...

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