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William Griffis v. Highmark Blue Cross Blue Shield of Pennsylvania

February 10, 2012

WILLIAM GRIFFIS
PLAINTIFF,
v.
HIGHMARK BLUE CROSS BLUE SHIELD OF PENNSYLVANIA, DEFENDANT,



The opinion of the court was delivered by: Conti, District Judge.

MEMORANDUM OPINION AND ORDER

INTRODUCTION

In this case, plaintiffs William Griffis ("Griffis") and T. Zenon Pharmaceuticals, doing business as Pharmacy Matters ("Pharmacy Matters," and together with Griffis, "plaintiffs"), asserted claims against defendant Highmark Blue Cross Blue Shield of Pennsylvania ("Highmark") under the Employee Retirement and Security Income Act of 1974 ("ERISA"), 29 U.S.C. §§ 1132 et seq., for (1) wrongful denial of benefits; (2) declaratory relief; (3) injunctive relief; and (4) unlawful delay of benefit payments pursuant to the Pennsylvania Quality Health Care Accountability and Protection Act (the "Health Care Act"), 40 PA. CONS. STAT. §§ 991.2101 et seq. After the court ordered the parties to determine if it was possible to conduct an administrative review of plaintiffs' claim, the parties reported to the court that the self-funded plan maintained by Penske Truck Company ("Penske") had paid the full amount of the allegedly wrongfully withheld ERISA benefits.*fn1 Pharmacy Matters voluntarily withdrew from the litigation. Now pending before the court are Griffis's motion for attorney fees (ECF No. 39) and Highmark's renewed motion to dismiss (ECF No. 37). For the reasons stated below, the court will GRANT the renewed motion to dismiss, but will delay ruling on the motion for attorney fees in order for the parties to conduct limited discovery.

BACKGROUND

The following facts are taken from the complaint filed in this case. They are recited only for the purpose of providing background information and are not admitted by Highmark. This background does not reflect any findings of fact by the court.

In February 2007, Griffis signed a "Service Agreement/Assignment of Benefits" which arguably assigned Griffis's rights to reimbursement and collection under his insurance policy to Factor Health Management, LLC ("FHM") in exchange for health services rendered.*fn2 (Service Agreement/Assignment of Benefits (ECF No. 1-2) at 1.) FHM and Pharmacy Matters are affiliated by contract. (Compl. (ECF No. 1) ¶ 7.)

In 2008, Highmark issued a medical insurance policy to Griffis which was effective during all times relevant to the case, from October to December 2008. (Id. ¶ 13.) Griffis suffers from hemophilia, a life-threatening disease that requires expensive blood-clotting factor treatment. (Id. ¶ 6.) Under the policy, Griffis was permitted to obtain covered services from participating providers and nonparticipating providers and receive reimbursement from Highmark.*fn3 (Id. ¶ 13.) Plaintiffs filed this action against Highmark for allegedly refusing to pay Pharmacy Matters in excess of $330,318.00 in benefit claims submitted between October and December 2008.

During a hearing on Highmark's motion to stay (ECF No. 23) and first motion to dismiss (ECF No. 8), held on July 26, 2011, the court requested the parties inquire about the viability of conducting an administrative review of the claims underlying the case. Following review, the court was informed that the benefits allegedly wrongfully not paid were paid in full by Penske.

STANDARD OF REVIEW

Pursuant to Rule 12(b)(1) of the Federal Rules of Civil Procedure, a court must dismiss a matter if it lacks subject-matter jurisdiction over the complaint. FED. R. CIV. P 12(b)(1).

Challenges to subject-matter jurisdiction under Rule 12(b)(1) may be facial or factual in form. Gould Elec. Inc.v. United States, 220 F.3d 169, 176 (3d Cir. 2000); Mortensen v. First Fed. Sav. and Loan Ass'n, 549 F.2d 884, 891 (3d Cir. 1977). A facial challenge attacks the complaint on its face and requires the court to consider only the complaint's allegations and to do so in the light most favorable to the plaintiff. Mortensen, 549 F.2d at 891. A factual challenge contests the existence of subject-matter jurisdiction, apart from any pleadings. Id. In reviewing a factual challenge, the court "is free to weigh the evidence and satisfy itself as to the existence of its power to hear the case," even where disputed material facts exist. Id. In a factual challenge, the plaintiff has the burden of persuasion to show that jurisdiction exists. Id.; Gould, 220 F.3d at 178.

A motion to dismiss filed pursuant to Federal Rule of Civil Procedure 12(b)(6) tests the legal sufficiency of the complaint. Kost v. Kozakiewicz, 1 F.3d 176, 183 (3d Cir. 1993). In deciding a motion to dismiss, the court is not opining on whether the plaintiff will be likely to prevail on the merits; rather, when considering a motion to dismiss, the court accepts as true all well-pled factual allegations in the complaint and views them in a light most favorable to the plaintiff. U.S. Express Lines Ltd. v. Higgins, 281 F.3d 383, 388 (3d Cir. 2002). While a complaint does not need detailed factual allegations to survive a Rule 12(b)(6) motion to dismiss, a complaint must provide more than labels and conclusions. Bell Atlantic Corp. v. Twombly, 550 U.S. 544, 555 (2007). A "formulaic recitation of the elements of a cause of action will not do." Id. (citing Papasan v. Allain, 478 U.S. 265, 286 (1986)). "Factual allegations must be enough to raise a right to relief above the speculative level" and "sufficient to state a claim for relief that is plausible on its face." Id. "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, 129 S. Ct. 1937, 1949 (2009) (citing Twombly, 550 U.S. at 556).

The plausibility standard is not akin to a "probability requirement," but it asks for more than a sheer possibility that a defendant has acted unlawfully. . . . Where a complaint pleads facts that are "merely consistent with" a defendant's liability, it "stops short of the ...


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