United States District Court, D. Idaho
JEFFERY HOPKIN, as the representative of, and on behalf of Rosa H., Terry J., Breanna M., Ariel N., Greg O., Tyler W., Gerald H., Allison M., Cameron B., Mason B., Walter F., Tamara G., Kassia G., Katherine G., Korryn G., Peter H., Taff H., Richard J., Terry J., Kiera J., Paula M., Virginia M., Michelle O., Ronald P., Teri S., Peter S., Haley B., Rosalba O., Millie W., Terry J., Natasha S., Nicholas F., Nathaniel D., Kody R., and JEFFERY HOPKIN in his capacity as a designated Beneficiary, Plaintiffs,
BLUE CROSS OF IDAHO HEALTH SERVICE, INC., or in the alternative, BLUE CROSS OF IDAHO CARE PLUS, INC., both Idaho corporations, Defendants.
MEMORANDUM DECISION AND ORDER
J. Lodge, United States District Judge.
before the Court is Defendant Blue Cross of Idaho Health
Service, Inc.'s (“Blue Cross of Idaho”)
Motion to Dismiss. The parties filed responsive briefing and
the motion is now ripe for decision. Having fully reviewed
the record herein, the Court finds that the facts and legal
arguments are adequately presented in the briefs and record.
Accordingly, in the interest of avoiding further delay, and
because the Court conclusively finds that the decision making
process would not be significantly aided by oral argument,
the Motion shall be decided on the record before this Court
without oral argument.
Jeffery Hopkin (“Dr. Hopkin”) is the owner of
Upper Valley Family Practice. (Dkt. 1, ¶ 1-2.) Dr.
Hopkin was the healthcare provider for the named individual
patients, plan participants, and/or beneficiaries for all the
claims at issue. (Dkt. 9, ¶ 2, 3.) Dr. Hopkin contends
that these individuals appointed him as their beneficiary and
to act as their personal representative for the purpose of
bringing the claims at issue. (Dkt. 9, ¶ 4.)
November 2011, Upper Valley Family Practice entered into a
Professional Health Care Provider Contract (“Provider
Contract”) with Defendant Blue Cross of Idaho Health
Service, Inc. (“Blue Cross of Idaho”). (Dkt. 6-3,
Ex. A; Hopkin Decl., Dkt. 19-15, ¶ 4.) Pursuant to the
Provider Contract, Upper Valley Family Practice performed
medical services for enrollees in health plans insured or
administered by Blue Cross of Idaho. (Dkt. 14-1.; see
generally Dkt. 9, ¶ 44-50, Dkt. 6-5, Ex. C.) Dr.
Hopkin provided medical services at Upper Valley Family
Practice and Upper Valley Family Practice billed Blue Cross
of Idaho for those medical services. (Dkt. 6-4; Hopkin Decl.,
Dkt. 19-15, ¶ 3.) Blue Cross of Idaho paid each of the
claims at issue in this case during 2013. (Dkt. 6-4.)
December 30, 2013, Blue Cross of Idaho sent Upper Valley
Family Practice a letter stating that “benefits have
been incorrectly applied to claims submitted by your office
for Antigen leukocyte cellular antibody (ALCAT) automated
food tests[, ]” which Blue Cross of Idaho considers
investigational. (Dkt. 6-4.) The letter further informed
Upper Valley Family Practice that, under Blue Cross Medical
Policy, they were prohibited from seeking payment or
reimbursement for investigational services under the
Professional Health Care Provider Contract (“Provider
Contract”). (Dkts. 9, 6-4, 14-1.) As a result of its
adverse benefit determination, Blue Cross of Idaho began
recouping the previously paid amounts by withholding monies
for properly billed claims for other patients and plan
participants from January through March of 2014 and then
again from May through July of 2014. (Dkt. 9, ¶ 19, 22.)
17, 2017, Dr. Hopkin, as a representative of and on behalf of
named patients and also on behalf of himself as a designated
beneficiary, filed suit against Blue Cross of Idaho. (Dkt.
1.) Dr. Hopkin brought suit pursuant to 29 U.S.C.
§§ 1106(b), 1132 and 28 U.S.C. § 2201 for
declaratory relief, injunctive relief, attorney's fees,
and damages alleging Blue Cross of Idaho violated its
fiduciary duties, ERISA, and the Claims Procedure Regulation
by making the reverse benefit determinations at issue and
recouping monies for the alleged overpayments. (Dkt. 9.) Dr.
Hopkin asks the Court to declare that Blue Cross of Idaho
“has no legal authority to reverse health benefit plan
claims determinations it previously, repeatedly, and
voluntarily made under the applicable health benefit
plans” and to enjoin Blue Cross of Idaho from doing so;
to enjoin Blue Cross of Idaho from recouping and/or
off-setting payments from other plan participants; and to
recover the monies Blue Cross of Idaho has already withheld
and obtain benefits owed to Dr. Hopkin. (Dkt. 9.)
October 6, 2017, Blue Cross of Idaho filed the instant Motion
to Dismiss on two bases: (1) failure to state a claim upon
which relief can be granted, or, in the alternative, (2) lack
of standing. (Dkt. 14-1.) Fundamentally, Blue Cross of Idaho
argues that Plaintiff, as a health care provider and without
valid assignments from the plan participants, lacks standing
to bring a civil enforcement action under ERISA. (Dkt. 21.)
FRCP 12(b)(6): Motion to Dismiss for Failure to State a
motion to dismiss made pursuant to Federal Rule of Civil
Procedure 12(b)(6) tests the legal sufficiency of a
party's claim for relief. When considering such a motion,
the Court's inquiry is whether the allegations in the
pleading are sufficient under applicable pleading standards.
Federal Rule of Civil Procedure 8(a) sets forth minimum
pleading rules, requiring only a “short and plain
statement of the claim showing that the pleader is entitled
to relief.” Fed.R.Civ.P. 8(a)(2).
general, a motion to dismiss will only be granted if the
complaint fails to allege “enough facts to state a
claim to relief that is plausible on its face.”
Bell. Atl. Corp. v. Twombly, 550 U.S. 544, 570
(2007). “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. The plausibility standard is not
akin to a ‘probability standard, ' but asks for
more than a sheer possibility that a defendant has acted
lawfully.” Ashcroft v. Iqbal, 556 U.S. 662,
678 (2009) (citations omitted).
the Court “must take all of the factual allegations in
the complaint as true” it is “not bound to accept
as true a legal conclusion couched as a factual
allegation.” Twombly, 550 U.S. at 555.
Therefore, “conclusory allegations of law and
unwarranted inferences are insufficient to defeat a motion to
dismiss for failure to state a claim.” Caviness v.
Horizon Comm. Learning Cent., Inc., 590 F.3d 806, 811-12
(9th Cir. 2010) (citation omitted).
the Court may not consider any material beyond the pleadings
in ruling on a motion to dismiss under Rule 12(b)(6). See
Branch v. Tunnell, 14 F.3d 449, 453 (9th Cir. 1994). A
Court may, however, “consider attachments to the
complaint and documents referred to in (but not attached to)
the complaint, where the authenticity of such document is not
in question.” Mueller v. Correction Corp. of
America, 2013 WL 431796, at *1 (D. Idaho 2013) (citing
Cooper v. Pickett, 137 F.3d 616 (9th Cir. 1997)).
But, where the parties rely on materials outside the
pleadings and the Court considers that evidence, the Court
must convert a 12(b)(6) motion into one for summary judgment
under Rule 56. United States v. Ritchie, 342 F.3d
903, 907 (9th Cir. 2003).
Hopkin referred to the Provider Contract, the Appointment and
Designation Forms, and the health plans in the Amended
Complaint. Further, Dr. Hopkin does not question the
authenticity of these documents. Accordingly, the Court may
consider these documents in this motion to dismiss without
converting the motion to one for summary judgment.
FRCP 12(b)(1): Motion to Dismiss for Lack of
III standing is an element of subject matter jurisdiction;
therefore, a party's lack of standing may be raised in a
motion under 12(b)(1). As a general matter, in considering a
12(b)(1) motion to dismiss, the court need not defer to a
plaintiff's factual allegations regarding jurisdiction.
However, where the motion to dismiss is based on lack of
standing, the reviewing court must defer to the
plaintiff's factual allegations, and further must
“presume that general allegations embrace those
specific facts that are necessary to support the
claim.” Lujan v. Defenders of Wildlife, 504
U.S. 555, 561 (1992).
doctrine of standing is based both on prudential concerns and
on constitutional limitations on the jurisdiction of the
federal courts.” Doran v. 7-Eleven, Inc., 524
F.3d 1034, 1039 (9th Cir. 2008). To determine whether a
dispute presents a case or controversy sufficient to give
rise to constitutional standing, the court applies a
(1) “[T]he plaintiff must have suffered an
‘injury in fact'- an invasion of a legally
protected interest which is (a) concrete and particularized,
and (b) actual or imminent, not conjectural or
hypothetical….” Id. (quoting
Lujan, 504 U.S. at 5601-61).
(2) “[T]here must be a causal connection between the
injury and the conduct complained of.” Id.
(3) “[I]t must be likely, as opposed to merely
speculative, that the injury will be redressed by a favorable
FRCP 12(b)(6): Motion to Dismiss for Failure ...