United States District Court, D. Montana, Billings Division
LAUREN F. SCHWARTZ, M.D. on assignment of AMANDA S., Plaintiff,
ASSOCIATED EMPLOYERS GROUP BENEFIT PLAN AND TRUST, and EMPLOYEE BENEFIT MANAGEMENT SYSTEMS, Defendants.
OPINION AND ORDER
P. WAITERS UNITED STATES DISTRICT JUDGE
the Court is a motion to dismiss filed by Defendant
Associated Employers Group Benefit Plan ("AEG")
(Doc. 12) and a motion to dismiss filed by Defendant Employee
Benefit Management Systems ("EBMS") (Doc. 10). For
the foregoing reasons, the motions are granted in part and
denied in part.
Facts alleged in complaint
Schwartz is a neurosurgeon from New Jersey. (Doc. 1 at
¶¶ 1, 10). In July 2013, while volunteering at a
Montana Camp Mak-A-Dream, she befriended a young woman named
Amanda. (Doc. 1 at ¶ 8). As a child, Amanda was
diagnosed with a brain tumor which required surgery and a
brain shunt. (Doc. 1 at ¶ 9). Amanda asked Schwartz to
be her doctor because her Montana doctor was not experienced
with her condition. (Doc. 1 at ¶ 10). Schwartz believed
Amanda would be better off receiving treatment closer to
home. (Doc. 1 at ¶ 14). Schwartz discussed insurance
coverage with Amanda's mother, who stated Amanda was
insured through EBMS. (Doc. 1 at ¶ 13). Schwartz reached
out to several doctors on Amanda's behalf but they either
failed to respond or declined to provide treatment. (Doc. 1
March 2014, Amanda's condition worsened. (Doc. 1 at
¶ 20). Out of fear Amanda was dying, Amanda's mother
contacted Schwartz. (Doc. 1 at ¶ 20). Schwartz told
Amanda's mother to contact Amanda's doctor and
request a CT Scan to determine if there was bleeding in
Amanda's head. (Doc. 1 at ¶ 21). After Amanda
underwent a CT Scan, a nurse called Schwartz and said
Amanda's condition was "out of their league."
(Doc. lat¶22). Schwartz contacted Hackensack University
Medical Center in New Jersey. (Doc. 1 at ¶ 23). Schwartz
explained Amanda had difficulty receiving treatment close to
home and needed emergency treatment. (Doc. 1 at ¶ 23).
Hackensack agreed to accept Amanda. (Doc. 1 at¶23).
contacted EBMS and stated Amanda needed to travel to New
Jersey on an emergency flight under medical observation.
(Doc. 1 at ¶ 24). EBMS administers claims under a
healthcare plan provided by AEG. (Doc. 1 at ¶¶
2-3). Schwartz explained to EBMS that she does not accept
Medicare or Medicaid and was relying on EBMS to cover
Amanda's treatment, including surgery. (Doc. 1 at ¶
24). EBMS told Schwartz Amanda's treatment would be
reimbursed in full. (Doc. 1 at ¶¶ 24-25).
was flown to New Jersey on an emergency flight. (Doc. 1 at
¶ 26). Upon landing, Amanda was rushed to the Hackensack
emergency room in unstable condition. (Doc. 1 at ¶¶
26-27). Schwartz then took Amanda to the operating room and
performed brain surgery. (Doc. 1 at ¶¶ 28-30). A
few hours after surgery, Amanda developed acute severe
meningitis and began having seizures. (Doc. 1 at ¶ 30).
Amanda was returned to the operating room for more surgery.
(Doc. 1 at ¶¶ 30-31). Due to the extensive
surgeries and complications, Amanda underwent a detailed
course of treatment for the next month. (Doc. 1 at ¶
31). During Amanda's rehabilitation, Schwartz spoke with
EBMS about paying for Amanda's treatment. (Doc. 1 at
¶ 33). EBMS again stated Schwartz would be reimbursed in
full. (Doc. 1 at ¶ 33).
point on the day Amanda arrived at Hackensack, she signed
Hackensack's general admission consent form. (Docs. 1 at
¶ 34; 1-2). The form had Schwartz's and Amanda's
names at the top. (Doc. 1-2). Amanda initialed the form at
the bottom. (Doc. 1-2). The form's assignment of benefits
clause stated "I authorize my health insurance benefits
to be paid directly to Hackensack University Medical
Center." (Doc. 1-2). The form's financial agreement
clause stated "I understand that the Medical Center bill
applies only to hospital charges and does not include any
charges or fees by physicians." (Doc. 1-2).
submitted a bill to AEG and EBMS in the amount of $476,
448.00 for Amanda's treatment. (Doc. 1 at ¶ 35). AEG
and EBMS paid Schwartz $31, 946.51, but refused to pay the
rest. (Docs. 1 at ¶¶ 37, 40). Schwartz appealed the
adverse decision but AEG and EBMS continued to refuse to pay
the remainder. (Doc. 1 at ¶¶ 38-40). Schwartz filed
suit to collect the remaining balance. (Doc. 1).
complaint contains three counts. Under count one, Schwartz
claims she is entitled to the remaining balance because
Amanda assigned Schwartz the rights to medical payments for
the treatment. Under count two, Schwartz claims she is
entitled to the remaining balance because EBMS promised
Schwartz would be reimbursed in full for the treatment and
Schwartz relied on that promise to her detriment. Under count
three, Schwartz claims she is entitled to the remaining
balance because AEG and EBMS breached their fiduciary duties
to Amanda. The parties have stipulated to the dismissal of
count three. The parties have also stipulated that
Amanda's insurance policy is governed by the Employee
Retirement Income Security Act (ERISA).
motion to dismiss for failure to state a claim is governed by
Fed.R.Civ.P. 12(b)(6). To survive a motion to dismiss,
"a complaint must contain sufficient factual matter,
accepted as true, to 'state a claim to relief that is
plausible on its face."' Ashcroft v. Iqbal,
556 U.S. 662, 678 (2009) (quoting Bell Atlantic
Corporation v. Twombly, 550 U.S. 544, 570 (2007)).
"A claim has facial plausibility when the pleaded
factual content allows the court to draw the reasonable
inference that the defendant is liable for the misconduct
alleged." Iqbal, 556 U.S. at 678. The complaint
is construed in the light most favorable to the non-moving
party. Davis v. HSBC Bank Nevada, N.A., 691 F.3d
1152, 1159 (9th Cir. 2012).
determining a motion to dismiss, a district court may
consider documents attached to the complaint and documents
"whose contents are alleged in a complaint and whose
authenticity no party questions." Knievel v.
ESPN, 393 F.3d 1068, 1076 (9th Cir. 2005).