New York Group For Plastic Surgery LLP v. Anthem Blue Cross

Background

New York Group For Plastic Surgery LLP, a physician practice group, sued Anthem Blue Cross and Anthem, Inc., collectively called “Anthem.” The practice alleged that its out-of-network surgeons performed a thoracodorsal artery perforator flap procedure on one breast and breast reconstruction on the other breast. It submitted invoices of about $100,000 for one surgeon, about $97,000 for another surgeon, and about $25,000 for an assistant surgeon. Anthem ultimately reimbursed $13,800.82, $10,386.18, and $4,448.96, respectively.

The practice alleged that Anthem had represented that out-of-network claims would be paid using an allowed amount based on the 90th percentile of Fair Health, but that the reimbursements were not based on that measure. Its second amended complaint asserted unjust enrichment and sought an accounting, including production of financial records that allegedly would show under-reimbursement.

Anthem moved to dismiss the entire second amended complaint under Rule 12(b)(6), which allows dismissal when a complaint does not state a legally sufficient claim. Anthem also argued that neither defendant was a proper party and that the claims were time-barred. The court addressed only whether the complaint stated claims for unjust enrichment and an accounting.

Unjust Enrichment

Under New York law, an unjust-enrichment claim requires allegations that the defendant benefited, that the benefit came at the plaintiff’s expense, and that fairness requires repayment. The court explained that courts consistently dismiss such claims against insurers when the medical services were provided at the patient’s request rather than at the insurer’s request.

The court held that the practice did not sufficiently allege how Anthem benefited from the surgeons’ performance of services for the patient. The court rejected the practice’s argument that Anthem was required under the Women’s Health and Cancer Rights Act to provide full coverage for the surgery. According to the court, that law requires coverage but does not require payment of 100 percent of the surgeon’s billed amount. The complaint did not allege that Anthem failed to provide the coverage required by that law.

Accounting Claim

An accounting is an equitable claim seeking an accounting of money or property. Under New York law, it generally requires a fiduciary or confidential relationship, money or property entrusted to the defendant, no adequate legal remedy, and, in some cases, a demand for an accounting that was refused. A normal business relationship alone is not enough; special circumstances must transform it into a fiduciary relationship.

The court held that the practice alleged only an arms-length business transaction with Anthem and did not allege a fiduciary or confidential relationship. The court therefore concluded that the accounting claim failed as well.

Disposition

The court granted Anthem’s motion to dismiss. It directed the Clerk of Court to close the motion at Docket Number 38 and close the case. The opinion did not state that the dismissal was with or without prejudice.