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OSF Healthcare System v. Insperity Group Health Plan

United States District Court, C.D. Illinois, Peoria Division

March 10, 2015

OSF HEALTHCARE SYSTEM, an Illinois not for profit corporation d/b/a SAINT FRANCIS MEDICAL CENTER, Plaintiff,
v.
INSPERITY GROUP HEALTH PLAN and UNITED HEALTHCARE INSURANCE COMPANY, Defendants

For OSF Healthcare System, doing business as Saint Francis Medical Center, Plaintiff: Kristin Lindsey Nieminski, LEAD ATTORNEY, Douglas N Koth, William L Gregory, KOTH & GREGORY PC, Bloomington, IL.

For Insperity Group Health Plan, UnitedHealthcare Insurance Company, Defendants: Curtis Dean Ripley, LEAD ATTORNEY, STINSON LEONARD STREET LLP, Minneapolis, MN.

Page 861

ORDER

SARA DARROW, UNITED STATES DISTRICT JUDGE.

Plaintiff OSF Healthcare System (" OSF" ), doing business as Saint Francis Medical Center, is suing Insperity Group Health Plan (" Insperity" ) and UnitedHealthCare Insurance Company (" United" ) over nonpayment of a medical bill. OSF sues for recovery of benefits under a provision of the Employee Retirement Income Security Act (" ERISA" ), 29 U.S.C. § 1132(a)(1)(B). Before the Court is Insperity's Rule 12(b)(6) Motion to Dismiss, also requesting oral argument. ECF No. 13. For the following reasons, Insperity's Motion to Dismiss is DENIED, along with the request for oral argument.

Page 862

BACKGROUND[1]

Michael Gray had health insurance coverage through Insperity, an employee medical benefit plan.[2] Compl. 2, ¶ 7. OSF provides medical services via a hospital in Peoria, Illinois. Id. at 1, 3; ¶ ¶ 1, 13. On or around November 8, 2011, Gray was transported to OSF from another hospital because the other hospital was unable to provide Gray with appropriate care for septicemia, acute respiratory failure, and pulmonary collapse. Id. at 1, 3; ¶ ¶ 2, 13. OSF provided medical services to Gray until December 23, 2011. Id. at 1, ¶ 2. Gray assigned his benefits under his health plan to OSF. Id. at 6, ¶ 27; Compl. Ex. G ¶ 3, ECF No. 1-5. The cost of the services OSF provided over this time was $506,209.30. Compl. 2, ¶ 4.

Insperity had contracted with United, an insurer, to provide health benefits to Gray. Compl. 8, ¶ 10; see Compl. Ex. C., ECF No. 1-5 at 1. United was designated as the Claims Administrator for the benefits it provided, with the power to " decide questions relating to benefit claims and appeals." Compl. Ex. B, Administaff Group Health Plan, 3.1; ECF No. 1. OSF submitted requests for payment. Compl. 2, ¶ 10. United refused to pay the entire amount requested, because OSF was a " non network health care provider." Id. at 2--3, ¶ 11. OSF repeatedly appealed the decision with United, which repeatedly refused to pay the requested sum. Id. at 4--5, ¶ ¶ 22--23. Ultimately, OSF recovered $97,588.04 of the outstanding amount. Id. 2 ¶ 6. OSF now seeks the remaining $408,621.26 from Insperity and United. Id. at 6, 12.

LEGAL STANDARD

I. Motion to Dismiss

In reviewing a motion to dismiss, a court must accept as true all well-pleaded facts in the complaint, and draw all reasonable inferences in favor of the plaintiff. Scanlan v. Eisenberg, 669 F.3d 838, 841 (7th Cir. 2012). A court will dismiss a complaint if it fails to state a claim upon which relief can be granted. Fed.R.Civ.P. 12(b)(6). In determining whether such a claim has been stated, a court should first identify pleadings that " because they are no more than conclusions, are not entitled to the assumption of truth." Ashcroft v. Iqbal, 556 U.S. 662, 679, 129 S.Ct. 1937, 173 L.Ed.2d 868 (2009). It should then take the remaining, well-pleaded factual allegations, " assume their veracity[,] and . . . determine whether they plausibly give rise to an entitlement to relief." Id. This means that a complaint must provide " allegations that raise a right to relief above the speculative level." Tamayo v. Blagojevich, 526 F.3d 1074, 1084 (7th Cir. 2008) (internal quotation marks omitted).

II. ERISA

ERISA " provides 'a panoply of remedial devices' for participants and beneficiaries of benefit ...


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