Neurosurgical also asserted that Amelia S. underwent stereotactic radiosurgical treatment for three brain tumors and that she transferred all of her benefit payments under her health insurance plan and ERISA rights to Neurosurgical, which then filed a health insurance claim for $48,686.00. Aetna approved a $2,619.00 claim payment.

Neurosurgical alleged that it appealed both claims and exhausted Aetna's administrative appeals process for each. Neurosurgical calculated that Aetna's underpayment for the two claims totaled $121,052.80.

Aetna moved to dismiss the action filed by Neurosurgical, asserting that Neurosurgical was neither a participant nor a beneficiary, and the health insurance plans for the patients in this case “expressly” prohibited assignments of benefits.

Neurosurgical responded that the patients had validly assigned their benefits to Neurosurgical, and that Aetna's anti-assignment provisions lacked the “requisite language . . . to render an assignment void, invalid or ineffective.” Neurosurgical added that the anti-assignment clauses in the Aetna health insurance plans should not be enforced “as a matter of policy, fairness, and common sense.”

The District Court's Decision

The district court granted Aetna's motion to dismiss, finding that that Aetna's anti-assignment clauses validly barred beneficiaries from assigning benefits.

In its decision, the district court explained that Section 502(a) of ERISA entitled “a participant or beneficiary” to bring a civil action “to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan.” 29 U.S.C. § 1132(a)(1)(B).

Healthcare providers, the district court said, did not qualify as “participants” or “beneficiaries” under ERISA.

The district court added, however, that healthcare providers could acquire derivative standing where the plan participant or beneficiary assigned rights to the provider.

Yet, the district court continued, anti-assignment clauses in ERISA-governed health insurance plans as a general matter were “enforceable.”

The district court said that anti-assignment clauses did not have to contain “magic words” such as “void” or “invalid” to be enforceable. According to the district court, the “nub” was whether the language was “unambiguous in its prohibition against assignment of benefits to Neurosurgical” and “clearly and unequivocally” precluded the patients from assigning benefits to Neurosurgical.” The anti-assignment clauses in the Aetna policies met that standard, according to the district court.

Accordingly, the district court concluded, Neurosurgical did not have a valid assignment, and as a matter of law did not have standing to assert an ERISA claim.

The case is Neurosurgical Associates of NJ, P.C. v. Aetna, Inc., No.: 2:17-cv-13210 (KSH) (CLW) (D.N.J. Feb. 22, 2019). Attorneys involved include: For NEUROSURGICAL ASSOCIATES OF NJ, P.C., on assignments of Isaac R., Lenny G., and Amelia S., Plaintiff: MICHAEL J. SMIKUN, LEAD ATTORNEY, LAW OFFICES OF SEAN R. CALLAGY, ESQ, PARAMUS, NJ. For AETNA, INC., Defendant: GREGORY SCOTT VOSHELL, LYNNE NICHOLE KOLODINSKY, LEAD ATTORNEYS, ELLIOT GREENLEAF, P.C., BLUE BELL, PA; THOMAS JACKSON ELLIOTT, LEAD ATTORNEY, ELLIOTT GREENLEAF, P.C., BLUE BELL, PA.