AFFILIATED ORTHOPAEDIC SPECIALISTS, PA v. ADVANTEK BENEFIT ADMINISTRATORS
3:20-cv-05903
D.N.J.Feb 18, 2021Background
- Plaintiff Affiliated Orthopaedic Specialists (a medical practice) provided treatment to a patient covered by an employer-based health plan for which Advantek Benefit Administrators was the claims administrator. Treatment occurred on three occasions between July 2018 and January 2019.
- The patient assigned her insurance benefits to Plaintiff; Plaintiff billed Advantek a total of $21,310 for the services.
- Advantek paid $4,837.03 and refused to pay the claimed remaining balance; Plaintiff contends the plan required reimbursement of $18,354.34 and seeks the unpaid difference of $13,517.31.
- Plaintiff pursued internal appeals with Advantek before filing suit, which were unsuccessful according to the complaint.
- Advantek was properly served but did not answer or otherwise respond; the clerk entered default on July 27, 2020, and Plaintiff moved for default judgment on November 18, 2020.
- The Court granted default judgment on February 18, 2021, concluding Plaintiff stated an ERISA § 502(a)(1)(B) claim and awarding $13,517.31.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether default judgment should be entered | Default judgment appropriate after clerk's entry of default; plaintiff prejudiced by lack of response | No opposition (no answer was filed) | Granted: factors (prejudice, no meritorious defense evident, culpable delay) favor default judgment |
| Whether plaintiff has an ERISA cause of action and is entitled to the unpaid benefits | Patient assigned benefits to Plaintiff, giving derivative standing under ERISA § 502(a)(1)(B); plaintiff is owed $13,517.31 | No defense presented | Held: Plaintiff has derivative standing and alleges entitlement to unpaid plan benefits; sum certain proven and awarded |
Key Cases Cited
- Allaham v. Naddaf, [citation="635 F. App'x 32"] (3d Cir. 2015) (discussing Rule 55 default-judgment framework and Court's discretion)
- Chamberlain v. Giampapa, 210 F.3d 154 (3d Cir. 2000) (identifying three factors controlling default-judgment discretion)
- Polidoro v. Saluti, [citation="675 F. App'x 189"] (3d Cir. 2017) (court accepts well-pleaded facts as true but need not accept legal conclusions or damage allegations)
- N. Jersey Brain & Spine Ctr. v. Aetna, Inc., 801 F.3d 369 (3d Cir. 2015) (healthcare provider gains derivative standing to sue under ERISA when patient assigns benefits)