*1270 OMNIBUS ORDER GRANTING IN PART AND DENYING IN PART JOINT MOTION TO DISMISS THE SECOND AMENDED CONSOLIDATED CLASS ACTION COMPLAINT
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*1271 [[Image here]]
I. INTRODUCTION
This multi-district litigation involves two separate categories of plaintiffs who have filed suit against various insurance companies that provide managed care. One group of plaintiffs consists of Providers 1 who allege that the managed care company defendants, both individually and in combination, engaged in a pattern of failing to pay claims in full and in a timely manner, thereby breaching certain agreements and selected federal and state statutes. The Providers include those in the Main Track nationwide class action complaint as well as certain tag-along plaintiffs transferred to this Court from locations around the country by the Judicial Panel on Multi-District Litigation.
Before the Court is the second phase of motions to dismiss in the Provider track of this litigation. Defendant managed care companies 2 jointly seek to dismiss various portions of the Main Track Second Amended Consolidated Class Action Complaint for failure to state a claim upon which relief can be granted. Through numerous pleadings spanning many months and a hearing on August 14, 2003, these well-matched parties have participated in a classic legal contest. For the reasons outlined below, the joint motion to dismiss is GRANTED in part and DENIED in part consistent with this opinion.
A. COMPLAINT
The Main Track Second Amended, Consolidated Class Action Complaint (the “SAC”) (D.E. No. 1607) contains ten separate causes of action: (1) RICO conspiracy, 18 U.S.C. § 1962(d); (2) RICO aiding and abetting, 18 U.S.C. § 2((1) and (2) collectively referred to herein as “secondary RICO violations”); (3) primary RICO, 18 U.S.C. § 1962(a) & (c); (4) RICO declaratory and injunctive relief, 18 U.S.C. § 1964(a); (5) breach of contract; (6) unjust enrichment/constructive contract; (7) violation of various state prompt pay statutes; (8) violation of the California Business & Professions Code § 17200; (9) violation of the Connecticut Unfair Trade *1272 Practices Act 3 ; and (10) violation of the New Jersey Consumer Fraud Act.
II. LEGAL STANDARD
A court will not grant a motion to dismiss unless the plaintiff fails to prove any facts that would entitle the plaintiff to relief.
Conley v. Gibson,
III. DISCUSSION
Coventry, Health Net, Humana, Pacifi-Care, Prudential, United, and WellPoint have filed a joint motion to dismiss the SAC. 4 Anthem and Coventry have also filed separate motions to dismiss. 5 The Court has issued several Orders of Dismissal as to previous versions of both Provider and Subscriber Track complaints. Many of these previous rulings are pertinent to resolution of the instant motions.
(1)The Court rejected Defendants’ position that claims under 18 U.S.C.1962(a) must result from the “investment” of racketeering proceeds, rather than merely flow from predicate acts of racketeering.
See St. Paul Mercury Ins. Co. v. Williamson,
(2) The Court rejected Defendants’ position that
Central Bank of Denver, N.A. v. First Interstate Bank of Denver, N.A.,
(3) The Court held that the central, enterprise allegations underlying all of Plaintiffs’ RICO claims were untenably broad, and that the supporting averments were too vague, incomplete or indefinite. Plaintiffs failed to identify the third-party entities which formed the enterprise, and also did not provide sufficient detail regarding the links between these third-party entities. Accordingly, the Court directed
*1273
Plaintiffs to “identify who comes within the ambit of [the RICO] enterprise, or where [plaintiffs’ RICO claims] begin and end.”
In re Managed Care Litig.,
(4) With regard to state prompt-pay statutes, the Court required Plaintiffs to “identify which state statutes are being alleged and which Defendants are alleged to have violated which statute” and “state how each Defendant violated the statute.” Id. at 1269-70.
A. RACKETEER INFLUENCED AND CORRUPT ORGANIZATIONS ACT (COUNTS I-IV)
The Racketeer Influenced and Corrupt Organizations Act (“RICO”) provides that it is “unlawful for any person employed by or associated with any enterprise engaged in, or the activities of which affect, interstate or foreign commerce, to conduct or participate, directly or indirectly, in the conduct of such enterprise’s affairs through a pattern of racketeering activity or collection of unlawful debt.” 18 U.S.C. § 1962(c). Therefore, “to state a RICO claim, a plaintiff must plead (1) that the defendant (2) through the commission of two or more acts (3) constituting a ‘pattern’ (4) of ‘racketeering - activity’ (5) directly or indirectly invests in, or maintains an interest in, or participates in (6) an ‘enterprise’ (7) the activities of which affect interstate or foreign commerce.”
McCulloch v. PNC Bank,
1. “ENTERPRISE”
a. Requirement of a Discernible “Entity”
Defendants argue that the SAC again fails to define a sufficiently discrete enterprise for purposes of RICO liability. Plaintiffs include the following entities within their definition of the Managed Care Enterprise (“MCE”): Defendants, their trade associations, a few named vendors, unidentified “health insurance companies not named as defendants herein,” and “other third party entities.” SAC ¶¶ 26-31. Plaintiffs previously alleged that the RICO enterprise comprised the entire health care industry, including both providers and the numerous different companies connected in some professional fashion with the nation’s system for providing private health care coverage. While the scope of the alleged enterprise is still quite large, the Court finds that Plaintiffs have answered the challenge and added the requisite amount of detail to successfully allege an association-in-fact enterprise.
An association-in-fact enterprise requires the existence of an
entity,
“an ongoing organization, formal or informal, and evidence that the various associates function as a continuing unit.”
United States v. Turkette,
While in particular cases the proof used to establish the enterprise and the racketeering pattern requirements may coalesce, the possibility of evidentiary overlap does not detract from the fact that the existence of an enterprise remains a separate element.
Turkette,
Defendants argue that the SAC’s factual averments are insufficient even to allege concerted action that legally amounts to a conspiracy, much less an “entity” with the type of ongoing organization and structure necessary to meet RICO’s enterprise requirement. They claim that Plaintiffs’ new allegations of a MCE continue to cast too wide a net, in effect over an entire industry. Moreover, Defendants assert that there are no specific factual allegations showing a common link between the alleged participants. Thus, they assert that this “nebulous, open-ended description” is insufficient.
Richmond v. Nationwide Cassel, L.P.,
*1275 Yet, the Eleventh Circuit has not bound itself to strict metaphysical structural requirements and has authorized just the type of allegations made .in this case.
“An enterprise under [RICO] is any individual, partnership, corporation, association, or other legal entity, and any union or group of individuals associated in fact though not a legal entity. Moreover, under our case law, a RICO enterprise need not possess an ascertainable structure distinct from the association necessary to conduct the pattern of racketeering activity.... We have held that Turkette left intact this Circuit’s holding in United States v. Elliott,571 F.2d 880 (5th Cir.1978), that the definitive factor in determining the existence of a RICO enterprise is the existence of an association of individual entities, however loose or informal, that furnishes a vehicle for the commission of two or more predicate crimes, that is, the pattern of racketeering activity requisite to the RICO violation.”
United States v. Goldin,
While Defendants protest that the level of factual detail has not been reached, the pleadings are justifiably limited at this stage because Plaintiffs have not had the aid of discovery. The Court finds that the preliminary sketch of a RICO enterprise provided by the Plaintiffs adequately meets .the Court’s challenge-. Moreover, although the MCE that the Provider Plaintiffs have alleged is admittedly larger in scope than the one found sufficient in the Subscriber Track, there are a few analogous similarities. First, the Plaintiffs have not.bundled a random assortment of contracts and labeled it an enterprise. Each of the entities are tied together with the common purpose established by the Defendants. Second, the associations and third-party entities are alleged to have a stake in the ongoing function of the enterprise. Indeed, the links between the entities go beyond ordinary contractual bonds — for example, the hiring of each other’s senior-level employees, the use of similar patient care guidelines and computer software packages, and formation and membership in trade associations that unify the industry voice. SAC ¶ 130.
Every individual entity plays a role in the enterprise equation: each Defendant and their subsidiaries throughout the country; other health insurance companies not expressly named; third party entities that develop claims processing systems or components; third party entities which promulgate patient care guidelines; third party entities that Defendants hire to review and wrongfully deny claims; trade associations; and a health industry database, MedUnite. SAC ¶ 127. The maintenance of this organized system requires an ongoing enterprise. Accordingly, the Plaintiffs have set out to the Court’s satisfaction the associational links comprising the Managed Care Enterprise and the Court therefore finds that Plaintiffs have *1276 sufficiently alleged an enterprise for the purposes of RICO.
b. Antitrust in Disguise
Defendants next argue that Plaintiffs’ concentration on “market dominance” confirms that the SAC is nothing more than vague antitrust allusions imper-missibly dressed in RICO garb. SAC ¶¶ 112-15, 130. RICO’s history indicates that Congress did not intend for it to be used as a vehicle for evading the strict legal requirements applicable to antitrust claims.
Sedima, S.P.R.L. v. Imrex Co.,
The broader regulation of competition, markets or lines of commerce remains the exclusive focus of antitrust laws.
Jennings v. Emry,
Defendants contend that Plaintiffs’ “antitrust” averments would require dismissal under settled doctrine, as evidenced by their failure to allege harm to competition or define the relevant product and geographic markets.
Feldman v. Palmetto Gen. Hosp., Inc.,
c. “Operation and Management” of the Enterprise
Section 1962(c) imposes RICO liability on a defendant only if it “conduct[s]” or “participate^] ... in the conduct” of an enterprise. Congress’ insistence that the defendant must have “conduct[ed]” the affairs of the enterprise is not merely synonymous with “aid and abet,” or otherwise “superfluous,” but rather constitutes a separate and distinct requirement.
Reves v. Ernst & Young,
Defendants argue that Plaintiffs merely recycle allegations of individual predicate acts that each Defendant is alleged to have committed in the course of the operation of its own business. SAC ¶¶ 112-14, 130. Nevertheless, the Court finds that these allegations are sufficient at this stage. Plaintiffs begin by alleging that Defendants have violated Section 1962(c) “by conducting ... the affairs of the Managed Care Enterprise.” See Am. RICO Case Statement ¶ 6(d). Plaintiffs paint a further picture of the enterprise’s operation and control by alleging that Defendants played a part in directing the affairs of the enterprise by developing guidelines and standards to use as criteria to deny claims, by hiring others to develop automated systems for manipulating claims, by creating MedUnite as a common entry point for physician data, and by approving on a CEO by CEO basis the joint actions of the Coalition for Quality Healthcare. SAC ¶ 130(a), (c), (f) & (g). These allegations, if established, would show that the MCE furnishes a vehicle for the commission of continuing predicate crimes with the Defendants squarely in the driver’s seat. While Defendants quibble about needing more specificity regarding the operation and control of the enterprise, the Court nevertheless finds that Plaintiffs have alleged the basic contours of control necessary to survive a Fed.R.Civ.P. 12(b)(6) motion.
2. PREDICATE ACTS
a. “Breach as Fraud” Theory
Anthem and the Joint Defendants contend that Plaintiffs’ mail and wire fraud allegations amount at most to breach of contract (or quasi-contract) not the criminal fraud prohibited by 18 U.S.C. §§ 1341, 1343 which constitute RICO predicate acts. They argue that most of the representations alleged by Plaintiffs are merely communications that announce the disposition of a particular request for contractual reimbursement. See Amended RICO Case Statement ¶¶ 70-237. Plaintiffs, however, allege that each Defendant became guilty of fraud by failing to disclose secret cost containment mechanisms — such as the use of computer software to review claims— that Defendants allegedly use to deny, diminish and delay payment for covered, medically necessary services. SAC ¶¶ 78, 84-96. Rather than honoring their contractual and quasi-contractual obligations, Defendants “use cost-based or other actuarial criteria unrelated to [contractual and quasi-contractual] requirements to approve and deny claims submitted by Plaintiffs and the class.” Id. ¶ 84.
At the outset, the Court notes that simple allegations of withholding or delaying payment under a contract, even for extortionate purposes, do not constitute criminal mail and wire fraud.
Johnson Enters. of Jacksonville, Inc. v. FPL Group, Inc.,
In addition, the Court also notes that the Defendants’ arguments do not apply to Plaintiffs who treated Defendants’ insureds outside of any contractual
*1278
relationship. Further, as to the contractual claims, commercial contractual relationships are generally not the type of special relationship of trust that imposes an affirmative duty to disclose information.
Langford v. Rite Aid,
In the SAC, the Plaintiffs allege a fraudulent scheme based upon the failure to disclose a plethora of automated processing techniques to diminish, deny or delay payments. SAC ¶ 78.
See McNally v. United States,
While Defendants insist on focusing on the individual contractual level in this class action, the Plaintiffs’ allegations of a fraudulent scheme takes place on a far wider systematic level — a significant distinction. Accordingly, while their claims are indeed embedded in a contractual relationship, Plaintiffs’s allegations of mail fraud continue to be viable.
b. Fraud Claims and Fed.R.Civ.P. 9(b)
The Joint Defendants also argue that all the fraud claims are not pled with the requisite particularity. Fed.R.Civ.P. 9(b);
see also United States ex rel. Clausen v. Lab. Corp. of Am.,
Plaintiffs allege that Defendants misrepresent that their capitation rates are ac-tuarially sound, SAC ¶ 103, that Defendants overcharge risk funds for the cost of prescription medicine, id. ¶ 106, that Defendants manipulate pharmacy risk pools so that there is never any money in the pools at the end of the year to pay doctors, id. ¶ 107, and that Defendants delay furnishing providers with initial capitation payments, id. ¶¶ 104-05. Moreover, Plain *1279 tiffs allege that the Providers possessing capitation agreements with one or more of the Defendants receive monthly capitation rolls supposedly listing the patients in their group, but that the rolls do not include enrolled patients who have yet to seek any treatment, allowing Defendants to retain the full premiums for “well” members and forcing the doctors to absorb the costs of treating a group artificially inflated with sick patients. SAC ¶¶ 105-106
Defendants claim that Plaintiffs have provided only one allegation of fraud relating to one Defendant’s capitation payments and have provided no specific allegations of fraud relating to any Defendant’s risk sharing arrangements. Once again, this argument hinges on levels of specificity which are not required at this stage. Plaintiffs have provided the same level of detail in the capitation allegations as they did for the claims processing allegation, which this court found sufficient for the purposes of pleading RICO mail and wire fraud. Similarly, other courts have found that such detail is not required for numerous misrepresentations that occur over an extended period of time.
Fujisawa Pharmaceutical Co. v. Kapoor,
c. Deprivation of a Property Interest
Striking at the substantive merits of Plaintiffs’ mail and wire fraud claims, Defendants contend that Plaintiffs’ claims of mail and wire fraud cannot be proven as a matter of law because the Plaintiffs have not alleged the deprivation of any cognizable property interest.
The Supreme Court has held that the “mail fraud statute is limited in scope to the protection of property rights.”
McNally v. United States,
Plaintiffs, however, argue that services indeed can be considered property, and allegations that they performed the services and were defrauded out of rightful monetary payments easily falls under the rubric of a property interest. The Court agrees. The allegations in part concern a scheme using claims processing mechanisms to deny, diminish, and delay payments for services that have been performed. Therefore, the providers are being deprived of a property right — in *1280 this case money rightfully theirs — in perhaps the most legally primitive sense.
3. PROXIMATE CAUSE
Defendants argue that Plaintiffs’ allegations that Defendants have injured individual physicians by economically manipulating the entire managed care industry fail under RICO’s stringent proximate cause requirements.
Holmes v. Sec. Invest Prot. Corp.,
In the SAC, Plaintiffs have alleged that their injuries result from the participants in the managed care industry who have been “coerced” into participating in Defendants’ supposed “scheme.” For example, Plaintiffs allege that Defendants’ subsidiaries enter into capitation agreements with providers through independent medical groups (“IPAs”). Many of these IPAs themselves receive monthly capitation payments for each enrolled patient and agree to assume responsibility for processing and paying the claims of their individual doctors. According to Plaintiffs, Defendants’ fraudulent misrepresentations render those payments actuarially unsound and cause the group’s capitation fund to run dry.
Defendants argue that it is speculation whether an individual doctor’s failure to receive payments is directly attributable to insufficient capitation payments as opposed to the business practices of individual medical groups or IPAs, including their administrative overhead, efficiency and claims processing procedures.
See Holmes,
The Court disagrees. Exploring Defendants’ nightmarish causal scenario is inappropriate at this stage and Defendants fail in their attempt to create multiple layers of attenuation. Nothing like the extended chain of causation that existed in Holmes exists here — indeed, Defendants’ conduct is alleged to be the precipitating force in the Plaintiffs’ injuries in a simple causal relationship. The fee-for-service Plaintiffs are injured when their bills are not paid in full by the Defendants. The capitation Plaintiffs are injured when they fail to receive payment, in this case, the full capitation payments that they are entitled to, directly or indirectly, through the IPAs that pass them along. Accordingly, Plaintiffs have satisfactorily alleged proximate cause.
4. RICO CONSPIRACY (SECTION 1962(D))
To successfully allege a Section 1962(d) claim, a plaintiff must allege “that the conspirators agreed to participate directly or indirectly in the affairs of an enterprise through a pattern of racketeering activity.”
United States v. Castro,
Defendants argue that Plaintiffs’ conspiracy allegations merely allege conscious parallelism and constitutionally protected (First Amendment) conduct.
See
SAC ¶¶ 116, 118, 120 (“Defendants employ similar business practices in dealing with claims for reimbursement and participate in trade associations and other industry groups that are vehicles for the exchange of sensitive information”). Defendants assert that this is an insufficient factual basis from which to infer an agreement to violate RICO.
O’Malley v. O’Neill,
In the previous Order of Dismissal, this Court found that the Plaintiffs had adequately pled a conspiracy claim under Section 1962(d). Nevertheless, the claim was dismissed due to a defect in the enterprise allegations. Now that the Court has found that the Plaintiffs have satisfied the enterprise pleading requirements in the newest iteration of the complaint, there is no reason to depart from the previous finding. Indeed, close inspection of the SAC demonstrates that Plaintiffs continue to satisfy the pleading requirements. An agreement to the overall objective of the conspiracy as well as to commit predicate acts is contained in Paragraph 117, the functional necessity of such an agreement is contained in Paragraph 118, and sub-agreements, like agreeing to use the same standards, guidelines and automated processing techniques to deny or dimmish claims are alleged in Paragraph 130(b) and (d). Paragraphs 112 through 120 of the SAC allege conduct from which the requisite agreement can be inferred.
As to the First Amendment concerns, Plaintiffs’ allegations go far beyond participation in trade associations. The First Amendment does not protect illegal conduct implemented through trade associations.
NAACP v. Claiborne Hardware Co.,
5. EQUITABLE RELIEF UNDER RICO (COUNT IV)
Defendants argue that RICO does not authorize a private plaintiff to obtain equitable or declaratory relief, only treble damages. 18 U.S.C. § 1964(a). Section *1282 1964(a) grants district courts “jurisdiction to prevent and restrain violations” of RICO by issuing various forms of injunctive relief — including “ordering dissolution or reorganization” — but does not expressly set forth a cause of action for any sort of relief. Section 1964(b) states that “[t]he Attorney General may institute proceedings under this section,” and that “[p]ending final determination thereof,” the court may enter appropriate interim restraining orders. Section 1964(c) provides that “[a]ny person injured in his business or property by reason of a [RICO] violation ... may sue ... and shall recover threefold the damages he sustains and the cost of the suit, including a reasonable attorney’s fee.”
There is no controlling legal precedent that governs the Court’s disposition of this issue. Defendants argue, however, that based upon the text, structure and history of the statute, only the Attorney General may seek final and interim injunctive relief. A slim plurality of courts of appeals appear to agree, but most have addressed the issue in terms of interim or temporary equitable relief.
Religious Tech. Ctr. v. Wollersheim,
One circuit court, however, has recently held that private parties may obtain in-junctive and declaratory relief under RICO.
NOW v. Scheidler,
“Section 1964(a) ... grants the district courts jurisdiction to hear RICO claims and also sets out general remedies, including injunctive relief, that all plaintiffs authorized to bring suit may seek. Section 1964(b) makes it clear that the statute is to be publicly enforced by the attorney general and it specifies additional remedies, all in the nature of interim relief that the government may seek. Section 1964(c) similarly adds to the scope of 1964(a), but this time for private plaintiffs. Those private plaintiffs who have been injured in their business or property by reason of a RICO violation are given a right to sue for treble damages.”
Id.
at 696. The decision in
NOW v. Scheidler
is most closely on point with the remedies sought in the SAC as
Scheidler
*1283
arose from the district court’s grant of permanent, rather than temporary, injunctive relief, akin to what Plaintiffs are seeking in the case at bar. Furthermore, few courts have squarely addressed the issue of the availability of equitable remedies and even then, do not reason in unison that permanent injunctive relief is unavailable.
See In re Fredeman Litig.,
6. MCCARRAN-FERGUSON ACT
Defendants contend that the McCarran-Ferguson Act, 15 U.S.C. § 1012(b) (the “Act”), bars several named Plaintiffs’ claims in Alabama, California, Florida and Louisiana. Section 1012(b) provides that “[n]o Act of Congress' shall be construed to invalidate, impair, or supersede any law enacted by any State for the purpose of regulating the business of insurance ... unless such Act specifically relates to the business of insurance.” 15 U.S.C. § 1012(b). The Act was enacted for the express purpose of rendering the antitrust laws inapplicable to insurers who are regulated by the several states, and in particular to allow insurers to form trade associations and share underwriting data.
Group Life & Health Ins. Co. v. Royal Drug Co.,
The Eleventh Circuit has directed a three part inquiry for the preemption analysis. First, was the relevant state law enacted “for the purpose of regulating the business of insurance?” Second, is the matter at issue (provider agreements) properly considered the “business of insurance?” Third, does the federal act (the Act) “specifically relate to the business of insurance?” Id. at 1240, 1245-46.
In its previous decisions, the Court has not specifically dealt with the issue of whether the Defendants’ challenged activities vis-à-vis the Providers fall under the “business of insurance.” The meaning of insurance in this context is a question of federal law.
Blackfeet,
In
Group Life & Health Insurance Co. v. Royal Drug Co.,
It is unclear whether the provider agreements at issue here constitute the “business of insurance” within the meaning of the Act.
Blackfeet National Bank v. Nelson,
Moreover, the SAC alleges practices which clearly do not deal with the transfer or spreading of a policy-holder’s risk. The provider contracts are simply business contracts that allow Defendants to carry out their obligations to their insureds. While some type of provider agreement may be necessary for the Defendants’ plans to exist, “it does not follow that because an agreement is necessary to provide insurance, it is also the ‘business of insurance.’ ”
Group Life & Health Insurance Co. v. Royal Drug Co.,
Defendants counter that the Court’s previous decisions in the subscriber track provide support for their contentions that the claims are created by an underlying insurance policy.
See
SAC ¶ 75 (“These services are provided based upon the fundamental premise that, if the services are covered by Defendants and are medically necessary, the Plaintiffs and class members will be compensated in a timely manner... ”). In this case, however, the relationship between the provider and insurance company is an arrangement for the purchase of goods and services.
Roy
*1285
al Drug,
Defendants also encourage the Court to adopt a more expansive interpretation of the “business of insurance.” Citing
United States Dep’t of the Treasury v. Fabe,
Nothing in
Fabe,
however, suggests that the Act sweeps within its scope all laws that affect insurance companies. Indeed, the Supreme Court in
Fabe
supported the interpretation of the “business of insurance” as focusing on the relationship between the insurance company and the policyholder.
See Blackfeet National Bank v. Nelson,
7. ARBITRABLE PRIMARY RICO CLAIMS
Defendants argue that secondary RICO claims (Counts I and II) that derive from primary RICO claims, 18 U.S.C. § 1962(a) and (c) (Count III), ordered to arbitration or abandoned by Plaintiffs must be dismissed, 10 because Plaintiffs may not recover for secondary violations without first establishing primary RICO violations. The issue presented by Defendants is indeed a novel one. Yet Defendants are unable to cite controlling case law on point that convinces this court to override Plaintiffs’ prerogative in framing their claims.
Defendants first submit that Plaintiffs must validly assert a direct RICO claim in order to maintain secondary claims including conspiracy and aiding and abetting. This is not possible, according to Defendants, given the Plaintiffs’ abandonment of arbitrable direct RICO claims. It is well established that if a plaintiff fails to state a claim of a primary RICO violation, then the plaintiffs civil conspiracy claims necessarily fails.
See, e.g., GE Invest. Private Placement Partners II v. Parker,
Civil conspiracy is not an independent cause of action; it is a liability spreading device based upon a viable underlying cause of action.
See United States Steel, LLC v. Tieco, Inc.,
Defendants’ attempt to piggyback on this line of reasoning is to no avail. Defendants do not cite to any controlling authority that squarely supports their theory.
11
In this case, as they must, Plaintiffs argue that, in the course of asserting their secondary RICO claims, they have pled and intend to prove that each Defendant committed primary RICO violations.
12
Nevertheless, Plaintiffs need not pursue a discrete claim,
ie.
seek judgment and damages, for the underlying violation that is the object of the conspiracy or the alleged aiding and abetting violation. Put another way, while it may be necessary for Plaintiffs to plead a violation of the direct RICO statute in order -to properly assert the secondary claims, it is not mandatory that they also seek relief for the underlying violation. Adoption of this principle
*1287
permits Plaintiffs to remain masters of their own complaint.
See Caterpillar, Inc. v. Williams,
Close inspection of the substantive principles contained in the secondary causes of action confirms this view. Under common law civil conspiracy law, Plaintiffs need not sue all co-conspirators.
Wilson P. Abraham Constr. Corp. v. Texas Indus., Inc.,
B. ERISA PREEMPTION
Defendants renew their reliance on the preemption provision of the Employee Retirement Income Security Act of 1974 (“ERISA”) in seeking to dismiss certain claims in the SAC. Defendants contend that the SAC’s new set of allegations reveal that Plaintiffs’ claims are not only substantially preempted by ERISA’s two species of preemption, Section 502 and Section 514, but also to the extent that Plaintiffs seek to pursue their non-participating provider claims through ERISA, those claims must be dismissed for failure to exhaust administrative remedies.
ERISA applies to any employee benefit plan, provided that it is established or maintained by an employer or employee organization engaged in commerce or in any industry or activity affecting commerce. 29 U.S.C. § 1003(a). The statute explicitly includes plans provided through the purchase of insurance. 29 U.S.C. § 1002(1). Section 514(a), the specific preemption provision, states that this federal statute preempts all state laws insofar as they “relate to” any employee benefit plan. 29 U.S.C. § 1144(a) (1988). A state law “relates to” a covered employee benefit plan “if it has a connection with or reference to such a plan.”
District of Columbia v. Greater Washington Bd. of Trade,
The Eleventh Circuit has recognized two types of ERISA preemption; complete preemption and defensive, or conflict, preemption. ERISA’s specific preemption provision under Section 514
*1288
triggers conflict preemption, which applies where the court has subject matter jurisdiction over the case but the plaintiffs claim is subject to ERISA’s express preemption provision, 29 U.S.C. § 1144(a) (i.e. if any of plaintiffs’ claims “relate to any employment benefit plan”). This “defensive” preemption does not provide independent federal subject matter jurisdiction. Rather, it provides an affirmative defense to state law claims.
See Butero v. Royal Maccabees Life Ins. Co.,
This Court has had occasion to consider the issue of ERISA preemption in a prior iteration of Plaintiffs’ complaint and previously found that Plaintiff providers in the
Shane
consolidated provider-track action could “bring their breach of contract claims free of the shadow of ERISA preemption.”
In re Managed Care Litigation,
On the other hand, there is another type of preemption provided by Section 502(a) of ERISA’s statutory scheme, which Defendants urge the Court to apply to a substantial number of claims in the most recent complaint. This complete preemption, or “super-preemption,” arises from Congress’s creation of a comprehensive remedial scheme in 29 U.S.C. § 1132 for loss or denial of employee benefits.
See Butero v. Royal Maccabees Life Insurance Co.,
1. SECTION 502 PREEMPTION
a. Express Contract Claims (Count V)
Defendants assert that the Provider Plaintiffs’ breach of contract claims are subject to complete preemption under Section 502(a) because they are attempting to assert an alternative basis, outside of ERISA, for enforcing plan obligations to pay for covered, medically necessary services. Confronted with this Court’s clear precedent of holding that ERISA preemption is inapplicable to the Plaintiffs’ state law contract claims, Defendants claim that regardless of whether there was ordinary preemption under Section 514(a), ERISA nonetheless preempts all the state law contract claims, whether or not they relate to an ERISA plan, because Plaintiffs seek to impose an alternative enforcement mechanism for benefits that are created by ERISA plans. Specifically, Defendants argue that under
Rush Prudential v. Moran,
At the outset, the Court notes that Section 502(a)(1)(B) provides that an ERISA plan “participant or beneficiary” may bring a civil action “to recover benefits due to him under the terms of his plan, or to clarify his rights to future benefits under the terms of the plan.” 29 U.S.C. § 1132(a)(1)(B). Defendants argue that Plaintiffs’ claims are substantially preempted by Section 502(a) of ERISA because Plaintiffs now concede that Defendants are liable under their state-law theories only for “medically necessary” services that are “covered” for Defendants’ insureds. SAC ¶ 76. Therefore, Defendants argue that the great bulk of plaintiffs’ state-law claims, if permitted to go forward, would plainly constitute the type of alternative enforcement mechanisms that are squarely foreclosed by ERISA’s “carefully integrated” civil enforcement provisions.
See Pilot Life Ins. Co. v. De
deaux,
Defendants, however, misconstrue the scope of preemption under Section 502(a). While Defendants read Section 502(a) to encompass a much broader area of preemption, by its very terms, Section 502(a) provides for preemption only in suits for benefits among ERISA entities.
See id. at
54,
Generally, health care providers such as the Provider Plaintiffs lack independent standing under ERISA’s statutory scheme because they are not ordinarily considered “beneficiaries” or “participants.”
See Cagle v. Bruner,
Here, there can be no doubt that Plaintiffs with express fee-for-service contracts are not ERISA beneficiaries because they are suing under the terms of their independent contracts with Defendants. Since Section 502(a) is meant to remedy the denial of ERISA benefits, it logically follows that doctors, who are not among the persons or entities entitled to bring an ERISA claim under Section 502(a), cannot be affected by this species of ERISA’s preemptive force if they are merely filing suit for payment under the terms of their independent contracts. Accordingly, the Court finds that the Plaintiffs’ breach of contract claims continue to remain outside of the shadow of ERISA preemption.
b. Constructive Contract Claims(NonParticipating Providers)(Count VI)
The issue of the non-participating providers gives the Court some pause. By definition, the non-participating providers lack an express contractual relationship with Defendants. Nevertheless, on the face of the SAC, there are at least two distinct sub-classes of non-participating providers lacking a contractual relationship: those with assignments from participants or beneficiaries (“Provider-Assignees”) and those without them.
*1291 Defendants contend that the Provider-Assignees’ constructive contract claims are subject to complete preemption under Section 502(a) of ERISA because whatever their characterization, they are in reality claims for ERISA plan benefits made by doctors rendered outside of a contractual relationship with the insurer. Defendants claim these claims can only be brought on the basis of an assignment of the patient’s rights.
Section 502(a)(1)(B) provides that an ERISA plan “participant or beneficiary” may bring a civil action “to recover benefits due to him under the terms of his plan, or to clarify his rights to future benefits under the terms of the plan.” 29 U.S.C. § 1132(a)(1)(B). As discussed
supra,
ERISA complete preemption exists only when the “plaintiff is seeking relief that is available under 29 U.S.C. § 1132(a).”
Butero v. Royal Maccabees Life Ins. Co.,
In the instant case, the first and third elements are undisputedly met. Therefore to determine whether the Provider-Assignees are in reality seeking relief under Section 502(a), the Court must decide first, whether they are indeed participants or beneficiaries in order to have standing under ERISA, and second, whether they are attempting to recover benefits due to them under the terms of an ERISA plan.
Since the Provider-Assignees possess assignments from plan beneficiaries, they clearly possess derivative standing under controlling Eleventh Circuit precedent. In
Cagle v. Bruner,
As to the fourth element of complete preemption, Defendants maintain that it is beyond dispute that Provider-Assignees are attempting to collect unpaid benefits due under a plan because there is no independent contract that entitles them to payment for services. The Court agrees. In possessing an assignment, the provider-assignee's hold the right to collect such unpaid benefits. Virtually every court to consider this question has held that reimbursement and related claims involving services provided to' ERISA beneficiaries on a non-participating basis may be pursued only through ERISA’s civil enforcement provision.
See, e.g., Hermann Hosp. v. MEBA Med. & Benefits Plan,
The Court consequently finds that Provider-Assignees possess derivative standing and thus all of their claims — including those for constructive contract — are recast under the doctrine of complete preemption as ERISA claims for benefits under Section 502(a). Accordingly, this statute constitutes them exclusive avenue for enforcing claims for ERISA benefits. 29 U.S.C. § 1132(a)(1)(B).
17
A caveat is in order, however. This finding is contingent upon production of valid subscriber assignments from the Provider-Assignee subclass. To the extent that Defendants are not able to produce proof of a valid assignment from patients, the derivative standing doctrine does not apply to those providers.
Hobbs v. Blue Cross Blue Shield of Ala.,
2. SECTION 514 PREEMPTION
a. Express Contract and Constructive Contract Claims
Although this Court previously held that Plaintiffs might pursue certain breach of contract claims notwithstanding ERISA, Defendants maintain that the new allegations in the SAC reveal that the issue of ERISA Section 514(a) preemption must be revisited. Under the new allegations, Defendants claim that Plaintiffs have conceded in the SAC that doctors are to be paid for “covered, medically necessary services.” Defendants assert that this Court’s previous opinion stressed that Plaintiffs’ claims — as they were then pleaded — “might sustain a breach of-contract claim without a need for reference to the interpretation of ERISA plans.”
In Re Managed Care Litig.,
Plaintiffs contend that the Court’s earlier decision, discussed
supra,
still controls the outcome here and Defendants’s arguments are largely semantic in nature. The Court agrees and sees no reason to depart from its previous ruling. The Provider Plaintiffs’ state law claims are still for payment for services rendered, not for ERISA benefits. Moreover, Plaintiffs contend, correctly, that Defendants’ attempt at linking the issue of plan interpretation to their allegations that the services are “covered” does not trigger ERISA preemption because the Defendants have already determined that these claims are
*1293
covered.
See
SAC ¶ 205. The dispute in this case centers on whether Defendants have the right to deny full and complete payment to doctors based upon facts that do not relate to issues of coverage, for example, bundling and downcoding.
See
SAC ¶ 84. Therefore, what is at issue is the amount of payment, not whether a right to payment exists.
See Blue Cross of California v. Anesthesia Care Assoc. Medical Group, Inc.,
i. Non-Participating, Non-Assignee Providers
As a subsidiary issue, Defendants contend that the constructive contract claims brought by non-participating Providers who lack assignments (“Non-Par Providers”) must be preempted under Section 514(a) because they are essentially promises to pay benefits embodied in the patients’ ERISA plans. Defendants argue that these claims necessarily “relate to” employee benefit plans.
See New York State Conference of Blue Cross & Blue Shield Plans v. Travelers Ins. Co.,
Plaintiffs assert that the preemption analysis for the constructive contract claims is no different than an express contract claim, since these continue to be claims by health care providers against plan insurers brought by independent third parties that do not require plan interpretation and promote the goals of ERISA.
See In re Managed Care Litig.,
The Non-Par Providers are independent third parties whose claims have accrued based on their status as a non-contracted health provider and not accrued upon an entitlement to benefits arising through an assignment of such benefits by patients treated by Plaintiff. Further, their constructive contract and unjust enrichment claims are not based upon the “relationship between the insured and insurer” but upon Defendants’ solicitation and knowing acceptance of the Providers’ services. SAC ¶¶ 210-214. Moreover, Defendants are alleged to engage in denying, diminishing, and delaying payments for these services. SAC ¶ 212.
While it is possible that some of the Non-Par Providers may obtain assignments, that fact alone does not force them to pursue the ERISA claims route instead of bringing claims against Defendants in their own independent right. In
Lordmann v. Equicor,
*1294 Given the similarity of the allegations to ones previously considered, the Court applies its prior ruling declining to extend the preemptive reach of ERISA to the claims of third-party-providers to the current subclass of non-participating providers who do not hold assignments. The claims made by these providers are not issues relating to the relationship between a beneficiary patient and the plan administrator; rather, they give rise to a separate relationship between the provider and plan administrator. Therefore, these claims fit logically within the framework set out by this Court’s previous decision.
b. Prompt Pay Claims (Count VII)
Defendants contend that all the “prompt pay claims based upon statutory rights of action are preempted by ERISA.” They assert that courts which have analyzed either the prompt pay statutes on which Plaintiffs rely or substantially similar statutes have concluded uniformly that claims under these provisions “relate to” ERISA plans and therefore are preempted under both Section 502(a) and Section 514(a),
See, e.g. Cramer v. Association Life Ins. Co.,
The Court finds that in line with its prior analysis the Providers are bringing their prompt pay claims in their provider capacities, rather than as assignees of plan benefits, the prompt pay claims are not preempted by ERISA § 514. Moreover, to the extent that prompt pay claims must be brought on the basis of patient assignments, they are brought under Section 502(a) of ERISA. SAC ¶¶ 221, 222.
c. Unfair Trade Practice Claims (Counts VIII and X)
The Provider Plaintiffs assert that their unfair trade practice claims are not preempted by ERISA because there are brought by health care providers against insurers in their own right rather than as assignees. Defendants contend that these type of claims are precisely the sort of state law claims which ERISA preempts.
See Anderson v. Humana, Inc.,
3. EXHAUSTION OF REMEDIES
Defendants argue that to the extent that Plaintiffs seek to pursue their Non-Participating Provider claims through the exclusive ERISA remedy, these claims must be dismissed for failure to exhaust administrative remedies. Therefore, Plaintiffs’ claims regarding nonparticipating providers who bring ERISA claims must be dismissed with leave to refile after exhaustion of administrative remedies.
*1295
It is well-established that plaintiffs must normally exhaust available administrative remedies under their ERISA-governed plans before they bring suit in federal court.
Springer v. Wal-Mart Assocs.’ Group Health Plan,
This Court must “apply the exhaustion requirement strictly” and “recognize narrow exceptions only based on exceptional circumstances.”
Perrino,
Second, Plaintiffs maintain that administrative remedies are inadequate because this is not a case involving claims by plan participants focused on their own care; rather, these claims are asserted by “busy doctors who are being nickelled (sic) and dimed to death on requests for payment that, on an individual basis, are just not worth pursuing.” Pl.’s Opp’n Br. at 45. Plaintiffs provide no basis in fact, however, for their allegation that the administrative remedies are inadequate because they are neither practical nor effective. Plaintiffs “do not plead the nonexistence of administrative review for a denial of benefits.”
In re Managed Care Litig.,
Finally, Plaintiffs claim that any meaningful or timely access to administrative review is alleged to have been blocked by “misleading coded explanations and by refusals] to disclose claims processing techniques.” SAC ¶¶ 98, 99. Again, Plaintiffs fail to specify any attempts to conduct a good faith inquiry into the applicability of these administrative proceedings.
In re Managed Care Litig.,
Accordingly, because Plaintiffs have failed to sufficiently plead an exception to the exhaustion requirement, the ERISA claims brought by Providers are DISMISSED with leave to re-file.
C. CHOICE OF LAW
Defendants assert that Plaintiffs are limited to invoking only the regulatory statutes of those States in which they reside or treat patients, on the basis of their contracts with the local subsidiaries of defendants with whom plaintiffs have dealt. In short, Defendants argue that Plaintiffs’ state law claims under out-of-state statutory schemes must be dismissed.
The Commerce Clause and Due Process Clauses limit the ability of each state to apply its own laws and policies to conduct occurring beyond its borders.
BMW of N. Am. v. Gore,
The Main Track Plaintiffs practice medicine — -and are presumably licensed to practice medicine — in only seven states: Alabama, California, Colorado, Florida, Georgia, Kentucky and Texas. SAC ¶¶ 11-29. The SAC is a composite of actions originally commenced in multiple jurisdictions including Kentucky
(Shane),
California
(Klay
and CMA), Alabama (Mangieri) and Georgia (Harrison). For each Plaintiff the controlling law is that of the state where the Plaintiff resides (or practices medicine) and where his dealings with Defendants’ corporate subsidiaries occurred and his alleged injuries were sustained.
Henderson v. Superior Ct.,
The Court finds that the Connecticut Unfair Trade Practices Act, the New Jersey Consumer Fraud Act and the various prompt pay statutes of applicable states can have no application to Plaintiffs that neither reside, treat patients nor have engaged in a relevant .transaction in that particular State. Nevertheless, while no named Plaintiff resides or practices medicine in either Connecticut or New Jersey, members of the class presumably do reside in all fifty states. The Court will revisit this issue further along the proceedings, as this ruling will become more applicable at the summary judgment stage when Plaintiffs’ claims will be fully fleshed out.
D. STATE COMMON LAW CLAIMS
1. QUASI-CONTRACT CLAIMS (COUNT VI)
Defendants contend that Plaintiffs may not simultaneously pursue contract and quasi-contract claims because under any applicable state law, a contracting party cannot assert quasi-contract claims.
19
Therefore, they argue Count VI fails to state a claim for relief because claims for unjust enrichment and breach of constructive contract will not lie in the face of an express contract. Further, states in which the Providers reside uniformly bar suits that maintain quasi-contractual theories, such as quantum meruit, in the face of an express contract between the parties.
See, e.g. Harris v. Schickedanz Bros.-Riviera Ltd.,
Plaintiffs do not dispute the principle, but maintain that it does not apply to their Count VI claims. (Plaintiffs' concede that a Count VI claim cannot be asserted against Anthem. Pl. Opp. at 51 n. 18). Plaintiffs maintain that while all of the Count VI Plaintiffs, with the exception of Dr. Mangieri, have contracts with one or more of the Defendants, they also have treated the insureds of one or more of the Defendants outside of any contractual relationship. SAC ¶¶ 11-18, 16, 18, 22, 27-29. Therefore, Plaintiffs are not asserting quasi-contractual theories for treatments of insured under express contracts. Given the complexity of relationships alleged in the SAC, this issue is essentially one of characterization. As a matter of law, however, the Court finds that Plaintiffs may not assert constructive contract claims against a Defendant where the Provider is also bringing a claim for breach of contract against the same Defendant.
In its separate brief, Coventry also asserts that neither of the quasi-contractual claims are stated because the benefit received when Providers, such as Dr. Backer, treated patients, they were obligated to provide treatment, and thus, these are not the kind of direct benefits required to support a claim. It is merely incidental or indirect. Plaintiffs contend, correctly, however, that satisfaction of an obligation will support a claim for unjust enrichment.
Restatement of the Law of Restitution, § I; Wolf v. National Council of Young Israel,
E. STATE STATUTORY CLAIMS 20
1. PROMPT PAY: PRIVATE RIGHT OF ACTION
Count VII asserts claims based upon the prompt pay statutes of 32 states. As a preliminary matter. Defendants concede that five states give those classes of individuals referenced in the particular statutes an express right of action (Alabama, Mississippi, Texas, Nevada and Virginia) 21 and that in four others a private right of action for certain classes exists by implication (Oklahoma, Maine, Massachusetts, New Hampshire). These unilateral concessions leaves 22 states in dispute where Plaintiffs claim that a private right of action exists.
Whether a private action can be implied from a statute depends upon legislative intent.
Transamerica Mortgage Advisors, Inc. v. Lewis,
Plaintiffs assert that each legislature must have implicitly intended to allow private rights of action in enacting prompt pay statutes. Pointing to the text of the prompt pay statutes, the Plaintiffs contend that while each statute was enacted to address payment disputes by insurer, they contain no specific mechanism — either by those effected or by insurance commissioners — to recover unpaid interest, which is the express remedy provided for violations. Plaintiffs argue that no rational legislature would expect state insurance commissioners to have the time, resources or inclination to take legal action to recover interest for individual providers and that state insurance commissioners are supposed to correct more widespread abuses. Plaintiffs also note that no state prompt pay statute expressly denies a private right of action and that no state provides an exclusive administrative enforcement scheme that applies only to claims under the prompt pay statutes.
Nevertheless, the Court cannot countenance flimsy evidence of intent premised on what is at best, seemingly logical assumptions. The Plaintiffs have conceded that when identifying private rights of action, legislative intent remains the touchstone. It is Plaintiffs’ burden to demonstrate that a private right of action is consistent with applicable legislative intent. Plaintiffs provide very little material evidence of legislative intent, but instead opine that the various state legislatures “must have intended” a dual enforcement regime. This appeals to one’s common sense, but it is more difficult to square with the text and structure of the actual provisions. Indeed, the remaining prompt pay statutes all have strong public enforcement mechanisms, including the right to impose fines, conduct hearings, and revoke certificates to sell insurance. Often, the legislature’s decision to- erect an express “array of administrative remedies” creates a “strong inference” that a legislature, state or federal, “did not intend to create a private right action.”
Ayres v. General Motors Corp.,
2. CAL. BUS. & PROFESSIONS CODE § 17200 (COUNT VIII)
The California Business and Professions Code Section 17200 defines unfair competition “as any unlawful, unfair, or fraudulent business act or practice.” Cal. Bus. & Prof.Code § 17200. Under Section 17200 (“UCL”), courts may not declare a practice “unlawful” or '“unfair” where the state has specifically declared the practice to be lawful.
See Cel-Tech Communications, Inc. v. Los Angeles Cellular Telephone Co.,
a. Interference with the Department of Managed Health Care’s Statutory Authority
Defendants first contend that Plaintiffs impermissibly seek to convert Section 17200 into an alternative regulatory framework for managed care. Defendants claim that as. these claims impermissibly intrude upon the regulatory functions of the California Department of Managed Health Care, the Section 17200 claims must be precluded.
Pursuant to the Knox-Keene Health Care Service Plan Act of 1975, a comprehensive scheme regulating almost every aspect of “health care service plans” in California has been erected.
See
Cal. Health & Safety Code §§ 1340, 1399.76;
see also id.
§ 1345(f) (defining the term “health care service plan” to include HMOs). Through the Knox-Keene Act, the California legislature intended to “occupy the field” and “to vest all authority to regulate and supervise health plans in the Department [of Managed Care].”
Van de Kamp v. Gumbiner,
At first blush, Defendants’ position seems compelling. The Plaintiffs’ claims are premised on Defendants’ alleged systematic practices that deny and delay their rightful payments. However, Defendants’ creative contention is not fully supported by relevant statutory or case law. Essentially, the Defendants ask this court, sitting in equity, to abstain from adjudicating the instant case.
See Desert Healthcare,
However, while the subject matter of this action may pique an academic interest of the Department of Managed Health Care, there is no evidence that this Court will engage in “broad-based complex economic regulation” if it allows the claims to proceed. In the case at bar, the Plaintiffs are not attempting to impose broad-based policy objectives on Defendants; rather they are asking the Court to enjoin current violations of their contractual duties to Plaintiffs and of relevant statutes. The remedies sought by Plaintiffs would be embedded in contractual relationships and representations made to Providers; uniform determinations of economic policy are therefore precluded by the very nature of the relief requested by Plaintiffs themselves.
Defendants’ reliance on
Samura v. Kaiser Foundation Health Plan,
Second, Defendants argue that this Court cannot entertain Section 17200 claims premised on practices alleged in the SAC because they have been permitted by the state regulatory structure and would countermand the state regulators’ exercise of the powers of oversight. Courts cannot declare a practice “unlawful” or “unfair” under Section 17200 where the state has itself specifically declared the practice to be lawful. Rather, “[i]f the Legislature has permitted certain conduct or considered a situation and concluded no action should lie, courts may not override that determination.”
Cel-Tech Communications, Inc. v. Los Angeles Cellular Tele
*1302
phone Co.,
In contending that the “great bulk of practices that plaintiffs seek to challenge are affirmatively permitted by th[e] state regulatory structure” the Defendants neglect to provide any specific evidence of statutory authority for this sweeping statement. Indeed, the Court is doubtful that the automated practices alleged by Plaintiffs, such as downcoding and bundling, are accepted by the appropriate regulatory authorities. Moreover, Defendants’ specific citations to California code provisions regarding setting actuarial rates for medical underwriting decisions and licensure are not applicable to the practices alleged by Plaintiff. See, e.g., Cal. Health & Safety Code §§ 1349, 1351(d), 1389.2.
Finally, this Court is not compelled to automatically divest itself of Section 17200 claims in all cases involving the conduct of health care plans. Notably, in an analogous case involving allegations of unfair payment patterns, another appellate court declined to defer to the Department of Managed Health Care.
See Coast Plaza Doctors Hosp. v. UHP Healthcare,
b. Remedies Under Section 17200
Defendants assert that Section 17200 does not authorize claims for money damages, and that such claims must be dismissed even if labeled as “restitution.”
See, e.g., Bank of the West v. Superior Court,
The restitution remedy, however, is one expressly available under the UCL to ensure that victims are returned to the status quo and to also to ensure that Defendants do not gains as a result of unlawful or deceptive conduct. Recent cases hold that Section 17200 authorizes restitution and disgorgement of profits resulting from unfair competition.
See Cortez v. Purolator Air Filtration Products Co.,
3. NEW JERSEY CONSUMER FRAUD ACT (COUNT X)
Defendants argue that Plaintiffs claims under the New Jersey Consumer Fraud Act, N.J.S. § 56:8-1 et seq. (the “New Jersey Act”) are preempted by a detailed state administrative framework governing claims payments and are, in any event, deficient under the terms of the statute itself. As a threshold issue, it appears that this Count only applies to Defendant Prudential.
The New Jersey Consumer Fraud Act provides in relevant part, that:
“The act, use or employment by any person of any unconscionable commercial practice, deception, fraud, false pretense, false promise, misrepresentation, or the knowing concealment, suppression or omission, in connection with the sale or advertisement of any merchandise ... or with the subsequent performance of such person as aforesaid, whether or not any person has in fact been mislead, deceived or damaged thereby, is declared to be an unlawful practice.” N.J.S. § 56:8-2.
Additionally, “[a]ny person who suffers any ascertainable loss of moneys or property ... as a result of the use or employment by another person of any method, act or practice declared unlawful by this act” may bring a claim under the statute. Id. § 56:8-19.
Plaintiffs allege that by failing to provide adequate reimbursement through implementation of the deceptive practices described in the SAC, Prudential has, in connection with the sale of health insurance, compromised the ability of physicians to provide continuity of care and the level of care by sound medical judgment by imposing financial hardships and undue burdens on physicians. SAC ¶¶ 121, 255. As such, Plaintiffs allege that the application of the New Jersey Act to the SAC will serve the interests of consumers.
The Court declines to accept Plaintiffs’s expansive interpretation, as it runs afoul of decisions that have established the outer boundaries of the statute. Plaintiffs offer no compelling precedent that mandates that this Court accept the applicability of the statute to the factual scenario presented by the SAC. It is true, as Plaintiffs point out, that “[t]he language of the [New Jersey Act] evinces a clear legislative intent that its provisions be applied broadly in order to accomplish its remedial purpose, namely to root out consumer fraud,”
Lemelledo v. Beneficial Mgmt. Corp.,
First, Plaintiffs are not “consumers” under the Act. The Act was enacted in response to sharp practices and dealings in the marketing of merchandise and real estate.
Daaleman v. Elizabethtown Gas. Co.,
Here, the Provider Plaintiffs cannot be considered “consumers” by any interpretive stretch of the New Jersey Act. Plaintiffs receive a “stream of income” for their services and they do not use or consume any economic goods or services offered for sale by Defendants. Nor is the provider relationship available to the public. In the SAC, Plaintiffs merely offered a conclusory allegation that they are “consumers” under the New Jersey Act. SAC ¶248. In response to Defendants’ briefing, however, Plaintiffs now argue that there is no requirement that the Plaintiff himself be a consumer, so long as the practices complained of are carried’ out in connection with the sale or advertising of any merchandise, including services offered directly or indirectly to the public. For instance, the definition of “consumer” explicitly includes associations. N.J.S. § 56:8—1(d). Nevertheless, while Plaintiffs attempt to wrap themselves in the laudatory goals of the New Jersey act, the fact remains that a desire to help consumers is insufficient as a matter of law because “[t]he cause of action is created only as to bona fide consumers of the product.”
See, e.g., Grauer v. Norman Chevrolet Geo,
Second, Plaintiffs’ provision of medical services to Defendants’ insureds does not constitute the “sale” of “merchandise” under the New Jersey Act. The New Jersey Act generally does not cover disputes as to amounts owed to professionals in connection with the rendition of professional services.
Hampton Hosp. v. Bresan,
F. MEDICAL ASSOCIATION STANDING
This court is a court of limited jurisdiction with the power to review only concrete controversies brought by plaintiffs with standing to raise the issue they seek to have the court decide.
Warth v. Seldin,
1. INDIVIDUAL STANDING: INJURY-IN-FACT
In order to allege a direct injury to the organization, at an “irreducible constitutional minimum,” the Associational Plaintiffs must allege (1) a cognizable “injury in fact” which is an invasion of a legally protected interest that is both “concrete and particularized” and “actual or imminent, not ‘conjectural’ or ‘hypothetical;’ ” (2) a “causal connection between the injury and the conduct complained of’ that is fairly traceable to the challenged action; and (3) a likelihood, as opposed to a mere speculative possibility, that the injury will be “redressed by a favorable decision.”
Lujan v. Defenders of Wildlife,
The Associational Plaintiffs allege, among other things, that the systemic practices being challenged in this lawsuit have caused them to lose membership and to expend their own time and resources fighting Defendants’ tactics. SAC ¶¶ 30-44. Defendants claim that the Associa
*1306
tional Plaintiffs lack any direct organizational injury because there are no “discrete programmatic concerns,” and further the Complaint lacks an objectively quantifiable, concrete set of costs, other than the cost of this litigation. For example, exploring Plaintiffs’ allegations that delayed and denied payments to individual physicians ultimately depress aggregate membership levels' would require a speculative tracing of economic ripple-effects through the associations’ membership rolls.
See National Taxpayers
Union,
Inc. v. United States,
Defendants, however, wade into territory that need not be entered at this stage of the proceeding.
See Havens Realty Corp. v. Coleman,
Contrary to the cases cited by Defendants where associations were found not to have standing, the Associational Plaintiffs in this case. are distinguishable because they are narrowly focused on the medical field and provide more services than just general advocacy and policy work.
See National Taxpayers Union, Inc. v. United States,
*1307 2. REPRESENTATIVE STANDING
Even assuming that the association has not suffered an injury-in-fact, Plaintiffs contend that an association may have standing “solely as a representation of its members.”
Warth v. Seldin,
Both parties concede that the first element is satisfied. Although the main-track Defendants effectively concede the existence of the second element, Defendant Coventry argues that the Medical Association of Georgia and Louisiana State Medical Society (“LSMS”) fail to meet the second prerequisite because the interests they seek to assert in this case are not “germane” to their organizational purposes because the “stated mission” of LSMS — “to provide leadership for the advancement of the health of the people of Louisiana”— cannot be construed to include litigating its physicians members’ contracts, nor do the Plaintiffs aver that the society’s 6,800 members joined LSMS with this purpose in mind.
Id.
at ¶ 42.
See, e.g., Brotherhood of Teamsters v. Brock,
The parties primarily dispute the existence of the third
Hunt
requirement. Defendants argue that extensive member participation will be necessary to both prove the Associational Plaintiffs’ claims and recover damages on their behalf. Defendants claim this case is based upon allegations of fraud and “failing to disclose internal policies” that result in the Defendants’ non-compliance with their contractual and non-contractual obligations. As such, resolution of this issue would require an investigation into the particular contracts signed by particular physicians not to mention whether arbitration agreements are included. Defendants also contend that the monetary relief requested for violations of the RICO statute would involve individualized investigations because associations have been barred from seeking monetary relief on behalf of their members.
See United Union of Roofers, Waterproofers, and Allied Trades No. 40 v. Insurance Corp. of Am.,
In certifying the Provider class, this Court has already held that Plaintiffs’ allegations can be resolved by the means of common proof and that individual issues do not predominate.
See In re Managed Care Litig.,
Second, the Associational Plaintiffs are not seeking damages for their members, only injunctive and declaratory relief.
See
SAC ¶ 30. It is well-established that an association may seek equitable relief on behalf of its members without running afoul of the third prong of the
Hunt
test.
See, e.g., Hunt v. Washington State Apple Advert. Comm.,
Defendant Coventry advances several additional arguments that are similarly without merit. First Coventry argues that associations cannot obtain equitable relief under RICO. This argument has been discussed
supra.
Second, Coventry asserts that the Associational Plaintiffs’ members have an adequate remedy at law for the remaining claims in the complaint. However, Plaintiffs correctly argue that whether money damages will prove to be an adequate remedy at law cannot be determined at this state of the proceeding. Finally, Coventry contends that the absence of any individual Plaintiffs from Louisiana precludes the Louisiana State Medical Society from obtaining relief. There is no requirement, however, for an association suing on behalf of its members be joined by any of them in order to bring a valid claim.
See, e.g., Doe v. Stincer,
G. PARENT-SUBSIDIARY RESPONSIBILITY
In the SAC, Plaintiffs assert two theories to hold the HMO holding compa *1309 nies liable for their subsidiaries’ acts: (a) an alter ego theory to “pierce the corporate veil” and (b) vicarious liability based on actual agency principles. Plaintiffs have sued the parent corporations rather than entities licensed in each State to administer and market bealth-coverage products, reasoning that “all substantive practices are established, implemented, monitored and ratified by” those parent companies and that “[l]ocal subsidiaries or affiliates of the named defendants do not function as independent corporate entities but rather have an alter ego relationship with the named defendants and function as agents under the Defendants’ direction and control.” SAC ¶ 45. Among the tools used by the parent companies to defraud Plaintiffs include the alleged auto-adjudication scheme.
Defendants contend that Plaintiffs allegations of individual liability of Defendant parent companies are insufficient to state a cause of action under settled principles of corporate liability. They claim that it is a “general principles of corporate law deeply ingrained in our economic and legal systems that a parent corporation ... is not liable for the 'acts of its subsidiaries.”
United States v. Bestfoods,
The Court finds that Plaintiffs sufficiently alleged direct liability of the parent corporations. First, although Plaintiffs have offered a menu featuring three theories of parent-subsidiary liability, they are primarily alleging that Defendants are subject to direct, rather than derivative or vicarious liability.
See
SAC ¶ 45 (“all of the substantive practices, policies, and procedures of the Defendants’ health plans are established, implemented, monitored, and ratified by the Defendants
themselves
”)(emphasis added). The Supreme Court has noted that in cases where the “alleged wrong can seemingly be traced to the parent through the conduit of its own personnel and management” and “the parent is directly a participant in the wrong .complained of’ will, in such “instances, [be] directly liable for its own actions.”
United States v. Bestfoods,
*1310 IV. CONCLUSION
THE COURT has considered the motion, the responses and the pertinent portions of the record, and being otherwise fully advised in the premises and in open court, it is
ADJUDGED that the joint motion to dismiss (D.E. No. 1662) is GRANTED in part and DENIED in part, with prejudice, consistent with the above opinion. Accordingly, Counts IX and X are dismissed in their entirety.
Notes
. The Main Track Provider Plaintiffs include: Charles B. Shane, M.D., Jeffrey Book, D.O., Michael Burgess, M.D., Edward L. Davis, D.O., Lance R. Goodman, M.D., R. Robert Harrison, M.D., Glenn L. Kelly, M.D., Leonard J. Klay, M.D., Eugene Mangieri, M.D., Kevin Molk, M.D., Martin Moran, M.D., Manuel Porth, M.D., Thomas Backer, M.D., David Boxstein, M.D., Susan Hansen, M.D., Andres Taleisnik, M.D., Julio Taleisnik, M.D., Roger Wilson, M.D., Navid Ghalambor, M.D., the California Medical Association, the Texas Medical Association, the Medical Association of Georgia, the Florida Medical Association, the Louisiana State Medical Association and the Denton County Medical Association (collectively referred to as "Plaintiffs" or "Providers”).
. The Main Track Defendants include: Uni-tedHealthcare, Inc. and UnitedHealth Group Incorporated Pk/a United Healthcare Corporation ("United"); Health Net, Inc. pk/a Foundation Health Systems, Inc. ("Health Net”), WellPoint Health Networks, Inc. ("WellPoint”), The Prudential Insurance Company of America ("Prudential”), CIGNA Corporation (“CIGNA”), PacifiCare Health Systems, Inc. ("PacifiCare”), Humana, Inc. and Humana Health Plan, Inc. ("Humana”), Coventry Health Care, Inc. ("Coventry”), and Anthem, Inc. ("Anthem”) (collectively referred to herein as "Defendants” or "HMOs”).
. Count IX only applies to Aetna entities which have settled their claims. In accordance with the Final Approval Order and Judgment as to Aetna, Inc. and Aetna-U.S. Healthcare, entered October 24, 2003, this Count is therefore dismissed.
. Aetna and CIGNA have settled their claims.
. The motions to dismiss filed by Anthem and Coventry shall be dealt with in a separate order.
.
See, e.g., 800537 Ontario, Inc. v. Auto Enters., Inc.,
. Plaintiffs have withdrawn their claims of extortion under the Hobbs and Travel Acts. See Transcript of Motion to Dismiss Hearing, p. 15.
. The Court notes that the Supreme Court expressly declined to address “whether a private plaintiff in a civil RICO action is entitled to injunctive relief under 18 U.S.C. § 1964."
Scheidler v. NOW,
. Since the claims asserted by the Plaintiffs are outside the business of insurance, the Court does not reach Defendants' specific, arguments concerning the insurance laws of four states.
. See Order Granting in Part and Denying in Part Various Defendants’ Motions to Compel Arbitration at 31 (December 11, 2000).
. When confronted with the precise issue, the Supreme Court has declined to resolve whether a § 1962(d) RICO conspiracy claim must be predicated on an actionable violation of §§ 1962(a)-(c).
Beck,
. Defendants’ reliance on
McCowan v. Sears, Roebuck & Co.,
. Courts have stressed the opposite logie—
i.e.,
requiring Plaintiffs to prove injury from a racketeering act first prevents them from simply alleging a RICO conspiracy and therefore evading the other elements of a RICO action.
See Beck v. Prupis,
. Other courts have also followed this line of analysis. See, e.g.
Blue Cross of California v. Anesthesia Care Associates Medical Group, Inc.,
. In order for state law claims to be subject to ERISA complete preemption, four elements must be present: (1) a relevant ERISA "plan"; (2) the plaintiff must have standing to sue; (3) the defendant must be an ERISA entity; and (4) the complaint must seek relief akin to what is available under 29 U.S.C. § 1132(a).
Butero
v.
Royal Maccabees Life Ins. Co.,
. The civil enforcement provisions state in pertinent part:
A civil action may be brought -
(1)by a participant or beneficiary
(A)for the relief provided for in subsection (c) of this section, or
(B) 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;
(2) by the Secretary, or by a participant, beneficiary, or fiduciary for appropriate relief under section 1109 of this title;
(3) by a participant, beneficiary, or fiduciary (A) to enjoin any act or practice which violates any provision of this sub-chapter or the terms of the plan, or (B) to obtain other appropriate equitable relief (i) to redress such violations or (ii) to enforce any provisions of this subchapter or the terms of this plan.
29 U.S.C. § 1132(a).
. Defendants do not expressly argue that claims brought by non-participating providers who do not hold assignments are completely preempted by Section 502(a).
See
Def. Reply at 37 n. 10. Nevertheless, without an assignment, the non-participating provider lacks standing under Section 502(a) and complete preemption is inapplicable.
See Sanson v. General Motors Corporation,
. While similar allegations regarding the costs of pursuing individual claims far exceeding their actual value were countenanced in this Court's Order Certifying the Provider Track Class, the inquiry for ERISA exhaustion requirements is distinguishable from concerns that underpin Fed R. Civ. P. 23(a). ERISA's statutory scheme strongly favors plan review procedures in order to minimize the cost of dispute resolution and prevent premature judicial intervention in the decision making process.
Mason v. Continental Group, Inc.,
. Plaintiffs asserting simultaneous contractual and quasi-contractual claims include plaintiffs Backer, Book, Boxstein, Burgess, Davis, Harrison, Molk, Moran, Porth, Shane, A. Taleisnik, and J. Taleisnik.
. It is unnecessary to analyze the Connecticut Unfair Trade Practices Act, because the only applicable Defendant is AETNA. See Order Denying Without Prejudice Certain Motions Filed by Defendants AETNA, Inc. and AETNA-U.S. Healthcare, Inc., dated June 4, 2003.
. Ala.Code § 27-1-19; Miss.Code Ann. § 83-9-5; Tex. Ins.Code Ann. § 20A.18B; Nev.Rev.Stat. Ann.’ §§ 689A.410, 689B.255 and 696C.185; and Va.Code Ann. § 38.2-3407.15.
. These states are Arizona, Arkansas, California, Colorado, Connecticut, Georgia, Illinois, Kansas, Kentucky, Louisiana, Maryland, Michigan, Missouri, New Mexico, New Jersey, New York, Ohio, Tennessee, and Washington. Plaintiffs have dropped all claims for interest under Pennsylvania's statute based upon a lower court ruling that this statute does not provide a private right of action.
. California Medical Association, the Denton County Medical Society, the Medical Association of Georgia, the Texas Medical Association, the Florida Medical Association and the Louisiana Medical Society.
. The Associational Plaintiffs only join selected claims asserted by the Provider Plaintiffs claims for RICO conspiracy under 18 U.S.C. § 1962(d); aiding and abetting RICO violations; breach of contract; "quasi-contract”; violations of the Connecticut Unfair Trade Practices Act, and violations of the New Jersey Consumer Fraud Act. The California Medical Association also asserts claims under California's “Unfair Competition Law,” Cal. Bus. & Prof.Code § 17200.
. In finding that the Plaintiffs have successfully alleged direct liability, the Court does not reach the two other bases of parent-subsidiary liability: (a) the agency theory where the parent corporation uses a subsidiary to do its bidding; and (b) the instrumentality theory, under which the plaintiff must establish that the parent exercised a significant degree
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of control over the subsidiary’s decision-making.
See, e.g., Frank v. West,
