Court Dismisses Out-of-Network Provider Lawsuit Against Health Plans

The United States District Court for the District of New Jersey recently dismissed a lawsuit brought by out-of-network orthopedic providers against various insurers of (and claims administrators for) employer-sponsored health benefit plans. Michael E. Holzapfel, Esq. of Becker LLC represented the lead defendant. Plaintiffs disagreed with the quantum of out-of-network benefit payments allowed under the defendants’ respective plans. Plaintiffs filed suit arguing that, as out-of-network providers, the plans had an obligation to pay plaintiffs’ usual, customary and reasonable (UCR) rates.

Plaintiffs prosecuted their claims as alleged assignees of their patients’ plan benefits, or, alternatively, as alleged attorneys-in-fact for their patients under powers-of-attorney. Plaintiffs advanced their claims for additional reimbursement under both state law and the Employee Retirement Income Security Act of 1974 (ERISA).


Becker LLC raised several objections to the complaint as it pertained to the firm’s client. First, plaintiffs’ state law claims were preempted under ERISA, given that they related to and were premised upon the existence of employer-sponsored ERISA plans. Read more

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