DA SILVA PLASTIC AND RECONSTRUCTIVE SURGERY v. UNITEDHEALTHCARE INSURANCE COMPANY OF NEW YORK INC (2025)

DECISION & ORDER

In an action, inter alia, to recover damages for breach of contract and unjust enrichment, the plaintiff appeals from an order of the Supreme Court, Suffolk County (Carmen Victoria St. George, J.), dated August 18, 2022.  The order granted the defendant's motion pursuant to CPLR 3211(a) to dismiss the complaint.

ORDERED that the order is modified, on the law, by deleting the provision thereof granting that branch of the defendant's motion which was pursuant to CPLR 3211(a) to dismiss so much of the first cause of action as sought to recover compensatory damages for the claim related to the patient “EC,” and substituting therefor a provision denying that branch of the motion;  as so modified, the order is affirmed, with one bill of costs to the defendant.

The plaintiff provided healthcare services to patients who were members of the Empire Plan, a health insurance plan administered by the defendant, UnitedHealthcare Insurance Company of New York, Inc. (hereinafter UHC), and submitted 38 claims to UHC for those services.  Although the plaintiff chose to remain an out-of-network provider for the Empire Plan, the plaintiff alleged that, pursuant to the Empire Plan's agreements with its members, the subject 38 Empire Plan members or their beneficiaries received medically necessary treatment from the plaintiff and, in exchange, assigned their rights to receive reimbursement from UHC for those services to the plaintiff.

After UHC failed to pay the 38 claims submitted by the plaintiff, the plaintiff commenced this action against UHC, asserting causes of action, inter alia, alleging breach of contract, breach of implied contract, unjust enrichment, and violations of Insurance Law § 3224–a, known as the Prompt Pay Law. Thereafter, UHC moved pursuant to CPLR 3211(a)(1) and (7) to dismiss the complaint.  In support of its motion, UHC submitted, among other things, the plan documents pertaining to 37 of the 38 Empire Plan members at issue.  However, UHC was unable to locate the relevant plan documents for a patient identified as “EC.” In an order dated August 18, 2022, the Supreme Court granted UHC's motion.  The plaintiff appeals.

The Supreme Court should have denied that branch of UHC's motion which was pursuant to CPLR 3211(a) to dismiss so much of the first cause of action, alleging breach of contract, as sought to recover compensatory damages for the claim related to EC. UHC failed to establish that any contractual provision barred EC from validly assigning his or her benefits under the Empire Plan to the plaintiff (see Neurological Surgery, P.C. v. Group Health Inc., 224 A.D.3d 697, 698, 204 N.Y.S.3d 565).

However, the Supreme Court properly granted that branch of UHC's motion which was pursuant to CPLR 3211(a) to dismiss so much of the first cause of action as sought to recover damages for the claims related to the 37 of the 38 Empire Plan members for whom UHC submitted the relevant plan documents.  Contrary to the plaintiff's contention, the plan documents conclusively established that any assignment of benefits made by those Empire Plan members was void, as the plans explicitly barred the members from assigning their benefits under the plans to a nonparticipating provider, such as the plaintiff (see Brettler v. Allianz Life Ins. Co. of N. Am., 40 N.Y.3d 450, 454, 203 N.Y.S.3d 518, 226 N.E.3d 885;  Kirell v. Vytra Health Plans Long Is., Inc., 29 A.D.3d 638, 638, 815 N.Y.S.2d 185;  Cole v. Metropolitan Life Ins. Co., 273 A.D.2d 832, 833, 708 N.Y.S.2d 789;  see also Angstadt v. Empire HealthChoice HMO, Inc., 2017 WL 10844692, *5, 2017 U.S. Dist. LEXIS 40406, *14-15 [E.D.N.Y., No. 15–CV–1823(SJF)(AYS)];  American Med. Assn. v. United Healthcare Corp., 2001 WL 863561, *12, 2001 U.S. Dist. LEXIS 10818, *42-43 [S.D.N.Y., No. 00 Civ. 2800(LMM), 00 Civ. 7246(LMM)]).  Contrary to the plaintiff's further contention, the complaint failed to sufficiently allege that UHC waived the anti-assignment provisions of the subject plans (see Sasson Plastic Surgery, LLC v. UnitedHealthcare of N.Y., Inc., 2022 WL 2664355, *2, 2022 U.S. Dist. LEXIS 123726, *4-5 [E.D.N.Y., No. 2:17–cv–1674(ENV)(ARL)];  Angstadt v. Empire HealthChoice HMO, Inc., 2017 WL 10844692, *6, 2017 U.S. Dist LEXIS 40406, *15-17).

Moreover, the Supreme Court properly granted those branches of UHC's motion which were pursuant to CPLR 3211(a) to dismiss the causes of action alleging breach of implied contract, unjust enrichment, and violations of the Prompt Pay Law with respect to all 38 Empire Plan members.  A cause of action predicated on a theory of implied contract is not viable where there is an express agreement that governs the subject matter underlying the action (see Clark–Fitzpatrick, Inc. v. Long Is. R.R. Co., 70 N.Y.2d 382, 388–389, 521 N.Y.S.2d 653, 516 N.E.2d 190;  Scott v. Fields, 92 A.D.3d 666, 669, 938 N.Y.S.2d 575;  Sasson Plastic Surgery, LLC v. UnitedHealthcare of N.Y., Inc., 2022 WL 2664355, *6, 2022 U.S. Dist LEXIS 123726, *15-16).  The cause of action alleging unjust enrichment was subject to dismissal because the medical services at issue were rendered at the behest of the subject members (see Pekler v. Health Ins. Plan of Greater N.Y., 67 A.D.3d 758, 760, 888 N.Y.S.2d 196;  Kirell v. Vytra Health Plans Long Island, Inc., 29 A.D.3d 638, 639, 815 N.Y.S.2d 185).  Finally, the cause of action alleging violations of the Prompt Pay Law was subject to dismissal because there was no allegation in the complaint that UHC failed to pay or dispute a claim within the statutorily specified time frame (see generally Insurance Law § 3224–a[a];  Maimonides Med. Ctr. v. First United Am. Life Ins. Co., 116 A.D.3d 207, 219, 981 N.Y.S.2d 739).

The plaintiff's remaining contentions are without merit.

CONNOLLY, J.P., WOOTEN, DOWLING and LOVE, JJ., concur.