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Roll v. Medical Mutual of Ohio

United States District Court, N.D. Ohio, Eastern Division

March 6, 2017

Stewart D. Roll, et al., Plaintiff,
v.
Medical Mutual of Ohio, Defendant.

          MEMORANDUM OF OPINION AND ORDER

          PATRICIA A. GAUGHAN United States District Judge

         Introduction

         This matter is before the Court upon defendant's Motion to Dismiss Plaintiff's Amended Complaint (Doc. 18). For the following reasons, the motion is GRANTED.

         Facts

         Plaintiffs Stewart and Bonnie Roll filed this First Amended Complaint against defendant Medical Mutual of Ohio. Plaintiffs are insured by a Policy of medical insurance issued by defendant. By letter of April 22, 2016, defendant denied a request to pay for Stewart Roll's surgery at the highest benefit level where the surgery would have been performed at an out-of-network facility. Defendant based the denial on the fact that the surgery could be performed at an in-network facility. Plaintiffs allege they had elected to have Stewart Roll's surgery and hospital stay at University Hospital's (UH) Main Campus, an out-of-network facility, because while Stewart's colorectal surgeon (Scott Steele, M.D.)[1] was treated as in-network under the policy, the doctor did not have privileges to perform the surgery at the Cleveland Clinic Foundation's (CCF) Main Campus, an in-network facility, or other UH facilities which were treated as in-network. Plaintiffs did not appeal the decision. In a May 2, 2016 correspondence to defendant “pertain[ing] to [the April 2016] adverse benefit determination, ” Stewart Roll requested “all documents, records and other matter in written and electronic form relevant to this denial, including but not limited to...” The letter lists eight categories of documents:

1. All contracts and other agreements for the last twenty years between Medical Mutual (MM) and Cleveland Clinic Foundation (CCF) which makes reference to: (a) MM treating all CCF hospitals as in-network; (b) MM treating any other non-CCF hospitals as out-of-network.
2. All contracts and other agreements for the last twenty years between UH Case Medical Center (UH) and MM which makes reference to: (a) MM treating any UH hospital as in-network; (b) MM treating any UH hospital as out-of-network;
3. All contracts and other agreements between MM and Scott R. Steele, M.D., which identifies Dr. Steele as being an MM in-network medical doctor;
4. MM's detailed criteria which led to this decision;
5. All communication between MM and Medicare about CCF's treatment as an in-network provider, and MM's treatment of any other hospital system as out-of-network;
6. MM's allowed CCF fee for the expected medical procedures for the patient's planned May 9, 2016 surgery;
7. MM's allowed UH fee for the expected medical procedures for the patient's planned May 9, 2016 surgery;
8. MM's reimbursement fee for MM gold and Medicare Plan A only patients to: (a) CCF, and (b) UH for the expected medical procedures for the patient's planned May 9, 2016 surgery.

         By letter of June 24, 2016, defendant responded to Steward Roll by providing the detailed basis of its denial. As to request numbers 1 and 2, defendant explained that the requested documents were confidential and proprietary and not relevant to its decision.[2]

         Plaintiffs allege that defendant's anti-competitive behavior has been the subject of a previous complaint filed by the United States and a local newspaper article.[3]

         The First Amended Complaint sets forth the following claims. Count One alleges that the failure to produce the documents is contrary to defendant's obligation to do so and has prevented plaintiffs from appealing the denial of their request to treat the surgery as in-network. Plaintiffs seek injunctive relief requiring the production of the documents as well as damages. Count Two alleges that defendant's discrimination in reimbursement rates for the same surgery and hospital stay has an anti-competitive effect on the prices charged by hospitals within the relevant market and has an adverse impact on which surgeons the plan beneficiaries and participants may use, in violation of 15 U.S.C. § 1, 2, and 14. Count Three alleges that the Policy is susceptible of more than one interpretation and defendant should have interpreted it so as to provide plaintiffs with the maximum level of cost reimbursement and coverage.

         This matter is now before the Court upon defendant's Motion to Dismiss.

         Standard of Review

         “Dismissal is appropriate when a plaintiff fails to state a claim upon which relief can be granted. Fed.R.Civ.P. 12(b)(6). We assume the factual allegations in the complaint are true and construe the complaint in the light most favorable to the plaintiff.” Comtide Holdings, LLC v. Booth Creek Management Corp., 2009 WL 1884445 (6th Cir. July 2, 2009) (citing Bassett v. Nat'l Collegiate Athletic Ass'n, 528 F.3d 426, 430 (6th Cir.2008)). In construing the complaint in the light most favorable to the non-moving party, “the court does not accept the bare assertion of legal conclusions as enough, nor does it accept as true unwarranted factual inferences.” Gritton v. Disponett, 2009 WL 1505256 (6th Cir. May 27, 2009) (citing In re Sofamor Danek Group, Inc., 123 F.3d 394, 400 (6th Cir.1997). As outlined by the Sixth Circuit:

Federal Rule of Civil Procedure 8(a)(2) requires only “a short and plain statement of the claim showing that the pleader is entitled to relief.” “Specific facts are not necessary; the statement need only give the defendant fair notice of what the ... claim is and the grounds upon which it rests.”Erickson v. Pardus, 551 U.S. 89, 93 (2007) (quoting Bell Atlantic Corp. v. Twombly, 550 U.S. 544, 555 (2007)). However, “[f]actual allegations must be enough to raise a right to relief above the speculative level” and to “state a claim to relief that is plausible on its face.” Twombly, 550 U.S. at 555, 570. A plaintiff must ‚Äúplead[ ] factual ...

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