X

Thank you for sharing!

Your article was successfully shared with the contacts you provided.

MEMORANDUM DECISION AND ORDER I. INTRODUCTION   MVP Health Plan (“Plaintiff”) brings this action against Cotiviti (formerly known as Verscend Technologies) (“Defendant”) seeking compensatory damages, punitive damages, declaratory relief, and attorney’s fees. See generally Dkt. No. 24, Amended Complaint. Defendant has moved (1) to dismiss all claims in Plaintiff’s complaint against it pursuant to Rules 12(b)(6) and 9(b), (2) for declaratory judgment pursuant to Rule 57, and (3) to strike claims for damages and fees and demand for a jury trial pursuant to Rules 12 and 39 of the Federal Rules of Civil Procedure. See generally Dkt. No. 26. II. BACKGROUND Plaintiff is a regional health plan that offers Medicare Advantage plans to its enrollees. Instead of receiving a fee from the Centers for Medicare and Medicaid Services (“CMS”) for each service an enrollee receives, the Medicare Advantage plans receive a monthly fee per enrollee, known as a “capitation payment.” The amount of the capitation payment that a Medicare Advantage plan receives varies for each enrollee. There is a base fee amount for an enrollee and then an additional fee based on the “risk adjustment processing system” (“RAPS”), which accounts for the financial risk an enrollee presents. Medicare Advantage plans also use RAPS data in preparing bids for submission in an annual competitive bidding process in which CMS determines the amount it will pay on each plan. CMS has specific requirements about how Medicare Advantage plans must submit enrollees’ diagnosis and treatment data, and which information they can and cannot submit as part of the RAPS data. On December 1, 2008, Plaintiff and Defendant (operating under a different name) entered into a Master Service Agreement (“the 2008 Contract”) whereby Defendant agreed to filter Plaintiff’s data, convert it into a format that CMS would accept, and submit the data to CMS on Plaintiff’s behalf. Plaintiff agreed to pay fees in exchange for the services rendered pursuant to the agreement and to assist Defendant in performing its responsibilities by providing Defendant with data and access to certain CMS systems. The parties extended the 2008 Contract by amendment in 2009 and again in 2011. Plaintiff alleges that Defendant materially breached the 2008 Contract and then concealed the breaches from Plaintiff. According to Plaintiff, Defendant’s filtering logic was fundamentally flawed; and Defendant submitted RAPS data to CMS that should have been omitted, while failing to submit data that should have been included, based on CMS’s criteria. Because of these errors, Plaintiff alleges that it was deprived of additional payments CMS owed it for coverage it was providing to its enrollees. Plaintiff also alleges that, because of the flawed filtering logic, its annual bid submissions to CMS were incorrect. Plaintiff further claims that Defendant assured it that the filtering logic was performing completely and accurately; and, instead of disclosing the flaws in the logic, Defendant sought to negotiate a new contract governing the relationship between the parties. Defendant proposed provisions in the new contract (“the 2017 Contract”) that would, according to Plaintiff, limit or eliminate liability for Defendant’s ongoing contractual breaches, which Defendant knew about but Plaintiff did not. The liability limiting provision in the 2017 Contract reads as follows: THE PARTIES AGREE THAT NO DIRECTOR, OFFICER, EMPLOYEE, AGENT, OR VOLUNTEER OF EITHER PARTY SHALL INCUR ANY FINANCIAL RESPONSIBILITY OR LIABILITY IN CONNECTION WITH THIS AGREEMENT. NOTWITHSTANDING ANYTHING TO THE CONTRARY, OR ANY FAILURE OF ESSENTIAL PURPOSE OF ANY LIMITED REMEDY, EVEN IF ADVISED OF THE POSSIBILITY OF LOSSES, IN NO EVENT SHALL EITHER PARTY, OR ITS AGENT, BE LIABLE FOR ANY CONSEQUENTIAL, INCIDENTAL, INDIRECT, TREBLE, OR SPECIAL DAMAGES, INCLUDING ANY LOST PROFITS, DATA, BUSINESS, GOODWILL, ANTICIPATED SAVINGS, OPPORTUNITY OR USE OR OTHER WHETHER IN CONTRACT (INCLUDING BREACH OF WARRANTY) OR IN TORT, AND INCLUDING, BUT NOT LIMITED TO, LOST PROFITS OR OTHER ECONOMIC LOSS. LIABILITY CAP. NOTWITHSTANDING ANYTHING TO THE CONTRARY, OR ANY FAILURE OF ESSENTIAL PURPOSE OF ANY LIMITED REMEDY, NEITHER PARTY’S AGREGATE LIABILITY, IF ANY, TO THE OTHER OR TO ANY THIRD PARTY FOR CLAIMED LOSS ARISING UNDER THIS AGREEMENT AND THE INCORPORATED BUSINESS ASSOCIATES AGREEMENT, SHALL EXCEED SEVEN TIMES FEES PAID OR PAYABLE BY [PLAINTIFF] FOR THE PRIOR 12 MONTH PERIOD PRECEDING THE CLAIM. See Dkt. No. 24-5 at Section V. Based on these allegations, Plaintiff asserts the following eight causes of action: (1) breach of the 2008 Contract; (2) breach of the covenant of good faith and fair dealing with respect to the 2008 Contract; (3) fraudulent inducement; (4) contract-based rescission; (5) declaratory judgment; (6) breach of the 2017 Contract; (7) breach of the covenant of good faith and fair dealing with respect to the 2017 Contract; and (8) unjust enrichment. See generally Dkt. No. 24. III. DISCUSSION A. The parties’ business relationship The parties dispute whether the 2008 Contract or the 2017 Contract controls their relationship. Defendant argues that the Court should dismiss Plaintiff’s claims regarding the 2008 Contract because the 2017 Contract is superseding. See Dkt. No. 26-1, Def’s Memorandum in Support, at 10-11. Conversely, Plaintiff claims that Defendant fraudulently induced it to sign the 2017 Contract; and, thus, that contract is invalid, and the 2008 Contract governs. See Dkt. No. 27, Pl’s Memorandum in Opposition, at 5-6. To resolve Defendant’s pending motion, the Court must first decide which contract controls. To do so, it must determine whether Defendant fraudulently induced Plaintiff to sign the 2017 Contract, as Plaintiff alleges in its third cause of action. B. Legal standards Defendant moves to dismiss Plaintiff’s third cause of action for fraudulent inducement pursuant to Rules 12(b)(6) and 9(b) of the Federal Rules of Civil Procedure. “To survive a motion to dismiss, a complaint must contain sufficient factual matter, accepted as true, to ‘state a claim to relief that is plausible on its face.’” Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009) (quoting [Bell Atl. Corp. v. Twombly, 550 U.S. 544,] 570, 127 S. Ct. 1955, 167 L. Ed. 2d 929 [2007]). “A claim has facial plausibility when the plaintiff pleads factual content that allows the court to draw the reasonable inference that the defendant is liable for the misconduct alleged.” Id. (citing [Twombly, 550 U.S.] at 556, 127 S. Ct. 1955, 167 L. Ed. 2d 929). “The plausibility standard is not akin to a ‘probability requirement,’ but it asks for more than a sheer possibility that a defendant has acted unlawfully.” Id. (citation omitted). “While a complaint attacked by a Rule 12(b)(6) motion to dismiss does not need detailed factual allegations…a plaintiff’s obligation to provide the ‘grounds’ of his ‘entitle[ment] to relief’ requires more than labels and conclusions, and a formulaic recitation of the elements of a cause of action will not do[.]” Bell Atl. Corp. v. Twombly, 550 U.S. 544, 555 (2007) (internal citations and quotations omitted). “ Determining whether a complaint states a plausible claim for relief will…be a context-specific task that requires the reviewing court to draw on its judicial experience and common sense.” Iqbal, 556 U.S. at 679 (citation omitted). When making its decision, this court must “accept all well-pleaded facts as true and consider those facts in the light most favorable to the plaintiff.” Chapman v. N.Y. State Div. for Youth, 546 F.3d 230, 235 (2d Cir. 2008) (citing Patane v. Clark, 508 F.3d 106, 111 (2d Cir. 2007) (per curiam)). C. Fraudulent inducement The elements of fraudulent inducement are “‘(1) a material misrepresentation or omission of fact; (2) made by defendant with knowledge of its falsity (3) and intent to defraud; (4) reasonable reliance on the part of the plaintiff; and (5) resulting damage to the plaintiff.’” Levine v. Landy, 860 F. Supp. 2d 184, 193 (N.D.N.Y. 2012) (quoting Crigger v. Fahnestock & Co., 443 F.3d 230, 234 (2d Cir. 2006)). Under New York law, “‘a claim for common law fraud will not lie if the claim is duplicative of a claim for breach of contract.’” Tarzy v. Dwyer, No. 18 Civ. 1456, 2019 U.S. Dist. LEXIS 3413, *26 (S.D.N.Y. Jan. 8, 2019) (quotation omitted). “[P]arallel fraud and contract claims may be brought if the plaintiff (1) demonstrates a legal duty separate from the duty to perform under the contract; (2) points to a fraudulent misrepresentation that is collateral or extraneous to the contract; or (3) seeks special damages that are unrecoverable as contract damages.” Merrill Lynch & Co. Inc. v. Allegheny Energy, Inc., 500 F.3d 171, 183 (2d Cir. 2007) (citing Bridgestone/Firestone v. Recovery Credit Servs. Inc., 98 F.3d 13, 20 (2d Cir. 1996)). In addition to pleading each of the elements of fraudulent inducement, a plaintiff must also plead the claim with the particularity Rule 9(b) requires. Rule 9(b) states, “In alleging fraud or mistake, a party must state with particularity the circumstances constituting fraud or mistake. Malice, intent, knowledge, and other conditions of a person’s mind may be alleged generally.” Fed. R. Civ. P. 9(b). Although fraudulent intent may be alleged generally, the Second Circuit has held, “‘we must not mistake the relaxation of Rule 9(b)’s specificity requirement regarding condition of mind for a license to base claims of fraud on speculation and conclusory allegations[,]…plaintiffs must allege facts that give rise to a strong inference of fraudulent intent.’” Lerner v. Fleet Bank, N.A., 459 F.3d 273, 290 (2d Cir. 2006) (quoting Acito v. IMCERA Group, Inc., 47 F.3d 47, 52 (2d Cir. 1995) (internal quotation and citation omitted)) (emphasis added). “‘The requisite “strong inference” of fraud may be established either (a) by alleging facts to show that defendants had both motive and opportunity to commit fraud, or (b) by alleging facts that constitute strong circumstantial evidence of conscious misbehavior or recklessness.’” Id. at 290-91 (quoting Shields v. Citytrust Bancorp, Inc., 25 F.3d 1124, 1128 (2d Cir. 1994)). Thus, to plead fraudulent inducement by misrepresentation with the specificity that Rule 9(b) requires, “‘the complaint must: (1) specify the statements that the plaintiff contends were fraudulent, (2) identify the speaker, (3) state where and when the statements were made, and (4) explain why the statements were fraudulent.’” Id. at 290 (quoting Mills v. Polar Molecular Corp., 12 F.3d 1170, 1175 (2d Cir. 1993)). Here, Plaintiff alleges that Defendant made false representations concerning its 2016 Service Organization Control (“SOC”) report, the 2016 “sweepback” report, and its reasons for negotiating the 2017 Contract. Specifically, Plaintiff asserts that Defendant’s COO, Jordan Bazinsky, endorsed an SOC report dated September 22, 2016, which “fairly present[ed]” Defendant’s systems and controls. See Dkt. No. 24 at

58-59. That SOC report represented that Defendant’s Risk Adjustment Process was performing “completely and accurately,” and its logic was appropriately filtering information. See id. at 60. In addition, during its “sweepback” process in early 2016, Defendant discovered that a draft of its RAPS submissions to CMS contained extraneous data. See id. at 67. One of Defendant’s employees, Deborah Coakley, reported the issue to one of Plaintiff’s employees, describing it as a “small and contained problem.” See id. at 68. Plaintiff contends that the filtering logic was not operating accurately, nor was the problem “small and contained.” Instead, Plaintiff claims that the filtering logic was “catastrophically flawed,” and the data submitted to CMS was erroneously under- and over-inclusive. See id. at

 
Reprints & Licensing
Mentioned in a Law.com story?

License our industry-leading legal content to extend your thought leadership and build your brand.

More From ALM

With this subscription you will receive unlimited access to high quality, online, on-demand premium content from well-respected faculty in the legal industry. This is perfect for attorneys licensed in multiple jurisdictions or for attorneys that have fulfilled their CLE requirement but need to access resourceful information for their practice areas.
View Now
Our Team Account subscription service is for legal teams of four or more attorneys. Each attorney is granted unlimited access to high quality, on-demand premium content from well-respected faculty in the legal industry along with administrative access to easily manage CLE for the entire team.
View Now
Gain access to some of the most knowledgeable and experienced attorneys with our 2 bundle options! Our Compliance bundles are curated by CLE Counselors and include current legal topics and challenges within the industry. Our second option allows you to build your bundle and strategically select the content that pertains to your needs. Both options are priced the same.
View Now
September 05, 2024
New York, NY

The New York Law Journal honors attorneys and judges who have made a remarkable difference in the legal profession in New York.


Learn More
April 25, 2024
Dubai

Law firms & in-house legal departments with a presence in the middle east celebrate outstanding achievement within the profession.


Learn More
April 29, 2024 - May 01, 2024
Aurora, CO

The premier educational and networking event for employee benefits brokers and agents.


Learn More

A large and well-established Tampa company is seeking a contracts administrator to support the company's in-house attorney and manage a wide...


Apply Now ›

We are seeking an attorney to join our commercial finance practice in either our Stamford, Hartford or New Haven offices. Candidates should ...


Apply Now ›

We are seeking an attorney to join our corporate and transactional practice. Candidates should have a minimum of 8 years of general corporat...


Apply Now ›
04/15/2024
Connecticut Law Tribune

MELICK & PORTER, LLP PROMOTES CONNECTICUT PARTNERS HOLLY ROGERS, STEVEN BANKS, and ALEXANDER AHRENS


View Announcement ›
04/11/2024
New Jersey Law Journal

Professional Announcement


View Announcement ›
04/08/2024
Daily Report

Daily Report 1/2 Page Professional Announcement 60 Days


View Announcement ›