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Bedwell v. Aetna, Inc.

United States District Court, S.D. Indiana, Evansville Division

July 23, 2015



RICHARD L. YOUNG, District Judge.

Plaintiff, Andrew Bedwell, brings a denial of benefits claim under his employersponsored health insurance plan. The Defendants, Meritain Health, Inc. and Aetna, Inc., d/b/a Aetna Health Insurance Company, now move for dismissal pursuant to Rule 12(b)(6) for failure to state a claim. Plaintiff requests oral argument on the issue. For the reasons set forth below, the court GRANTS Defendants' Motion to Dismiss and DENIES Plaintiff's Request for Oral Argument.

I. Background

On July 6, 2011, Plaintiff, was injured in a motor vehicle accident and was treated for his injuries at Deaconess Hospital in Evansville, Indiana. (Am. Compl. ¶¶ 1, 2). Plaintiff's Amended Complaint alleges each Defendant breached the terms of his employer-funded health insurance policy by "refus[ing] to make the contractually mandated payment to Deaconess Hospital." ( Id. ¶¶ 6, 10).

At the time of the accident, Plaintiff was insured under an ERISA-governed plan, entitled the "AmeriQual Group, LLC Group Health Plan" (the "Plan[1]"). ( Id. ¶ 3; Ex. A, §

1 at 1). A copy of the Plan documents is attached as Exhibit A to the Amended Complaint. The Plan defines the Plan Administrator as "the Company" and the Plan Supervisor as Meritain Health, Inc. (Ex. A, § 3.65; Ex. A, § 3.66, as amended by the Sixth Amendment to January 2005 Restatement of AmeriQual Group, LLC Group Health Plan). As Plan Supervisor, Meritain Health provides claims administration services. (Ex. A, § 3.66, at 18). Defendant, Aetna, Inc., owns Meritain Health. (Am. Compl. ¶ 9).

II. Request for Oral Argument

Plaintiff filed a request for oral argument. The court finds oral argument is not necessary for a full and fair resolution of this case. Accordingly, Plaintiff's Request for Oral Argument is DENIED.

III. Discussion

"To survive a motion to dismiss under Rule 12(b)(6), a complaint must state a claim to relief that is plausible on its face.'" Adams v. City of Indianapolis, 742 F.3d 720, 728 (7th Cir. 2014) (quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007)). A claim is plausible when it "allows the court to draw the reasonable inference that the defendant is liable for the misconduct alleged." Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009).

Defendants argue there is no contract between Plaintiff and Meritain and Plaintiff and Aetna; therefore, they cannot be held liable for breach of contract. Plaintiff does not dispute the fact that a contract does not exist between Plaintiff and Defendants. Instead, Plaintiff argues that he is a third-party beneficiary to a contract alleged to exist between Meritain and AmeriQual.

The resolution of this motion turns on the law of ERISA. "[T]he ERISA civil enforcement mechanism is one of those provisions with such extraordinary pre-emptive power' that it converts an ordinary state common law complaint into one stating a federal claim for purposes of the well-pleaded complaint rule.'" Aetna Health, Inc. v. Davila, 452 U.S. 200, 209 (2004) (quoting Metropolitan Life Ins. Co. v. Taylor, 481 U.S. 58, 65-66 (1987)). Thus, "claims by a beneficiary for wrongful denial of benefits (no matter how they are styled) have been held by the Supreme Court to fall [ ] directly under § 502(a)(1)(B) of ERISA, which provides an exclusive federal cause of action for resolution of such disputes.'" Vallone v. CNA Fin. Corp., 375 F.3d 623, 638 (7th Cir. 2004) (quoting Taylor, 481 U.S. at 62-63). Plaintiff's claims, whether styled as breach of contract claims or third party beneficiary claims, seek benefits due under an ERISAgoverned plan. Accordingly, Plaintiff's claims are preempted.

Having so found, the court must determine whether the facts, as alleged by Plaintiff, "support any kind of relief." McDonald v. Household Intern, Inc., 425 F.3d 424, 429 (7th Cir. 2005). The facts as alleged in Plaintiff's Amended Complaint give rise to the plausible inference that a party is liable for the denial of benefits under ERISA. For purposes of a denial of benefits claim, the proper defendant is the party having the obligation to pay. Larson v. United Health Ins. Co., 723 F.3d 905, 913 (7th Cir. 2013) ("[A] cause of action for benefits due' must be brought against the party having the obligation to pay."). Normally, that party is the ERISA plan itself. Id. (citing Feinberg v. RM Acquisition, LLC, 629 F.3d 671, 673 (7th Cir. 2011)).

Plaintiff correctly points out that Meritain, as Plan Supervisor, provides "claims administration services, " (Ex. A, § 3.66 at 18), and is "responsible for adjudicating Claims for Benefits, " ( id., § 14.03 at 66). But under the terms of the Plan documents, only the Plan has the ultimate obligation to pay. (Ex. A, § 6 at 34) ("On receipt of satisfactory proof of claim, the Plan will pay benefits up to the maximum shown in the Schedule of Benefits for Major Medical Benefits"); see also id., § 14 at 65 ("Benefits will be paid under this Plan only if the Plan ...

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