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Kersey v. Anthem Insurance Companies, Inc.

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

November 17, 2017

TERESA KERSEY, Plaintiff,
v.
ANTHEM INSURANCE COMPANIES, INC., Defendant.

          ENTRY ON MOTION TO DISMISS

          Hon. William T. Lawrence, Judge

         This cause is before the Court on the motion to dismiss filed by Defendant Anthem Insurance Companies, Inc. (“AICI”) (Dkt. No. 29). The motion is fully briefed and the Court, being duly advised, DENIES the motion for the reasons set forth below.

         I. BACKGROUND

         The following allegations are set forth in Plaintiff Teresa Kersey's Amended Complaint. Kersey obtained a health insurance plan with AICI through her employer, the Archdiocese of Cincinnati. The plan was “through a ‘Blue Access Health Benefit Plan' health insurance policy, Group Name ‘Archdiocese of Cincinnati', [sic] Group Number 00070374, Plan Number 0032, Subscriber ID Number YRP133M5672.” Dkt. No. 27 at 6. While the plan was in effect, Kersey suffered a severe stroke in Tanzania, which rendered her paralyzed on the right side of her body and without the ability to speak. Kersey was taken to a nearby medical facility in a remote area for medical attention, but the facility lacked the necessary medical resources to treat her condition. As a result, Kersey required an immediate emergency air ambulance transport from the medical facility to a hospital in the United States capable of treating her condition.

         Kersey's family found an emergency air ambulance medical transport company, Aerocare Medical Transport System, Inc. (“Aerocare”), which could provide her with medical transportation to the United States. Kersey's family contacted AICI's representatives to confirm that this transport would be covered by Kersey's insurance. AICI, however, “knowing the urgent nature of this request, instead delayed and insisted that the request undergo a tedious, time consuming preauthorization process prior to confirming her coverage for this transport, ” id. at 2, and unreasonably delayed its approval for the preauthorization of the emergency flight, which resulted in Kersey's transportation to the United States being delayed for four days after she made the initial request with AICI.

         After Kersey was transported to the Cincinnati Stroke Center in Ohio, Aerocare submitted the air ambulance claim to AICI for payment on behalf of Kersey. In response, AICI paid only eight percent of the $2, 139, 000.00 air ambulance claim. As a result, Kersey is responsible to Aerocare for the remaining $1, 959, 000.00.

         II. STANDARD OF REVIEW

         AICI moves to dismiss Kersey's Complaint pursuant to Federal Rule of Civil Procedure 12(b)(6) for failure to state a claim for which relief can be granted. In reviewing a Rule 12(b)(6) motion, the Court “must accept all well pled facts as true and draw all permissible inferences in favor of the plaintiff.” Agnew v. Nat'l Collegiate Athletic Ass'n, 683 F.3d 328, 334 (7th Cir. 2012). For a claim to survive a motion to dismiss for failure to state a claim, it must provide the defendant with “fair notice of what the . . . claim is and the grounds upon which it rests.” Brooks v. Ross, 578 F.3d 574, 581 (7th Cir. 2009) (quoting Erickson v. Pardus, 551 U.S. 89, 93 (2007)) (omission in original). A complaint must “contain sufficient factual matter, accepted as true, to state a claim to relief that is plausible on its face.” Agnew, 683 F.3d at 334 (citations omitted). A complaint's factual allegations are plausible if they “raise the right to relief above the speculative level.” Bell Atlantic Corp. v. Twombly, 550 U.S. 544, 556 (2007). Detailed factual allegations are not required, but a plaintiff's complaint may not simply state “an unadorned, the defendant-unlawfully-harmed-me accusation.” Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009).

         III. DISCUSSION

         Viewing only the allegations in the Amended Complaint, there is no question that Kersey adequately states a claim against AICI. She alleges that AICI is contractually obligated under her insurance policy to pay her claim for air ambulance services and that it breached that obligation and did so in bad faith. AICI argues that the Court may, and should, look beyond the allegations of the Amended Complaint and examine the contract at issue which, it argues, establishes that it is not a party to the contract and therefore has no obligation to Kersey. “It is well settled that in deciding a Rule 12(b)(6) motion, a court may consider documents attached to a motion to dismiss . . . if they are referred to in the plaintiffs complaint and are central to his claim.” Brownmark Films, LLC v. Comedy Partners, 682 F.3d 687, 690 (7th Cir. 2012) (internal quotations and citation omitted). The document that AICI has provided, however, appears to be only part of the relevant contract.

         The document submitted by AICI is entitled “Your Health Benefit Booklet.” Dkt. No. 30-1 at 3 (hereinafter referred to as “the Booklet”). The Booklet contains the following definitions:

• Administrative Services Agreement-The agreement between the Administrator and the Employer regarding the administration of certain elements of the health care benefits of the Employer's group health plan.
• Administrator-An organization or entity that the Employer contracts with to provide administrative and claims payment services under the Plan. The Administrator is Community Insurance Company. The Administrator provides administrative claims payment services only and does not ...

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