Nystrom v. AmerisourceBergen Drug Corporation et al
Filing
41
ORDER denying 8 Motion to Dismiss (Written Opinion). Signed by Senior Judge David S. Doty on 11/6/2013. (PJM)
UNITED STATES DISTRICT COURT
DISTRICT OF MINNESOTA
Civil No. 13-557(DSD/JJK)
Quinn Nystrom,
Plaintiff,
ORDER
v.
AmerisourceBergen Drug Corporation,
AmerisourceBergen Group Health and
Welfare Plan (Plan No. 625) and Aetna
Life Insurance Company,
Defendants.
Mark A. Smith, Esq., Elizabeth I. Wrobel, Esq. and Wrobel
& Smith, PLLP, 1599 Selby Avenue, Suite 105, St. Paul, MN
55105, counsel for plaintiff.
Patrick H. O’Neill, Jr., Esq. and Larson King, LLP, 30
East Seventh Street, Suite 2800, St. Paul, MN 55101 and
Edna S. Kersting, Esq. and Wilson, Elser, Moskowitz,
Edelman & Dicker, LLP, 55 West Monroe Street, Suite 3800,
Chicago, IL 60603, counsel for defendants.
This matter is before the court upon the motion to dismiss by
defendant Aetna Life Insurance Company (Aetna).
Based on a review
of the file, record and proceedings herein, and for the following
reasons, the court denies the motion.
BACKGROUND
This insurance benefit dispute arises out of medical care
received by plaintiff Quinn Nystrom.
Nystrom had health insurance
through an insurance plan (Plan)1 provided by her former employer,
defendant AmerisourceBergen Drug Corporation (AmerisourceBergen).
AmerisourceBergen was also the statutory administrator of the Plan.
Am. Compl. ¶ 6.
Nystrom alleges that Aetna was a third-party
service provider and claims administrator to the Plan.
Id. ¶ 8.
On June 19, 2012, Nystrom was admitted to Timberline Knolls
Residential
Treatment
Center
(Timberline
Knolls),
disorder treatment center in Lemont, Illinois.
an
Id. ¶ 22.
eating
Per the
terms of the Plan, Aetna administered the pre-certification process
for residential treatment facilities.
Id. ¶ 5.
As part of that
process, Timberline Knolls requested authorization for inpatient
treatment from Aetna.
Id. ¶ 34.
Aetna denied authorization.
Id.
On June 26, 2012, Nystrom’s treating psychiatrist, Dr. Lauren
Kofod, participated in a telephonic appeal of the decision, which
Aetna denied.
Id. ¶ 35.
Nystrom again appealed the denial, and
Aetna again denied authorization on June 28, 2012.
Id. ¶ 37.
On March 11, 2013, Nystrom filed suit, alleging a claim under
the Employee Retirement Income Security Act (ERISA).
Aetna moves
to dismiss.
1
Nystrom also named the Plan as a defendant in this action.
2
DISCUSSION
I.
Standard of Review
To survive a motion to dismiss for failure to state a claim,
“a complaint must contain sufficient factual matter, accepted as
true, to state a claim to relief that is plausible on its face.”
Braden v. Wal-Mart Stores, Inc., 588 F.3d 585, 594 (8th Cir. 2009)
(citations and internal quotation marks omitted).
facial
plausibility
when
the
plaintiff
[has
“A claim has
pleaded]
factual
content that allows the court to draw the reasonable inference that
the defendant is liable for the misconduct alleged.”
Ashcroft v.
Iqbal, 129 S. Ct. 1937, 1949 (2009) (citing Bell Atl. Corp. v.
Twombly, 550 U.S. 544, 556 (2007)).
Although a complaint need not
contain detailed factual allegations, it must raise a right to
relief above the speculative level.
See Twombly, 550 U.S. at 555.
“[L]abels and conclusions or a formulaic recitation of the elements
of a cause of action” are not sufficient to state a claim.
Iqbal,
129 S. Ct. at 1949 (citation and internal quotation marks omitted).
The court does not consider matters outside the pleadings under
Rule 12(b)(6).
See Fed. R. Civ. P. 12(d).
consider matters
contradict
the
of
public
complaint,
record
as
and
well
The court, however, may
materials
as
that
materials
do
that
not
are
“necessarily embraced by the pleadings.” See Porous Media Corp. v.
Pall Corp., 186 F.3d 1077, 1079 (8th Cir. 1999) (citation and
internal quotation marks omitted).
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II.
ERISA
Nystrom alleges a claim under 29 U.S.C. § 1132(a)(1)(B), which
provides that “[a] civil action may be brought ... by a participant
or beneficiary ... to recover benefits due to [her] under the terms
of [her] plan, to enforce [her] rights under the term of the plan,
or to clarify [her] rights to future benefits under the terms of
the plan.”
Aetna argues that dismissal is warranted because the
only proper parties to a suit under § 1132(a)(1)(B) are (1) the
statutory Plan administrator and (2) the Plan itself.
In support,
Aetna argues that the statute provides that “[a]ny money judgment
under this subchapter against an employee benefit plan shall be
enforceable only against the plan as an entity and shall not be
enforceable against any other person unless liability against such
person
is
established
subchapter.”
in
his
individual
capacity
Id. § 1132(d)(2) (emphasis added).
under
this
Indeed, “[t]he
employee benefit plan itself is ordinarily liable for benefits
payable under the terms of the plan and is thus the primary
defendant in a section [1132(a)(1)(B)] action.”
Ross v. Rail Car
Am. Grp. Disability Income Plan, 285 F.3d 735, 740 (8th Cir. 2002)
(citations omitted). Additionally, the Eighth Circuit has squarely
held that, in addition to the plan itself, a statutory plan
administrator may be a proper party to a § 1132(a)(1)(B) action.
See Layes v. Mead Corp., 132 F.3d 1246, 1249 (8th Cir. 1998).
4
Nystrom responds that Aetna exercised control over the Plan’s
decision-making and claims processes and, thus, is a proper party
to the suit.
The Eighth Circuit has not ruled on “whether some
party other than the one designated in the plan instrument can be
a ‘de facto’ administrator of the plan.”
Hall v. Lhaco, Inc., 140
F.3d 1190, 1195 (8th Cir. 1998) (citation omitted); see id. (noting
circuit split and reserving ruling on issue).
The language of the relevant statutory provision, however,
imposes no explicit limitations on persons or entities that may be
defendants.
The
only
statutory
limitations
regarding
the
identities of parties relate to who constitutes a proper plaintiff.
See 29 U.S.C. § 1132(a) (identifying “[p]ersons empowered to bring
a civil action”); cf. Harris Trust & Sav. Bank v. Salomon Smith
Barney Inc., 530 U.S. 238, 246 (2000) (allowing suit against a nonfiduciary
under
ERISA
§
502(a)(3)
and
noting
that
“[o]ther
provisions of ERISA, by contrast, do expressly address who may be
a defendant” (citations omitted)).
Because the statute does not
expressly limit persons or entities that may be defendants, other
circuit courts
allow
suits
against
third-party
administrators
(TPAs) such as Aetna when the TPA exercises “actual control” over
the claims.
See, e.g., LifeCare Mgmt. Servs. LLC v. Ins. Mgmt.
Adm’rs Inc., 703 F.3d 835, 844-45 (5th Cir. 2013); Cyr v. Reliance
5
Standard Life Ins. Co., 642 F.3d 1202, 1205-07 (9th Cir. 2011) (en
banc); Gomez-Gonzalez v. Rural Opportunities, Inc., 626 F.3d 654,
665 (1st Cir. 2010).
The court finds the reasoning of these courts persuasive and
holds that “a TPA may be held liable ... if it exercises ‘actual
control’ over the benefits claims process.”
LifeCare Mgmt., 703
F.3d at 844. This conclusion is buttressed by Eighth Circuit dicta
noting that the amount of control that a plan administrator exerts
is relevant to whether or not they are a proper defendant.
See
Garren v. John Hancock Mut. Life Ins. Co., 114 F.3d 186, 187 (11th
Cir. 1997) (per curiam) (“The proper party defendant in an action
concerning ERISA benefits is the party that controls administration
of the plan.”), cited with approval in Layes, 132 F.3d at 1249.
Here, Nystrom alleges that Aetna exerted considerable control
over the certification decision-making and appeals processes and
that Aetna made the ultimate decision to deny coverage. Am. Compl.
¶¶ 34-37.
Such allegations, at this stage in the proceedings, are
sufficient to state a claim that Aetna exercised “actual control”
over the Plan.
As a result, dismissal is not warranted.
6
CONCLUSION
Accordingly, based on the above, IT IS HEREBY ORDERED that the
motion to dismiss [ECF No. 8] is denied.
Dated:
November 6, 2013
s/David S. Doty
David S. Doty, Judge
United States District Court
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