Weeks v. UMR, Inc.
Weeks v. UMR, Inc.
Opinion of the Court
This cause is before the Court on Defendant UMR, Inc.'s ("UMR") motion to dismiss, ECF No. 11. For the reasons that follow, Defendant's motion is GRANTED.
BACKGROUND
Plaintiff Joanne Weeks alleges she has healthcare coverage through the Asarco LLC Medicare Supplement Health Benefit Plan ("Plan"), which is administered by UMR. Am. Compl. ¶ 8, ECF No. 10; Plan, Mem. Supp. Mot. Dismiss Ex. A, ECF No. 12-1.
In June and July of 2015, Plaintiff Marchele Mahnesmith, Weeks's daughter and healthcare power of attorney, repeatedly contacted UMR to determine whether the Plan covered in-home healthcare services for Weeks, who suffers from dementia, delirium, and arthritis. UMR's automated message advised her that she could not rely on information given during the phone call. Id. ¶ 17. Once Mahnesmith reached a UMR employee, she asked whether in-home healthcare services would be covered under Weeks's Plan. Id. ¶ 18. The UMR employee, who knew about the recorded message but who also knew that Mahnesmith would rely on the information provided anyway in order to plan for Weeks's medical needs, informed her that Weeks's Plan would cover in-home healthcare services. Id. ¶¶ 19-22, 35. UMR also told Preferred Home Health Care ("Preferred"), Mahnesmith's chosen provider, that Weeks's Plan covered one hundred percent of the cost of the in-home healthcare services Preferred contemplated providing for Weeks. Id. ¶ 26. In reliance on UMR's continued verbal approvals and assurances to herself and Preferred, Mahnesmith contracted with Preferred to provide in-home healthcare services to Weeks. Id. ¶¶ 27-28. Ultimately, UMR refused to provide full payment for Weeks's in-home healthcare services under the Plan, so Mahnesmith "was forced to hastily find alternative, more reasonably price[d] care for [Weeks] outside [Mahnesmith's] home." Id. ¶¶ 29-30. Weeks was moved to an assisted living facility and, as a result, suffered from additional health issues and severe emotional distress. Id. ¶ 32. Mahnesmith suffered severe emotional distress due to the rushed treatment change, Preferred's unpaid invoices, and seeing the decline in Weeks's health and mental wellbeing after she was moved to the assisted living facility. Id. ¶ 33. UMR intended Mahnesmith to rely on its erroneous statements, did not intend to be bound by them, and was aware of Weeks and Mahnesmith's vulnerability to financial injury and emotional distress in this context. Id. ¶¶ 35, 43.
On October 19, 2017, Plaintiffs filed a complaint in state court. UMR timely removed the action pursuant to
DISCUSSION
I. Legal Standard
A. Motion to Dismiss
A court will dismiss a complaint if it fails to state a claim upon which relief can be granted. Fed. R. Civ. P. 12(b)(6). Typically, a complaint does not have to anticipate an affirmative defense. Bausch v. Stryker Corp. ,
B. Preemption
There are two types of ERISA preemption. One is called complete preemption and is actually a jurisdictional analysis. If a plaintiff files a claim in state court that is essentially a claim for benefits under
Defendant's motion to dismiss is based first on conflict preemption, which is an affirmative defense based on the Supremacy Clause of the Constitution that "operates to prevent the enforcement of state laws that conflict with federal laws or regulations." Fifth Third Bank ex rel. Tr. Officer v. CSX Corp. ,
[ERISA's] § 502(a) set[s] forth a comprehensive civil enforcement scheme that represents a careful balancing of the need for prompt and fair claims settlement procedures against the public interest in encouraging the formation of employee benefit plans. The policy choices reflected in the inclusion of certain remedies and the exclusion of others under the federal scheme would be *949completely undermined if ERISA-plan participants and beneficiaries were free to obtain remedies under state law that Congress rejected in ERISA. "The six carefully integrated civil enforcement provisions found in § 502(a) of the statute as finally enacted ... provide strong evidence that Congress did not intend to authorize other remedies that it simply forgot to incorporate expressly."
Pilot Life Ins. Co. v. Dedeaux ,
In addition to the limited remedies available in § 1132(a), § 1144(a) (also referred to as § 514) states that ERISA "shall supersede any and all State laws insofar as they may ... relate to any employee benefit plan." This explicit preemption provision "is conspicuous for its breadth," FMC Corp. v. Holliday ,
Since ERISA's enactment, courts have been struggling to identify claims that "relate to" ERISA-regulated employee benefit plans and are therefore preempted. Pilot Life Ins. , 481 U.S. at 44, 47-48,
[T]he Supreme Court has identified at least three instances where a state law can be said to have a "connection with" or "reference to" employee benefit plans, when it (1) "mandate[s] employee benefit structures or their administration;" (2) binds employers or plan administrators to particular choices or precludes uniform administrative practice, thereby functioning as a regulation of an ERISA plan itself; and (3) provides an alternative enforcement mechanism to ERISA.
Trs. of AFTRA Health Fund v. Biondi ,
II. Analysis
A. Preemption pursuant to § 1144(a)
The Court must first assess whether the Plan is regulated by ERISA and, if so, whether Plaintiffs' claims "relate to" ERISA. ERISA defines an employee welfare benefit plan as a plan "established or maintained by an employer ... for the purpose of providing for its participants or their beneficiaries ... medical, surgical, or hospital care."
Plaintiffs allege two state law claims. The ICFA prohibits "unfair or deceptive acts or practices ... in the conduct of any trade or commerce." 815 ILCS 505/2. Such a claim requires:
(1) a deceptive [or unfair] act or practice by the defendant; (2) the defendant intended that the plaintiff rely on the deception; (3) the deceptive act occurred in a course of conduct involving trade or commerce; and (4) actual damage to the plaintiff; (5) proximately caused by the deceptive act.
Phila. Indem. Ins. Co. v. Chi. Title Ins. Co. ,
[f]irst, [that] the conduct involved [was] truly extreme and outrageous. Second, [that] the actor ... either intend[ed] that his conduct inflict severe emotional distress or kn[e]w that there [wa]s at least a high probability that his conduct w[ould] cause severe emotional distress. Third, [that] the conduct ... in fact cause[d] severe emotional distress.
Schweihs v. Chase Home Fin., LLC ,
Defendant argues Plaintiffs' claims relate to the ERISA Plan because they require an interpretation of the Plan and misrepresentation of benefits claims are foreclosed in the Seventh Circuit. Mem. Supp. Mot. Dismiss 7. In support, Defendant cites Plumb v. Fluid Pump Serv., Inc. ,
Defendant also cites Pohl v. Nat'l Benefits Consultants, Inc. ,
Plaintiffs attempt to distinguish between a claim seeking coverage equal to that promised by a plan representative, which they seem to concede would be preempted, and a claim seeking damages caused by a deceptive or unfair act (UMR's misrepresentation), which they argue would not be preempted. Mem. Supp. Resp. Mot. Dismiss 5. This is a distinction without a difference because both claims require the existence of a plan and seek a benefit not owed by the Plan pursuant to state law claims rather than those available under § 1132(a)(1)(B). As described above, ERISA's purpose is to provide a civil enforcement scheme that is predictable, preserves plan assets for covered claims, and encourages employers to create benefit plans.
Plaintiffs argue this deceptive act occurred outside of any plan or plan administration, Mem. Supp. Resp. Mot. Dismiss 2, 3, 4, 7, and point to Biondi for support. In Biondi , the trustees of a plan sued a participant, who continued to list his former spouse on his medical plan for five years after the two divorced, for fraud to recover money paid to the ex-wife's medical providers. Biondi ,
Plaintiffs argue their claims are similarly not preempted because even though Defendant's statements were made in the context of an ERISA Plan, they do not require the Court to interpret or apply the Plan's terms. Biondi is easily distinguished. In Biondi , the plan trustees sought to recover benefits fraudulently paid on behalf of a former beneficiary.
Plaintiffs rely principally on Metro. Life Ins. Co. v. Yitao Sun , No.
The court determined, by looking at the policies issued under the ERISA plan, that as long as Policy 1 was in effect, Policy 2 was void. Id. at *3, 5 (holding that "under the express and unambiguous terms of the plan documents" only "Policy 1 remained in effect"). Metlife argued Sun's ICFA and fraud claims should be preempted because they sought to utilize Illinois law as an alternative enforcement mechanism and required the court to interpret provisions of the ERISA plan. Id. at *10. The court determined that the claims would be preempted only if the ERISA plan was a critical element of the claims or the court would have to interpret the ERISA plan to adjudicate the claims. Id. The court concluded that the claims were not preempted. "MetLife led the Decedent and Sun to believe that ... Sun['s designation] as a beneficiary was proper, and after the Decedent died, informed Sun it was not ... Although the context of Sun's fraud claims involves an ERISA plan, Sun's allegations focus on conduct extrinsic to the plan." Id. (quotation marks omitted). The Court does not find this case persuasive. The court's conclusion that Metlife's conduct was deceptive and misleading first required an interpretation of policies issued under the ERISA plan before turning the "focus [to] conduct extrinsic to the plan," that is, Metlife's acting as if Policy 2 was still in force.
Plaintiffs' claims are similar. Plaintiffs imply Defendant falsely stated that in-home healthcare services were covered under the Plan. Am. Compl. ¶¶ 26, 29, 38.
*953ICFA claim relies on the Plan's existence and a determination that Defendant made a deceptive statement about its terms. Plaintiffs argue these acts occur outside of the Plan because they involve misstatements about it, but to agree with Plaintiffs, the Court would have to interpret the Plan's terms.
Plaintiffs' IIED claim depends on the alleged misinterpretation of the Plan's benefits. Such a determination also requires the Court to determine that UMR's statement about coverage conflicted with the Plan's terms. See Kolbe & Kolbe Health & Welfare Benefit Plan v. Med. Coll. of Wis., Inc. ,
B. § 1132(a)(1)(B)
Because Weeks has coverage under the Plan, she could theoretically bring a claim for unpaid benefits pursuant to
Defendant is an independent third party administrator tasked with processing claims and other duties for the Plan administrator. Am. Compl. ¶¶ 9, 11; Plan 1. UMR "do[es] not assume liability for benefits payable under this Plan, since [it is] solely [a] claims-paying agent[ ] for the Plan administrator." Plan 1.
"[A] cause of action for 'benefits due' must be brought against the party having the obligation to pay." Larson v. United Healthcare Ins. Co. ,
CONCLUSION
Defendant's Motion to Dismiss, ECF No. 11, is GRANTED. Defendant's Motion for Leave to Reply, ECF No. 16, is GRANTED. The Clerk is directed to file the Reply, ECF No. 16-1, on the docket. The Clerk is directed to enter judgment as follows: IT IS ORDERED AND ADJUDGED that this case is dismissed without prejudice, and close the case.
On a motion to dismiss, all well-pleaded allegations in the complaint are taken as true and viewed in the light most favorable to the plaintiff. Indep. Trust Corp. v. Stewart Info. Servs. Corp. ,
Plaintiffs argue the Court may not consider the Plan when evaluating Defendant's motion to dismiss because the Amended Complaint does not refer to the Plan document, allege benefits were owed under the Plan, allege that coverage was denied or granted, or allege that the Plan is central to Plaintiffs' claims. Mem. Supp. Resp. Mot. Dismiss 2, ECF No. 12. The Amended Complaint refers to Weeks's Plan eleven times; the Court may consider the Plan. See Williamson v. Curran ,
Plaintiffs allege Preferred's invoices exceed $ 150,000.00. Am. Compl. ¶ 51.
While the Seventh Circuit has at times counseled against a defendant moving to dismiss under Rule 12(b)(6) rather than moving for judgment on the pleadings under Rule 12(c), Bausch ,
Plaintiffs assert that an inquiry concerning eligibility and coverage under an ERISA plan is not subject to ERISA regulation. "If an individual asks a question concerning eligibility for coverage under a plan without making a claim for benefits, the eligibility determination is not governed by the claims procedure rules." Benefit Claims Procedure Regulation FAQs, Department of Labor, https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/benefit-claims-procedure-regulation (last visited September 20, 2018). Plaintiffs do not explain how this interpretation of the ERISA regulations affects whether a state claim relates to an ERISA plan.
The court acknowledged that it resolved the preemption issue with only a two-paragraph response from Metlife. Yitao Sun ,
Plaintiffs also allege UMR's practice of answering coverage questions without intending to be bound by them and knowing that Plaintiffs would rely on them is a deceptive act intended to inflict emotional distress. Am. Compl. ¶¶ 48, 49, 53, 62, 63. In response to the motion to dismiss, Plaintiffs claim, without further development, that Defendant's decision to "provid[e] any statement of coverage" is an unfair and/or deceptive act under the ICFA. Mem. Supp. Resp. Mot. Dismiss 6. To establish an ICFA claim, Plaintiffs must allege they relied on Defendant's deceptive act-"providing any statement of coverage" is not enough because it is not inherently unfair or deceptive. The Court finds these allegations do not advance Plaintiffs' cause.
Defendant also argues Plaintiffs have not exhausted the administrative remedies available to participants claiming ERISA benefits. A court may grant a motion to dismiss on the basis of exhaustion, an affirmative defense, if the complaint itself establishes it. See Collins ,
Reference
- Full Case Name
- Joanne WEEKS and Marchele Mahnesmith v. UMR, INC., a corporation
- Cited By
- 3 cases
- Status
- Published