Becher v. United Healthcare Servs., Inc.
Opinion of the Court
Plaintiff Thomas Becher, individually and on behalf of those similarly situated, filed this lawsuit against defendants United Healthcare Services, Inc. ("United"), The Prudential Insurance Company of America ("Prudential"), and AARP. Plaintiff asserts that he and his wife, Jerri Becher, purchased an insurance policy from an AARP agent, and that this policy insured both of them. Since purchasing this policy, plaintiff alleges, both Prudential and United have underwritten the policy. Plaintiff's Complaint asserts that defendants breached the insurance policy when United refused to indemnify him for a hospital visit. Now, all defendants, together, ask the court to dismiss plaintiff's Complaint under Federal Rule of Civil Procedure 12(b)(6). Doc. 14. They argue *1106dismissal is proper because plaintiff was not an insured party under the policy.
Plaintiff has filed a Response (Doc. 22), and defendants have filed their Reply (Doc. 23). But, plaintiff asks the court to strike defendants' Reply because it includes a copy of what defendants assert is the application form for the insurance policy at issue. Doc. 24. This application, plaintiff alleges, falls outside the collection of materials that a federal court can consider on a motion to dismiss. The court discusses this issue first, and then addresses the merits of defendants' Motion to Dismiss. Ultimately, the court concludes that plaintiff has stated plausible claims and denies defendants' Motion to Dismiss.
I. Motion to Strike
Defendants attached the application form for the insurance policy at issue to their Reply in support of their Motion to Dismiss. Doc. 23-2. Plaintiff asks the court to strike defendants' Reply. While the court agrees with plaintiff that it cannot consider the application form when ruling on a 12(b)(6) motion, the court declines to strike defendants' Reply in its entirety. Instead, for reasons explained below, the court declines to consider the application form and any argument relying on it.
When considering a motion to dismiss under Rule 12(b)(6), the court generally "may not look beyond the four corners of the complaint." Am. Power Chassis, Inc. v. Jones , No. 13-4134-KHV,
The court agrees that the insurance policy itself is a document that is central to plaintiff's claim. Indeed, plaintiff already has attached the policy to the Complaint. But defendants ask the court also to consider the application form that led to the insurance policy. The court may not do so without converting the motion into a summary judgment motion. The application does not fall within any of the three exceptions recognized by the Tenth Circuit that permit a district court to consider a matter outside the pleadings without converting the motion into one seeking summary judgment. The Circuit has recognized *1107the following three exceptions to the four corners of the complaint rule: (1) "documents that the complaint incorporates by reference"; (2) "documents referred to in the complaint if the documents are central to the plaintiff's claim and the parties do not dispute the documents' authenticity"; and (3) matters "which a court may take judicial notice." Gee v. Pacheco ,
Defendants here do not argue that the application qualifies under any of the three exceptions. Doc. 25 at 1-3. Instead, defendants argue that the court should consider the application as part of the policy based on Kansas law.
With a different showing, the issue whether the court could consider the application for insurance would pose an interesting question. But the Kansas Administrative Regulation above and several Kansas case authorities require insurers to comply with that regulation before an application is part of an insurance policy. Here, nothing establishes that the application form qualifies for one of the limited exceptions to the rule against considering matters outside the pleadings. Also, defendants have not demonstrated that they complied with the Kansas regulation. The court thus cannot consider the application form as part of plaintiff's policy and, subsequently, when deciding defendants' Motion to Dismiss.
The court also declines to convert defendants' Motion into a motion for summary judgment. Several reasons support this outcome. First, none of the parties ask the court to convert the Motion in this fashion. See Geer ,
Finally, plaintiff asks the court to strike defendants' Reply in its entirety. Rather than striking the whole Reply, the court exercises its discretion and simply will disregard the application form and all arguments that reference it. See *1108Rezac Livestock Comm'n Co. v. Pinnacle Bank ,
II. Defendants' Motion to Dismiss (Doc. 14)
The court now turns to the substance of defendants' Motion to Dismiss (Doc. 14). Its analysis begins by identifying the operative facts governing defendants' motion.
A. Facts
The following facts come from plaintiff's Complaint (Doc. 1). The court accepts facts asserted by the Complaint as true and views them in the light most favorable to plaintiff. Burnett v. Mortg. Elec. Registration Sys., Inc. ,
Around April 1, 1993, plaintiff and his wife, Jerri Becher, met with an AARP agent and purchased an insurance policy titled "Plan B8." Plan B8 policies provide fixed daily benefits for specified hospital stays, intensive care unit stays, and outpatient hospital care (collectively called "covered events"). The Plan B8 policy was issued on April 1, 1993.
In the mid- to late-1990s, United began underwriting and administrating Plan B8 policies. Prudential underwrote and administered Plan B8 policies when it issued the policy at issue here. In the section of the Plan B8 policy titled, "Who is Covered," the policy provides: "The person or persons (the member and the spouse of the member) named above are covered from the Effective Date shown if the required premium contribution has been paid when due. The term you refers individually to each person named." Doc. 1-1 at 1. "Mrs. Jerri Becher" is named under the heading "issued to."
*1109From April 1993 to about October 2004, plaintiff and his wife paid a monthly premium of $ 36.25 in exchange for coverage under Plan B8. And from November 2004 to January 2016, plaintiff and his wife paid a monthly premium of $ 34.25. Those premiums added up to more than $ 9,500.
On January 20, 2016, plaintiff visited a hospital on an inpatient basis and was released the next day. After he was *1110released, plaintiff filed a claim with United, the claims administrator, requesting $ 69 as indemnification for the hospital stay.
Defendants now ask the court to dismiss plaintiff's Complaint under Rule 12(b)(6) on the same grounds-i.e. , the policy does not cover plaintiff. Doc. 14.
B. Legal Standard
Federal Rule of Civil Procedure 8(a)(2) requires a Complaint to contain "a short and plain statement of the claim showing that the pleader is entitled to relief." Although this rule "does not require 'detailed factual allegations,' " it demands more than "[a] pleading that offers 'labels and conclusions' or 'a formulaic recitation of the elements of a cause of action.' " Ashcroft v. Iqbal ,
For a complaint to survive a motion to dismiss under Rule 12(b)(6), the pleading "must contain sufficient factual matter, accepted as true, to 'state a claim for relief that is plausible on its face.' "
*1111When assessing whether a plaintiff has stated a plausible claim, the court must assume that the complaint's factual allegations are true. Iqbal ,
C. Analysis
Defendants contend that the insurance policy at issue did not cover plaintiff because the policy didn't name him as an insured. Indeed, only plaintiff's wife, Jerri Becher, is named on the policy. But plaintiff asserts that he is covered because the coverage provision includes the language, "(the member and the spouse of the member)." Doc. 1-1 at 1. This motion thus turns on whether plaintiff's interpretation of the insurance contract at issue here is plausible.
1. Choice of Law
First, the court must determine which state's contract law to apply to determine whether plaintiff's breach of contract and declaratory relief claims are plausible. Plaintiff has pleaded facts sufficient to establish that the court has diversity subject matter jurisdiction under
When a contractual dispute contests the "substance of [a party's contractual] obligation," Kansas courts apply the choice of law rule known as lex loci contractus , or "the law of the state where the contract is made." Moses v. Halstead ,
2. Contract Interpretation
a. Kansas law
Kansas law classifies contract interpretation and construction as issues of law that the court must decide. Kindergartners Count, Inc. v. DeMoulin ,
To determine whether the contract's language is ambiguous, a court first *1112must apply "pertinent rules of interpretation to the face of the instrument" and conclude that they "leave[ ] it genuinely uncertain which one of two or more meanings is the proper meaning." Liggatt v. Emp'rs Mut. Cas. Co. ,
"To determine whether an insurance contract is ambiguous ... the court must view the language as to what a reasonably prudent insured would understand the language to mean." City of Shawnee v. Argonaut Ins. Co. ,
b. The insurance contract
Here, defendants invoke five rules of contract interpretation trying to show plaintiff has not alleged facts sufficient to create a plausible inference that the policy covered him. Doc. 15 at 8-9; Doc. 23. They are: (1) reading the contract's plain language; (2) looking to the last antecedent rule; (3) harmonizing contract provisions; (4) avoiding superfluity; and (5) avoiding absurd results.
When it describes who is covered by the policy, the policy provides: "The person or persons (the member and the spouse of the member) named above are covered from the Effective Date shown if the required premium contribution has been paid when due. The term you refers individually to each person named." Doc. 1-1 at 1. Plaintiff does not argue that he is an individual "named above" on the policy; rather, his Complaint theorizes that the words inside the parenthetical-"the member and the spouse of the member"-presumptively cover him under the policy. In the alternative, the Complaint alleges, the insurance policy is ambiguous, and its content must be construed against the drafters-here, the defendants.
Defendants first argue that the parenthetical, given its plain meaning, merely modifies the person or persons named on the policy. They assert that the parenthetical provides an option for coverage rather than a requirement for who must be covered. Defendants contend that plaintiff has not alleged plausibly that the insurance policy covered him because he was not named as an insured under the policy. Conversely, as discussed above, plaintiff argues that the plain meaning of the parenthetical language presumptively covers him as an insured.
Next, defendants invoke the last antecedent rule. The rule provides:
In construing statutes, qualifying words, phrases and clauses are ordinarily confined to the last antecedent, or to the words and phrases immediately preceding. The last antecedent, within the meaning of this rule, has been regarded as the last word which can be made an antecedent without impairing the meaning of the sentence.
*1113Barten v. Turkey Creek Watershed Joint Dist. No. 32 ,
Third, the parties agree that Kansas law requires the court to "harmonize" contract language by "not constru[ing] ... [a contract's] paragraphs or clauses so as to make them conflict with each other," but rather, the court must "construe them so as to give to each and all their terms full force and operation." Cobb, Stribling & Co. v. Ins. Co. of N. Am. ,
Fourth, defendants argue interpreting the parenthetical language as a definition that presumptively covers plaintiff under the policy would render other provisions of the policy superfluous. For example, defendants contend, the policy provides that "[i]f the member dies, the spouse, if covered under the Group Policy, may elect to continue coverage by paying the required premium contribution." Doc. 1-1 at 5. Defendants argue that, if the parenthetical language were read to mandate coverage of the named insured's spouse, regardless of whether the spouse was named on the policy, the policy language "if covered under the Group Policy" would be unnecessary. But plaintiff asserts that the policy covers spouses presumptively with the words in the parenthetical, and a spouse would be entitled to continued coverage automatically under the policy.
Finally, the parties agree that Kansas law favors avoiding contract interpretations that "vitiate the purpose or reduce the terms of the contract to an absurdity." First Nat'l Bank of Olathe v. Clark ,
c. Defendants' Motion to Dismiss (Doc. 14)
Kansas law allows a beneficiary of an insurance policy to bring a breach of contract claim against the issuing insurer. Wunschel v. Transcontinental Ins. Co. ,
*1114Stechschulte v. Jennings ,
Here, the court can draw a "reasonable inference" that plaintiff is entitled to recover for defendants' alleged breach of the insurance contract. See Iqbal ,
Plaintiff alleges that Prudential underwrote and administered Plan B8 policies when it issued the policy in question. He alleges, on information and belief, that United began underwriting and administrating Plan B8 policies in the mid- to late-1990s. Also, plaintiff alleges that AARP acted as an agent of both United and Prudential, and vice versa. Doc. 1 at 2. He directs the court to the insurance policy document: the first page contains both AARP and Prudential's logos. Doc. 22 at 10. These alleged facts, plaintiff contends, are "sufficient ... to meet the definition of an implied agency under Kansas law, since the appearance of the Prudential and AARP logos is intended to give the viewer the perception that these organizations are behind the Policy."
The court agrees with plaintiff. These allegations go beyond a "conclusory" recitation of the elements of a breach of contract claim. And they do so for each of the three defendants. See Bixler ,
Finally, plaintiff seeks declaratory relief to establish his rights under the policy. Doc. 1 at ¶¶ 56-58. Plaintiff alleges that the policy, at a minimum, is ambiguous and should be interpreted against defendants. Id. at ¶ 56. And plaintiff seeks a declaration that the policy covers spouses of individuals named on the policy document. Id. at ¶ 58. Plaintiff asserts, based on the contract interpretation grounds discussed above, that he is covered under the policy, and defendants' actions continue to harm him. Doc. 22 at 9. Plaintiff also argues that defendants are "large, sophisticated actors" who can affect many individuals in Kansas and beyond. Id. He and the putative *1115class seek a declaration of their rights under the policy because there is an actual controversy with defendants about the policy's coverage terms. Id. ; see also Doc. 1 at ¶¶ 56-58.
Courts can "declare the rights and other legal relations of any interested party seeking such declaration, whether or not further relief is or could be sought."
III. Conclusion
For the reasons explained above, the court grants plaintiff's Motion to Strike (Doc. 24) in part and denies it in part, as set forth in this Order. The court also denies defendants' Motion to Dismiss (Doc. 14).
IT IS THEREFORE ORDERED BY THE COURT THAT plaintiff Thomas Becher's Motion to Strike (Doc. 24) is granted in part and denied in part.
IT IS FURTHER ORDERED THAT defendants United Healthcare Services, Inc., The Prudential Insurance Company of America, and AARP's Motion to Dismiss (Doc. 14) is denied.
IT IS SO ORDERED.
Defendants request oral argument on their Motion to Dismiss. Doc. 14 at 1. D. Kan. Rule 7.2 provides, "The court may set any motion for oral argument or hearing at the request of a party or on its own initiative." After considering the parties' written submissions, the court concludes that they explain the parties' positions effectively. The court thus concludes that oral argument would not assist its work, and it denies defendants' request.
The crux of the named plaintiff's immediate dispute arises from denial of a $ 69 claim for indemnification. Doc. 1 at 4 (Compl. ¶ 22). The Complaint claims that
Our Circuit has explained that the CAFA's "in controversy" term "traces it lineage all the way back to the Federal Judiciary Act of 1789" and, possibly, beyond. Hammond v. Stamps.com, Inc. ,
has never required a party seeking to invoke federal jurisdiction to show that damages "are greater" or will likely prove greater "than the requisite amount" specified by the statute. Instead, the term has required a party seeking federal jurisdiction to show only and much more modestly that "a fact finder might legally conclude" that damages exceed the statutory amount. As the Supreme Court has explained, to justify dismissal under this standard "it must appear to a legal certainty that the claim is really for less than the jurisdictional amount."
In short, the court is satisfied that the Complaint makes sufficient allegations to satisfy this modest standard at this stage of the case. The court does not prejudge any future jurisdictional concerns, however.
Case-law data current through December 31, 2025. Source: CourtListener bulk data.