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Bland v. Exxonmobil Medical Plan

United States District Court, D. Colorado

August 6, 2018

BRANDIN BLAND and CRAIG HOSPITAL Plaintiffs,
v.
EXXONMOBIL MEDICAL PLAN, an Employee Welfare Benefit Plan, and AETNA LIFE INSURANCE COMPANY, Defendants.

          RECOMMENDATION REGARDING DEFENDANTS' MOTION TO DISMISS

          GORDON P. GALLAGHER UNITED STATES MAGISTRATE JUDGE.

         This matter comes before the Court on Defendants' motion to dismiss (ECF # 19), [1]Plaintiffs' response (ECF# 47) and Defendants' reply (ECF #50). The motion has been referred to this Magistrate Judge for recommendation (ECF #24).[2] The Court has reviewed the pending motion, response, reply and all attachments. The Court has also considered the entire case file, the applicable law, and is sufficiently advised in the premises. Oral argument has not been requested and the Court finds that it is not necessary in this circumstance. This Magistrate Judge recommends that the motion be GRANTED in-part and DENIED in-part.

         Plaintiffs sole claim for relief is an enforcement action under 29 U.S.C. §1132(a)(1)(B), the Employee Retirement Income Security Act (ERISA) (ECF #1, p. 3). Plaintiff Bland, following a terrible automobile accident on the Western Slope, was ultimately a patient at Craig Hospital[3] (ECF #1, p. 3, paras. 13-14). Plaintiff Bland was admitted to Craig Hospital on 5/9/16. Id. at p. 3, para. 15. As set forth, Aetna Life Insurance Company (Aetna), “is the claims fiduciary and claims administrator for the mandatory appeals under the medical plan at issue.” Id. at p .2, para. 5. This involves an ExxonMobil Medical Plan (Plan). Id. at p. 2, para. 6.

         Plaintiff states that “[o]n or about July 18, 2016, Aetna issued two (2) denials on behalf of the Plan.” Id. at p. 3, para. 17. Plaintiff claims that Aetna denied a transfer of Plaintiff Bland to Quality Living on the basis that care could be provided on an outpatient basis. Id. at p. 3, para. 18. A second denial was for continued inpatient care at Craig Hospital. Id. at p. 4, para. 20.

         Quality Living Denial

         Plaintiffs assert that the first denial, the Quality Living denial, was appealed on an expedited basis on July 19, 2016, pro se. Id. at p. 4, para. 21. That appeal was denied July, 20, 2016. Id. at p. 4, para. 22. An expedited voluntary second level appeal of the Quality Living denial occurred on August 18, 2016. Id. at p. 4, para. 23. Plaintiffs assert that, rather than rule on the voluntary second level appeal, “Defendants issued a revised first level appeal decision letter, omitting, among other things, information regarding Bland's right to submit a voluntary second level appeal.” Id. at pp. 4-5, para 24. Plaintiffs confess that the Quality Living Denial is precluded by the one year “contractual state of limitations” and indicate that they “are not seeking benefits for Brand's transfer to QLI because Brandin was placed in an alternate facility that was paid for by Colorado Medicaid.” Plaintiffs' response (ECF #47, p. 13).

         Continued Inpatient Care Denial

         Plaintiffs assert that the inpatient care denial was appealed on January 12, 2017. Id. at p. 5, para. 25. There is some further dispute over when Defendants received the January 12, 2017 appeal and an assertion that no determination was ever rendered on the January 12, 2017 appeal. See ECF #1, pp. 5-6, paras. 26, 28, 29, 30, &31.

         Suit was filed December 15, 2017. Id.

         Plaintiffs claim that Aetna's original denials of both initial appeals, dated June 18, 2016, were “unreasonable, arbitrary and capricious.” Id. at p. 7, para. 33. Plaintiffs claim that Defendants failed to: (1) make a determination regarding the voluntary second level appeal as to Quality Living; (2) make a determination as to the mandatory appeal on the continued care matter; and (3) provide certain mandatory information pursuant to 29 CFR § 2560.503-1(m)(8) which was requested on July 28, 2016 and August 9, 2016. Id. at p. 7, para. 34. Plaintiffs also claim exhaustion of administrative remedies has occurred. Id. at p. 7, para. 36.

         Standard of Review

         The Court may dismiss a complaint for failure to state a claim upon which relief can be granted. Fed.R.Civ.P. 12(b)(6). Dismissal under Rule 12(b)(6) may also be based on the lack of a cognizable legal theory. See Golan v. Ashcroft, 310 F.Supp.2d 1215, 1217 (D. Colo. 2004). To withstand a Rule 12(b)(6) motion to dismiss, a complaint must contain enough allegations of fact, which, taken as true, “state a claim to relief that is plausible on its face.” Bell Atlantic Corp. v. Twombly, 550 U.S. 544, 570 (2007); Khalik v. United Air Lines, 671 F.3d 1188, 1190 (10th Cir. 2012). Although allegations of fact are accepted as true, legal conclusions are not. Ashcroft v. Iqbal, 556 U.S. 662, 678-79 (2009). Mere “labels and conclusions” and “a formulaic recitation of the elements of a cause of action” will not suffice. Twombly, 550 U.S. at 555. “Factual allegations must be enough to raise a right to relief above the speculative level.” Id. Accordingly, the Court disregards conclusory statements and looks only to whether the remaining factual allegations plausibly suggest the defendant is liable. Khalik, 671 F.3d at 1190-91.

         Where the allegations in a complaint “are so general that they encompass a wide swath of conduct, much of it innocent, then the plaintiffs have not nudged their claims across the line from conceivable to plausible.” Robbins v. Oklahoma, 519 F.3d 1242, 1247 (10th Cir. 2008) (internal quotations omitted) (“The nature and specificity of the allegations required to state a plausible claim will vary based on context . . . [and] requires the reviewing court to draw on its judicial experience and common sense.” Kansas Penn Gaming, LLC v. Collins, 656 F.3d 1210, 1214-15 (10th Cir. 2011)).

“The mere metaphysical possibility that some plaintiff could prove some set of facts in support of the pleaded claims is insufficient; the complaint must give the court reason to believe this plaintiff has a reasonable likelihood of mustering factual support for these claims.” Ridge at Red Hawk, L.L.C. ...

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