Devito v. Aetna, Inc.

• Decision Date: 25 February 2008
• Docket Number: Civil Case No. 07-0418(FSH).
• Citation: 536 F.Supp.2d 523
• Parties: DeVITO et al., Plaintiffs, v. AETNA, INC. et al., Defendants.
• Court: U.S. District Court — District of New Jersey

Page 523

536 F.Supp.2d 523

DeVITO et al., Plaintiffs, v. AETNA, INC. et al., Defendants.

Civil Case No. 07-0418(FSH).

United States District Court, D. New Jersey.

February 25, 2008.

Bruce H. Nagel, Randee M. Matloff, Nagel Rice, LLP, Roseland, NJ, for Plaintiffs.

Lisa M. Walsh, Tricia B. O'Reilly, Patricia A. Lee, Connell Foley LLP, Roseland, NJ, Edward Wardell, Kelly, Wardell, Craig, Annin & Baxter, Haddonfield, NJ, for Defendants.

ORDER and OPINION

HOCHBERG, District Judge.

This matter is before the Court upon Defendants' (collectively "Aetna") Motion to Dismiss Plaintiffs' First Amended Complaint (DKT# 58). The Court has jurisdiction over this matter pursuant to 28 U.S.C. § 1331. Plaintiffs also assert jurisdiction under the Class Action Fairness Act, 28 U.S.C. § 1332(d)(2)(A) because the amount in controversy allegedly exceeds $5 million and a member of the Plaintiff Class is a citizen of a state different from any Defendant. The Court has considered the arguments of the parties on the papers pursuant to Federal Rule of Civil Procedure 78.

I. FACTS

Named Plaintiffs DeVito and Meiskin are New Jersey residents covered by insurance policies issued by Aetna and governed by ERISA. See First Amended Complaint (DKT# 46) ("Compl.") ¶¶ 4; 5. Both Plaintiffs have daughters who suffer from eating disorders and both Plaintiffs have sought coverage for treatment their daughters' eating disorders under their respective insurance policies. Plaintiff DeVito sought coverage for treatment of eating disorders, which, on at least One occasion, Defendants denied as "not medically necessary." Plaintiff Meiskin sought and was provided benefits for treatment of his daughter's, eating disorders, but coverage was cut off, when it exceeded the contractual limitations for coverage of non-Biologically Based Mental Illnesses ("BBMI"). The gravamen of Plaintiffs' claims is that Aetna improperly denied coverage for treatment sought for their daughters' eating disorders by improperly classifying eating disorders as "non-Biologically Based Mental Illnesses." In so doing, Plaintiffs allege that Defendants breached their insurance contracts, violated their fiduciary duties, and denied Plaintiffs benefits to which they are entitled.

Plaintiffs' claims are based upon the language of their respective insurance policies. Both policies contain identical language regarding coverage for Biologically-Based Mental Illnesses:

BENEFITS FOR BIOLOGICALLY BASED MENTAL ILLNESS OR ALCOHOL ABUSE. We cover treatment of. Biologically-based Mental Illness or Alcohol Abuse the same way We would for any other illness, if such treatment is prescribed by a Network Provider upon prior written Referral by a Member's Primary Care Physician.

Petrozelli Cert. (DKT# 6) Ex. A (DeVito policy) at 44; Ex. B (Meiskin Policy) at 39. Both policies define BBMIs in the same way:¹ BIOLOGICALLY-BASED MENTAL ILLNESS. A mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but note limited to: schizophrenia; schizoaffective disorder; major depressive disorder; bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder; panic disorder and pervasive developmental disorder or autism.

Id. Ex. A (DeVito policy) at 10; Ex. B (Meiskin Policy) at 7.

Both policies also contain identical clauses limiting coverage for treatment of non-BBMIs to "twenty (20) outpatient visits per Calendar Year ... [and] up to thirty (30) days of inpatient care benefits for ... Non-Biologically-based Mental Illnesses." Id. Ex. A (DeVito policy) at 43; Ex. B (Meiskin Policy) at 39. Plaintiffs' policies also provide for "up to sixty (60) more outpatient visits by exchanging one or more of the inpatient hospital days...." Id. Both policies define non-BBMIs in the same way:²

NON-BIOLOGICALLY-BASED MENTAL ILLNESS. An Illness which manifests symptoms which are primarily mental or nervous for which the primary treatment is psychotherapy or psychotropic medication where the Illness is not biologically-based.

In determining whether or not a particular condition is a Non-Biologically-based Mental Illness, We may refer to the current edition of the Diagnostic and Statistical Manual of Mental Conditions of the American Psychiatric Association.

Id. Ex. A (DeVito policy) at 17-18; Ex. B (Meiskin Policy) at 14.

Plaintiffs concede that neither DeVito nor Meiskin fully exhausted Aetna's internal appeals procedure as to each of their claims for benefits prior to filing this suit. On January 26, 2007 Plaintiffs filed a Complaint in this Court. The Court held oral argument on October 10, 2007 on Defendants' motion to dismiss Plaintiffs' original complaint,³ during which Plaintiffs were granted leave to amend their complaint. The Amended Complaint that is the subject of the present motion to dismiss was filed on October 29, 2007. Defendants filed the instant Motion to Dismiss the First Amended Complaint on. November 30, 2007. Defendants first argue that the Court should abstain from considering Plaintiffs' claims under the doctrine expounded in Burford v. Sun Oil Co., 319 U.S. 315, 63 S.Ct. 1098, 87 L.Ed. 1424 (1943). Defendants argue in the alternative that Plaintiffs' state law claims under New Jersey's Mental Health Parity Law should be dismissed as preempted by ERISA and that all counts should be dismissed for failure to exhaust and for failure to state a claim upon which relief can be granted.

II. STANDARD

In a motion to dismiss "[w]e are required to accept as true all factual allegations in the complaint and draw all inferences from the facts alleged the light most favorable to the plaintiff." Haspel State Farm Mut. Auto. Ins. Co., 241 Fed. Appx. 837, 839 (3d Cir.2007). A complaint must plead "only enough facts to state a claim to relief that is plausible on its face." Bell Atlantic Corp. v. Twombly, ___ U.S. ___, 127 S.Ct. 1955, 1974, 167 L.Ed.2d 929 (2007). "While a complaint attacked by a Rule 12(b)(6) motion to dismiss does not need detailed factual allegations, a plaintiffs obligation to provide the grounds' of his entitle[ment] to relief requires more than labels and conclusions, and a formulaic recitation of the elements of a cause of, action will not do." Id. at 1964-65 (internal citations omitted). To survive a motion to dismiss, the factual allegations in the complaint must "contain either direct or inferential allegations respecting all the material elements necessary to sustain recovery under some viable legal theory." Id. at 1969 (quoting Car Carriers, Inc. V. Ford Motor Co., 745 F2d 1101, 1106 (7th Cir.1984)).

III. DISCUSSION

At the outset it is critical to clarify the issues presented by, Plaintiffs' Complaint. Plaintiffs do not challenge New Jersey's Parity Law. See N.J. STAT. ANN. § 26:2J-4.20. Rather, Plaintiffs challenge Defendant Aetna's handling of Plaintiffs' benefit claims under the contractual terms of Plaintiffs' respective insurance policies. See Compl. ¶¶ 11 (Count One) ("Aetna has breached its contract of insurance with plaintiffs and all class members...."), 23 (Count Two) ("By failing to provide coverage for all treatment and care relating to Eating Disorders, Aetna breached their contracts with plaintiffs and the class in violation of ERISA."). Although certain definitions in Plaintiffs' insurance contracts are substantially similar to some contained in the Parity Law, the claims before the court concern Aetna's interpretation of the contractual language as applied to each Plaintiff. Plaintiffs, in essence, contend that their eating disorders should have been handled as Biologically Based Mental Illnesses and covered under the policy provisions that apply to BBMIs. "The denial of "benefits by an ERISA plan administrator or fiduciary is reviewed under the arbitrary and capricious standard." Brandeburg v. Corning Inc. Pension Plan for Hourly Employees, 243 Fed.Appx. 671, 672-73 (3d Cir.2007); see also Pinto v. Reliance Standard Life Ins. Co., 214 F.3d 377, 393 (3d Cir.2000) (adopting sliding scale to determine level of scrutiny in arbitrary and capricious review).

A. Burford Abstention

Defendants first argue that the Court should abstain under the doctrine expounded in Burford v. Sun Oil Co., 319 U.S. 315, 63 S.Ct. 1098, 87 L.Ed. 1424 (1943), and should instead defer to the "primary jurisdiction" of the New Jersey Department of Business and Insurance ("DOBI"). Under Burford, the Court undertakes a two-step analysis. "The first question [when considering Burford, abstention] is, whether `timely and adequate state-court review' is available." Riley v. Simmons, 45 F.3d 764, 771 (3d Cir.1995) (citing New Orleans Public Service, Inc. v. Council of City of New Orleans, 491 U.S. 350, 361, 109 S.Ct: 2506, 105 L.Ed.2d 298 (1989) ("NOPSI")). The second prong of the Burford doctrine, as refined in NOPSI, requires a court to examine three issues: "(1) whether the particular regulatory scheme involves a matter of substantial public concern, (2) whether it is the sort of complex, technical regulatory scheme to which the Burford abstention doctrine usually is applied, and (3) whether federal review of a party's claims would interfere with the state's efforts to establish and maintain a coherent regulatory policy." Chiropractic Am. v. Lavecchia, 180 F.3d 99, 105 (3d Cir.1999) (internal citation omitted). "Federal courts more readily abstain from a case that contains no issue of federal law." Lac D'Amiante du Quebec, Ltee v. Am. Home Assur. Co., 864 F.2d 1033, 1044 (3d Cir.1988).

Defendants' arguments focus on Burford's second step. Defendants note that a "legislative solution," which would prospectively extend Parity Law coverage to eating disorders, has passed the New Jersey Senate and is currently pending before the New Jersey Assembly. Defendants argue that this pending leg...