O'Dowd v. Anthem Health Plans, Inc.
| Decision Date | 30 September 2015 |
| Docket Number | Civil Action No. 14-cv-02787-KLM |
| Parties | LAURAL O'DOWD, for herself and all others similarly situated, Plaintiff, v. ANTHEM HEALTH PLANS, INC., doing business as Anthem Blue Cross and Blue Shield, ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC., doing business as Anthem Blue Cross and Blue Shield, and WELLPOINT, INC., Defendants. |
| Court | U.S. District Court — District of Colorado |
ENTERED BY MAGISTRATE JUDGE KRISTEN L. MIX
This matter is before the Court1 on Defendant Rocky Mountain Hospital and Medical Service, Inc. d/b/a Anthem Blue Cross and Blue Shield's ("Anthem") Motion to Dismiss Amended Complaint in Part [#29]2 (the "Motion"). Plaintiff filed a Response [#33] and Defendant Anthem filed a Reply [#34] in further support of the Motion. The Court has reviewed the Motion, the Response, the Reply, the entire docket, and the applicable law, and is sufficiently advised in the premises. For the reasons set forth below, the Motion [#29] is GRANTED in part and DENIED in part.
Plaintiff3 asserts four claims against Defendant Anthem relating to reimbursement provided by Anthem for psychiatric care under her medical insurance policy. Plaintiff alleges that she was responsible for paying the charges associated with her out-of-network psychiatric care that exceeded the Maximum Allowable Amount paid by Defendant Anthem under the policy. Am. Compl. [#27] ¶ 16. Plaintiff maintains that her husband also received care from a different out-of-network psychiatrist.4 Id. ¶ 15. Plaintiff alleges that the Maximum Allowable Amount for each of the two out-of-network doctors was not the same even though the two doctors provided the same psychiatric services as evidenced by the Current Procedural Terminology ("CPT") codes in their billings. Id. ¶¶ 17-20. Plaintiff alleges that Defendant Anthem's "varying reimbursement rate was not based on quality or performance measures." Id. ¶ 20. Plaintiff maintains that one of the out-of-network providers was incorrectly listed in Anthem's database as a primary care physician and that Defendant Anthem's "system of reimbursement results in different rates being applied to substantially identical services" when performed by a primary care physician or a psychiatrist. Id. ¶ 21. In short, according to Plaintiff, "licensed mental health professionals are reimbursed at lower rates than professionals who are licensed to treat physical illness,even though the latter are providing the same services . . . ." Id. § 31. "These mental health professionals then balance bill their patients to make up for the lower reimbursement rate." Id. As a result, Plaintiff brings the following claims against Defendant Anthem: (1) a claim seeking a declaratory judgment that Defendant Anthem violated Colo. Rev. Stat. §§ 10-16-704, 10-16-104, and 10-16-107.7; (2) a claim seeking injunctive relief under ERISA5, 29 U.S.C. § 1132(a)(3); (3) a claim for payment of benefits and associated interest under ERISA, 29 U.S.C. § 1132(a)(1)(B); and (4) a breach of fiduciary duty claim that mentions 29 U.S.C. §§ 1002 and 1104. Id. §§ 41-68.
In the Motion, Defendant Anthem argues that Plaintiff's second and fourth claims should be dismissed in their entirety and that the first and third claims are subject to dismissal in part. Motion [#29] at 1-3. With regard to Plaintiff's second claim, Defendant Anthem argues that this claim must be dismissed because (1) 29 U.S.C. § 1132(a)(1)(B) provides the exclusive remedy for Plaintiff's claim and (2) this claim is based on an alleged violation of Colo. Rev. Stat. § 10-16-104(7), which was repealed effective January 1, 2014. Id. at 8-9. With regard to Plaintiff's fourth claim, Defendant Anthem argues that this claim is subject to dismissal because (1) it is duplicative of Plaintiff's second claim, (2) it fails to set forth colorable allegations of harm to the plan itself, and (3) Plaintiff does not allege that Defendant Anthem has discretion in determining reimbursement amounts for mental health services. Id. at 9-13. Defendant Anthem avers that all of Plaintiff's claims should be dismissed to the extent they are based on alleged violations of Colo. Rev. Stat. § 10-16-104and Colo. Rev. Stat. § 10-16-704. Id. at 13-14. Defendant Anthem further argues that Plaintiff's first claim should be dismissed to the extent it is brought under any law other than 29 U.S.C. § 1132(a)(1)(B) because this statute provides Plaintiff's exclusive remedy for the alleged harm. Id. at 15-16.
In the Response, Plaintiff maintains that Defendant Anthem's argument that 29 U.S.C. § 1132(a)(1)(B) provides the exclusive remedy for her claims and that therefore her second and fourth claims should be dismissed would unfairly prejudice her. Response [#33] at 3-4. Specifically, Plaintiff maintains that "it is possible that there may be a determination on the merits that § 1132(a)(1)(B) does not provide relief in this case" and, as a result, "Plaintiff would be unable to seek equitable relief if the § 1132(a)(3) claim is prematurely dismissed . . . ." Id. at 4. Plaintiff avers that "it is premature to dismiss adequately pled claims seeking alternative forms of relief." Id. at 5. Plaintiff also argues at length that 29 U.S.C. § 1132(a)(3) "includes those forms of relief that were traditionally available in equity," and that she should therefore be able to pursue injunctive relief. Id. at 5-8. Plaintiff next argues that even if Colo. Rev. Stat. § 10-16-104(7) was repealed, "the legislature provided that existing plans remained subject to all preexisting provisions, including" Colo. Rev. Stat. § 10-16-104(7). Id. at 9; id. at 10-12 (). With regard to Colo. Rev. Stat. § 10-16-107.7, Plaintiff argues that this statute only allows reimbursement rates to vary among medical providers based on quality or performance measures. Id. With regard to her second claim, Plaintiff further argues that she is not seeking identical relief under 29 U.S.C. § 1132(a)(1)(B) and § 1132(a)(3). Id. at 12. With regard to her fourth claim, Plaintiff avers that she has adequately stated a breach of fiduciary duty claim. Id. at 13-16. Finally, Plaintiff argues that her first claim should notbe dismissed in part, as argued by Defendant Anthem, because "the Colorado statutes at issue are not preempted." Id. at 16-17. With regard to Defendant Anthem's argument that all claims are subject to dismissal to the extent that they are based on alleged violations of Colo. Rev. Stat. §§ 10-16-104 and 10-16-704, Motion [#29] at 13-14, Plaintiff states that she "is not seeking relief under [Colo. Rev. Stat.] § 10-16-704." Response [#33] at 16.
In its Reply, Defendant Anthem revisits its argument that Plaintiff's second claim is subject to dismissal because it is duplicative of her claim based on 29 U.S.C. § 1132(a)(1)(B) and provides additional legal support for its position. Reply [#34] at 2-3. Defendant Anthem also distinguishes CIGNA Corp. v. Amara, 131 S.Ct. 1866 (2011), a case relied on by Plaintiff. Id. at 3-4. Defendant Anthem further argues that Plaintiff introduces a new theory of liability—unjust enrichment—in her Response that is not included in her Amended Complaint. Id. at 5-7. Defendant Anthem avers that Plaintiff's argument that she should be allowed to plead alternative bases for relief does not save her second claim because the claims are not alternative or inconsistent, but rather "entirely duplicative." Id. at 7-8. With regard to Plaintiff's argument that the repeal of Colo. Rev. Stat. § 10-16-104(7) does not moot her claim, Defendant Anthem maintains that "the new statute is not sufficiently similar to the repealed one to avoid mootness." Id. at 9. As a result, Defendant Anthem argues that Plaintiff's request for an injunction must be dismissed as moot. Id. Defendant Anthem further notes that the Amended Complaint "focuses on claims reimbursed prior to July 2012," which pre-dates the newly enacted statute, Colo. Rev. Stat. § 10-16-107.7, and that Plaintiff did not seek an injunction barring future violations of the new statute in her Amended Complaint. Id. at 10. Defendant Anthem then revisits its argument that Plaintiff's fourth claim for breach of fiduciary duty should bedismissed for failure to state a claim. Id. at 10-14. Defendant Anthem further argues that "to the extent [it is] brought under 1132(a)(2)," this claim "fails because it is not brought on behalf of the plan." Id. at 14. Defendant Anthem then reiterates its argument that all of Plaintiff's claims should be dismissed in part to the extent they are premised on Colo. Rev. Stat. §§ 10-16-704 and 10-16-104(5.5(a)(1). Id. at 15-16. Finally, Defendant Anthem revisits its argument that Plaintiff's first claim should be dismissed to the extent it is brought under any law other than 29 U.S.C. § 1132(a)(1)(B) because this statute provides the exclusive remedy. Id. at 16-17.
The Court has jurisdiction over this case pursuant to 28 U.S.C. § 1331.
The purpose of a motion to dismiss pursuant to Federal Rule of Civil Procedure 12(b)(6) is to test "the sufficiency of the allegations within the four corners of the complaint after taking those allegations as true." Mobley v. McCormick, 40 F.3d 337, 340 (10th Cir. 1994); Fed R. Civ. P. 12(b)(6) (). "The court's function on a Rule 12(b)(6) motion is not to weigh potential evidence that the parties might present at trial, but to assess whether the plaintiff's complaint alone is legally sufficient to state a claim for which relief may be granted." Sutton v. Utah State Sch. for the Deaf & Blind, 173 F.3d 1226, 1236 (10th Cir. 1999) (citation omitted). To withstand a motion to dismiss pursuant to Federal Rule of Civil Procedure 12(b)(6), "a complaint must contain enough allegations of fact 'to state a claim to...
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