Whiting v. Aarp, Civil Case No. 09-455(RJL).
| Decision Date | 28 March 2010 |
| Docket Number | Civil Case No. 09-455(RJL). |
| Citation | 701 F.Supp.2d 21 |
| Parties | Susan WHITING, Plaintiff,v.AARP and United Healthcare Insurance Company, Defendants. |
| Court | U.S. District Court — District of Columbia |
Stan M. Doerrer, Tracy Diana Rezvani, Finkelstein, Thompson LLP, Washington, DC, Lester L. Levy, Michele F. Raphael, Wolf Popper LLP, New York, NY, for Plaintiff.
William Dean Coston, Martin L. Saad, Venable, LLP, Kenneth Lee Blalack, II, Brian David Boyle, David J. Sandler, Michael Thakur, Scott M. Edson, O'Melveny & Myers LLP, Washington, DC, for Defendants.
Plaintiff, Susan Whiting (“Whiting”), brings this action against AARP and United HealthCare Insurance Company (“United HealthCare” and, together with AARP, “defendants”) alleging breach of contract, violation of the District of Columbia Consumer Protection Procedures Act (“CPPA”), and unjust enrichment. Currently before the Court are AARP's Motion to Dismiss Counts II, III, and IV of the Complaint for failure to state a claim upon which relief can be granted pursuant to Fed.R.Civ.P. 12(b)(6) and United Healthcare's Motion to Dismiss Counts I, II, and III of the Complaint, also pursuant to Rule 12(b)(6). Upon consideration of the parties' pleadings, relevant law, and the entire record herein, the Court GRANTS both defendants' motions.
Plaintiff is a resident of Arizona and a member of AARP. Compl. ¶ 6. In or around August 2007, Whiting received a letter signed by the Vice President of Member Services, AARP Health Care Options that described the AARP Medical Advantage Plan, which has been underwritten by United HealthCare since 2003 and characterized by the defendants as “an affordable alternative to major medical insurance.” Id. ¶¶ 11, 12, 14 see also Decl. of Scott M. Edson in Support of Def. United HealthCare Ins. Co.'s Mot. to Dismiss (“Edson Decl.”) Ex. A. 1 Indeed, in the letter that Whiting received in 2007, the AARP Medical Advantage Plan was described as suitable “if you're between jobs, retired early, or find yourself needing primary health insurance.” Compl. ¶ 14; see also Edson Decl. Ex. B. Enclosed with the letter were marketing materials for the plan that stated, the “AARP Medical Advantage Plan is not a major medical health plan, but is a good option if you need essential health benefits today at an affordable price.” Edson Decl. Ex. C. The marketing materials also acknowledged that AARP “is not the insurer” but instead “contracts with insurers to make coverage available to AARP members.” Id.
On September 12, 2007, at the age of 59, Whiting applied for the AARP Medical Advantage Plan and selected the Gold level of coverage. Compl. ¶ 20. She received a letter dated September 25, 2007, welcoming her to AARP Health Care Options and confirming her enrollment in the AARP Medical Advantage Plan. Id. ¶ 21. The Certificate of Insurance for the AARP Medical Advantage Plan was included with this letter. Id.
The first page of the Certificate of Insurance states, “Benefits are payable as shown in the Schedule of Benefits for” eight listed categories of medical costs, including Radiology Services and Laboratory/Pathology Services. Compl. ¶ 35. In a section entitled “WHAT IS COVERED,” the Certificate provides that “United HealthCare will pay the Applicable Benefit shown in the Schedule of Benefits for the following covered stays and services which are not otherwise excluded (see WHAT IS NOT COVERED).” Id. ¶ 39; Edson Decl. Ex. D at 5. The Certificate of Insurance then specifies what is covered in each of the eight listed categories of medical costs, including the two at issue in this case:
Edson Decl. Ex. D at 7 (italicized emphasis added); Compl. ¶ 39. The Certificate next identifies a series of exclusions under the heading “WHAT IS NOT COVERED,” including:
Inpatient Confinements That Are Not Covered-An inpatient Hospital confinement is not covered if the primary purpose of the confinement is to provide any of the following types of care: (1) care of the type provided in a clinic, rest home, convalescent home, home for the aged or assisted living center; (2) skilled nursing care; (3) intermediate care, extended care or custodial care; (4) residential care or care of the type provided in a domiciliary unit; (5) care of the type provided in a hospice; (6) care of the type provided in an Ambulatory Surgical Center or dialysis center; or (7) care consisting primarily of scheduled classes, training, education and/or recreation....
Edson Decl. Ex. D at 8; Compl. ¶ 42. The Certificate also included a Schedule of Benefits, which is a detailed list of the rates at which specific rates will be paid. Edson Decl. Ex. D at 12-17; Compl. ¶¶ 46-47. The first two pages of the Schedule of Benefits set forth the benefits payable under each of the eight categories of medical costs listed in the “WHAT IS COVERED” section. Edson Decl. Ex. D at 5, 12-13. For both the Radiology Benefit and the Laboratory/Pathology Benefit, the Schedule of Benefits refers to additional tables that more specifically enumerate the rates at which covered benefits will be paid. Id. at 17. The monthly premium for the Gold level of coverage was $247.00 for individuals ages 55 through 59 and $264.25 for individuals ages 60 through 64. Compl. ¶ 23. Whiting has timely paid her monthly premiums since her enrollment in the AARP Medical Advantage Plan. Id.
On September 23, 2008, Whiting was admitted to the emergency room at Banner Desert Medical Center (“Medical Center”) in Phoenix, Arizona, for medical problems later found to be related to her gall bladder. Compl. ¶ 24. She was admitted as an inpatient to the Medical Center from the emergency room the same day. Id. ¶ 25. On September 26, 2008, Whiting underwent surgery to remove her gall bladder. Id. ¶ 26. She was released from the hospital the following day. Id. ¶ 27.
On or about November 24, 2008, Whiting received a bill from the Medical Center in the amount of $44,368.95. Compl. ¶ 28. The bill included items related to her hospitalization, including room and board, pharmacy, drugs, supplies, laboratory/ pathology services, and radiology services. Id. United HealthCare paid $4500.00 of this bill, based on a rate of $1500.00 per day in the hospital. Id. ¶ 29. United HealthCare also paid separately for the surgeon who performed Whiting's surgery and for a total of ten physician visits in the Medical Center. Id. United HealthCare did not pay for, among other things, any laboratory/pathology services or radiology services, leaving the plaintiff with an outstanding bill of $39,868.95. Id. ¶ 30.
After United HealthCare refused to pay the remainder of her hospital bill, Whiting submitted claims to United HealthCare for the medical expenses she incurred, including the radiology and laboratory services. Compl. ¶ 31. In response to her claims, United HealthCare stated, “As the services by associated radiologists on 9/23/08-9/24/08 were performed in an inpatient setting, no benefits are payable.” Id. ¶ 32. She received a similar response to an inquiry she submitted on the AARP website: Id. ¶ 33 (alteration in original).
On March 5, 2009, plaintiff filed this suit as a purported class action against United HealthCare and AARP.2 Whiting asserts four causes of action: (1) breach of contract against United HealthCare only; (2) breach of a third-party contract against both United HealthCare and AARP; (3) violation of the CPPA against both United HealthCare and AARP; and (4) unjust enrichment against AARP only. Both defendants move to dismiss the counts filed against them.
Federal Rule of Civil Procedure 12(b)(6) provides that a district court shall dismiss a complaint for “failure to state a claim upon which relief can be granted.” Fed.R.Civ.P. 12(b)(6). Although all factual allegations in a complaint are assumed to be true when deciding a Rule 12(b)(6) motion, and all reasonable inferences are drawn in a plaintiff's favor, the Court need not accept either inferences “unsupported by the facts laid set out in the complaint” or “legal conclusions cast in the form of factual allegations.” Kowal v. MCI Commc'ns Corp., 16 F.3d 1271, 1276 (D.C.Cir.1994). “While a complaint attacked by a Rule 12(b)(6) motion to dismiss does not need detailed factual allegations, a plaintiff's 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.” Bell Atl. Corp. v. Twombly, 550 U.S. 544, 555, 127 S.Ct. 1955, 167 L.Ed.2d 929 (2007) (alteration in original) (citations and internal quotation marks omitted). To survive a motion to dismiss, a complaint must contain sufficient factual...
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