United States District Court, D. Connecticut
PRICEWATERHOUSECOOPERS LLP HEALTH AND WELFARE BENEFITS PLAN, Plaintiff,
ARTHUR A. MAYER and JAMES O. GASTON, Defendants.
RULING ON MOTION TO DISMISS
A. BOLDEN UNITED STATES DISTRICT JUDGE.
LLP Health and Welfare Benefits Plan (“PWC”)
brings this action against Arthur Mayer and his personal
injury attorney, James O. Gaston, under the Employee
Retirement Income Security Act of 1974, as amended, 29 U.S.C.
§§ 1001, et seq. (“ERISA”) for
health insurance reimbursement. Mr. Gaston moves to dismiss
because PWC failed to state a claim upon which relief can be
granted. Motion to Dismiss, ECF No. 19 (“ECF No.
following reasons, the Court DENIES Mr.
Gaston's motion to dismiss.
FACTUAL AND PROCEDURAL BACKGROUND
a self-funded employee welfare benefit plan under 29 U.S.C.
§ 1001. Am. Compl., ECF No. 14. PWC covered Mr. Mayer.
Id. at ¶ 5. The PWC Summary Plan
Description gives full rights to PWC to recover from
employees or dependents for the cost of health benefits paid
on their behalf under the PWC health plan. Id. at
¶ 8. The plan description states in pertinent
TO SUBROGATION/THIRD PARTY RECOVERY
You shall cooperate with PWC and its agents in a timely
manner to protect its legal and equitable rights to
subrogation and reimbursement.
If a third party may be liable for a covered medical expense
that you or your Dependent have incurred, the Plan has a
right of subrogation to any claim that you or your Dependent
have against the third party. The Plan will then be entitled
to be paid back from any amount that you or your Dependent
recover against the third party for any expenses that the
Plan has had, and the recipient of any such recovered amounts
shall hold the funds in constructive trust for the Plan. The
Plan has a right of reimbursement against any recovery by you
or your Dependents from a third party. No. court costs or
attorneys' fees may be deducted from the Plan's
recovery without the Plan's express written consent and
the Plan is not required to participate in or pay court costs
or attorneys' fees to the attorney hired by you or your
Dependents to pursue damages or personal injury claims. No.
so-called "fund doctrine" or "common fund
doctrine" right shall defeat the Plan's rights.
Regardless of whether you or your Dependents have been fully
compensated or made whole, the Plan may collect from you or
your Dependents the proceeds of any full or partial recovery
that you or your Dependents or legal representative obtain,
whether in the form of a settlement (either before or after
any determination of liability) or judgment. The proceeds
available for collection by PWC shall include, but not be
limited to, any and all amounts whether designated in any
settlement or judgment as economic damages, noneconomic
damage, punitive damages, attorneys' fees or otherwise.
You shall not, without PWC's written consent, settle any
claim for an amount less than the amount that PWC has paid or
advanced on your behalf.
11, 2015, Mr. Mayer suffered injuries in a motor vehicle
accident. Id. at ¶ 9. PWC spent $44, 167.59 for
Mr. Mayer's health care in connection with those
Gaston represented Mr. Mayer in the civil action arising from
Mr. Mayer's accident in Connecticut Superior Court
(“Mayer Litigation”). Id. at
¶ 6. Before the Mayer litigation settled, PWC
allegedly gave notice to Mr. Mayer, through Mr. Gaston, of
PWC's right of subrogation and reimbursement from all
proceeds of payment, settlement, or judgment in the
Mayer Litigation. Id. at ¶ 12. PWC
alleges that Mr. Gaston settled the Mayer Litigation
for at least $250, 000. Id. at ¶ 11. The
Amended Complaint also alleges that Mr. Gaston holds or has
disbursed part of the proceeds of the Mayer
Litigation to himself while no payment has been to PWC.
Id. at ¶ 13-14.