United States District Court, D. Connecticut
ESTATE OF CAROL A. KENYON, Plaintiff,
L M HEALTHCARE HEALTH REIMBURSEMENT ACCOUNT et al., Defendants.
ORDER GRANTING MOTIONS TO DISMISS
Jeffrey Alker Meyer, United States District Judge.
Kenyon needed an emergency medical flight from Puerto Rico to
Florida. So she contacted an air ambulance operator, who in
turn contacted her insurer, who in turn stated that the
flight was a covered benefit. The air ambulance then flew
Kenyon to Florida. Several months later, it turned out that
Kenyon's insurer was only willing to pay about 5% of the
air ambulance bill.
estate now seeks to recover what it claims are the benefits
owed to her under her insurance policy. It has asserted
claims under both the federal Employee Retirement Income
Security Act (“ERISA”), and for promissory
estoppel under Connecticut state law. The defendants have
moved to dismiss most of the claims, alleging that they are
not properly pleaded against them and preemption. I agree
with defendants' arguments and will therefore dismiss
Count One as to defendant Triple S Blue Card and Counts Two,
Three, and Four against all defendants. This case shall
proceed solely on the estate's claim under Count One
against the remaining defendants for wrongful denial of ERISA
following facts as alleged by the plaintiff in the complaint
are accepted as true for purposes of ruling on
defendants' motion to dismiss. Doc. #1. Plaintiff the
estate of Carol Kenyon is the insured and named beneficiary
of the L M Healthcare Health Reimbursement Account ERISA
insurance plan. Doc. #1 at 2 (¶¶ 1, 2). Defendant
L&M Healthcare was Kenyon's employer, id. at
5-6 (¶ 28), and is a Connecticut company that sponsors
the plan and is ultimately responsible for paying claims
under the plan. Id. at 2 (¶ 6). Defendant
Anthem Blue Cross Blue Shield is the plan administrator.
Ibid. (¶ 2). Anthem is also the designated
claims administrator for the plan. Ibid. (¶ 4).
Defendant Triple S Blue Card is a Puerto Rico company.
Ibid. (¶ 5). The estate alleges that the plan
designated Triple S as the entity “to decide the appeal
of the denial of benefits at issue in this matter, ”
and that Triple S “participated in and approved the
decision-making process and failed to process the appeal of
the denial at issue in this matter.” Ibid.
March 13, 2017, non-party CustomAir Ambulance was contacted
about carrying Kenyon on an emergency medical flight.
Id. at 3-4 (¶¶ 12-13). CustomAir became
Kenyon's agent in obtaining reimbursement for the flight,
ibid. (¶ 12), and received preapproval from
Anthem to provide the flight as a medically necessary covered
benefit under Kenyon's plan. Id. at 4
(¶¶ 14-15). CustomAir relied on this information to
fly Kenyon from Puerto Rico to Florida on March 16.
Ibid. (¶¶ 16-17).
then submitted a claim for benefits, billing the plan the
customary and reasonable amount of $437, 320. Ibid.
(¶¶ 18-19). On September 5, the plan issued an
explanation of benefits that “substantially denied the
claim” and reimbursed CustomAir for only $20, 300.
Ibid. (¶ 20).
working on behalf of Kenyon, CustomAir appealed. Id.
at 5 (¶ 23). Apparently working on the basis of the
“Summary Plan Description, ” which the complaint
alleges “states that out-of-area appeals should be
handled by the [Blue Cross] provider that initiated the
service, ” ibid. (¶ 24), CustomAir first
appealed to Triple S on November 28. Ibid.
(¶¶ 23-24). Triple S refused to consider the appeal
because it had not adjusted the original claim.
Ibid. (¶ 24). An appeal was then made to Anthem
on December 5. Ibid. (¶¶ 23, 25).
CustomAir followed up after Anthem had not responded within
60 days, and was advised that Anthem would not process the
appeal. Ibid. (¶ 25). CustomAir then contacted
an Anthem vice president, who referred CustomAir to
Anthem's risk management division. Ibid. (¶
25). Anthem's risk management division also did not
process the appeal. Ibid. (¶ 26).
Kenyon's estate filed suit against the plan, Anthem,
Triple S, and L&M Healthcare. Doc. #1. The estate has
asserted claims for wrongful denial of benefits under ERISA,
id. at 7 (¶¶ 40-47) (Count One), breach of
fiduciary duty under ERISA, id. at 7-8 (¶¶
48-43) (Count Two), equitable estoppel under the federal
common law of ERISA, id. at 8-9 (¶¶ 44-51)
(Count Three), and promissory estoppel under Connecticut
common law, id. at 9-10 (¶¶ 52-57) (Count
Four). Triple S has moved to dismiss Count One on the ground
that it is an improper ERISA defendant. Doc. #36-1 at 1. The
remaining defendants have moved to dismiss Counts Two, Three,
and Four on the ground that they are inadequately pleaded
and, in the case of Count Four, preempted by ERISA. Doc.
#26-1 at 1, 9. The estate has consented to the dismissal of
Count Two, Doc. #30 at 3, and Triple S has adopted the other
defendants' arguments as to Counts Three and Four. Doc.
#36 at 1.
purposes of a motion to dismiss for failure to state a claim,
the Court must accept as true all factual matters alleged in
a complaint, although a complaint may not survive unless the
facts it recites are enough to state plausible grounds for
relief. See, e.g., Ashcroft v. Iqbal, 556
U.S. 662, 678 (2009); Kim v. Kimm, 884 F.3d 98, 103
(2d Cir. 2018). This “plausibility” requirement
is “not akin to a probability requirement, ” but
it “asks for more than a sheer possibility that a
defendant has acted unlawfully.” Iqbal, 556
U.S. at 678. Because the focus must be on what facts a
complaint alleges, a court is “not bound to accept as
true a legal conclusion couched as a factual
allegation” or “to accept as true allegations
that are wholly conclusory.” Krys v. Pigott,
749 F.3d 117, 128 (2d Cir. 2014). In short, my role in
reviewing a motion to dismiss under Rule 12(b)(6) is to
determine if the complaint-apart from any of its conclusory
allegations-alleges enough facts to state a plausible claim
benefits claim against Triple S (Count One)
S argues that Count One should be dismissed against it
because it is not a proper defendant to a claim for benefits
under asserted under ERISA § 502(a)(1)(B), 29 U.S.C.
§ 1132(a)(1)(B). Doc. #36-1 at 6. The estate objects,
arguing instead that Triple S is a claims administrator
properly subject to suit under § 502(a)(1)(B). I agree
with Triple S.
Second Circuit has recently clarified the scope of what kind
of entities are proper defendants under § 502(a)(1)(B).
Although it had previously held that “only the plan and
the administrators and trustees of the plan in their capacity
as such may be held liable, ” Leonelli v. Pennwalt
Corp., 887 F.2d 1195, 1199 (2d Cir. 1989), the Second
Circuit has revised this view to make clear that “where
the claims administrator has ‘sole and absolute
discretion' to deny benefits and makes ‘final and
binding' decisions as to appeals of those denials, the
claims administrator exercises total control over claims for
benefits and is an appropriate defendant in a §
502(a)(1)(B) action for benefits.” N.Y. State
Psychiatric Ass'n v. UnitedHealth Grp., 798 F.3d
125, 132 (2d Cir. 2015). Because there is no dispute that
Triple S was not a plan or plan administrator, the question
of Triple S's role as a defendant turns on whether it has