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Wallace v. Blue Cross and Blue Shield

United States District Court, S.D. Alabama, Northern Division

September 29, 2014

JANE WALLACE, et al., Plaintiffs,
v.
BLUE CROSS AND BLUE SHIELD OF ALABAMA, Defendant.

REPORT AND RECOMMENDATION

WILLIAM E. CASSADY, Magistrate Judge.

This matter is before the Magistrate Judge for entry of a report and recommendation, pursuant to 28 U.S.C. § 636(b)(1)(B), on the Defendant's motion to dismiss (doc. 16), the Plaintiffs' response (doc. 21) and the Defendant's reply (doc. 22). After consideration of the Defendant's motion and the briefs of the parties, it is the Magistrate Judge's RECOMMENDATION that the Defendant's motion to dismiss be GRANTED as discussed below.

Background

The Plaintiffs, Jane Wallace and her husband, John Wallace, bring this action under the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001, et seq. ("ERISA"), following the Defendant, Blue Cross Blue Shield of Alabama's denial of Ms. Wallace's request for health benefits. (Doc. 11.) The Plaintiffs are participants in a medical insurance plan governed by ERISA and administered by the Defendant. ( Id., ¶ 1.) In April 2011, as part of her treatment for breast cancer, Ms. Wallace underwent a lumpectomy. ( Id., ¶ 8; doc. 21 at 1.) Plaintiffs allege that, "pursuant to the recommendation and advice of [Ms. Wallace's] surgeon, reconstructive surgery was scheduled and was determined to be medically and reasonably necessary as a result of her treatment for breast cancer." (Doc. 11, ¶ 8.) Plaintiffs allege that "the Defendant... refused to cover said surgery and... wrongfully determined that the medical treatment recommended for Jane Wallace is simply cosmetic surgery, ' and therefore not covered." ( Id., ¶ 12.) The Plaintiffs contend that the Defendant should not have refused to cover the surgery because the surgery was "reconstructive, " rather than "cosmetic." ( Id., ¶ 11.)[1]

In Count I of the Amended Complaint, the Plaintiffs assert a breach of fiduciary duty claim under section 502(a)(2) of ERISA. ( Id., ¶¶ 13-20.) Specifically, the Plaintiffs allege that the Defendant "breached its [fiduciary] duty by wrongfully failing and refusing to provide the necessary insurance coverage for the medical procedure that was recommended by [Ms.] Wallace's treating physician, and which is a covered benefit in Defendant's policy." ( Id., ¶ 18.) In Count II, the Plaintiffs assert a claim for denial of benefits under section 502(a)(1)(B) of ERISA. ( Id., ¶¶ 21-28.) The Plaintiffs allege that "[Ms.] Wallace's claim was wrongfully denied by the Defenant, as the Plan provides for a beneficiary under the plan to receive coverage for reconstructive surgery." ( Id., ¶ 25.) In Count III, the Plaintiffs seek "equitable relief pursuant to ERISA § 502(a)(3)(B)." ( Id., ¶¶ 29-32.) Specifically, the Plaintiffs "seek a Declaratory Judgment from this Court [that (1)] declar[es] that the medical procedure proposed and recommended by the treating surgeon of the Plaintiffs is in fact covered by the medical insurance contract... and [(2)]... order[s] the Defendant to provide medical insurance coverage for said reconstructive surgery." ( Id., ¶ 32.)

The Defendant has filed a motion to dismiss with prejudice all claims asserted in the Amended Complaint pursuant to Fed.R.Civ.P. 12(b)(6). (Doc. 16.) The Plaintiffs have filed a response in opposition to the motion (doc. 21), and the Defendant has filed a reply in support of the motion (doc. 22).

Legal Standard for Rule 12(b)(6) Motion to Dismiss

A Rule 12(b)(6) motion to dismiss for failure to state a claim questions the legal sufficiency of a complaint (or portions of a complaint); therefore, in assessing the merits of a Rule 12(b)(6) motion, the court must assume that all the factual allegations set forth in the complaint are true, see, e.g., United States v. Gaubert, 499 U.S. 315, 327 (1991); Powell v. Lennon, 914 F.2d 1459, 1463 (11th Cir. 1990), and all factual allegations, moreover, are to be construed in the light most favorable to the plaintiff, see, e.g., Brower v. County of Inyo, 489 U.S. 593, 598 (1989); see also Speaker v. U.S. Dep't of Health & Human Servs. Ctrs. for Disease Control & Prevention, 623 F.3d 1371, 1379 (11th Cir. 2010) (same).

Rule 8(a)(2) generally sets the benchmark for determining whether a complaint's allegations are sufficient to survive a Rule 12(b)(6) motion. See Ashcroft v. Iqbal, 556 U.S. 662, 677-78 (2009) ("Under Federal Rule of Civil Procedure 8(a)(2), a pleading must contain a short and plain statement of the claim showing that the pleader is entitled to relief.' As the Court held in Twombly, ... the pleading standard Rule 8 announces does not require detailed factual allegations, ' but it demands more than an unadorned, the defendant-unlawfully-harmed-me accusation."). Indeed, "[a] pleading that offers labels and conclusions' or a formulaic recitation of the elements of a cause of action will not do.'" Id. at 678 (quoting Bell Atlantic Corp. v. Twombly, 550 U.S. 544, 555 (2007)). "Nor does a complaint suffice if it tenders naked assertion[s]' devoid of further factual enhancement.'" Id. (quoting Twombly, 550 U.S. at 557).

To survive a motion to dismiss, a complaint must contain sufficient factual matter, accepted as true, to state a claim to relief that is plausible on its face. A claim has facial plausibility when the plaintiff pleads factual content that allows the court to draw the reasonable inference that the defendant is liable for the misconduct alleged. The plausibility standard is not akin to a probability requirement, but it asks for more than a sheer possibility that a defendant has acted unlawfully. Where a complaint pleads facts that are merely consistent with a defendant's liability, it stops short of the line between possibility and plausibility of entitlement to relief.
Two working principles underlie our decision in Twombly. First, the tenet that a court must accept as true all of the allegations contained in a complaint is inapplicable to legal conclusions. Threadbare recitals of the elements of a cause of action, supported by mere conclusory statements, do not suffice. Rule 8 marks a notable and generous departure from the hyper-technical, code-pleading regime of a prior era, but it does not unlock the doors of discovery for a plaintiff armed with nothing more than conclusions. Second, only a complaint that states a plausible claim for relief survives a motion to dismiss. Determining whether a complaint states a plausible claim for relief will... be a context-specific task that requires the reviewing court to draw on its judicial experience and common sense. But where the well-pleaded facts do not permit the court to infer more than the mere possibility of misconduct, the complaint has alleged-but it has not show[n]-that the pleader is entitled to relief.

Id. at 678-79 (internal citations and quotation marks omitted); see also id. at 680 (a plaintiff must nudge his claims "across the line from conceivable to plausible."); compare Speaker, 623 F.3d at 1381 ("[G]iven the pleading standards announced in Twombly and Iqbal, [plaintiff] must do more than recite [] statutory elements in conclusory fashion. Rather, his allegations must proffer enough factual content to raise a right to relief above the speculative level.'"), with Robinson v. Correctional Med. Assocs., Inc., Civil Action No. 1:09-cv-01509-JOF, 2010 WL 2499994, at *2 (N.D.Ga. June 15, 2010) ("Factual allegations in a complaint need not be detailed but must be enough to raise a right to relief above the speculative level on the assumption that all the allegations in the complaint are true (even if doubtful in fact).'" (quoting Twombly, 550 U.S. at 555) (internal citations and emphasis omitted)).

Analysis

I. Section 502(a)(2) Breach of Fiduciary Duty Claim

Section 502(a)(2) of ERISA authorizes civil actions "brought... by the Secretary, or by a participant, beneficiary or fiduciary for appropriate relief under section 409 [of ERISA]." 29 ...


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