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Birmingham Plumbers v. Blue Cross Blue Shield of Alabama

United States District Court, N.D. Alabama, Southern Division

March 8, 2018

BIRMINGHAM PLUMBERS AND STEAMFITTERS LOCAL UNION NO. 91 HEALTH AND WELFARE TRUST FUND, Plaintiff,
v.
BLUE CROSS BLUE SHIELD OF ALABAMA, Defendant.

          MEMORANDUM OPINION [1]

          JOHN H. ENGLAND, III UNITED STATES MAGISTRATE JUDGE

         Plaintiff Birmingham Plumbers and Steamfitters Local Union No. 91 Health and Welfare Trust Fund (the “Employer Health and Welfare Trust Fund” or “Plaintiff”) initiated this action against Defendant Blue Cross Blue Shield of Alabama (“BCBS”) alleging a claim for breach of fiduciary duty under the Employee Retirement Income Security Act (“ERISA”) and a claim for breach of contract based on the Administrative Services Agreement (“ASA”) between BCBS and Birmingham Plumbers and Steamfitters Local No. 91 (“Employer”). (Doc. 1). BCBS has moved to dismiss the complaint pursuant to Federal Rule of Civil Procedure 12(b)(6).[2] (Doc. 8). The motion is fully briefed and ripe for review. (Docs. 12 & 19). For the reasons stated below, BCBS's motion to dismiss, (doc. 8), is GRANTED.

         I. Factual Background

         Plaintiff asserts that BCBS, in its role as third-party claims administrator for the Employer's Group Medical Plan and Group Dental Plan (the “Plan”), breached its fiduciary duty and contractual duty by continuing to pay claims for a Plan participant suffering from end stage renal disease (“ESRD”) after the participant became Medicare-eligible. (See doc. 1; doc. 8-1 at 14). Specifically, Plaintiff alleges the Plan should have become a secondary payer to Medicare after acting as primary payer for the first thirty months of the participant's ESRD treatment. (Id. at ¶ 22).

         In approximately November 2010, a Plan participant was diagnosed with ESRD and began dialysis treatment. (Doc. 1 at ¶ 24). Plaintiff alleges BCBS was aware of the ESRD diagnosis, based on the fact BCBS paid the claim for dialysis and other treatment. (Id. at ¶ 25). Plaintiff further alleges that, because eligibility in the Plan is available only to individuals or dependents of individuals that are employed in the Plumbing and Steamfitting trade, BCBS knew the participant was covered based on this employment and knew or should have known the employee had participated in the Plan for over ten years. (Id. at ¶¶ 26-27).

         According to the complaint, the Plan participant became eligible to enroll in Medicare because of the ESRD diagnosis no later than September 2013; however, the participant did not enroll in Medicare. (Id. at ¶ 27). From September 2013 until December 2014, the Plan paid benefits for diagnosis and treatment related to ESRD. (Id. at ¶ 28). Plaintiff alleges BCBS was aware that the participant had been diagnosed with ESRD, was aware that thirty months had elapsed since the diagnosis, and was aware that the participant had not enrolled in Medicare. (Id. at ¶ 29). Plaintiff further alleges BCBS knew or should have known that the participant was eligible for Medicare. (Id.).

         II. Standard of Review

         Under Federal Rule of Civil Procedure 8(a)(2), a pleading must contain “a short and plain statement of the claim showing the pleader is entitled to relief.” “[T]he pleading standard Rule 8 announces does not require 'detailed factual allegations, ' but it demands more than an unadorned, the-defendant-unlawfully-harmed-me accusation.” Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009) (citing Bell Atlantic v. Twombly, 550 U.S. 544, 555 (2007)). Mere “labels and conclusions” or “ a formulaic recitation of the elements of a cause of action” are insufficient. Iqbal, 556 U.S. at 678. (citations and internal quotation marks omitted). “Nor does a complaint suffice if it tenders 'naked assertion[s]' devoid of 'further factual enhancement.” Id. (citing Bell Atl. Corp., 550 U.S. at 557).

         Rule 12(b)(6), Fed. R. Civ. P., permits dismissal when a complaint fails to state a claim upon which relief can be granted. “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.” Iqbal, 556 U.S. at 678 (citations and internal quotation marks omitted). A complaint states a facially plausible claim for relief “when the plaintiff pleads factual content that allows the court to draw the reasonable inference that the defendant is liable for the misconduct alleged.” Id. (citation omitted). The complaint must establish “more than a sheer possibility that a defendant has acted unlawfully.” Id.; see also Bell Atl. Corp., 550 U.S. at 555 (“Factual allegations must be enough to raise a right to relief above the speculative level.”). Ultimately, this inquiry is a “context-specific task that requires the reviewing court to draw on its judicial experience and common sense.” Iqbal, 556 U.S. at 679.

         III. Analysis

         At several instances throughout its response, Plaintiff urges that the court must accept as true all allegations in the complaint. (See doc. 12 at 3, 10, 16). Despite Plaintiff's urging, this general rule is not an absolute. The requirement the court accept the facts in the complaint as true when evaluating a Rule 12(b)(6) motion to dismiss is limited. The court is not required to ignore specific factual details of the pleadings in favor of general conclusory allegations and, as more relevant here, when exhibits contradict the general and conclusory allegations of the pleadings, the exhibits govern. Griffin Indus., Inc. v. Irvin, 496 F.3d 1189, 1205-06 (11th Cir. 2007). This means, to the extent any of Plaintiff's general and conclusory allegations are inconsistent with the plain and unambiguous language of the ASA, the ASA governs.

         A. ERISA Fiduciary Duty Claim

         Count 1 of Plaintiff's complaint alleges a breach of fiduciary duty claim. (Doc. 1 at 9). “To establish liability for a breach of fiduciary duty under any of the provisions of ERISA § 502(a), a plaintiff must first show that the defendant is in fact a fiduciary with respect to the plan.” Cotton v. Mass. Mut. Life Insur. Co., 402 F.3d 1267, 1277 (11th Cir. 2005). Under ERISA, “a person is a fiduciary with respect to the plan to the extent . . . he has any discretionary authority or discretionary responsibility in the administration of such plan. 29 U.S.C. § 1002(21)(A).

         Fiduciary responsibilities may be divided up among various ERISA fiduciaries. See 29 U.S.C. §1104(c)(1) (“The instrument under which a plan is maintained may expressly provide for procedures . . . for allocating fiduciary responsibilities (other than trustee responsibilities) among named fiduciaries. . . .”). In such situations, each party “is a fiduciary only ‘to the extent' it performs a fiduciary function.” Cotton, 402 F.3d at 1277 (quoting definition of “fiduciary” from 29 U.S.C. § 1002(21)(a)). “As such, fiduciary status under ERISA is not an “all-or-nothing concept, ' and ‘a court must ask whether a person is a fiduciary with respect to the particular activity at issue.'” Id. (quoting Coleman v. Nationwide Ins. Co., 969 F.2d 54, 61 (4th Cir. 1992)). Subject to limited exceptions, [3] when fiduciary obligations are allocated among entities, a ...


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