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Hilton v. King Pharmaceuticals

August 22, 2006


The opinion of the court was delivered by: Magistrate Judge Inman


During the relevant time, plaintiff's husband was an employee of King Pharmaceuticals Inc. ("King"). King established and maintained a self-funded group health insurance plan ("Plan") for its employees. By virtue of her husband's employment with King, plaintiff became a participant or beneficiary under the Plan in June 2002.

Plaintiff was morbidly obese and suffered from health problems attendant to that obesity. After consultation with Dr. Scott Watson in January 2002, plaintiff determined to undergo gastric bypass surgery.

It is beyond argument that the health insurance plan maintained by King was covered by the provisions of the Employment Retirement Income Security Act of 1974 ("ERISA").*fn1 King was the plan administrator of the Plan, and it contracted with Acordia National, Inc. ("Acordia") to administer claims made by beneficiaries of the Plan.

Plaintiff underwent laparoscopic bilateral gastric bypass surgery on July 19, 2002, incurring in excess of $30,000.00 in medical bills in the process. As claims administrator, Acordia refused to pay these bills, asserting that gastric bypass surgery was explicitly excluded from coverage under the Plan. King concurred in that decision.

Plaintiff subsequently filed this suit, alleging that Acordia had "pre-certified" the surgical procedure, thereby indicating to her and her physicians that the procedure was (1) covered under the Plan, and (2) that all claims would be paid. Plaintiff first claims, in general terms, that she was denied benefits proffered to her under the Plan, relying on 29 U.S.C. § 1132(a)(1)(B). Secondly, she alleges that either King or Acordia, or both of them, are fiduciaries in the sense of 29 U.S.C. § 1002(21)(A), and that they breached their fiduciary duty by intentionally or negligently misleading plaintiff regarding the Plan's coverage for the gastric bypass procedure. Somewhat in a similar vein, by amendment to her complaint plaintiff also insists that King and Acordia should be estopped to deny coverage in light of their "pre-certification" of the procedure.

Plaintiff also alleges causes of action based on common law fraud and breach of contract.

Under any or all of the foregoing asserted causes of action, plaintiff seeks a recovery for 80% of her total medical expenses,*fn2 as well as prejudgment and postjudgment interest on that amount. Additionally, plaintiff claims that the defendants refused to provide to her any information or documentation regarding her claim and the denial thereof, and she seeks a judgment in the amount of $100.00 per day from the date of the defendants' refusal pursuant to 29 U.S.C. § 1132(c)(1).

The defendants have filed a joint motion to dismiss (Doc. 14), and an amended joint motion to dismiss (Doc. 21).

Defendants' motions to dismiss were supported by matters outside the record,*fn3 prompting the plaintiff to file a motion asking that the joint motion to dismiss be converted into one for summary judgment under Rule 56. Over the defendants' vigorous opposition, the court granted that motion. In retrospect, that was an error, but fortunately not an unrectifiable one. Defendants' motion to dismiss, as amended, will be treated as such.

King and Acordia first argue that the gastric bypass procedure is explicitly and unequivocally excluded from coverage under the Plan. Of that, there is no doubt. In the "Exclusions and Limitations" section of the Plan booklet, paragraph nn, the following language appears: "Care and treatment of obesity, weight loss or dieting control whether or not it is, in any case, a part of the treatment Plan for another Sickness; . . . ."

Defendants also insist that plaintiff's claims and causes of action are preempted by ERISA and that plaintiff's suit therefore should be dismissed because (1) she did not exhaust her administrative remedies under the Plan, which is a requirement within the Sixth Circuit before an ERISA civil action may be maintained, Miller v. Metropolitan Life Ins. Co., 925 F.2d 979 (6th Cir. 1991). Defendants also argue that plaintiff's breach-of- fiduciary claims should be dismissed because the recovery of damages "is a right reserved exclusively to an ERISA plan, not individual plan participants," relying upon 29 U.S.C. § 1109, Massachusetts Mut. Life Ins. Co. v. Russell, 473 U.S. 134, 142 (1985), and Weiner, D.P.M. v. Klaus & Co., Inc., 108 F.3d 86, 91-92 (6th Cir. 1997).

Next, defendants assert that plaintiff's common law claim for breach of contract and fraud must be dismissed because §§ 502(a)(2) and (a)(3) of ERISA*fn4 provide an adequate remedy.

Lastly, with regard to plaintiff's claim for the statutory penalty under 29 U.S.C. ยง 1132(c)(1) for defendants' refusal to furnish her the information she requested, defendants argue (1) that the statute does not obligate a plan administrator to provide an explanation of denials of claims, and in any event the administrator is not obligated to furnish plan documents and information to a beneficiary's ...

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