JOHN S. BRYANT, Magistrate Judge.
For the reasons stated below, the Magistrate Judge
Plaintiff's Complaint was originally filed in the Circuit Court for Davidson County, Tennessee on October 14, 2014. (Docket Entry 1-1). Defendants Cigna Corporation (Cigna), Connecticut General Life Insurance Company (Connecticut General), and Zotec Partners, LLC (Zotec) removed the action to this Court on November 20, 2014. (Docket Entry 1). The case was later referred to the Magistrate Judge. (Docket Entry 5 and 13).
On January 5, 2015, Defendant Zotec filed an Answer, and Defendants Cigna and Connecticut General filed a joint Motion to Dismiss. (Docket Entry 33 and 35). Plaintiff did not respond to the Motion to Dismiss.
A motion to dismiss based on lack of standing is appropriately brought under Fed. R. Civ. P. 12(b)(1) because standing is a jurisdictional matter, "and a plaintiff's lack of standing . . . deprive[s] a court of jurisdiction." Ward v. Alternative Health Delivery Sys., Inc., 261 F.3d 624, 626 (6th Cir. 2001) (citations omitted).
When analyzing a motion to dismiss under Fed. R. Civ. P. 12(b)(6), the Court must construe the complaint in the light most favorable to the plaintiff and accept the plaintiff's factual allegations as true. Gunasekera v. Irwin, 551 F.3d 461, 466 (6th Cir. 2009). "Bare assertions of legal conclusions" are not enough to avoid dismissal. Tahfs v. Proctor, 316 F.3d 584, 590 (6th Cir. 2003) (citation omitted). To survive a motion to dismiss, the complaint must contain "enough facts to state a claim to relief that is plausible on its face." Bridge v. Ocwen Fed. Bank, FSB, 681 F.3d 355, 358 (6th Cir. 2012) (quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007)). The facts alleged by the plaintiff must "allow[] the court to draw the reasonable inference that the defendant is liable for the misconduct alleged." Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009). When presented with a pro se complaint, the court should liberally construe it and hold it "to less stringent standards than the formal pleadings prepared by attorneys." Bridge, 681 F.3d at 358.
The court may properly consider "exhibits attached to [the] defendant's motion to dismiss so long as they are referred to in the complaint and are central to the claims contained therein, without converting the motion [to dismiss] to one for summary judgment." Rondigo, L.L.C. v. Twp. of Richmond, 641 F.3d 673, 680-81 (6th Cir. 2011) (citation omitted).
Plaintiff alleges that "Cigna, by colluding with Zotec . . ., has been able to manipulate the coding on tens of millions of records" in a scheme to "artificially influence member premiums through incentives, strategic claims acceptance, and exploiting weaknesses in the ICD-9
In 2011, Plaintiff worked for Zotec as a business intelligence analyst and data warehouse developer. (Docket Entry 1-1, p. 33). He believes that Zotec's business model is "based on a scheme to commit fraud." (Docket Entry 1-1, p. 33). In support of this allegation, Plaintiff states that while he was employed by Zotec, the company used improper coding practices, did not require phone representatives to take notes when discussing billing disputes, did not log or track billing disputes, concealed diagnosis codes in bills, used an automated phone system to discourage complaints, and used psychological tactics and hiring methods to prevent employees from discovering fraud. (Docket Entry 1-1, p. 33-38). After Plaintiff confronted his manager about these concerns, Plaintiff's employment was terminated. (Docket Entry 1-1, p. 39).
Thereafter, Plaintiff worked for NewQuest, LLC (NewQuest)
Through the Plan, Plaintiff received testosterone treatments. (Docket Entry 1-1, p. 27). He did not have an "issue getting treatment or having the claim submitted for insurance coverage through CIGNA." (Docket Entry 1-1, p. 27). Plaintiff became concerned that Cigna covered the treatments as "medically necessary" even though the clinics Plaintiff had visited had not followed the appropriate protocols.
Plaintiff sets forth the following causes of action: (1) consumer fraud; (2) wire fraud pursuant to 29 U.S.C. § 1105; (3) fraud in the inducement; (4) negligence; (5) breach of fiduciary duty; (6) breach of fiduciary duty to an ERISA plan; (7) breach of contract; and (8) breach of promises. (Docket Entry 1-1, p. 42-61).
As an initial matter, Plaintiff cannot maintain a claim for wire fraud. (Docket Entry 1-1, p. 47). Liberally construing the claim, the Magistrate Judge finds that Plaintiff attempts to state a claim under 18 U.S.C. §§ 1341 and 1343, which are federal mail and wire fraud statutes.
Liberally construing Plaintiff's Complaint, the Magistrate Judge finds that Plaintiff's claim for "Breach of Fiduciary Duty to an ERISA Plan" is brought under 29 U.S.C. § 1132(a)(3), which provides that:
29 U.S.C. § 1132(a)(3).
Plaintiff also argues that he suffered economic injury, including "the amount of the difference between the price [Plaintiff] paid for Cigna's insurance premiums . . . and the diminished value reflecting premiums that were established as a result of unethical and unscrupulous practices." (Docket Entry 1-1, p. 57-58). Plaintiff seeks injunctive relief, restitution, punitive damages, costs, and attorneys' fees. (Docket Entry 1-1, p. 58).
It is well settled that the relief available under 29 U.S.C. § 1132(a)(3) is limited to remedies "traditionally viewed as `equitable,' such as injunction or restitution." Allinder v. InterCity Products Corp. (USA), 152 F.3d 544, 552 (6th Cir. 1998) (quoting Mertens v. Hewitt Associates, 508 U.S. 248, 255 (1993)) (internal quotation removed); see also Loren v. Blue Cross & Blue Shield of Mich., 505 F.3d 598, 609 (6th Cir. 2007). Legal restitution; i.e., monetary damages, is not available under § 1132(a)(3). Cent. States, Se. & Sw. Areas Health & Welfare Fund v. First Agency, Inc., 756 F.3d 954, 960 (6th Cir. 2014). Equitable restitution may be available under this section if the plaintiff seeks to recover "
To the extent that Plaintiff seeks monetary and punitive damages, these forms of legal relief are unavailable under § 1132(a)(3). Additionally, Plaintiff's request that Cigna "make full restitution of all funds wrongfully obtained, held or charged" is unavailable under § 1132(a)(3), for Plaintiff does not specify from which fund he seeks to recover. Even assuming that Plaintiff intends to recover from the Plan account, the account funds are not in Cigna's possession. The Plan is sponsored by HealthSpring and administered by Connecticut General; Cigna does not control the Plan account. (Docket Entry 37-1; 37-2, p. 6; 37-3; 37-4). Plaintiff's claim for injunctive relief remains.
To pursue an ERISA claim in federal court, the plaintiff must have constitutional standing (Article III standing) and statutory standing. Loren, 505 F.3d at 606. A plaintiff's failure to establish constitutional standing requires dismissal for lack of subject matter jurisdiction. Id. at 607. Constitutional standing is satisfied by showing that the plaintiff "(1) . . . suffered an
Plaintiff fails to establish constitutional standing. Even assuming that the Complaint establishes an injury in fact by alleging a breach of fiduciary duty, Plaintiff fails to show that the breach is fairly traceable to Cigna's actions or that the injunctive relief sought would redress the alleged breach because Cigna is not a Plan fiduciary.
To maintain a claim for breach of fiduciary duty under ERISA, the plaintiff has the burden of proving "(1) that the defendant is a plan fiduciary; (2) that the defendant breached its fiduciary duty; and (3) that the breach caused harm to the plaintiff." Thorn v. Northside Hosp., No. 1:07-CV-155, 2008 WL 2600791, at *3 (W.D. Mich. June 24, 2008) (citing Brosted v. Unum Life Ins. Co. of Am., 421 F.3d 459, 465 (7th Cir. 2005)). For purposes of ERISA, "fiduciary" is given a functional definition. Smith v. Provident Bank, 170 F.3d 609, 613 (6th Cir. 1999). A person is a plan fiduciary if "he exercises
Plaintiff's claim against Cigna must fail because Plaintiff does not plead facts to support a finding that Cigna was a Plan fiduciary. Plaintiff's conclusory assertion that Cigna owed him a fiduciary duty is insufficient. (Docket Entry 1-1, p. 57). The Plan was sponsored by HealthSpring and was administered by Connecticut General. (Docket Entry 37-1; 37-2, p. 6; 37-3; 37-4). The Plan gave the Plan administrator "
Ultimately, Plaintiff does not plead facts to show, and the Magistrate Judge cannot infer, that Cigna had any discretionary authority or control over the Plan. Any action or inaction on Cigna's part could not, therefore, be a breach of a fiduciary duty owed to Plaintiff. Furthermore, the injunctive relief Plaintiff seeks would not redress the injury alleged because Cigna does not have control or authority over the Plan. Plaintiff does not discuss the role of Connecticut General or HealthSpring in this cause of action, and the Magistrate Judge cannot infer that Plaintiff meant to implicate another party instead of Cigna. For all of these reasons, the Magistrate Judge finds that Plaintiff lacks Article III standing to raise this claim.
Only a "participant, beneficiary, or fiduciary" may bring a civil suit under 29 U.S.C. § 1132(a)(3).
Hansen v. Harper Excavating, Inc., 641 F.3d 1216, 1226 (10th Cir. 2011). Although the Sixth Circuit typically applies a "zone of interests" test to analyze statutory standing under ERISA, the Sixth Circuit applies the Firestone factors to suits brought by former employees. Bridges v. Am. Elec. Power Co., 498 F.3d 442, 444 n.1 (6th Cir. 2007).
The Magistrate Judge finds that Plaintiff is not a "participant" as defined by ERISA. Plaintiff is not currently, and is not reasonably expected to be, in covered employment. Plaintiff's employment with NewQuest and participation in the Plan ended in October 2012. (Docket Entry 1-1, p. 26, 31; 36, p. 3). This lawsuit was filed two years later, in October 2014. (Docket Entry 1-1). Further, it does not appear that Plaintiff reasonably expects to return to covered employment. Last, Plaintiff does not seek benefits under the Plan. Quite to the contrary, Plaintiff claims that Defendants erred by granting him benefits under the Plan. He seeks to recoup the difference between the services he paid for and the services he received. Even if he did seek additional benefits, however, Plaintiff fails to state a colorable claim that he would prevail in a suit against Cigna since Cigna is not a party to the Plan and has no role in administering the Plan. Additionally, it does not appear that eligibility requirements for the Plan will be fulfilled in the future. Plaintiff is not a Plan "participant" and therefore lacks statutory standing to maintain a claim under 29 U.S.C. § 1132.
ERISA preemption was intended "to avoid conflicting federal and state regulation and to create a nationally uniform administration of employee benefit plans." Penny/Ohlmann/Nieman, Inc. v. Miami Valley Pension Corp., 399 F.3d 692, 698 (6th Cir. 2005). The relevant ERISA section, ERISA § 514(a), 29 U.S.C. § 1144(a), provides that the ERISA provisions "shall supersede any and all State laws insofar as they may now or hereafter
State laws are said to relate to ERISA plans if they "(1) mandate employee benefit structures or their administration; (2) provide alternative enforcement mechanisms; or (3) bind employers or plan administrators to particular choices or preclude uniform administrative practice." Girl Scouts of Middle Tennessee, Inc. v. Girl Scouts of the U.S.A., 770 F.3d 414, 419 (6th Cir. 2014) (citation omitted). A state-law cause of action is preempted insofar as it "duplicates, supplements, or supplants" the remedies available under ERISA. Id. Additionally, "if resolution of the state-law claim necessarily requires evaluation of the plan and the parties' performance pursuant to it," the claim relates to the plan and is preempted. Cataldo v. U.S. Steel Corp., 676 F.3d 542, 557 (6th Cir. 2012) (citation omitted) (internal quotation removed). In other words, if the defendant's legal duty arose solely from the plan, a claim for breach of that duty may only be brought under § 1132. Thurman v. Pfizer, Inc., 484 F.3d 855, 860 (6th Cir. 2007); Briscoe v. Fine, 444 F.3d 478, 499-500 (6th Cir. 2006).
Using the same operative facts that underlie the ERISA claim, Plaintiff alleges that Cigna and Zotec engaged in consumer fraud through deceptive business practices. (Docket Entry 1-1, p. 43-47). As a result of this alleged misconduct, Plaintiff states that he paid inflated health care premiums and underwent unnecessary testosterone treatment. (Docket Entry 1-1, p. 45-46).
This cause of action relates to the Plan and is therefore preempted. A state-law claim for consumer fraud may not be used as an alternative enforcement mechanism to ensure that a welfare benefit plan is properly administered. See Briscoe, 444 F.3d at 499 ("That the plaintiffs have captioned what is essentially a breach-of-fiduciary-duty claim as a suit for fraud, misrepresentation, and concealment does not alter the fact their state-law cause of action mirrors their federal claim under ERISA."). This claim is preempted.
According to Plaintiff, Cigna wrongfully induced Plaintiff to enroll in its Plan through Cigna's "misrepresentation and omissions." (Docket Entry 1-1, p. 51). This deception allegedly resulted in Plaintiff paying an inflated premium which was more than Cigna's services were worth. (Docket Entry 1-1, p. 53). Plaintiff seeks injunctive relief, restitution, costs, and punitive damages. (Docket Entry 1-1, p. 53).
Very similar to Plaintiff's claim of consumer fraud, this claim also relates to the Plan and is preempted. Rather than seeking to rescind the welfare benefit plan, Plaintiff seeks to be restored to the position he would be in if Cigna had conducted itself according to its alleged pre-policy representations. Attacks on the way a plan is administered must be raised under ERISA, not as a claim of fraud in the inducement. Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 48 (1987) (holding that a claim for fraud in the inducement, among other claims, was preempted insofar as it was based on the way claims for benefits were processed).
In Count IV, Plaintiff claims that Cigna and Zotec were negligent in their failure to investigate the possibility of false claims and ensure that medical coding was done correctly. (Docket Entry 1-1, p. 53). This failure allegedly increased Plaintiff's health care premium and enabled Plaintiff to receive testosterone treatments. (Docket Entry 1-1, p. 55).
This claim relates to the Plan, and accordingly, it is preempted. To determine whether Plaintiff suffered injury from negligent handling of fraud investigations and coding practices, this Court would necessarily need to evaluate the Plan and the Defendants' performance pursuant to it. See Cataldo, 676 F.3d at 557 (holding that state-law claims for fraud and negligence, among other claims, were preempted because a resolution of the claims would entail an evaluation of the plan). The claim is preempted.
Plaintiff's common law breach of fiduciary duty claim (Docket Entry 1-1, p. 55-56) is preempted, for it has long been held that "[c]ommon law breach of fiduciary duty claims are . . . preempted by ERISA." Smith, 170 F.3d at 613 (citation omitted).
Plaintiff alleges that Cigna failed to live up to the promises it made concerning the Plan. (Docket Entry 1-1, p. 58). This claim unmistakably relates to the Plan because adjudication of this claim would require the court to assess the Plan and Cigna's performance pursuant to it. See Cataldo, 676 F.3d at 557; see also Goldman v. BCBSM Found., 841 F.Supp.2d 1021, 1027 (E.D. Mich. 2012) (holding that a breach of contract claim "clearly falls within ERISA's preemptive force"). The claim is preempted.
It is not altogether clear whether Plaintiff intended the section entitled "Breach of Promises" to be included in his "Breach of Contract" claim. Nevertheless, the assertions contained within Plaintiff's "Breach of Promises" section are likewise preempted. This section repeats allegations from many of the aforementioned claims: failing to upgrade to ICD-10, failing to investigate fraud properly, and not honoring the terms of a contract, all of which resulted in an inflated premium price and receipt of unnecessary medical treatment. (Docket Entry 1-1, p. 58-61). This claim is also preempted. Any duties arising from these alleged promises are solely due to the existence of the Plan. See Thurman, 484 F.3d at 860.
For the reasons stated above, the Magistrate Judge
Under Fed. R. Civ. P. 72(b), the parties have fourteen (14) days, after being served with a copy of this Report and Recommendation (R&R) to serve and file written objections to the findings and recommendation proposed herein. A party shall respond to the objecting party's objections to this R&R within fourteen (14) days after being served with a copy thereof. Failure to file specific objections within fourteen (14) days of receipt of this R&R may constitute a waiver of further appeal. 28 U.S.C. § 636(b)(1); Thomas v. Arn, 474 U.S. 140, 155 reh'g denied, 474 U.S. 1111 (1986); Cowherd v. Million, 380 F.3d 909, 912 (6th Cir. 2004).