ALLISON D. BURROUGHS, District Judge.
In this action brought under the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001
Currently before the Court are (1) Ms. Nicholas' Motion to Take Limited Focused Discovery [ECF No. 30], which requests that several interrogatories and document requests be allowed, and (2) CLICNY's Motion for Judgment on the Pleadings and Motion to Strike Demand for Jury Trial, which seeks to dismiss the second count for breach of contract and to strike Ms. Nicholas' demand for a jury trial. [ECF No. 21]. For the reasons stated herein, Ms. Nicholas' Motion to Take Discovery is
From September 1997 to March 2006, Ms. Nicholas worked at Pfizer, most recently as a European Financial Shares Services Quality Manager. [R. 156; R. 1051].
By letter dated November 22, 2006, CLICNY denied Ms. Nicholas' claim for LTD benefits. [R. 1050-1053]. In April 2007, Ms. Nicholas appealed and after an additional review, CLICNY again denied her claim. [R. 1079-1081]. In December 2007, Ms. Nicholas again appealed and CLICNY declined to consider her second appeal. [R. 1173]. While this process was ongoing, Ms. Nicholas applied for benefits under the Social Security Act and in April 2007, the Social Security Administration issued a decision finding Ms. Nicholas disabled as of September 1, 2006. [R. 339-342].
In November 2009, through a new attorney, Ms. Nicholas sought an additional appeal of CLICNY's decision to deny her LTD benefits and CLICNY agreed to complete an appeal review. [R. 1186-1215; R. 2887]. By letter dated March 19, 2010, CLICNY issued a check to Ms. Nicholas in the amount of $127,870.80, which represented benefits due to her from September 28, 2006 to September 27, 2008 (the "Own Occupation" period under the LTD Plan). [R. 2894]. In a subsequent letter, CLICNY declined to provide LTD benefits beyond that point, finding that Ms. Nicholas was capable of performing light and sedentary occupations. [R. 2919-2921]. CLICNY subsequently considered two additional appeals and both times declined to extend benefits beyond the Own Occupation period. [R. 3237-3239; R. 3403-3406]. On November 2014, Ms. Nicholas filed her Complaint with this Court. [ECF No. 1].
On May 13, 2013, the Life Insurance Company of North America, Connecticut General Life Insurance Company, CIGNA Health and Life Insurance, the Massachusetts Division of Insurance and other state insurance regulators entered into a Regulatory Settlement Agreement ("RSA"). [ECF No. 2]. The three companies that signed the RSA (collectively the "CIGNA Companies") are under the control of CIGNA, Corp. [ECF No. 1 ¶ 45]. The RSA arose from a series of examinations by state insurance regulators into the claim handling practices of the CIGNA Companies. [ECF No. 2 at 1-2]. Under the RSA, the CIGNA Companies agreed to institute a plan of corrective action, establish a remediation program to reevaluate certain LTD claims that were previously denied, and to pay fines.
Ms. Nicholas' breach of contract claim relates to the RSA's remediation program. The RSA required the CIGNA Companies to remediate LTD claims made by residents of several states, including Massachusetts, which were denied or terminated from January 1, 2009 to December 31, 2010.
First before the Court is Ms. Nicholas' Motion to Take Limited Focused Discovery [ECF No. 30], in which Ms. Nicholas requests that the Court allow five interrogatories and three document requests directed towards CLICNY. "ERISA benefit-denial cases typically are adjudicated on the record compiled before the plan administrator."
Despite this, the First Circuit has recognized that narrowly tailored "conflict-oriented" discovery is sometimes permissible in an ERISA benefit-denial case.
Here, CLICNY was responsible for both evaluating and paying Ms. Nicholas' LTD benefit claim. [ECF No. 31 at 1; R. 12]. Thus, the conflict of interest identified by the Supreme Court in
CLICNY contends that even where a defendant is both the plan administrator and payor, conflict-oriented discovery is only permissible where plaintiff can demonstrate a "`colorable claim of bias,' or in other words, that the denial of benefits was improperly influenced by the CLICNY's conflict of interest." [ECF No. 35 at 3]. CLICNY cites to several cases where discovery was not allowed because, despite the presence of a structural conflict of interest, plaintiff failed to make a showing that the conflict influenced the administrator's decision to deny benefits.
Ms. Nicholas requests that the Court permit five interrogatories and three document requests related to the conflict. She seeks information about the relationship between CLICNY, medical consultant MES Solutions, and Dr. Darrin Campo, who was hired through MES Solutions to evaluate Ms. Nicholas' claim in 2011. Interrogatories 1-3 ask about the number of and outcomes in CLICNY disability claims evaluated by Dr. Campo from 2011-2013; and interrogatories 4-5 ask about the number of and compensation received for CLICNY disability claims involving MES Solutions from 2011-2013. Ms. Nicholas' three document requests seek: (1) documents showing CLICNY's procedures to prevent or mitigate the effect of structural conflicts; (2) CLICNY's policies and procedures relevant to the handling of Ms. Nicholas' claim; and (3) performance evaluations of Jessica Minyon, an Appeal Claim Manager who denied Ms. Nicholas' appeal, from 2011-2014.
In similar circumstances, courts in this district have allowed more and less extensive discovery than what Ms. Nicholas requests. In
In this case, the Court denies Ms. Nicholas' requested interrogatories 1-3, which concern the track record of Dr. Campo. CLICNY has stated that it does not keep track of past LTD claims by medical reviewer [ECF No. 35, Ex. 1 ¶ 3] and that it would need to manually review each claim file from 2011-2013 to obtain the information requested. [ECF No. 35, at 13]. The Court agrees that such burdensome discovery is not warranted, especially in light of Dr. Campo's certifying at the end of his medical report that he has "no direct or indirect financial incentive for a particular determination." [R. 1012]. Moreover, the Court will not permit Ms. Nicholas' document request targeted at CLICNY's general policy and procedures, since the administrative record already contains a substantial collection of such documents. [R. 2166-2497]. Last, the Court will not permit Ms. Nicholas' document request seeking performance evaluations for Jessica Minyon, since this falls beyond the "narrowly tailored" discovery permitted in an ERISA benefit-denial case.
Ms. Nicholas' remaining interrogatories and document requests provide a reasonable framework for the narrow discovery appropriate here. CLICNY is ordered to: (1) report the total compensation paid to MES Solutions in 2011 and explain CLICNY's basis for determining how much to compensate MES Solutions in 2011; (2) explain the basis or method for compensating Dr. Campo and explain what input, if any, CLICNY has into which doctors are selected by MES Solutions to evaluate CLICNY's LTD benefit claims; and (3) produce documents showing CLICNY's procedures, if any, to prevent or mitigate the effect of structural conflicts. Such limited discovery will fill the existing gaps in the administrative record and help the Court to determine the significance of the conflict in this case.
Also before the Court is CLICNY's Motion for Judgment on the Pleadings and Motion to Strike Demand for Jury Trial, which seeks to dismiss Count II of the Complaint for breach of contract and to strike Ms. Nicholas' demand for a jury trial. In Count II, Ms. Nicholas alleges that CLICNY breached the RSA by failing to remediate her claim. [ECF No. 1 ¶ 63]. Under the RSA's remediation provision, CLICNY was required to reassess LTD claims made by residents of several states, including Massachusetts, which were denied or terminated from January 1, 2009 to December 31, 2010. [ECF No. 2 at 76]. Ms. Nicholas alleges that CLICNY should have, but did not, reassess her claim pursuant to this provision of the RSA. In its Motion for Judgment on the Pleadings, CLICNY contends that this breach of contract claim is preempted by ERISA and that, in any event, Ms. Nicholas lacks standing to bring a claim under the RSA.
A Rule 12(c) motion for judgment on the pleadings "is treated much like a Rule 12(b)(6) motion to dismiss." Perez-Acevedo v. Rivero-Cubano, 520 F.3d 26, 29 (1st Cir. 2008). Therefore, to survive a motion for judgment on the pleadings, a plaintiff "must state a claim that is plausible on its face." Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007). When reviewing a 12(c) motion, "the court must view the facts contained in the pleadings in the light most favorable to the nonmovant and draw all reasonable inferences therefrom to the nonmovant's behoof." R.G. Fin. Corp. v. Vergara-Nunez, 446 F.3d 178, 182 (1st Cir. 2006). The court may supplement the facts contained in the pleadings by considering documents fairly incorporated therein and facts susceptible to judicial notice. Id.; see also Curran v. Cousins, 509 F.3d 36, 44 (1st Cir. 2007) (in evaluating a Rule 12(c) motion, a court may "consider documents the authenticity of which are not disputed by the parties" as well as "documents central to the plaintiffs' claim" and "documents sufficiently referred to in the complaint"). Here, therefore, in addition to the Complaint, the Court may consider the RSA, which was attached to the Complaint and is central to Ms. Nicholas' breach of contract claim. [ECF No. 2].
The parties agree that Ms. Nicholas is not a party to the RSA. The RSA is an agreement between Life Insurance Company of North America, Connecticut General Life Insurance Company, CIGNA Health Insurance Company, the Massachusetts Division of Insurance and other state insurance regulators. [ECF No. 2 at 1].
Under Pennsylvania law, "a non-party to a contract may bring a breach of contract claim if it is an intended third party beneficiary, i.e., if the contract expresses both parties' intent to benefit it or `the circumstances are so compelling that recognition of the beneficiary's right is appropriate to effectuate the intention of the parties . . . .'" QVC, Inc. v. Resultly, LLC, No. CV 14-6714, 2016 WL 521197, at *3 (E.D. Pa. Feb. 10, 2016) (quoting Am. Stores Props., Inc. v. Spotts, Stevens & McCoy, Inc., 651 F.Supp.2d 349, 352-53 (E.D. Pa. 2009)).
There is no language in the RSA evincing an intent that the CIGNA Companies, or CLICNY, may be held liable to third parties in the event of a breach. Rather, the RSA sets forth a comprehensive monitoring and enforcement mechanism that includes specific remedies for noncompliance, including state-imposed fines and penalties, but does not include a private right of action by individual claimants. [ECF No. 2 at 8-9]. Accordingly, Ms. Nicholas is not a third party beneficiary of the RSA and may not bring a breach of contract suit to enforce its terms. It is true that there is no express language in the RSA stating that individuals like Ms. Nicholas may not act as third party beneficiaries. To bring suit as a third-party beneficiary of a government contract, however, a plaintiff must point to language affirmatively showing that the contracting parties intended to be held liable to third parties in the event of a breach. The RSA does not include any such language and instead contains a detailed remedial provision that disclaims any intent to give individual claimants a right to enforce its terms. Count II of the Complaint is therefore dismissed.
For the foregoing reasons, Ms. Nicholas' Motion to Take Discovery is GRANTED IN PART and CLICNY's Motion for Judgment on the Pleadings and Motion to Strike Demand for Jury Trial is GRANTED. The parties are directed to file a status report by March 9, 2016, which should include a proposed schedule for the case going forward as well as a description of Ms. Nicholas' proposed amendments to the complaint. They parties may also file a proposed protective order at that time.