ROBERT G. JAMES, District Judge.
The Report and Recommendation of the Magistrate Judge having been considered, no objections thereto having been filed, and finding that same is supported by the law and the record in this matter,
IT IS ORDERED, ADJUDGED, AND DECREED that Defendants' Joint Motion for Partial Summary Judgment [Doc. No. 31] is hereby GRANTED, and judgment is entered in favor of Defendants declaring 1) that Plaintiff's state law claim for unpaid benefits under the Plan is completely preempted by ERISA and, thus, recast as a claim under ERISA § 502(a)(1)(B), and 2) that Plaintiff's state law claims for penalties and detrimental reliance under Louisiana Revised Statute § 22:1821 and Louisiana Civil Code Article 1967, respectively, are conflict-preempted by ERISA.
IT IS FURTHER ORDERED, ADJUDGED, AND DECREED that Plaintiff's state law claims for penalties and detrimental reliance under Louisiana Revised Statute § 22:1821 and Louisiana Civil Code Article 1967, respectively, are hereby DISMISSED WITH PREJUDICE, as preempted.
IT IS FURTHER ORDERED that Defendant Vantage Health Plan, Inc.'s "Motion to Dismiss pursuant to Rule 12(b)(6) for Failure to Exhaust Administrative Remedies and in the Alternative, for Summary Judgment" [Doc. No. 11], and Defendants Louisiana Corrugated Products, LLC, and U.S. Corrugated, Inc.'s Motion for Judgment on the Pleadings (converted to a motion for summary judgment) [Doc. No. 17] are each GRANTED IN PART. Plaintiffs recast claim for unpaid benefits under ERISA § 502(a)(1)(B) are hereby DISMISSED WITHOUT PREJUDICE. Defendants' motions [Doc. Nos. 11 & 17] otherwise are DENIED.
IT IS FURTHER ORDERED that this matter is hereby STAYED for a period of 60 days, so Plaintiff may exhaust administrative remedies, and, thereafter, amend his Complaint to assert his then exhausted § 502(a)(1)(B) claim. If Plaintiff instead desires to forego his § 502(a)(1)(B) claim and proceed solely with his COBRA claim, he shall file a notice in the record no later than November 21, 2014.
KAREN L. HAYES, United States Magistrate Judge.
Before the undersigned magistrate judge on reference from the District Court are three motions: 1) motion to dismiss pursuant to Rule 12(b)(6) and in the alternative for summary judgment [doc. # 11] filed by defendant, Vantage Health Plan, Inc. ("Vantage"); 2) motion for judgment on the pleadings [doc. # 17] filed by defendants, Louisiana Corrugated Products, LLC and U.S. Corrugated, Inc. (collectively, "LAC"); and 3) motion for partial summary judgment [doc. # 31] filed jointly by defendants, Vantage and LAC. As explained in greater detail below, it is recommended that defendants' joint motion for partial summary judgment [doc. # 31] be GRANTED; that defendants' motion to dismiss pursuant to Rule 12(b)(6) and in the alternative for summary judgment [doc. # 11] and motion for judgment on the pleadings (converted motion for summary judgment) [doc. # 17] both be GRANTED-IN-PART; and that the matter be stayed for a period of 60 days.
On March 11, 2014, Carl DeWayne Wright filed the instant suit for damages in the 4th Judicial District Court for the Parish of Ouachita, State of Louisiana, against his former employer—LAC, and the issuer of his employer's group health care policy—Vantage. (Petition, ¶¶ 1-4). Wright alleges that in January 2014, Vantage pre-authorized his surgery with neurosurgeon, Bernie McHugh, M.D. (Petition, ¶¶ 8-10; Jan. 7, 2014, Letter from Vantage to Dr. McHugh, Petition, Exh. A).
Wright alleges that he was not notified of his "alleged termination" as required by the Consolidated Omnibus Budge Reconciliation Act ("COBRA"), and thus, did not have the opportunity to obtain replacement health care insurance. Id., ¶ 14. He further contends that he relied to his detriment on Vantage's post-surgery, pre-authorization. Id., ¶ 15.
Wright alleges that as a result of defendants' conduct and omissions, he has been deprived of further necessary medical care, which has protracted his disabilities. Id., ¶ 16. Thus, he seeks damages for prolonged pain and suffering, loss of income, increased and extended medical expense, the cost of the unpaid treatment rendered by Dr. McHugh, out of pocket medical expenses, reduction in his chances of recovery because of the delay in treatment, and the reduction in, and/or loss of portability of insurance coverage. Id., ¶ 17. He also seeks reasonable attorney's fees for failure to provide proper and required notice of termination. Id., ¶ 18.
On April 3, 2014, Wright amended his petition to assert claims for statutory penalties and attorney's fees stemming from defendants' conduct, including their failure to provide proper notice of termination and to pay insurance benefits as required. See 1st Suppl. & Amend. Petition. The next
On April 15, 2014, Vantage filed the instant motion to dismiss for failure to state a claim for which relief can be granted pursuant to Federal Rule of Civil Procedure 12(b)(6), or in the alternative, motion for summary judgment in accordance with Federal Rule of Civil Procedure 56. LAC filed a motion for judgment on the pleadings pursuant to Federal Rule of Civil Procedure 12(c) on April 21, 2014. Both motions seek to dismiss plaintiff's claims for failure to exhaust available administrative remedies before filing suit.
Defendants' motions rely on the premise that the underlying group health care insurance policy issued by Vantage is an employee welfare benefit plan under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq. On April 30, 2014, however, plaintiff filed his opposition memoranda, in which he took issue with defendants' premise. See Pl. Opp. Memos. [doc. # s 21 & 22]. On May 8, 2014, defendants filed their reply memoranda. [doc. # s 26 & 28]. Because the motions implicated threshold issues regarding ERISA, and whether ERISA preempted all related state law claims, the court ordered the parties to submit a joint stipulation, statement, or dispositive motion to address these matters. (May 12, 2014, Order [doc. # 29]).
On May 19, 2014, the parties jointly stipulated that
(Joint Stipulation [doc. # 30]).
However, the parties were unable to agree as to whether ERISA preempted all state law claims related to the employee benefit plant at issue. Accordingly, on May 27, 2014, LAC and Vantage joined in a motion for partial summary judgment seeking a determination that all of plaintiffs claims are preempted by ERISA. Plaintiff filed his opposition to the motion on June 18, 2014. (Opp Memo. [doc. # 36]). LAC and Vantage filed a joint reply brief on June 24, 2014. (Reply [doc. # 41]). Thus, the matter is ripe.
Rule 12(c) provides that "[a]fter the pleadings are closed—but early enough not to delay trial—a party may move for judgment on the pleadings." Fed.R.Civ.P. 12(c) (emphasis added). Here, LAC's Rule 12(c) motion is premature because none of the defendants have filed an answer, and therefore, the pleadings are not closed. See Supreme Laundry Serv., L.L.C. v. Hartford Cas. Ins. Co., 521 F.3d 743, 746 (7th Cir.2008) (party may move for judgment on pleadings after the filing of complaint and answer); New York State United Teachers v. Thompson, 459 F.Supp. 677, 680 (N.D.N.Y.1978) (Rule 12(c) motion may not be made by a defendant until after he has answered). Nonetheless, because the Rule 12(c) standard is the same as the Rule 12(b)(6) standard,
In any event, if evidence outside of the pleadings is presented to the court and used in deciding a 12(b)(6) or 12(c) motion, the court must convert the matter to a motion for summary judgment. Fed. R.Civ.P. 12(d); Knighton v. Merscorp Inc., 304 Fed.Appx. 285, 287 (5th Cir.2008) (citing Fernandez-Montes v. Allied Pilots Ass'n, 987 F.2d 278, 283 (5th Cir.1993)). In the matter sub judice, Vantage submitted an affidavit from its compliance coordinator, Jessica Self, in which she averred that Wright had not filed a grievance or appeal. (Self Affidavit; Vantage M/Dismiss/MSJ). Defendants necessarily rely on this evidence to support their exhaustion argument; thus, the court must convert the 12(b) and (c) motions into motions for summary judgment. Fed.R.Civ.P. 12(d).
In the event of conversion, Rule 12(d) requires that all parties be afforded a reasonable opportunity to present all material pertinent to a motion for summary judgment. Id. Specifically, the notice and hearing requirements of Rules 12(b) and 56(c) of the Federal Rules of Civil Procedure must be adhered to. Mackey v. Owens, 1999 WL 423077 (5th Cir. June 2, 1999) (unpubl.).
The court, however, need not give a party "express notice" that a motion to dismiss will be treated as a motion for summary judgment:
Mackey, supra (internal citation omitted).
Here, however, plaintiff had notice that Vantage's motion could be treated as a motion for summary judgment because Vantage alternatively sought relief under Rule 56, as necessary.
Furthermore, the court always possesses the inherent authority to dismiss an action sua sponte, without motion by a defendant. McCullough v. Lynaugh, 835 F.2d 1126, 1127 (5th Cir.1988) (citing Link v. Wabash R.R. Co., 370 U.S. 626, 630-31, 82 S.Ct. 1386, 8 L.Ed.2d 734 (1962)); see also Spann v. Woods, 66 F.3d 322, 1995 WL 534901, at *2 (5th Cir.1995) (unpubl.). Finally, a report and recommendation itself provides sufficient notice to the parties. McCoy v. Wade, 2007 WL 1098738, *1 (W.D.La. Mar. 12, 2007) (citing Magouirk v. Phillips, 144 F.3d 348, 359 (5th Cir.1998)).
Summary judgment is appropriate when the evidence before the court shows "that there is no genuine issue as to any material fact and that the moving party is entitled to judgment as a matter of law." Fed.R.Civ.P. 56(b). A fact is "material" if proof of its existence or nonexistence
"[A] party seeking summary judgment always bears the initial responsibility of informing the district court of the basis for its motion, and identifying those portions of `the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any,' which it believes demonstrate the absence of a genuine issue of material fact." Celotex Corp. v. Catrett, 477 U.S. 317, 323, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986) (quoting Anderson, 477 U.S. at 247, 106 S.Ct. 2505). "The moving party may meet its burden to demonstrate the absence of a genuine issue of material fact by pointing out that the record contains no support for the non-moving party's claim." Stahl v. Novartis Pharm. Corp., 283 F.3d 254, 263 (5th Cir. 2002). Thereafter, if the non-movant is unable to identify anything in the record to support its claim, summary judgment is appropriate. Id. "No genuine issue of material fact exists if the summary-judgment evidence is such that no reasonable juror could find in favor of the nonmovant." Jenkins v. Methodist Hospitals of Dallas, Inc., 478 F.3d 255, 260 (5th Cir.2007) (citation omitted).
In evaluating the evidence tendered by the parties, the court must accept the evidence of the non-movant as credible and draw all justifiable inferences in its favor. Anderson, 477 U.S. at 255, 106 S.Ct. 2505. While courts will "resolve factual controversies in favor of the non-moving party," an actual controversy exists only "when both parties have submitted evidence of contradictory facts." Little v. Liquid Air. Corp., 37 F.3d 1069, 1075 (5th Cir.1994). There can be no genuine issue as to a material fact when a party fails "to make a showing sufficient to establish the existence of an element essential to that party's case, and on which that party will bear the burden of proof at trial." Celotex Corp., 477 U.S. at 322-323, 106 S.Ct. 2548. This is true "since a complete failure of proof concerning an essential element of the nonmoving party's case necessarily renders all other facts immaterial." Id. at 323, 106 S.Ct. 2548.
When a movant bears the burden of proof on an issue, he must establish "beyond peradventure
There are two distinct types of preemption under ERISA: complete preemption under § 502(a) (the civil enforcement provision codified at 29 U.S.C. § 1132(a)) and conflict or express preemption under § 514 (codified at 29 U.S.C. § 1144(a)). See Ellis v. Liberty Life Assur. Co. of Boston, 394 F.3d 262, 275 n. 34 (5th Cir. 2004); Cunningham v. Petroleum Prof'l Int., Civ. Action No. 04-2528, 2006 WL 1044153 (W.D.La. Apr. 19, 2006). The former supports federal question jurisdiction, whereas the latter does not. Vega v. National Life Ins. Services, Inc., 188 F.3d 287,
Complete preemption occurs when a federal statute wholly displaces a state law cause of action, and in effect, converts or recasts the state law claim into a federal cause of action. Metropolitan Life Insurance Company v. Taylor, 481 U.S. 58, 62-66, 107 S.Ct. 1542, 95 L.Ed.2d 55 (1987); Aetna Health, Inc. v. Davila, 542 U.S. 200, 207-211, 124 S.Ct. 2488, 159 L.Ed.2d 312 (2004).
The court discerns from plaintiffs petition, as amended, state law claims for recovery of health benefits purportedly due under a group health plan; statutory penalties and fees for failure to timely pay the foregoing benefits under Louisiana Revised Statute § 22:1821; and a claim for detrimental reliance under Louisiana Civil Code Article 1967 stemming from Vantage's after-the-fact, preauthorization of plaintiff's surgery
Wright does not explain the statutory or codal authority for his claim to recover unpaid benefits. The omission, however, is of no moment, because whether the claim derives from § 22:1821, Civil Code Article 1994 for breach of contract, or some other source, the end result is still the same. It is manifest that Wright could have brought his claim for failure to pay healthcare benefits under ERISA § 502(a)(1)(B).
In contrast to § 22:1821, ERISA's § 502(a)(1)(B) does not authorize penalties for the unreasonable failure to timely pay benefits. Accordingly, the court will analyze this claim and plaintiff's claim for detrimental reliance under principles of ordinary or express preemption.
ERISA's express preemption provision, § 514(a), states that ERISA "shall supersede any and all State laws insofar as they may now or hereafter relate to any employee benefit plan. . . ." 29 U.S.C. § 1144(a) (emphasis added). This provision is purposefully expansive, and is intended to "ensure that employee benefit plan regulation would be exclusively a federal concern." Davila, 542 U.S. at 208, 124 S.Ct. at 2495. Thus, any state-law cause of action that "duplicates, supplements, or supplants the ERISA civil enforcement remedy conflicts with the clear congressional intent to make the ERISA remedy exclusive and is therefore pre-empted." Davila, supra.
The courts apply a two-prong test to determine whether a state law "relates to" an employee health benefit plan for purposes of ERISA preemption: "(1) whether the state law claims address areas of exclusive federal concern, such as the right to receive benefits under the terms of an ERISA plan; and (2) whether the claims directly affect the relationship among the traditional ERISA entities—the employer, the plan and its fiduciaries, and the participants and beneficiaries." King v. Bluecross Blueshield of Alabama, 439 Fed.Appx. 386, 389 (5th Cir.2011) (citing inter alia Woods v. Tex. Aggregates, L.L.C., 459 F.3d 600, 602 (5th Cir.2006)). Because ERISA preemption is an affirmative defense, defendants bear the burden of proof on both elements. Bank of Louisiana v. Aetna U.S. Healthcare Inc., 468 F.3d 237, 242 (5 th Cir.2006) (citations omitted).
It is manifest that plaintiffs claims are conflict-preempted by ERISA. Courts consistently have recognized that ERISA preempts a claim for unpaid benefits, penalties, and fees under Louisiana Revised Statute § 22:657 (now § 22:1821).
Furthermore, although ERISA does not per se preempt claims for detrimental reliance,
Plaintiff does not seriously contest the foregoing analysis. Instead, he contends that his claim(s) fall under ERISA's "savings clause," which provides that "[e]xcept as provided in subparagraph (B), nothing in this subchapter shall be construed to exempt or relieve any person from any law of any State which regulates insurance, banking, or securities." 29 U.S.C. § 1144(b)(2)(A).
To affect the risk-pooling arrangement, a "statute must alter the scope of permissible bargains between insurers and insureds and thus substantially affect the risk-pooling arrangements that insurers may offer." Ellis, 394 F.3d at 277-78 (citations and internal quotation marks omitted). Statutes that are remedial in nature, i.e. that provide remedies "to which the insured may turn when injured by the bad faith of the insurer," do not affect the bargain that an insurer makes with its insured, and therefore, do not affect the "risk" contracted for by the insurer. Ellis, supra.
Here, § 22:1821 authorizes recovery of benefits due under the policy, plus penalties and fees for an insurer's unreasonable failure to timely pay benefits. La. R.S. § 22:1821. As such, it is remedial in nature and does not affect the risk (a participant's health care costs) contracted for under the policy. See Ellis, supra; Letter v. Unumprovident Corp., Civ. Action No. 02-2694, 2003 WL 22077803 (E.D.La. Sept. 5, 2003) (§ 22:657 does not
ERISA requires that employee benefit plans provide administrative remedies for persons whose claims for benefits have been denied. 29 U.S.C.A. § 1133. The Fifth Circuit has adopted "the common law rule that a plaintiff generally must exhaust administrative remedies afforded by an ERISA plan before suing to obtain benefits wrongfully denied." Chailland v. Brown & Root, Inc., 45 F.3d 947, 950 (5th Cir.1995) (emphasis added) (citing Denton v. First Nat'l Bank of Waco, Tex., 765 F.2d 1295, 1300-03 (5th Cir.1985)).
A plaintiff must exhaust an administrative remedy available under an ERISA plan, even if that remedy is phrased permissively. Long v. Aetna Life Ins. Co., Civ. Action No. 14-403, 2014 WL 4072026 (E.D.La. Aug. 18, 2014) (citations omitted). Moreover, "plaintiffs seeking ERISA plan benefits are bound by the plan's administrative procedures and must use them before filing suit even if they have no notice of what those procedures are." Bourgeois, 215 F.3d at 480 (citation omitted).
Here, the Plan provides that a member has the right to file a complaint related to coverage. (Plan, Section XII: Appeal and Grievance Procedures; M/Dismiss, Exh. [doc. # 12]). An appeal is a complaint that the member files when he wants Vantage to reconsider and change a
In the instant case, it is uncontroverted that Wright failed to exhaust even the first step of the foregoing appeal procedure. (Affidavit of Jessica Self; M/Dismiss, Exh. 1). Instead, plaintiff argues that exhaustion is futile because it is unlikely that Vantage will find him to be still employed at the time he received the medical care, and thus eligible for benefits. See PL Opp. Memo., pg. 6 [doc. # 36]. However, "[a] failure to show hostility or bias on the part of the administrative review committee is fatal to a claim of futility." Harris v. Trustmark Nat. Bank, 287 Fed.Appx. 283, 295 (5th Cir.2008) (quoting McGowin v. ManPower Int'l, Inc., 363 F.3d 556, 559 (5th Cir.2004)). Here, plaintiff has not demonstrated that Vantage is hostile towards, or biased against, him. Thus, his futility argument lacks merit. Harris, supra.
Pursuant to the parties' joint stipulation, the court finds that the subject plan is an ERISA plan. Furthermore, plaintiffs state law claim for failure to pay benefits under the plan is completely preempted and recast as a claim under ERISA § 502(a)(1)(B). However, because plaintiff failed to exhaust administrative remedies before filing suit, his converted claim under ERISA § 502(a)(1)(B) is premature and must be dismissed without prejudice until such time as he exhausts those remedies. See Galvan v. SBC Pension Benefit Plan, 204 Fed.Appx. 335, 340 (5th Cir. 2006). Plaintiff's remaining state law claims for recovery of penalties and fees under § 22:1821 and for detrimental reliance damages under Louisiana Civil Code Article 1967 are conflict-preempted by ERISA. Thus, they are subject to dismissal, with prejudice, on that basis. The court will maintain plaintiff's claim for failure to provide COBRA notification against both LAC and Vantage,
IT IS RECOMMENDED that defendants' joint motion for partial summary judgment [doc. # 31] be GRANTED, and that judgment be entered in favor of defendants declaring 1) that plaintiff's state law claim for unpaid benefits under the Plan is completely preempted by ERISA, and thus, recast as a claim under ERISA § 502(a)(1)(B), and 2) that plaintiff's state law claims for penalties and detrimental reliance under La. R.S. § 22:1821 and Louisiana Civil Code Article 1967, respectively, are conflict-preempted by ERISA.
IT IS FURTHER RECOMMENDED that plaintiff's state law claims for penalties and detrimental reliance under Louisiana Revised Statute § 22:1821 and Louisiana Civil Code Article 1967, respectively, be DISMISSED, with prejudice, as preempted.
IT IS FURTHER RECOMMENDED that the motion to dismiss pursuant to Rule 12(b)(6) and in the alternative for summary judgment [doc. # 11] filed by defendant, Vantage, and the motion for judgment on the pleadings (converted motion for summary judgment) [doc. # 17] filed by defendant(s), LAC, be GRANTED IN PART, and that plaintiff's recast claim for unpaid benefits under ERISA § 502(a)(1)(B) be DISMISSED, without prejudice.
IT IS FURTHER RECOMMENDED the motions [doc.# s 11 & 17] otherwise be DENIED.
IT IS FURTHER RECOMMENDED that the court stay the matter for a period of 60 days to permit plaintiff to exhaust administrative remedies (if he is so inclined), and thereafter, to amend his complaint to assert his then exhausted § 502(a)(1)(B) claim.
Under the provisions of 28 U.S.C. § 636(b)(1)(C) and F.R.C.P. Rule 72(b), the parties have
The court further notes, at this juncture, that plaintiff's claim for failure to provide timely notice under COBRA alleges a statutory violation that does not require administrative exhaustion. See Thompson v. Origin Tech. In Bus., Inc., Civ. Action No. 99-2077, 2001 WL 1018748 (N.D.Tex. Aug. 20, 2001) (administrative exhaustion does not apply to action for failure to notify under COBRA); Sample v. City of Sheridan, Civ. Action No. 10-01452, 2012 WL 1247223 (D.Colo. Apr. 13, 2012) (exhaustion of administrative remedies is not required when claim for denial of COBRA benefits is based on a statutory violation of ERISA).