KATHERINE B. FORREST, District Judge.
This ERISA action was originally commenced in May 2011. Now, more than three years later, and one trip up to the Circuit and back, this Court again has before it motions by defendants for summary judgment or dismissal as to all remaining claims.
Marianne Gates ("plaintiff' or "Gates") and the members of the classes that she seeks to represent, were or are participants in and/or beneficiaries of employee health care plans sponsored by private companies, including AllianceBernstein L.P. ("AB"), and partially or fully administered and/or insured by defendant United Healthcare Insurance Company ("URIC"). (Second Amended Class Action Complaint ("SAC") ¶ 2, ECF No. 75.) Plaintiff Gates is a retired employee of AB and a participant in the Life, AD&D, Disability & Medical Plan for Employees of AllianceBernstein L.P., the AllianceBernstein L.P. Retiree Plan for Employees of AllianceBernstein L.P., and the AllianceBernstein L.P. United Healthcare Indemnity Plan (together, the "Other AB Plans"). (
Gates has, in her personal capacity and as a representative of putative classes, sued URIC as Claims Administrator of the Copay Plan, AB as the Sponsor and Plan Administrator of the Copay Plan, and the Copay Plan itself. (
Gates' claims may be grouped into three categories: benefits claims (First and Second Claims for Relief), procedural claims (Third and Fourth Claims for Relief), and a monitoring claim (Fifth Claim for Relief).
The First and Second Claims for Relief are at the heart of this lawsuit. They seek monetary damages and injunctive relief in connection with Gates' assertion that she has not been paid the full benefits she is owed. Plaintiff claims that URIC applied an erroneous methodology to its calculation of her benefits. The First Claim for Relief references both monetary and prospective injunctive relief against the AB defendants but the parties have argued it as if it is limited to monetary relief.
The parties' main dispute as to these claims relates to whether the terms of the Summary Plan Description ("SPD") which lay out the coordination of benefits ("COB") methodology are ambiguous in whole or in part, thereby allowing for interpretation by URIC and application of the arbitrary-and-capricious standard to such interpretation. Plaintiff asserts that the terms are unambiguous in whole, requiring literal application and permitting no exercise of interpretative discretion by URIC. Defendants argue the opposite. The answer to the question of ambiguity determines the outcome of defendants' motion as to the First Claim. As to the Second Claim, even if the language is unambiguous, there is a further question as to whether injunctive relief is an available remedy. Plaintiff argues that even though she is no longer a participant in the Copay Plan, injunctive relief remains available because she seeks to represent a class some of whose members may still be participants.
Plaintiffs Third and Fourth Claims for Relief relate to the same alleged concern that UHIC (not named as a defendant in the Third Claim) has breached its fiduciary duties by failing to comply with the appropriate claims procedure as established by the Copay Plan. The Third Claim is asserted against the AB Plans only. The Fourth Claim is asserted against UHIC only.
Neither claim is a model of clarity. However, at bottom, the language of the claims includes sufficient references to be construed as alleging violations of ERISA § 503 relating to claims procedures, as well as breaches of fiduciary duty under § 404 for the § 503 violations. In addition, however, the Fourth Claim for Relief asserts a claim pursuant to § 502(a)(2) for relief under§ 409-which relates to a loss in Plan assets. No such loss is in fact described or alleged. The § 502(a)(2) and accompanying§ 409 claims are irrelevant to the facts alleged in the SAC or in the record on this motion.
The Third Claim for Relief is against the Plan
The AB defendants seek judgment on this claim on several grounds: first, on the ground that the claim is asserted against, not on behalf of, the Plan, and the Plan is not a fiduciary; second, on the ground that a failure to comply with claims procedures required by§ 503 cannot constitute a§ 404 breach of fiduciary duty; third, on the ground that plaintiff may only seek to establish a breach of fiduciary duty under§ 502(a)(2), not under§ 502(a)(3); and finally, on the ground that, in any event, remedies for violations of§ 503 are administrative only and injunctive relief is not available.
Plaintiff counters by explaining that her Third Claim is based on § 503's requirement that all participants are entitled to some measure of due process in connection with claims for benefits, and that she did not receive such process. In this regard, she asserts that it is irrelevant that she has named only the Plan as defendant in this claim since it is clear on the face of her claim that she is alleging a breach of fiduciary duty by UHIC. She concedes that the Plan is not a fiduciary; rather, she asserts that the Plan is bound by the requirements of§ 503. Plaintiff argues that she can allege a violation of§ 503 and seek relief under § 502(a)(3) without resort to a claim based on a breach of fiduciary duty. In terms of injunctive relief, plaintiff argues that she has an existing claim-unaffected by the fact that she is no longer a participant in the Copay Plan-for a full and fair review of her claim.
The Fourth Claim for Relief, alleged only against UHIC, alleges a violation of § 502(a)(2), with§ 409 as its remedy. Only secondarily does it reference § 502(a)(3). Defendant UHIC argues that§§ 502(a)(2) and 409 are inapplicable in this case. It then turns to the portion of the Fourth Claim which seeks to invoke more general remedial relief under § 502(a)(3)-a provision not tied to a loss or misuse of plan assets.
UHIC argues that in order to seek relief under§ 502(a)(3), plaintiff must show an underlying violation of ERISA. UHIC argues that plaintiff has not alleged a cognizable violation. But while the Fourth Claim for Relief does not specifically reference § 503, it plainly alleges a violation of§ 503. That section is the substantive portion of ERISA requiring establishment and compliance with certain claims procedures.
UHIC additionally argues that§ 503 claims are limited to claims against employee benefit plans, and that UHIC is a Claims Administrator, not a plan. This is where plaintiffs additional assertions in the Fourth Claim with regard to UHIC's breach of fiduciary duty come into play. According to plaintiff, as Claims Administrator, UHIC was tasked with complying with§ 503, and this it failed to do, thereby breaching its fiduciary duties. In short, while the Fourth Claim for Relief does state a claim under ERISA, it does so under a combination of§§ 502(a)(3), 503, and 404-not §§ 502(a)(2) and 409.
Defendants also argue that, in all events, the remedies available for a § 503 violation are administrative only, including deemed administrative exhaustion or remand. But this ignores that a breach of fiduciary duty may be addressed more generally under§ 502(a)(3), which plaintiff asserts with regard to this claim.
The Fifth Claim for Relief is asserted against AB and seeks to hold it liable for failing adequately to monitor and terminate URIC. This claim alleges violations of§§ 502(a)(2) and 409. It does not seek relief under any other provision of ERISA.
The AB defendants argue, as they have elsewhere, that§§ 502(a)(2) and 409 are inapplicable to the facts as alleged. In addition, they argue that the claim is really one for liability for breach of a co-fiduciary's duties pursuant to § 405. Plaintiff did not plead § 405. That provision requires (1) knowingly participating in or concealing of an act or omission of another fiduciary, knowing that such act or omission was a breach of fiduciary duty; or (2) enabling another fiduciary to commit a breach through failure to comply with § 404; or (3) knowing that another fiduciary has committed a breach and failing to take remedial steps.
The terms of the Copay Plan are set forth in the Plan Document and the SPD. (
The SPD provides that AB has "delegated to the Claims Administrator [UHIC] the exclusive right to interpret and administer the provisions of the Plan. The Claim Administrator's decisions are conclusive and binding." (SPD at 65.) The SPD further provides that AB and URIC have the "sole and exclusive discretion" to "[i]nterpret Benefits under the Plan," "[i]nterpret the other terms, conditions, limitations and exclusions of the Plan, including this SPD," and "[m]ake factual determinations related to the Plan and its Benefits." (
To determine benefits under the Copay Plan requires reference to a number of different provisions contained within Section 7 of the SPD, entitled "Coordination of Benefits." All of Section 7 is concerned in one way or another with instances in which more than one "Coverage Plan" may apply, and how benefits are determined in such a situation. It starts by defining "When Coordination of Benefits Applies." It states, "This coordination of benefits (COB) provision applies when a person has health care coverage under more than one benefit plan." (SPD at 66.) It then informs the reader that:
(
(
Plaintiff Gates is undisputedly retired from AB. It is also undisputed that for purposes of applying the COB methodology, Medicare is her Primary Coverage Plan and the Copay Plan is secondary. As plaintiff is covered under two plans, one turns to the next subsection, entitled "Effect on the Benefits of this Plan." (SPD at 69.) That subsection provides the methodology for benefit payments in such a situation. It states, first, that "[w]hen this [that is, the Copay Plan] is secondary, it may reduce its benefits by the total amount of benefits paid or provided by all Coverage Plans Primary to this Coverage Plan." (
(
(
Plaintiff alleges that the above-quoted language sets forth a clear methodology for determining benefits when, as was the case with her, a participant is retired, Medicare eligible, and receives services from a provider who has elected to opt out of Medicare. First, the Plan must determine the payments that the Plan would have paid had it been the Primary Coverage Plan. Relying on the definition of when a Coverage Plan is primary, plaintiff argues that the Plan must use the methodology that it would have used if it were primary without considering Medicare's benefits. The parties do not dispute that in such instances UHIC applies a reimbursement percentage defined in the Copay Plan to the usual and customary rate ("UCR") for the procedure at issue. UHIC obtains the usual and customary rate from a database UHIC rents from Fair Health, Inc.
The Plan must then determine the amount that Medicare would have paid had the provider not opted out. Finally, the Plan must deduct the amount that Medicare would have paid (as if it had been paid) from the amount that the Copay Plan would pay. The key language for this step is quoted above and included here for ease of reference:
(SPD at 69.) According to plaintiff, the formula would work as follows in practice:
(
Defendants disagree with this methodology. According to defendants, the key to the difference lies in a portion of the methodology plaintiff spends little time on—determination of the "Allowable Expense." Defendants assert that the term "Allowable Expense" is quantitative in that it allows UHIC to determine a particular dollar amount to plug into its calculation; according to plaintiff, "Allowable Expense" is qualitative—it is a determination as to whether a particular expense is "allowable," not necessarily the amount. Put another way, plaintiff argues that "Allowable Expense" refers to whether the expense is allowed; defendants argue that it refers to the dollar amount of such expense, that is, the "amount" allowed.
According to defendants, the "Allowable Expense" is used twice in the calculation of benefits—first, as the "full amount that would have been payable under Medicare" and, second, as the monetary amount used to calculate what the Copay Plan "would have paid had it been the Primary Coverage Plan." According to defendants, when a participant uses a provider who has opted out of Medicare, it is reasonable to use the same Allowable Expense—defined as the amount the participant paid to the opt-out provider—in both the first and second step of the equation; otherwise, there would be one amount for the Allowable Expense under Medicare and a second
According to defendants, and as implemented in connection with plaintiffs claims here, the formula is as follows:
(Pl.'s AB Opp. at 6.) Thus, using plaintiffs formula, her benefits for Procedure X should have been $197.90; using defendants' formula, those benefits would instead be $80.
For the reasons set forth below, the Court finds that (1) the COB methodology is unambiguous; (2) that injunctive relief is not available for past violations under § 502(a)(1) or § 502(a)(3)-for either benefits determinations or claims procedures. And finally, while plaintiff might be able to state a claim against AB for co-fiduciary liability, the only relief sought for such violation is injunctive relief, which is unavailable to plaintiff or otherwise procedurally nonsensical. Accordingly, defendants' motion is DENIED as to the First Claim for Relief and GRANTED as to all other claims.
Summary judgment may not be granted unless all of the submissions taken together "show[] that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Fed. R. Civ. P. 56(a). The moving party bears the initial burden of demonstrating "the absence of a genuine issue of material fact."
When a summary judgment motion is properly supported by documents or other evidentiary materials, the opposing party must set out specific facts showing a genuine issue for trial, and cannot rely merely on allegations or denials contained in the pleadings.
ERISA was passed in 1974 to:
29 U.S.C. § 1001(b) [ERISA § 2(b)];
A "fiduciary" is defined as one who with respect to a plan:
29 U.S.C. § 1002(21)(A) [ERISA § 3(21)(A)]. Fiduciary duties are set forth in ERISA § 404. That provision provides that "a fiduciary shall discharge his duties with respect to a plan solely in the interest of the participants and beneficiaries and—"
29 U.S.C. § 1104(a)(1)(D) [ERISA § 404(a)(1)(D)]. ERISA § 409(a) provides for certain—but not exclusive-remedies for breach of fiduciary duties. This section applies when such breach has resulted in a loss of plan assets:
29 U.S.C. § 1109(a) [ERISA § 409(a)].
29 U.S.C. § 1105(a) [ERISA § 405(a)]. ERISA § 502 contains general provisions regarding civil enforcement of ERISA violations. That section provides that,
29 U.S.C. § 1132(a) [ERISA § 502(a)]. ERISA § 503 contains provisions relating to claims procedures. It requires that every employee benefit plan-which, per the definition section, includes medical plans—shall:
29 U.S.C. § 1133 [ERISA § 503].
The ERISA statute does not contain a standard of review for actions under § 1132(a)(1)(B) [ERISA § 502(a)(1)(B)] challenging benefit eligibility determinations.
Another name for "disputed or doubtful" language,
When terms in a plan require no construction, deference to a fiduciary is neither appropriate nor required.
The threshold question for this Court is whether some or all of the claim language used to calculate benefits for plaintiff under the Copay Plan is ambiguous. If it is, then a deferential standard of review is appropriate and a fiduciary's rational interpretation must control.
The Court's conclusion that the language is unambiguous is based on its view that simply reading the language of the Plan provides answers each step of the way-without the need for further interpretation-as to how benefits should be calculated. The Court also agrees with plaintiff that her method of calculation reflects the clear steps the Plan requires. Marching through the terms of the Copay Plan informs the reader how to calculate the first input into the formula-the "full amount Medicare would have paid." That amount is knowable from public sources: an arm of the U.S. Department of Health and Human Services ("UHHS") puts out a fee schedule (http://www.cms.gov/apps/physician-fee-schedule/search/searchcriteria.aspx) that provides Medicare payment amounts, depending on year, geographic region, CPT code, and other parameters—
Defendants argue that interpretation is required. In particular, they argue that the term "Allowable Expense" requires interpretation, and that it is rational to have the same "Allowable Expense" at each step of the COB calculation. If there is ambiguity, defendants also argue that various policy and procedural arguments support the rationality of their approach. But the term "Allowable Expense" is quite clear, and it does not mean what defendants assert. Nor does it play the role in the COB methodology that they assert. There is no basis for some numberwhich is neither an amount Medicare would have paid nor an amount the Copay Plan would have paid-to be plugged in as the "Allowable Expense."
The lack of ambiguity forecloses the interpretation defendants have proffered as a basis for summary judgment on plaintiffs First Claim for Relief. Defendants' motion as to that claim is therefore DENIED.
Defendants argue that even if plaintiff has a claim for damages with regard to her First Claim for Relief, she may not seek prospective injunctive relief in her Second Claim for Relief pursuant to ERISA § 502(a)(3). In that claim, plaintiff seeks to prohibit defendants from using the UHIC "Estimating Policy" in the future. The Court agrees with defendants.
Two key facts are undisputed: (1) no class has yet been certified in this action-Gates is the sole plaintiff at present; and (2) plaintiff is no longer a participant in the Copay Plan.
As a matter of law, in order to pursue the remedy of an injunction, plaintiff must be able to show that she is likely to suffer the same injury in the future.
On the undisputed facts, there is no real or immediate threat that the use of the Estimating Policy with regard to benefits under the Copay Plan will impact plaintiff in any way. Her individual claim for injunctive relief is therefore untenable.
Nor does plaintiff have the ability
Plaintiff cites
In this case, at this point in time, this Court is not faced with questions of justiciability. The Court's determination as to whether to grant or deny judgment is based on whether plaintiff has raised a triable issue as to the claim as to which judgment is sought. Here, she has not and, based on her own facts, cannot. Accordingly, while plaintiff may pursue a claim for damages, and indeed may seek certification of a class, at this time she cannot maintain her request for injunctive relief.
Plaintiffs Third and Fourth Claims for Relief assert breaches of fiduciary duties with regard to claims procedures. Plaintiff seeks administrative relief as to herself and prospective injunctive relief as to unnamed potential class members.
As a threshold matter, as set forth above with regard to the Second Claim for Relief, injunctive relief is not available to plaintiff. She is concededly no longer a participant in the Copay Plan-she so asserts in the SAC. (SAC ¶ 41.) She is therefore not at risk of being harmed or impacted by any future failures with regard to claims procedures. In the absence of available relief, her claim, insofar as it relates to such relief, must fail. In terms of administrative relief as to which she has a live claim, remanding plaintiffs claims would serve no purpose other than that achieved if her First Claim for Relief succeeds-that is, payment for benefits. Remand and deemed exhaustion are nonsensical in the context of this case, which has been pending for several years.
The lack of a separate remedy for these claims requires their dismissal. The Court notes, however, that it has considered the parties' additional arguments. First, the Court agrees that to the extent that either claim seeks to impose liability under §§ 502(a)(2) and 409 for failures to comply with claims procedure requirements, those sections are inapplicable. Section 502(a)(2) invokes the § 409which relates to a loss in plan assets. There is no claim here of any loss in Plan assets.
The Court has analyzed plaintiffs claims under§ 503 more generally, along with§ 404, and in terms of relief otherwise possible under§ 502(a)(3). Section 404 generally requires all fiduciaries to discharge their duties "in accordance with the documents and instruments governing the plan." 29 U.S.C. § 1104 [ERISA § 404]. There is at least a triable issue of fact as to whether UHIC, in the Fourth Claim, complied with its § 404 obligations. On this basis alone, the claim could proceed if the injunctive relief sought were available. However, for the reasons set forth above, it is not.
Defendants also seek dismissal of this claim because "the Section 503 claims administration requirements do not implicate the fiduciary duties specified in Section 404(a)(1)(D)." (Memorandum of AB Defendants in Support of Motion for Summary Judgment at 18, ECF No. 125.) According to defendants, claims administration duties are found in Part 5 of ERISA, entitled "Administration and Enforcement," and it is this section which sets forth statutory provisions regarding claims procedures. Defendants point to the fact that Part 5 is distinct from Part 4 of the statute, which is entitled "Fiduciary Responsibility." Defendants further argue that the disclosure obligations in § 404 are with regard to pension benefit plans, not welfare benefit plans-and as a health care plan, the Copay Plan is a welfare benefit plan.
This Court disagrees with these arguments. As an initial matter, there is no triable issue of fact as to whether UHIC was a fiduciary of the Copay Plan-it plainly was. It was delegated the responsibility for administering all claims and to making any interpretations necessary. Here, plaintiff correctly alleges that, in connection with those administration duties, UHIC made interpretations that it should not have. The Court found, in connection with the First Claim, that the COB methodology in the Copay Plan is clear and unambiguous and that UHIC applied erroneous methodology contrary to the plain language of the Copay Plan.
It is also clear that§ 404 does apply to the type of claim-and the type of employee welfare plan it is based on-here asserted. The definitions of "employee welfare benefit plan" and "plan" (as set forth above) eliminate any doubt as to that point.
With regard to the Fourth Claim, there is no reasonable doubt that UHIC was acting as a fiduciary when it made its benefit determinations. When URIC applied its interpretation to a claim for benefits, and paid a participant accordingly, it was undertaking many functions simultaneously: an interpretive function in which it was exercising its discretion (wrongly as it turns out), as well as a bookkeeping and administrative function when it cut the check and sent it to the participant. In exercising its duties in determining whether or not to pay a claim here, it was acting as a fiduciary; when it was simply cutting the check that it had otherwise determined should be cut, it was acting in a simple ministerial capacity. This is consistent with the Supreme Court's discussion in
In
Defendants argue that§ 503 addresses only procedural aspects of the claims process and does not create any substantive fiduciary duties. Defendants cite
626 F.3d 66, 74 (2d Cir. 2010) (citations omitted). This case is consistent, not inconsistent, with this Court's determination. UHIC was wearing more than one hat at different points in the process of considering and then paying out a particular amount of benefits. As discussed above, some its acts were merely ministerial, others were not. It cannot be the case that in determining and then applying the COB methodology-with the result of paying participants less than the amount to which they are entitled under the plain reading of the Plan terms-URIC was acting merely ministerially. Indeed, determining how much to pay is at the heart of UHI C's fiduciary role.
Plaintiffs Fifth Claim for Relief is against AB only. As the Court has stated above, to the extent that plaintiff seeks injunctive relief with regard to this claim, no facts support such a claim. Without any available relief, even a past violation of this provision leads nowhere.
Though it does not plead§ 405, the Fifth Claim is plainly an unartful attempt to assert co-fiduciary liability. The claim asserts that AB breached its fiduciary obligation to the Plan by failing to monitor, terminate, and replace UHIC as the Plan's Claim Administrator when it breached its obligations. But even in the absence of pleading the correct section, plaintiff has failed to support her claim with the requisite statutory elements of knowledge, enabling, or failing to remedy. See 29 U.S.C § 1105(a) [ERISA § 405(a)].
For the reasons set forth above, defendants' motions are DENIED as to the First Claim for Relief and GRANTED as to the Second, Third, Fourth, and Fifth Claims for Relief. Plaintiffs motion pursuant to Rule 56 of the Federal Rules of Civil Procedure (ECF No. 133) is DENIED as moot in light of the Court's determinations. The Clerk of Court is directed to terminate the motions at ECF Nos. 124, 127, and 133.
SO ORDERED.
(SPD at 67.) The parties do not dispute that this example is not on all fours with the facts before this Court as Medicare does not, strictly speaking, "negotiate its fees" with any particular provider. This example is inapplicable; it requires interpretation in what this Court finds to be otherwise unambiguous language.