Whiting v. AARP & Unitedhealthcare Insurance
394 U.S. App. D.C. 421
| D.C. Cir. | 2011Background
- Whiting purchased United Healthcare insurance through an AARP-marketed plan described as a bridge, not a major medical plan.
- Whiting incurred a gall bladder surgery; United paid inpatient benefits but denied laboratory/pathology and radiology costs when performed in an inpatient setting.
- Whiting sued United and AARP for breach of Certificate, breach of the AARP-United agreement, DC Consumer Act claims, and unjust enrichment, seeking class certification.
- Certificate caps and coverage terms for Radiology and Laboratory/Pathology benefits are stated with per-procedure limits and are tied to outpatient settings; inpatient coverage is not clearly described in those sections.
- Promotional materials state outpatient-only benefits; the district court dismissed the complaint for failure to state a claim, holding the contract unambiguous under DC law.
- On appeal, the DC Circuit reviewed de novo and affirmed dismissal, finding no ambiguity and that extrinsic materials confirmed the outpatient-only interpretation.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the Certificate is ambiguous about inpatient radiology/pathology coverage. | Whiting argues ambiguity exists; inpatient lab/radiology may be covered due to lack of explicit 'outpatient only' language in the WHAT IS COVERED section. | United/AARP contend the contract unambiguously covers radiology/pathology only in outpatient settings and the Note confirms inpatient exclusion. | No ambiguity; breach claims fail. |
| Whether promotional materials create ambiguity about inpatient coverage. | Marketing promises and broad claims mislead a reasonable consumer into thinking inpatient radiology/pathology are covered. | Extrinsic materials show outpatient-only coverage; contract language controls; no ambiguity. | Promotional materials do not create ambiguity; claims fail. |
| Whether Whiting is an intended third-party beneficiary of the AARP-United agreement. | Whiting is an intended beneficiary to obtain insurance for members. | Claim is redundant of breach and not showing coverage beyond the Certificate terms; insufficient pleadings. | No third-party beneficiary claim viable. |
| Whether the DC Consumer Act claim survives given the alleged misrepresentations. | Marketing language and brochure mislead a reasonable consumer into thinking inpatient radiology/pathology are covered. | No reasonable consumer would be misled; context and chart show outpatient-only limits; claims fail as a matter of law. | Consumer Act claim dismissed. |
| Whether the unjust enrichment claim survives. | AARP retained royalties; enrichment should be unjust given misrepresentations. | Enrichment depends on surviving contract or statutory claims; otherwise unjustified. | Unjust enrichment claim properly dismissed. |
Key Cases Cited
- Travelers Indem. Co. of Ill. v. United Food & Commercial Workers Int'l Union, 770 A.2d 978 (D.C.2001) (interpret ambiguous terms in insurance contracts; prose must align with reasonable expectations)
- Cameron v. USAA Prop. & Cas. Ins. Co., 733 A.2d 965 (D.C.1999) (insurer must spell out exclusions in plain terms)
- In re Corriea, 719 A.2d 1234 (D.C.1998) (language and meaning orientation in contract interpretation)
- Tillery v. District of Columbia Contract Appeals Bd., 912 A.2d 1169 (D.C.2006) (interpretation of contract language based on common speech imports)
- Trudeau v. FTC, 456 F.3d 178 (D.C.Cir.2006) (non-misleading as a matter of law where no reasonable person would be misled)
- Walker v. Nat'l Recovery, Inc., 200 F.3d 500 (7th Cir.1999) (context for reasonable consumer interpretation; not controlling here but cited as contrast)