ORDER and OPINION
This matter is before the Court upon Defendant Horizon Blue Cross Blue Shield of New Jersey’s (“Horizon”) motion to dismiss both the Beye complaint (Beye DKT# 119) and the Foley complaint (Foley DKT# 91), and the Magellan Defendants’ 1 motion to dismiss the Beye Complaint (Beye DKT# 120, 121) and the Foley Complaint (Foley DKT# 92, 93). 2 The Court has jurisdiction over Plaintiffs Drazin and Byram’s claims pursuant to ERISA § 502, 29 U.S.C. § 1132, and 28 U.S.C. § 1331. 3 The Plaintiffs assert jurisdiction in this Court over non-ERISA Plaintiffs Sedlak and Beye pursuant to the Class Action Fairness Act (“CAFA”), 28 U.S.C. § 1332(d). The Court heard oral argument in this matter on October 10, 2007, after which the Court terminated Horizon’s first motion to dismiss in order to permit Plaintiffs to amend their complaints to add the Magellan Defendants. The Magellan Defendants and Horizon filed the instant motions to dismiss on January 29, 2008.
I. FACTS
These cases are class actions brought on behalf of class members who are covered by ERISA and non-ERISA health insurance policies issued by Defendant Hori
As in the related case
DeVito v. Aetna,
“the gravamen of Plaintiffs’ claims is that [Horizon] improperly denied coverage for treatment sought for their daughters’ eating disorders by improperly classifying eating disorders as ‘non-Biologically Based Mental Illnesses.’ ”
Biologically-based Mental Illness means a mental or nervous condition that is caused by biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to schizophrenia; schizoaffective disorder; major depressive disorder; bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder; panic disorder and pervasive developmental disorder or autism.
Morelia Cert. Ex. C (Byram Policy) at 13; see also Ex. A (Beye Policy) at 6; Ex E (Drazin Policy) at 10. Plaintiffs Beye, By-ram, and Drazin’s policies also contain a substantially similar definition for “non-Biological-based Mental Illness” 7
Non-Biologically Based Mental Illness means an Illness which manifests symptoms which are primarily mental or nervous for which the primary treatment is psychotherapy or psychotropic medication where the Illness is not biologically-based.
In determining whether or not a particular condition is a Non-Biologically-based Mental Illness, Horizon BCBSNJ may refer to the current edition of the Diagnostic and Statistical Manual of Mental Conditions of the American Psychiatric Association.
Morelia Cert. Ex. C (Byram Policy) at 22; see also Ex. A (Beye Policy) at 14; Ex. E (Drazin Policy) at 23.
Three of the four Plaintiffs’ policies cover treatment for BBMIs “at parity” with other illnesses as required by the New Jersey Mental Health Parity Law. 8 In other words, treatment for BBMIs under those policies is subject only to the policy deductible and coinsurance payment, if any, and, in some cases, to preauthorization. See Morelia Cert. Ex. C (Byram Policy) at 51 (“Horizon BCBSNJ pays benefits for the ... treatment of [BBMIs] the same way Horizon ... would for any other Illness, if such treatment is prescribed by a Practitioner.”); see also Ex. A (Beye Policy) at 20; Ex. E (Drazin Policy) at 31. Three of the Plaintiffs’ policies also contain coverage limitations for non-BBMIs, limiting inpatient and outpatient treatment for non-BBMIs to a certain number of days or visits per year and, in some cases, per lifetime. See Morelia Cert. Ex. C. (Byram Policy) at 61; Ex. A (Beye Policy) at 24; Ex. E (Drazin Policy).
Plaintiffs Beye and Drazin received coverage for their daughters’ eating disorders treatments as non-BBMIs. Both Plaintiffs exhausted the limited benefits available for non-BBMIs under the terms of their plans.
Defendant Horizon filed its first motion to dismiss on April 25, 2007. Following oral argument on October 10, 2007, 9 the Beye Plaintiffs filed a third amended complaint (Beye DKT# 80) and the Foley Plaintiffs filed a second amended complaint (DKT# 59), adding the Magellan Defendants. The Court terminated Horizon’s motion to dismiss on January 17, 2008 pursuant to Magistrate Judge Shwartz’s order that the parties submit new omnibus motions responding to the amended complaints in their entirety. The parties thereafter filed the instant motions to dismiss.
II. STANDARD
Motions to dismiss under Federal Rule of Civil Procedure 12(b)(6) for failure to state a claim result in a determination on the merits at an early stage of a plaintiffs case.
See Mortensen v. First Fed. Sav. and Loan Ass’n,
The Supreme Court’s Twombly formulation of the pleading standard can be summed up thus “stating ... a claim requires a complaint with enough factual matter (taken as true) to suggest” the required element. This “does not impose a probability requirement at the pleading stage,” but instead “simply calls for enough facts to raise a reasonable expectation that discovery will reveal evidence of’ the necessary element.
Phillips v. County of Allegheny,
III. ANALYSIS
A Horizon’s Motion to Dismiss
1. Burford Abstention
Horizon first argues that this Court should abstain from considering Plaintiffs’ claims pursuant to the doctrine espoused in
Burford v. Sun Oil Co.,
Under Burford, the Court undertakes a two-step analysis. “The first question [when considering Burford abstention] is whether ‘timely and adequate state-court review" is available.” Riley v. Simmons,45 F.3d 764 , 771 (3d Cir.1995) (citing New Orleans Public Service, Inc. v. Council of City of New Orleans,491 U.S. 350 , 361,109 S.Ct. 2506 ,105 L.Ed.2d 298 (1989) (“NOPSI”)). The second prong of the Burford doctrine, as refined in NOPSI, requires a court to examine three issues: “(1) whether the particular regulatory scheme involves a matter of substantial public concern, (2) whether it is ‘the sort of complex, technical regulatory scheme to which the Burford abstention doctrine usually is applied,’ and (3) whether federal review of a party’s claims would interfere with the state’s efforts to establish and maintain a coherent regulatory policy.” Chiropractic Am. v. Lavecchia,180 F.3d 99 , 105 (3d Cir.1999) (internal citation omitted). “Federal courts more readily abstain from a case that contains no issue of federal law.” Lac D’Amiante du Quebec, Ltee v. Am. Home Assur. Co.,864 F.2d 1033 , 1044 (3d Cir.1988).
Id. at 527-28. 10
Turning to the second prong first, Defendants argue that this is the kind of case “where the state has created a complex regulatory scheme central to state interests and federal jurisdiction would be disruptive of the state’s efforts.”
Chandler v. Omnicare/HMO, Inc.,
Defendants argue that this pending legislature is grounds for Burford abstention. Although a pending bill may be enacted into law and, in the future, change the Parity Law, such a change would not provide coverage to Plaintiffs for the time period relevant to this case. This case involves claims for past coverage of eating disorders and Defendants do not suggest that the proposed billwould apply retroactively. See Transcript of 10/10/2007 Oral Argument (“Tr.”) at 84(l)-(8) (conceding that proposed bill is not retroactive).[ 11 ] A potential, prospective change in the law does not provide a basis for this Court to abstain from deciding a claim based on contractual language [contained in the relevant policies]....
Id. at 528.
Both the ERISA and non-ERISA Plaintiffs claim that Horizon breached the terms of their insurance contracts. As a result, “[w]hether the Parity Law is changed or modified does not affect this case. The ... language in the insurance policies governs this case, regardless of further changes in the Parity Law.” Id. In the instant cases, “the Court is asked ... to consider the terms of Plaintiffs’ insurance policies and [Horizon]’s handling of benefit claims made pursuant to those policies”. Id. In other words, in addressing Plaintiffs’ claims, the Court is not faced with “complex policy trade-offs between costs and coverage” or “[e]omplex policy and clinical decisions”. Mot. at 10. The Court need only interpret Plaintiffs’ contracts of insurance, and, in the case of the ERISA Plaintiffs, consider whether Defendants’ denials of coverage were arbitrary and capricious. This is a routine task that is familiar to this and all federal district courts and is not grounds for Burford abstention.
Turning back to the first prong of
Bur-ford,
Horizon argues that the state scheme provides for timely and adequate state court review, and that this Court should therefore abstain from hearing Plaintiffs’ claims. Hor. Mot. at 11. Defendant argues that under New Jersey Appellate Rule 2:2-3(a)(2), Plaintiffs could have appealed an adverse IURO decision to the Superior Court of New Jersey.
12
The mere availability of review by an IURO and the Appellate Division neither compels nor warrants
Burford
abstention and nothing in
Burford
suggests otherwise.
See DeVito,
For the reasons stated above, the Court will not abstain from Plaintiffs’ claims based on the doctrine expounded in
Burford v. Sun Oil Co.,
ii. Exhaustion of IURO Review and “Primary Jurisdiction”
Horizon argues in the alternative that, if the Court does not defer under
Burford,
then it should either dismiss ERISA Plaintiff Drazin’s claim for failure to exhaust his right to IURO review or the Court should “exercise its discretion” and defer to the “primary jurisdiction” of DOBI.
13
Mot. at 14. The Court rejected these argument in
DeVito. See
iii. Subject Matter Jurisdiction and Appellate Review of an IURO Decision
Horizon next argues that the Court must dismiss the claims of ERISA Plaintiff Byram and non-ERISA Plaintiffs Beye and Sedlak for failure to appeal their adverse IURO decisions to the Appellate Division. This argument was essentially abandoned as to ERISA Plaintiff Byram at oral argument. See Tr. 49(22)-(25) (“Well, if you’ve got an ERISA beneficiary, we do agree that they would have the right to come to federal court.”). Beneficiaries and participants in ERISA plans have a right to have their claims heard in federal court without regard to diversity or amount in controversy. See 29 U.S.C. §§ 1132(d), (e). ERISA Plaintiff Byram is not required to appeal his adverse IURO ruling to the Appellate Division before filing suit in this Court.
Moreover, by its own terms New Jersey Rule of Court 2:2-3(a)(2) does not require this Court to defer the instant dispute to an IURO. The rule states in relevant part that “appeals may be taken to the Appellate Division as of right ... (2) to review final decisions or actions of any state administrative agency or officer....” N.J.R. Ct. 2:2-3(a)(2). However, Defendants do not cite-and the Court has been unable to locate-any case or statute in which an IURO is described as a “state administrative agency or officer.” “State Agency” is defined in the New Jersey Administrative Procedures Act as
each of the principal departments in the executive branch of the State Government, and all boards, divisions, commissions, agencies, departments, councils, authorities, offices or officers within any such departments now existing or hereafter established and authorized by statute to make, adopt or promulgate rules or adjudicate contested cases, except the office of the Governor.
N.J. Stat. Ann. § 52:14B-2(a). By contrast, the New Jersey code defines “IURO” as follows:
‘Independent utilization review organization (IURO)’ means an independent organization, comprised of physicians and other health care professionals representative of the active practitioners in New Jersey, with which the Department contracts in accordance with [N.J. Admin. Code § ] 11:24-8.8 to conduct independent medical necessity or appropriateness of services appeal reviews brought by a member or provider on behalf of the member, with the member’s consent.
N.J. Admin. Code. § 11:24-1.2 (emphasis added). Although the APA’s definition of “State Agency” provides a long and apparently exhaustive list of state bodies includ
iv. Claims of “Not Medically Necessary” Plaintiffs Byram and Sedlak
Both Horizon and Magellan 15 move to dismiss all claims brought by non-ERISA Plaintiff Sedlak and ERISA Plaintiff Byram, both of whom were denied benefits as “not medically necessary.” 16 The crux of both Defendants’ argument is that “[t]he No Medical Necessity Plaintiffs’ claims are nothing but speculation,” Hor. Mot. at 19, and “medical necessity” is a threshold issue “because Plaintiffs’ policies prohibit coverage for treatment that is not medically necessary whether or not the illness is BBMI.” Hor. Mot. at 3. Defendants’ position is that, because the medical necessity decision precedes and is independent of the BBMI/non-BBMI determination, those Plaintiffs who were denied on medical necessity grounds were never subject to the BBMI/non-BBMI determination, and therefore have failed to state a claim upon which relief may be granted.
Similarly to the Plaintiffs in
DeVito,
however, Plaintiffs Byram and Sedlak have
Plaintiff[s Byram and Sedlak] must demonstrate — either at trial or in a subsequent motion [for summary judgment] — the connection between those claims denied as “not medically necessary” and Defendants’ allegedly improper treatment of eating disorders as non-BBMIs. This may be a difficult burden for Plaintiffis] ... to carry, but [their] allegations nevertheless entitle [them] to proceed with discovery at this stage of the litigation.
DeVito,
Plaintiffs do not allege that Defendants are required to find all treatment for eating disorders “medically necessary.” Rather, Plaintiffs allege that Defendants’ denial of claims on grounds that the treatment was “not medically necessary” was pretextual. Plaintiffs allege that Defendants have improperly denied some claims as “not medically necessary” because of Defendants’ policy of denying all such claims in violation of the terms of Plaintiffs’ contracts. Whether Plaintiffs’ pretext allegations are true or false is an issue that will be determined when the case reaches the merits stage.
Id. at n. 7.
In certain respects, the Plaintiffs in Beye and Foley may have an even more difficult burden to demonstrate pretext. Unlike the Plaintiffs in DeVito, both By-ram and Sedlak appealed their “not medically necessary” determinations to IUROs, and in both cases the IUROs affirmed Horizon’s decision. While the IURO decisions are persuasive evidence that Horizon’s “not medically necessary” determinations were non-pretextual, Plaintiffs Byram and Sedlak will have the opportunity to take discovery on this issue. This issue may be appropriately raised in a subsequent motion for summary judgment.
v. ERISA Preemption of Common Law and State Claims
Horizon and Magellan move to dismiss the state and common law claims of the two ERISA Plaintiffs, Byram and Dra-zin. Specifically, Defendants move to dismiss counts one (common law breach of contract), two (common law breach of implied duty of good faith and fair dealing), four (statutory violations of New Jersey’s Parity Law), five (statutory violations of the New Jersey Consumer Fraud Act), six (statutory violations of the Pennsylvania Unfair Trade Practices and Consumer Protections Law), seven (common law unjust enrichment), eight (common law misrepresentation), nine (tortious interference with contract rights), and ten (third party beneficiary breach of contract) of the Beye Complaint, and counts two (Parity Law claim) and four (New Jersey Consumer Fraud Act claim) of the Foley Complaint.
The critical determination for purposes of ERISA preemption is whether Plaintiffs’ claims “relate to” an ERISA benefit plan. It is well established that § 514(a)
preempts ‘any and all State laws insofar as they may now or hereafter relate to any employee benefit plan’ covered by ERISA. In this context, the term ‘State law1 encompasses state common law causes of action, as it includes ‘all laws, decisions, rules, regulations or other state action having the effect of law, of any State.’
Sciotto v. U.S. Healthcare Systems of Pa.,
No. 01-4973,
The Court discussed ERISA preemption in DeVito. There, the Court noted:
In Aetna Health Inc. v. Davila the Supreme Court noted that “ERISA’s ‘comprehensive legislative scheme’ includes ‘an integrated system of procedures for enforcement.’ This integrated enforcement mechanism, ERISA § 502(a) ... is a distinctive feature of ERISA, and essential to accomplish Congress’ purpose of creating a comprehensive statute for the regulation of employee benefit plans.”542 U.S. 200 , 208,124 S.Ct. 2488 ,159 L.Ed.2d 312 (2004) (internal citations omitted). The [Supreme] Court went on to conclude that[:]
[i]t follows that if an individual brings suit complaining of a denial of coverage for medical care, where the individual is entitled to such coverage only because of the terms of an ERISA-regulated employee benefit plan, and where no legal duty (state or federal) independent of ERISA or the plan terms is violated, then the suit falls “within the scope of’ ERISA § 502(a)(1)(B). In other words, if an individual, at some point in time, could have brought his claim under ERISA § 502(a)(1)(B), and where there is no other independent legal duty that is implicated by a defendant’s actions, then the individual’s cause of action is completely pre-empted by ERISA § 502(a)(1)(B).
DeVito,
ERISA Plaintiff Drazin concedes that his Parity Law claim and his New Jersey Consumer Fraud Act claim are preempted by ERISA. See Foley Opp. at 16 (“Plaintiffs concede that it [sic] may not pursue the state law claims as to those plaintiffs whose right to benefits are governed by ERISA.”). The Court will grant Defendants’ motion to dismiss the ERISA Plaintiff Drazin’s Parity Law claim and New Jersey Consumer Fraud Act claim.
ERISA Plaintiff Byram has not been as forthcoming in assessing the impact of this Court’s ruling in DeVito on his Parity Law claim. For that reason, it is worth restating the Court’s analysis so there is no question as to the nature of the claims that have survived the instant motions to dismiss. As the Court explained in DeVito,
Plaintiffs’ [ERISA] policies contain language substantially similar to that contained in the Parity Law. As a , result, even if the Parity Law provides a private cause of action, the parity language contained in Plaintiffs’ [ERISA] policies is coterminous with any privately enforceable right that might arise under the Parity Law. The Court therefore finds that [ERISA] Plaintiffs would have no private cause of action under the Parity law that they do not already have under the terms of their respective policies. This point is critical to the Court’s preemption analysis.
In the case at bar, Plaintiffs’ alleged entitlement to benefits under either the Parity Law or ERISA arises “only because of the terms of an ERISA-regulat-ed employee benefit plan.... ” [Aetna Health, 542 U.S. at 210 ,124 S.Ct. 2488 ] Stated differently, Parity Law “liability would exist here only because of [Defendants’] administration of ERISA-regu-lated benefit plans. [Defendants’] potential liability under the [Parity Law] in th[is] case[ ], then, derives entirely from the particular rights and obligations established by the benefit plans.” Id. at 213,124 S.Ct. 2488 . Further, because the parity language in Plaintiffs’ policies gives rise to the same rights as those arguably available under the Parity Law, “no legal duty (state or federal) independent of ... the plan terms [has been] violated.” Id. In other words, Defendants’ duties under the Parity Law are identical to their duties under the parity language in Plaintiffs’ policies. Therefore, because Plaintiffs can bring their claims under ERISA § 502(a)(1)(B), and because there is no other independent legal duty implicated by Defendants’ actions, any individual cause of action under the Parity Law would be completely pre-empted by ERISA § 502(a)(1)(B) and the Supreme Court’s preemption analysis in Aetna Health.
DeVito,
Plaintiff Byram argues that because her contract contains language that provides rights substantially similar to those provided by the Parity Law, she may also pursue her claim under the Parity Law. See Beye Opp. at 16 (“As a result all plaintiffs may pursue their claims under the Parity Law.”), 21 (“As discussed supra, Byram may assert claims under the Parity Law as these claims are expressly incorporated into her contract.”). This is not so. As the above quotation makes clear, in DeVito the Court was explicit that all Parity Law claims are preempted as to ERISA Plaintiffs who have contractual rights coterminous with those arguably provided by the Parity Law. To be clear, this is not, as Byram would have it, the same thing as saying that ERISA Plaintiffs may pursue their Parity Law claim. Based on the Parity-Law-like language in their contracts, the ERISA Plaintiffs may pursue their contractual claim to benefits governed by all the familiar ERISA processes and procedures. To the extent that the Parity Law may provide an implied right of action, those Parity Law claims are dismissed as preempted with respect to ERISA Plaintiffs Byram and Drazin.
Byram also argues that she “may ... assert state law claims for unjust enrichment, misrepresentation, and consumer fraud” because “these claims are independent of the ERISA relationship.... ” Beye Opp. at 21. The gravamen of the Byram’s misrepresentation claims is that, when By-ram subscribed to the plan, “Horizon represented ... that it provided unlimited inpatient coverage for BBMI conditions .... ” See Beye Compl. ¶ 47; see also Beye Opp. at 22 (“Plaintiffs expected to receive parity coverage for BBMIs when they subscribed to the policies based on Horizon’s representations that their insurance provided such coverage.”), 23 (“Specifically, Plaintiffs contend that they were induced into subscribing to Horizon’s policies based on defendant’s misrepresentations of parity coverage.”). After Byram subscribed to the plan, however, Byram alleges that “Horizon and/or Magellan acted arbitrarily and capriciously or otherwise wrongfully by determining eating disorders were non-BBMI.... ” Beye Compl. ¶ 47.
Byram argues that claims against “sellers of insurance for misrepresenta
The cases Byram cites are not to the contrary. In
Wilson v. Zoellner
the Eighth Circuit reversed the District Court’s holding that Plaintiffs negligent misrepresentation claim was preempted by ERISA.
In
Martin v. Pate,
the plaintiff alleged that the insurer “knew or should have known of plaintiffs pre-existing condition and that despite such knowledge defendants represented that the ‘policy [issued by Continental] would insure plaintiff for such pre-existing condition.’ ”
For the above reasons, the Court will grant Defendants’ motion to dismiss By-ram’s remaining state law claims for common law unjust enrichment (count seven), and common law misrepresentation (count eight), and Byram’s claim under the New Jersey Consumer Fraud Act (count five) as preempted by ERISA § 514(a) and § 502(a). 18
v. ERISA Claims of non-ERISA Plaintiffs
To the extent that the Beye and Foley complaints can be read to state ERISA claims on behalf of the non-ERISA Plaintiffs, Horizon moves to dismiss those claims. An ERISA claim may only be brought by a “participant or beneficiary” of an ERISA plan. See 29 U.S.C. § 1132(a)(1). To the extent that the non-ERISA Plaintiffs’ bring ERISA claims, the Court will grant Defendants’ motion to dismiss those claims.
vi. Parity Law Claim
Both Horizon and Magellan move to dismiss Plaintiffs’ Parity Law claims, arguing that the Parity Law does not provide an implied private cause of action. As discussed in Part III.A.V, supra, the Court will grant Defendants’ motion to dismiss the ERISA Plaintiffs’ Parity Law claims for the reasons discussed in that section.
All the parties agree that the applicable test for determining whether a statute provides an implied cause of action is set forth in
R.J. Gaydos Ins. Agency, Inc. v. National Consumer Insurance Co.,
To determine if a statute confers an implied private right of action, courts consider whether: (1) plaintiff is a member of the class for whose special benefit the statute was enacted; (2) there is any evidence that the Legislature intended to create a private right of action under the statute; and (3) it is consistent with the underlying purposes of the legislative scheme to infer the existence of such a remedy.
R.J. Gaydos,
This inquiry is a delicate one that raises serious issues of comity and federalism. Since
Cort
was decided, federal courts have become increasingly reluctant to imply causes of action in federal laws.
See, e.g., Thompson v. Thompson,
The question is not yet squarely presented because, at this stage of the case, the Court is not yet certain of its jurisdiction over the non-ERISA Plaintiffs.
21
Plaintiffs assert that this Court has jurisdiction over the non-ERISA Plaintiffs pursuant to CAFA, 28 U.S.C. § 1832(d).
22
Plaintiffs, as “the party invoking federal jurisdiction[,] bear[ ] the burden of demonstrating its existence.... ”
Hart v. FedEx Ground Package System Inc.,
Defendants take issue with Plaintiffs’ jurisdictional allegations, but, at this stage, do not offer evidence to refute Plaintiffs’ assertions. Magellan notes that “[b]e-cause discovery is ongoing, it is not clear at this point whether the claims of the non-ERISA plaintiffs satisfy CAFA’s amount in controversy requirement.” Mag. Mot. at 2 n. 1. Horizon made similar allegations in its November 29, 2007 supplemental brief, alleging that “Plaintiffs will be unable to show [that the amount in controversy exceeds] $5,000,000” and that “Horizon is in the process of compiling potential damages and putative class membership numbers and expects to have such information shortly.”
23
See
Horizon’s Brief on
CAFA also provides a “home-state controversy” exception in § 1332(d)(4)(B) and a “local controversy” exception in § 1332(d)(4)(A). Under those exceptions, the Court “shall” decline to exercise jurisdiction if, among other things, greater than two-thirds of the plaintiff classes are citizens of the state in which the action was filed.
24
See
28 U.S.C. § 1332(d)(4). “[T]he party seeking to take advantage of the home-state or local exception to CAFA jurisdiction has the burden of showing that it applies.”
Hart,
Because the issue has not been fully briefed, the Court does not reach the question of whether the Parity Law provides an implied cause of action for the non-ERISA Plaintiffs. During the pendency of this motion, the parties completed discovery. Based on that discovery, the Court will provide Defendants with thirty days to move for dismissal for lack of subject matter jurisdiction over the non-ERISA Plaintiffs. Alternatively, if there is no dispute between the parties as to this Court’s jurisdiction over the non-ERISA Plaintiffs, the parties shall file a joint statement setting forth the factual basis for the Court’s jurisdiction (or lack thereof), along with accompanying proof. In the interim, the Court will deny Defendants’ motion to dismiss the non-ERISA Plaintiffs’ Parity Law claim without prejudice to re-raising it in a subsequent motion for summary judgment if the Court concludes that it has jurisdiction over the non-ERISA Plaintiffs,
viii. Other Claims
Horizon moves to dismiss certain common law claims of non-ERISA Plaintiffs Beye and Sedlak. Specifically, Horizon moves to dismiss Beye’s common law misrepresentation claim, Beye and Sedlak’s New Jersey Consumer Fraud Act claims, Beye’s Pennsylvania Consumer Fraud Act Claim, and Beye’s Unjust Enrichment claim. Magellan moves to dismiss Beye’s common law breach of fiduciary duty claim, Beye and Sedlak’s third party beneficiary breach of contract claim, Beye and Sedlak’s tortious interference with contract claim, Beye and Sedlak’s New Jersey Consumer Fraud Act claims, and Beye’s Pennsylvania Consumer Fraud Act claim. For the reasons stated in Part III.A.vi,
Both Horizon and Magellan also move to dismiss the Foley Plaintiffs’ ERISA breach of fiduciary duty claim as duplicative of the Foley Plaintiffs’ ERISA breach of contract claim. The Court addressed and rejected this argument in Be-Vito:
Defendants move to dismiss Plaintiffs’ Third Count for breach of fiduciary duty. Defendants argue that Plaintiffs’ breach of fiduciary duty claim pursuant to ERISA § 502(a)(3) is duplicative of their claim for benefits under ERISA § 502(a)(1)(B). Defendants direct the Court to Varity Corp. v. Howe,516 U.S. 489 , 515,116 S.Ct. 1065 ,134 L.Ed.2d 130 (1996) to support their argument that a plaintiff may not bring a claim for breach of fiduciary duty that is duplica-tive of her claim for benefits under § 502(a)(1)(B).
There is a split among circuits and within this district as to the effect of Varity Corp. and Great-West Life & Annuity Ins. Co. v. Knudson,534 U.S. 204 ,122 S.Ct. 708 ,151 L.Ed.2d 635 (2002), on a plaintiffs ability to simultaneously pursue claims for benefits under § 502(a)(1)(B) and for breach of fiduciary duty under § 502(a)(3). See, e.g., Wolfe v. Lu, No. 06-0079,2007 WL 1007181 , *8-9 (W.D.Pa. Mar.30, 2007) (noting that “the issue has been addressed by many district courts within our circuit with differing results” and collecting cases); Tannenbaum v. UNUM Life Ins. Co. of Am., No. 03-1410,2004 WL 1084658 , *3 (E.D.Pa. Feb.27, 2004) (noting that “[t]he courts of appeals are split over whether Varity ever permits a plaintiff who has been denied benefits to simultaneously bring an action for benefits under § 1132(a)(1)(B) and an action for breach of fiduciary duty under § 1132(a)(3)(B)” and collecting cases). The Third Circuit has not expressly addressed this issue. See Wolfe,2007 WL 1007181 at *8.
The Court is persuaded by the reasoning of those courts that have found that Varity does not establish a bright-line rule at the motion to dismiss stage of the case. See, e.g., Wolfe,2007 WL 1007181 at *8-9; Parente v. Bell Atl. Pa., No. 99-5478,2000 WL 419981 , *3 (E.D.Pa. Apr.18, 2000) (“Instead of a bright-line rule, Varity requires an inquiry into whether ‘Congress provided adequate relief for a beneficiary’s injury.’ ”); Moore v. First Union Corp., No. 00-2512,2000 WL 1052140 , *1 (E.D.Pa. July 24, 2000) (“As was recently noted by this Court, Varity does not propose a bright-line rule that a claim for equitable relief under § 1132(a)(3) should be dismissed when a plaintiff also brings a claim under § 1132(a)(1)(B)”); see also Crummett v. Metro. Life Ins. Co., No. 06-1450,2007 WL 2071704 , *3 (D.D.C. Jul.16, 2007) (“The court agrees that dismissal of § 502(a)(3) claims should not automatically occur simply because a complaint also brings § 502(a)(1)(B) claims.”).
Several cases in this circuit have concluded that claims under § 1132(a)(3) are not properly dismissed at the motion to dismiss stage merely because a plaintiff has also brought a claim under § 1132(a)(1)(B). See, e.g., Wolfe,2007 WL 1007181 at *9 (“This Court concludes that the holding of Varity does not mandate dismissal of a § 1132(a)(3)(B) claim whenever a § 1132(a)(1)(B) claim is also brought. At [the motion to dismiss stage], Plaintiff should be allowed to pursue both claims.”); Tannenbaum,2004 WL 1084658 at * 4 (“It is too early in these proceedings to decide whether Plaintiffis contractually entitled to benefits under the Plan. If Plaintiff is not entitled to benefits under the Plan, Plaintiff might still be entitled to ‘other appropriate equitable relief to remedy any breaches of fiduciary duty by Defendants.”); Nicolaysen v. BP Amoco Chem. Co., No. 01-5465, 2002 WL 1060587 , at * 2 (E.D.Pa. May 23, 2002) (“[The court] denies the motion to dismiss as applied to Plaintiffs’ claims for breach of fiduciary duty at this time. Defendants’ argument may be reasserted at the summary judgment stage.”); Moore v. First Union Corp., No. 00-2512,2000 WL 1052140 , *1 (E.D.Pa. July 24, 2000) (“To dismiss Count II of plaintiffs complaint at this stage would be premature. Therefore, defendants’ motion to dismiss will be denied.”). Defendants’ motion to dismiss on this basis is denied at this time; it may be renewed in a summary judgment motion after full discovery.
DeVito,
B. Magellan’s Motion to Dismiss
To the extent that the Magellan Defendants’ motions to dismiss raise the same arguments as those raised by Horizon, those arguments are considered above. Magellan also raises certain arguments that are inapplicable to Horizon, as set forth herein.
1. Magellan Health Services, Inc. and Magellan Behavioral Health, Inc. are not Parties to the Managed Care Service Agreement (“MCS Agreement”) with Horizon
Magellan moves to dismiss all claims against Magellan Health Services, Inc. and Magellan Behavioral Health, Inc. because those entities are not signatories to the MCS agreement with Horizon. Magellan argues that these entities cannot be held liable for breaching a contract to which they were not signatories.
See, e.g., Fox Fuel, a Div. of Keroscene, Inc. v. Delaware County Schools Joint Purchasing Bd.,
Plaintiffs concede that only Green Spring Health Services, Inc. and Magellan New Jersey are signatories to the MCS agreements with Horizon. However, the Foley Plaintiffs have alleged that Magellan Health Services, Inc. and Magellan Behavioral Health, Inc. “promulgated and/or implemented claims processing criteria at the various relevant times.” Foley Compl. ¶ 11. The Beye Plaintiffs have alleged that Magellan Health Services, Inc. and Magellan Behavioral Health, Inc. are “spe-ciality organization[s] authorized by Horizon to administer its managed mental health system.” Beye Compl. ¶¶ 13, 15. Moreover, the Complaints both note that Green Spring has done business as Magellan Behavioral Health, Inc. 26 See Beye Compl. ¶ 14; Foley Compl. ¶ 9.
Magellan moves to dismiss Drazin’s ERISA breach of fiduciary duty claim brought pursuant to § 502(a)(3). Magellan argues that, as a matter of law, it is not an ERISA fiduciary and Drazin’s claim against it must therefore be dismissed. ERISA defines a fiduciary in § 1002(21)(A). That definition explains that
a person is a fiduciary with respect to a plan to the extent (i) he exercises any discretionary authority or discretionary control respecting management of such plan or exercises any authority or control respecting management or disposition of its assets, (ii) he renders investment advice for a fee or other compensation, direct or indirect, with respect to any moneys or other property of such plan, or has any authority or responsibility to do so, or (iii) he has any discretionary authority or discretionary responsibility in the administration of such plan.
29 U.S.C. § 1002(21)(A). As another court in this Circuit has explained,
in order to hold [defendant] liable for breach of a fiduciary duty, plaintiffs must establish that (1) [defendant] performed discretionary functions for the plan, and (2) those particular functions are related to the breach of duty claimed by plaintiffs. In other words, there must be a nexus between the breach and the discretionary authority exercised.
Marks v. Independence Blue Cross,
Because the determination of whether a party is an ERISA fiduciary is “a functional one”,
Smith v. Provident Bank,
Magellan argues that claims against Green Spring, Magellan Health Services, Inc., and Magellan Behavioral Health, Inc. arising before January 5, 2004 are barred by Magellan’s bankruptcy discharge.
27
A District Court may take judicial notice of bankruptcy proceedings.
See, e.g., Oneida Motor Freight, Inc. v. United Jersey Bank,
Pursuant to 11 U.S.C. § 1141(d)(1)(A),
the confirmation of a [bankruptcy] plan ... discharges the debtor from any debt that arose before the date of such confirmation ... whether or not (I) a proof of the claim based on such debt is filed or deemed filed under section 501 of this title; (ii) such claim is allowed under section 502 of this title; or (iii) the holder of such claim has accepted the plan.
11 U.S.C. § 1141(d)(1)(A). Consequently, the court’s confirmation order states that,
upon the Effective Date, all existing Claims against the Debtors ... shall be ... discharged and terminated, and all holders of Claims ... shall be precluded and enjoined from asserting against the Reorganized Debtors ... any other or further Claim ... based upon any act or omission, transaction, or other activity of any kind or nature that occurred prior to the Effective Date [of January 5, 2004], whether or not such holder has filed a proof of claim or proof of equity interest, and whether or not the facts of or legal bases therefor were known or existed prior to the Effective Date.
Quinn Cert. Ex. 3. Claims such as those brought by Plaintiffs would constitute “debts” under the Bankruptcy Code.
See
11 U.S.C. §§ 101(12) (“The term ‘debt’ means liability on a claim.”), 101(5) (“The term ‘claim’ means ... right to payment, whether or not such right is reduced to judgment, liquidated, unliquidated, fixed, contingent, matured, unmatured, disputed, undisputed, legal, equitable, secured, or unsecured....”). “The pivotal issue is the time at which the [party] had a ‘claim’ ... under ERISA.”
CPT Holdings, Inc. v. Indus. & Allied Employees Union Pension Plan, Local 73,
The Foley ERISA Plaintiffs argue that both their ERISA breach of fiduciary duty claims and their non-ERISA common law breach of fiduciary duty claims did not arise until the plan participants had knowledge of the breach. 28 See Foley Opp. at 14. Under ERISA,
No action may be commenced under this subchapter with respect to a fiduciary’s breach of any responsibility, duty, or obligation under this part, or with respect to a violation of this part, after the earlier of (1) six years after (A) the date of the last action which constituted a part of the breach or violation, or (B) in the case of an omission the latest date on which the fiduciary could have cured the breach or violation, or (2) three years after the earliest date on which the plaintiff had actual knowledge of the breach or violation;
29 U.S.C. § 1113. The Third Circuit has explained that “where a claim is for breach of fiduciary duty, to be charged with actual knowledge ‘requires knowledge of all relevant facts at least sufficient to give the plaintiff knowledge that a fiduciary duty has been breached or ERISA provision violated.’ ”
Cetel v. Kirwan Financial Group, Inc.,
There is no question that, under
Cetel,
Plaintiffs had “actual knowledge” at the time their claims were denied, both of the facts that give rise to their breach of fiduciary duty claim, and that those facts might constitute a breach of § 502(a)(3) or some other section of ERISA. As in
Cetel,
“[t]he totality of this information unequivocally demonstrates that plaintiffs were not only aware of all the material necessary to determine that defendants had [denied their benefits], but also that defendants’ [denials] were suspect.”
Cetel,
As to the Foley non-ERISA Plaintiffs, in New Jersey, a claim for breach of fiduciary duty accrues “when ‘the right to institute and maintain a suit first arose,’ or more specifically, when the act or injury occurs.”
Estate of Parr v. Buontempo Ins. Services,
[C]rucial inquiry is ‘whether the facts presented would alert a reasonable person exercising ordinary diligence that he [ ] was injured due to the fault of another’. The standard is basically an objective one-whether Plaintiff ‘knew or should have known’ of sufficient facts to start the statute of limitations running.
Id.
(quoting
Szczuvelek v. Harborside Healthcare Woods Edge,
As a result, the Court will dismiss claims against Green Spring, Magellan Health Services, Inc., and Magellan Behavioral Health, Inc. for benefits that were denied prior to January 5, 2004.
See, e.g., MCI Worldcom Network Services,
IV. CONCLUSION
For the reasons stated above, the Court will grant in part and deny in part Defen
Notes
. When the Court refers to "the Magellan Defendants” or "Magellan” it is referring collectively to Magellan Health Services, Inc., Green Spring Health Services, Inc. d/b/a/ Magellan Behavioral Health, and Magellan Behavioral Health of New Jersey, LLC.
. The Magellan Defendants filed two separate motions to dismiss in both Beye and Foley, for a total of four motions. One motion in each case was filed on behalf of Magellan Health Services, Inc., Magellan Behavioral Health, Inc. and Magellan Behavioral Health of New Jersey, LLC; the other was filed on behalf of Green Spring Health Services, Inc. Although the motions are docketed separately, all four briefs are the same. Because the motions are identical, the Court will not distinguish between them in this opinion.
.ERISA Plaintiff Bradley was voluntarily dismissed as a named Plaintiff in the Beye Complaint on January 29, 2008. ERISA Plaintiff Foley was voluntarily dismissed as a named Plaintiff in the Foley Complaint on July 11, 2008.
. Plaintiffs Byram and Drazin’s policies are governed by ERISA, 29 U.S.C. § 1001, et seq., and Plaintiffs Beye and Sedlak have non-ERISA plans
. The Parity Law reads in relevant part:
"Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder or autism. "Same terms and conditions” means that the health maintenance organization cannot apply different copayments, deductibles or health care services limits to biologically-based mental health care services than those applied to other medical or surgical health care services.
N.J. Stat. Ann. §§ 26:2J-4.20 (HMOs), 17:48-6v (Hospital Service Corporations), 17:48-7u (Medical Service Corporations), 17:48E-35.20 (Health Service Corporations), 17:B:26-2.1s (Health Insurance other than Group and Blanket Insurance), 17B:27-46.1v (Group Health and Blanket Insurance), 17B:27A-7.5 (Individual Health Insurance Reform).
.Non-ERISA Plaintiff Sedlak’s policy differs from the other three. Plaintiff Sedlak's policy does not include a definition of Biologically-based Mental Illness and instead contains a definition for "Mental or Nervous Condition” as follows:
[A] condition which manifests symptoms which are primarily mental or nervous, whether organic or non-organic, biological or non-biological, chemical or non-chemical in origin and irrespective of cause, basis or inducement, for which the primary treatment is psychotherapy or psychotherapeutic methods of psychotropic medication. Mental or Nervous Conditions include, but are not limited to, psychoses, neurotic and anxiety disorders, schizophrenic disorders, affective disorders, personality disorders, and psychological or behavioral disorders associated with transient or permanent dysfunction of the brain or related neurohor-monal systems. Mental or Nervous Condition does not include Substance Abuse or Alcoholism.
Morelia Cert. Ex. F (Sedlak Policy) at 11 (emphasis added). Plaintiff Sedlak’s policy also does not contain a definition for "non-Biologically-based Mental Illness.” Finally, Plaintiff Sedlak’s policy does not provide the terms of coverage for BBMIs and/or non-BBMIs. Rather, the policy describes coverage for "Mental or Nervous Conditions and
. The New Jersey Parity Law does not define the term "non-BBMI.”
. The relevant portion of the New Jersey Parity Law reads as follows:
Every enrollee agreement delivered, issued, executed or renewed in this State pursuant to P.L.1973, c. 337 (C.26:2J-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of Health and Senior Services, on or after the effective date of this act shall provide health care services for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the agreement.
N.J. Stat. Ann. §§ 26:2J-4.20 (HMOs), 17:48-6v (Hospital Service Corporations), 17:48-7u (Medical Service Corporations), 17:48E-35.20 (Health Service Corporations), 17:B:26-2.1s (Health Insurance other than Group and Blanket Insurance), 17B:27-46.1v (Group Health and Blanket Insurance), 17B:27A-7.5 (Individual Health Insurance Reform).
. The Court heard oral argument in DeVito v. Aetna, No. 07-0418, Beye v. Horizon, Civ. No. 06-5337, and Foley v. Horizon, Civ. No. 06-6219, together on October 10, 2007.
. With regard to the ERISA Plaintiffs Byram and Drazin, it is also worth repeating the Court’s reminder to the parties in DeVito:
At the outset it is critical to clarify the issues presented by Plaintiffs’ Complaint[s]. Plaintiffs do not challenge New Jersey’s Parity Law. See N.J. Stat. Ann. § 26:2J-4.20. Rather, Plaintiffs challenge Defendants'] ... handling of Plaintiffs’ benefit claims under the contractual terms of Plaintiffs’ respective insurance policies. [See Foley Compl. V 13 ("The language of the Parity law has been expressly incorporated by reference in each of the Horizon policies for the named plaintiffs and the proposed class."); Beye Compl. ¶¶ 22-25 ("According to all these Horizon plans, defendants are legally obligated to provide unlimited in-patient and out-patient coverage for BBMI conditions.... ”).] Although certain definitions in Plaintiffs' insurance contracts are substantially similar to some contained in the Parity Law, the claims before the court concern [Defendants'] interpretation of the contractual language as applied to each Plaintiff. Plaintiffs, in essence, contend that their eating disorders should have been handled as Biologically Based Mental Illnesses and covered under the policy provisions that apply to BBMIs. "The denial of benefits by an ERISA plan administrator or fiduciary is reviewed under the arbitrary and capricious standard." Brandeburg v. Corning Inc. Pension Plan for Hourly Employees,243 Fed.Appx. 671 , 672-73 (3d Cir.2007); see also Pinto v. Reliance Standard Life Ins. Co.,214 F.3d 377 , 393 (3d Cir.2000) (adopting sliding scale to determine level of scrutiny in arbitrary and capricious review).
. As noted above, the Court held oral argument on the motions to dismiss in Beye, Foley, and DeVito together on October 10, 2008. At oral argument it was Horizon's counsel who conceded that “the current draft of the law is not retroactive.” Tr. at 84(5)-(6).
. New Jersey Appellate Rule 2:2-3(a)(2) provides in relevant part that "appeals may be taken to the Appellate Division as of right (2) to review final decisions or actions of any state administrative agency or officer....”
. Beye, Byram, and Sedlak have exhausted their right to IURO review.
. The cases Defendant cites are not to the contrary. In
In re Failure by the Dept, of Banking and Ins. to Transmit a Proposed Dental Fee Schedule to OAL,
. The Magellan Defendants make several of the same arguments made by Horizon. Where both Horizon and the Magellan Defendants make the same argument, the Court note that fact and deal with those arguments together in this section. The Court addresses the Magellan Defendants’ separate arguments in Part III.B, infra.
.The Magellan Defendants’ motion identifies Plaintiffs Byram and Drazin as the Plaintiffs who were denied benefits as “not medically necessary.” See Mag. Mot. at 35. According to the joint chart the parties provided to the Court, however, Plaintiff Dra-zin’s "not medically necessary" determination was reversed on IURO review, after which his daughter exhausted her non-BBMI benefits. See Nagel Cert. Ex. A; Foley DKT# 87. By contrast, Sedlak’s "not medically necessary” determination was affirmed by the IURO. See id. Based on the information provided to the Court, it appears that Horizon correctly identified Plaintiffs Sedlak and Byram as the "not medically necessary” Plaintiffs.
.
Woodworker's Supply, Inc. v. Principal Mut. Life Ins. Co.
is inapposite because it does not concern the provision of benefits under the terms of an ERISA plan.
. Byram concedes that she cannot state claims for common law breach of contact (count one) or breach of implied duty of good faith (count two).
See
Beye Opp. at 21 n. 7. Byram does not mention or attempt to preserve her state-law claims for tortious interference with contract rights (count nine) or third party beneficiary breach of contract (count ten). Those claims are also clearly preempted by ERISA.
See, e.g., Paneccasio v. Unisource Worldwide, Inc.,
Byram is a New Jersey citizen and therefore has no grounds upon which to bring a claim under the Pennsylvania Unfair Trade Practices and Consumer Protections Law.
See, e.g., Baker v. Family Credit Counseling Corp.,
. The test set forth in
Cort
has four factors, the fourth being "is the cause of action one traditionally relegated to state law, in an area basically the concern of the States, so that it would be inappropriate to infer a cause of action based solely on federal law?”
Cort,
. As the Seventh Circuit recently noted, “[w]ithout state authority to guide us, '[w]hen given a choice between an interpretation of [state] law which reasonably restricts liability, and one which greatly expands liability, we should choose the narrower and more reasonable path (at least until the [state] Supreme Court tells us differently).’ ”
Pisciotta v. Old Nat. Bancorp,
. The Foley non-ERISA Plaintiffs have filed a claim in New Jersey state court, Nancy Reinhard v. Horizon, et al, No. ESX-L-618-08, and they are "prepared to pursue all non-ERISA claims in that action if the Court determines that there is no supplemental or CAFA jurisdiction for the non-ERISA ... claims.” See Opp. at 28 n. 6.
. Plaintiffs also assert supplemental jurisdiction under 28 U.S.C. § 1367. That section sets forth a discretionary standard in § 1367(c). By contrast, if the "home state controversy” and "local controversy” exceptions to CAFA apply, those sections direct that the Court shall decline jurisdiction over the matter. Compare 28 U.S.C. § 1332(d)(4) ("[a] district court shall decline to exercise jurisdiction”) with 28 U.S.C. § 1367(c). Because the exceptions in § 1332(d)(4) are mandatory, the Court should determine whether it is precluded from exercising jurisdiction under § 1332(d)(4) first, before considering whether it will exercise supplemental jurisdiction under 28 U.S.C. § 1367.
.As all parties are aware, “subject-matter jurisdiction, because it involves the court’s power to hear a case, can never be forfeited or waived.”
Arbaugh v. Y & H Corp.,
. Both Magellan and the Beye Plaintiffs discuss whether Magellan is a “primary defendant” for purposes of § 1332(d)(4)(B). See Mag. Mot. at 12; Beye Opp. at 9. Because neither Magellan nor Horizon has presented evidence that greater than two-thirds of the class members are from New Jersey, it would be premature for the Court to address this question of law at this time. The Court also notes that the parties have not discussed the "local controversy” exception set forth in § 1332(d)(4)(A), which does not contain the “primary defendant” language.
. Even if neither § 1332(d)(4)(A) or § 1332(d)(4)(B) apply, CAFA’s discretionary exception, found in § 1332(d)(3), may apply.
. Magellan concedes that "doing business as" another company does not create a separate entity under the law. See
Trustees of the Mason Tenders, Dist. Council Welfare Fund, Pension Fund, Annuity Fund and Training Program Fund v. Faulkner,
. Magellan Behavioral Health of New Jersey, IXC did not file for bankruptcy and is not affected by the other Magellan Defendants' bankruptcy. The discussion in this section does not apply to that entity.
. The Beye Complaint is limited to those claims which arose or accrued after Green Spring, Magellan Health Services, Inc., and Magellan Behavioral Health, Inc. emerged from bankruptcy on January 5, 2004. See Beye Compl. at 6 n. 1. The Foley Complaint makes no mention of the bankruptcy proceedings.
