Gallagher v. Cigna Healthcare of Maine, Inc.Gallagher v. Cigna Healthcare of Maine, Inc.
ORDER ON MOTION TO DISMISS
Before the Court is a Motion to Dismiss filed by Defendant CIGNA Healthcare of Maine, Inc. (“CIGNA”) (Docket # 9), and Defendant Uday Deshmukh M.D. has joined the Motion (Docket # 21). CIGNA and Dr. Deshmukh move to dismiss Counts I through VI and Count X of Plaintiffs First Amended Complaint. For the reasons stated below, the Court GRANTS the Motion.
I. LEGAL STANDARD
Pursuant to Rule 12(b)(6), a party is entitled to have a claim against it dismissed when the allegations on which the claim depends “fail[ ] to state a claim upon which relief can be granted.” Fed. R.Civ.P. 12(b)(6). When considering a motion under Rule 12(b)(6), the Court must accept as true the well-pleaded factual alie-
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gations of the complaint, draw all reasonable inferences in the plaintiffs favor, and determine whether the complaint, when taken in the light most favorable to the plaintiff, sets forth sufficient facts to support the claim for relief.
Clorox Co. v. Proctor & Gamble Commercial Co.,
II. BACKGROUND
Plaintiff Janice Gallagher is the personal representative of her deceased husband, Bradley Gallagher. Mr. Gallagher was an employee of Bath Iron Works (“BIW”), a General Dynamics Corporation (“General Dynamics”), from 1968 until he was unable to work due to his deteriorating health. CIGNA administered and was the claims fiduciary of BIW’s group health care plan (“the health care plan” or “the plan”) and General Dynamics was the Plan Administrator and Plan Sponsor of the health care plan. The health care plan is an employee benefit plan within the meaning of Section 3(b) of the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1002(3). Mr. Gallagher was a participant in the plan.
This case arises out of Defendant CIG-NA’s denial of health insurance benefits to Mr. Gallagher in the form of skilled nursing care. In short, Mr. Gallagher suffered from a host of serious medical conditions, including Type II diabetes. On September 6, 2006, Mr. Gallagher underwent amputation of his right leg below the knee. Following the amputation, Mr. Gallagher commenced rehabilitation until September 22, 2006, when he developed septicemia and a urinary tract infection. He was admitted to acute care at Central Maine Medical Center (“CMMC”). Upon discharge from CMMC on October 4, 2006, Mr. Gallagher was admitted to the Win-ship Green Nursing Home 1 (“Winship Green”) for skilled, 24-hour nursing care.
On October 31, 2006, CIGNA notified Winship Green that further in-patient skilled nursing care was denied. Numerous individuals, including his doctor, nurse and social worker, appealed CIGNA’s decision on behalf of Mr. Gallagher. At the time CIGNA denied further inpatient skilled nursing care, Mr. Gallagher’s amputation site was open, with his femur bone protruding. CIGNA, via Dr. Desh-mukh, 2 the head Medical Director for CIG-NA, upheld its decision. On November 6, 2006, Mr. Gallagher was discharged from Winship Green to the care of his wife, who had no medical training. On November 19, 2006, Mr. Gallagher was seen at CMMC for emergency treatment. Mr. Gallagher was admitted to CMMC on the same day and diagnosed with sepsis. He died later that day.
On August 16, 2007, Plaintiff filed her Complaint in the Sagadahoc Superior Court in the State of Maine. On September 13, 2007, Defendant CIGNA removed *291 the case to Federal Court (Docket # 1). After removal, Plaintiff filed an Amended Complaint asserting ten claims and naming as Defendants CIGNA, General Dynamics, Winship Green and Dr. Desh-mukh. (Docket # 5). 3 Specifically, the Complaint asserts causes of action for carrier liability under the Health Improvement Act, 24-A M.R.S.A. § 4313 against CIGNA (Count I), violation of Maine’s Unfair Claims Settlement Practices Act, 24-A M.R.S.A. § 2436-A against CIGNA and General Dynamics (Count II), breach of contract against CIGNA and General Dynamics (Count III), intentional infliction of emotional distress against CIGNA, General Dynamics and Winship Green (Count IV), negligent infliction of emotional distress against CIGNA, General Dynamics and Winship Green (Count V), health plan negligence against CIGNA and General Dynamics (Count VI), violation of Maine law regarding care at a long-term care facility against Winship Green (Count VII), wrongful denial of health benefits under ERISA against CIGNA and General Dynamics (Count VIII), breach of fiduciary duty under ERISA against CIGNA, General Dynamics and Dr. Deshmukh (Count X) and failure to comply with terms of the plan document against CIGNA and General Dynamics (Count XI).
On October 15, 2007, CIGNA filed a Motion to Dismiss (Docket # 9). Through the Motion to Dismiss, CIGNA asserts that Counts I through VI are preempted by ERISA, 29 U.S.C. § 1132(a) et seq., and that Count X for breach of fiduciary duty cannot survive because Plaintiff has available a remedy under § 1132(a)(1)(B). On November 29, 2007, Dr. Deshmukh joined CIGNA’s Motion to Dismiss (Docket # 21). 4
III. DISCUSSION
ERISA is a comprehensive statute designed to promote the interests of employees and their beneficiaries by regulating the creation and administration of employee benefit plans.
Pilot Life Ins. Co. v. Dedeaux,
A. ERISA Preemption
There are two components to ERISA’s extensive preemptive force. First, ERISA section 514(a) expressly preempts “any and all State laws insofar as they may now or hereafter relate to any employee benefit plan.” 29 U.S.C. § 1144(a). Second, section 502(a) of ERISA contains a comprehensive scheme of civil remedies to enforce ERISA’s provisions. See 29 U.S.C. § 1132(a). Thus, the Court must determine whether Counts I through VI fall under either of these preemptive provisions.
1. Preemption under section 514(a)
Under section 514(a), Congress specifically preempted “all State laws insofar as they may now or hereafter relate to any employee benefit plan.” 29 U.S.C. § 1144(a). Statutory provisions, court decisions, common law causes of action and state law from all other sources are encompassed by ERISA’s sweeping preemp
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tion clause. 29 U.S.C. § 1144(c)(1) (“State law” is expansively defined under ERISA to include “all laws, decisions, rules, regulations, or other State action having the effect of any law, of any State”);
see also Pilot Life Ins. Co.,
Although Congress did not define in the statute what it meant by state laws that “relate to” an ERISA benefit plan, the Supreme Court has stated that the words “relate to” are to be given their “broad common-sense meaning” of having “a connection with or reference to ... a plan.”
Pilot Life Ins. Co.,
2. Preemption under section 502
In addition to section 514 preemption, ERISA provides for complete preemption under section 502(a). Section 502(a)(1)(B) provides: “A civil action may be brought (1) by a participant or beneficiary ... (B) to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan.” 29 U.S.C. § 1132(a)(1)(B). Section 502(a), by providing a civil enforcement cause of action, completely preempts any state cause of action seeking the same relief, regardless of how artfully pleaded. A state cause of action that would fall within the scope of this remedial scheme is preempted as conflicting with the intended exclusivity of ERISA’s remedial scheme, even if those causes of action would not necessarily be preempted by section 514(a).
See Aetna Health Inc. v. Davila,
In accord with the Congressional purpose of creating a uniform regulation, ERISA’s civil enforcement provision is a comprehensive remedial scheme. Indeed, the Supreme Court has stated that section 502(a),
represents a careful balancing of the need for prompt and fair claims settlement procedures against the public interest in encouraging the formation of employee benefit plans. The policy choices reflected in the inclusion of certain remedies and the exclusion of others under the federal scheme would be completely undermined if ERISA-plan participants and beneficiaries were free to obtain remedies under state law that Congress rejected in ERISA. The six carefully integrated civil enforcement provisions found in § 502(a) of the statute as finally enacted ... provide strong evidence that Congress did not intend to authorize other remedies that it simply forgot to incorporate expressly.
Davila,
B. Plaintiffs Claims
The pending Motion to Dismiss, requires the Court to determine whether Counts I through VI are subject to one or both of the ERISA preemption provisions just described.
1. Carrier Liability under the Health Plan Improvement Act (Count I)
Count I asserts a cause of action under the Health Plan Improvement Act, 24-A M.R.S.A. section 4313. Section 4313 provides that:
A carrier has the duty to exercise ordinary care when making health care treatment decisions that affect the quality of the diagnosis, care or treatment provided to an enrollee and is liable for damages as provided in this section for harm to an enrollee proximately caused by the failure of the carrier or its agents to exercise such ordinary care.
24-A M.R.S.A. § 4313. Defendant CIG-NA argues that this Maine statute codifies common law negligence and that Plaintiffs claim based on the statute is preempted by ERISA. In determining whether a claim is preempted by ERISA, the Court must examine Plaintiffs complaint, the statute on which it is based and, potentially, the plan documents.
See Davila,
In the First Amended Complaint, Plaintiff asserts that CIGNA failed to exercise ordinary care in making the healthcare treatment decisions regarding Mr. Gallagher and breached the duty to exercise ordinary care when those decisions resulted in Mr. Gallagher’s ultimate death. (See First Am. Compl.(Docket # 5) at 7.) Specifically, Plaintiff alleges that despite her husband’s need for skilled nursing care and the support of her husband’s health care team, CIGNA refused to cover the requested skilled nursing care. After careful consideration of Plaintiffs claim in Count I, it is clear that the action complained of is CIGNA’s denial of benefits under the terms of the ERISA regulated plan.
Notably, section 4313 does not impose any duties outside of ERISA or the terms of the health care plan. Section 4313(6) explicitly states: “This section does not create any obligation on the part of a carrier to provide an enrollee any health care treatment or service that is not covered by the enrollee’s health plan policy or contract.” 24-A M.R.S.A. § 4313(6). As a result, a carrier can be liable under section 4313 only if it denied coverage for skilled care that was covered by the health care plan.
See, e.g., Davila,
In short, interpretation of the terms of the health care plan would be an essential part of the section 4313 claim and liability would exist under section 4313 only because of CIGNA’s administration of the ERISA regulated health care plan.
See id.
Because the Court would have to consult the ERISA plan to resolve the state law claim, the state law “relates to” an ERISA plan and is preempted by section 514(a).
See, e.g., Harris,
In addition, Plaintiff brings this claim “only to rectify a wrongful denial of benefits promised under [an] ERISA-regu-lated plan[ ], and do[es] not attempt to remedy any violation of a legal duty independent of ERISA.”
Davila,
In response to the Motions to Dismiss, Plaintiff states that ERISA does not preempt state laws that regulate insurance. It is true that § 1144(b)(2)(A) acts as a “savings clause” for laws that regulate insurance, and states: “[N]othing 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). Plaintiff, however, fails to demonstrate or even attempt to argue how the state law that forms the basis for Count I “regulates insurance” within the meaning of the statute.
5
See Hotz v. Blue Cross and Blue Shield of Mass., Inc.,
2. Violation of Maine’s Unfair Claims Settlement Practices Act (Count II)
In Count II, Plaintiff claims a cause of action under Maine’s Unfair Claims Settlement Practices Act, 24-A M.R.S.A. § 2436-A (“UCSPA”). UCSPA provides a civil cause of action for a person injured by that person’s insurer when “[without just cause, [the insurer] fail[s] to effectuate prompt, fair and equitable settlement of claims submitted in which liability has become reasonably clear.” 24 M.R.S.A. § 2436-A(l)(e). The statute goes on to define “without just cause.”
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“[A]n insurer acts without just cause if it refuses to settle claims without a reasonable basis to contest liability....” 24 M.R.S.A. § 2436-A(2). As with the claim under the Health Plan Improvement Act (Count I), the UCSPA “relates to” an ERISA benefit plan and is preempted.
See Harris,
Plaintiffs claim under Maine’s UCSPA would necessarily require the Court to examine the plan. Indeed, to resolve Count II, the Court would need to consider whether liability had become clear and whether CIGNA had a reasonable basis to contest liability; an inquiry that would inevitably require delving into the details of the plan. Plaintiffs Complaint highlights this concern: “CIGNA intentionally denied benefits to Bradley Gallagher .... and ... CIGNA violated UCSPA when they failed to settle Mr. Gallagher’s claims within a reasonable time without a reasonable basis to contest liability.” (First Am. Compl. at 8.) Furthermore, this Court previously has held that a cause of action under section 2436-A is preempted by ERISA.
See Nicholson v. Prudential Ins. Co.,
3. Common Law Causes of Action
Counts III through VI asserts claims based on common law causes of action, including: Count III. Breach of Contract: CIGNA breached its contract by failing to provide covered benefits; Count IV. Intentional Infliction of Emotional Distress: CIGNA, General Dynamics and Winship Green foreseeably, intentionally and/or recklessly caused severe emotional distress by discontinuing benefits; Count V. Negligent Infliction of Emotional Distress: the negligent discontinuation of benefits foreseeably caused severe emotional distress; and Count VI. Health Plan Negligence: CIGNA and General Dynamics were negligent in denying contractually guaranteed medical benefits in a dilatory fashion. The gravamen of each these claims is the improper denial of the claimed benefit, skilled nursing care. The viability of these claims is foreclosed by Supreme Court and First Circuit precedent and each is preempted by ERISA.
See Davila,
In Count III, Plaintiff presses a claim of common law breach of contract. Specifically, the First Amended Complaint states: “CIGNA breached its contract of insurance with Bradley Gallagher by failing to provide covered benefits.... ” (First Am. Compl. at 8.) 6 In addition, Count VI asserts a cause of action for “Health Plan Negligence:” “CIGNA and General Dynamics Corporation were negligent in denying contractually guaranteed medical benefits in such a dilatory fashion that Mr. Gallagher was injured, and died.” (Id. at II.) In response to the Motion to Dismiss, Plaintiff argues generally that “[s]tate law claims for breach of contract ... and negligence regarding the health insurance contract are in no way related to or connected with the terms of the BIW/General *296 Dynamics plan itself.” (Pl.’s Resp. to Mot. of Def. CIGNA Healthcare of Maine, Inc. to Dismiss Counts I-VI and X of Pl.’s First Am. Compl. with Incorporated Mem. of Law (“Plaintiffs Response”) (Docket # 13) at 5.)
Nonetheless, the heart of Plaintiffs claims in Counts III and VI is CIGNA’s denial of benefits under the plan. Because the terms of Plaintiffs policy, an ERISA plan, governed his entitlement to benefits, it would be impossible to determine whether the decision by CIGNA to deny benefits constituted a breach of contract or negligence without consulting and applying the terms of the ERISA plan. Plaintiffs claims therefore not only “relate to” his claim for benefits under the policy, they are “inseparably connected” to that policy.
See Zipperer v. Raytheon Co. Inc.,
Plaintiffs claims in Counts IV and V for emotional distress are also predicated on the denial of benefits. Indeed, for the intentional infliction of emotional distress claim, Plaintiff claims that the denial of benefits foreseeably caused severe emotional distress, while Plaintiffs claim for negligent infliction of emotional distress asserts that the negligent discontinuation of benefits caused severe emotional distress. As in
Carrasquillo v. Pharmacia Corporation,
where the Plaintiffs claim for intentional infliction of emotional distress was “simply a reiteration of the facts supporting” the preempted claims, here “because the emotional distress claim obviously piggybacks on the facts underlying the [breach of contract and negligence claims], which are preempted, the emotional distress claim[s], too [are] preempted.”
Car-rasquillo v. Pharmacia Corp.,
In addition, a primary purpose of the ERISA preemption provisions was the prevention of a multiplicity of state regulation and alternative enforcement mechanisms.
New York State Conference of Blue Cross & Blue Shield Plans v. Travelers Ins. Co.,
C. Breach of Fiduciary Duty under ERISA (Count X)
In Count X, Plaintiff asserts a cause of action for breach of fiduciary duty against CIGNA, General Dynamics and Dr. Desh-mukh. Plaintiff invokes two separate sections of ERISA as the statutory basis for her complaint, section 409 and section 502(a)(3). In their Motions to Dismiss, Defendants CIGNA and Dr. Deshmukh argue that Plaintiff cannot maintain a cause of action under section 409 because it provides a cause of action only with respect to remedies that protect the entire plan. In *297 response, Plaintiff states: “Plaintiff concedes that § 409 does not provide a remedy to individual Plan beneficiaries and therefore withdraws its claim under § 409.” (PL’s Resp. at 8.) Thus, the Court will limit its consideration of breach of fiduciary duty to section 502(a)(3).
Section 502(a)(3) provides that a participant or beneficiary may bring a civil action “to enjoin any act or practice which violates any provision of this title or the terms of the plan or ... to obtain other appropriate equitable relief ... to redress such violations or ... to enforce any provisions of this title or the terms of the plan.” 29 U.S.C. § 1132(a)(3). Only appropriate equitable relief is permitted under section 502(a)(3).
Id.
The Supreme Court has held that “equitable relief’ includes “those categories of relief that were typically available in equity (such as injunction, mandamus, and restitution, but not compensatory damages).”
Mertens v. Hewitt Assocs.,
Turning to Plaintiffs claim, Count X asserts a cause of action for breach of fiduciary duty in violation of section 502(a)(3). As with the other claims, the heart of Count X is the denial of benefits that Plaintiff asserts caused Mr. Gallagher’s ultimate death. While the requested remedy in the First Amended Complaint is injunctive and equitable relief, Plaintiffs Response to the Motions to Dismiss belies the true nature of the Complaint: “[N]ow that Mr. Gallagher has died, he is no longer in need of future insurance coverage, but rather compensation for the loss of his life.” (Pl.’s Resp. at 12.) Plaintiff here does not seek equitable relief, but compensatory damages, which are not available under section 502(a)(3).
See Todisco,
Further, the First Amended Complaint also contains a claim under section 502(a)(1)(B). Count VIII asserts a cause of action for wrongful denial of benefits under section 502(a)(1)(B) and (g)(1) of ERISA. The availability of relief under section 502(a)(1)(B) makes a suit under section 502(a)(3) inappropriate. As this Court has previously stated, “First Circuit caselaw is clear that equitable relief under section 1132(a)(3) is inappropriate when a party is entitled to pursue plan benefits or enforce plan rights under section 1132(a)(1)(B).”
Kourinos v. Interstate Brands Corp.,
IV. CONCLUSION
For the foregoing reasons, the Court GRANTS the Defendants’ Motions to Dis *298 miss (Docket # s 9 & 21). Therefore, the Court ORDERS that Counts I through VI and Count X of Plaintiffs First Amended Complaint be and hereby are DISMISSED with prejudice as against Defendants CIGNA and Dr. Deshmukh.
SO ORDERED.
Notes
. Defendant Kindred Nursing Centers West, LLC. is a Delaware Limited Liability Company doing business in Maine as the Winship Green Nursing Home.
. Dr. Deshmulch is a Lead Medical Director for CIGNA. In this capacity, Dr. Deshmukh was responsible for the medical decisions made by physicians within his 'department, including the decision to deny the benefits at issue in this case.
. The counts within the Complaint are numbered one through eleven, but there is no Count IX.
. Defendants General Dynamics and Winship Green have not moved to dismiss, and the Court makes no representations as to the claims pressed against these defendants.
. Plaintiff makes this general argument with respect to Counts I and II. Count II is addressed in the next section, and the Court's analysis applies with equal force to Counts I and II.
. Plaintiff also states that CIGNA breached its implied contractual duty to act in good faith and deal fairly with its insured. The Law Court has noted that the breach of the covenant of good faith and fair dealing is not a separate cause of action in the state of Maine.
See Marquis v. Farm Family Mut. Ins. Co.,