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Potter v. Blue Shield of California Life & Health Insurance Co.

United States District Court, C.D. California

November 26, 2014







Before the Court is Defendant's Motion to Dismiss Plaintiff's First Amended Complaint (Dkt. 29). Having considered the Motion, Opposition, and Reply, the Court hereby GRANTS in part and DENIES in part the Motion.


Plaintiff John Potter (" Plaintiff"), the father of an adult child diagnosed with severe mental health issues, brings this ERISA claim to recover funds he expended paying for his son's stay at a residential treatment facility after coverage was denied.

Plaintiff is a subscriber under an employee benefit group health plan issued by Defendant Blue Shield of California Life and Health Insurance Company (" Defendant"), an employee welfare benefit plan. First Amended Complaint (" FAC") (Dkt. 22-1) ¶ 3. Plaintiff's dependent son, Nicholas Potter (" Nicholas"), is also a covered beneficiary under the Plan. Id.

At all relevant times, Plaintiff's son suffered from bipolar disorder, anxiety disorder, polysubstance dependence, and attention-deficit/hyperactivity disorder (" ADHD"). Id. ¶ 7. Bipolar disorder is a severe mental illness under California law. Id. Throughout the course of processing the claims at issue in this litigation, Nicholas was suffering from his severe mental illness and was a disabled person within the meaning of California Civil Code Section 1761(g). Id. ¶ 8. At all times during the processing of the claims at issue, Defendant communicated only with Plaintiff regarding the claims at issue. Defendant made payments for the dates of service that Defendant elected to cover directly to the Plaintiff, not his dependent son Nicholas. Id.

On January 17, 2012, Nicholas was admitted to Innercept LLC (" Innercept"), a residential treatment center for adolescents and young adults. Id. Plaintiff paid for his son's stay and treatment at Innercept for the period of January 17 through May 31, 2012. Id. He submitted claims to Defendant for reimbursement of the amounts paid. Id. Defendant reimbursed Plaintiff for the amount he paid for this treatment, by checks made out to the Plaintiff. Id. ¶ 9, Ex. A.

Plaintiff also paid for his son's treatment at Innercept for June through September 2012. Id. ¶ 10. He submitted claims for this this treatment on September 13, 2012. Id. Plaintiff did not receive immediate payment of the claims from the Defendant. Instead, he received two letters dated October 15, 2012 stating that additional time was needed to process the claims. Id. ¶ 11. These letters were addressed to Plaintiff. Id ¶ 11, Ex. B.

In a letter dated November 13, 2012, addressed to Plaintiff, Defendant wrote that the claims were in process but it needed " previously requested information." Id. ¶ 12, Ex. C. Plaintiff contacted Innercept and Defendant, and was told conflicting stories about whether the information had been transmitted. Id. ¶ 13. In a letter dated December 11, 2012, Defendant again told Plaintiff that the claims were in process and that it had not received the requested information. Id. ¶ 14. Plaintiff called Innercept once more and asked them to speak with Defendant about what information it needed. Id. ¶ 15. Innercept called back and informed Plaintiff that Defendant requested that codes be changed on the claims. Id.

After receiving the new codes, in March 2013, Plaintiff resubmitted the claims for costs incurred from June through December 2012. Id. ¶ 16. Plaintiff later received a letter dated May 14, 2013, stating that Defendant still could not process the claims relating to dates of service June 1 to September 30, 2012, and needed more information. Id. ¶ 18, Ex. F. Plaintiff's wife resubmitted the claims to a Blue Shield representative. Id.¶ 19, Exh. G. Defendant responded in September 2013, indicating that they had all necessary information to process the claim.

On September 27, 2013, Defendant issued an Explanation of Benefits (EOBs) for dates of service June 1 to September 30, 2012. Id. ¶ 21. The EOB was addressed to Plaintiff. Defendant denied the claims on the grounds that " the service is not medically necessary. " Id. ¶ 21, Ex. H. On October 24, 2013, Defendant issued EOBs regarding the October to December dates of service, indicating it could not process the claims because it needed additional information. Id. ¶ 22, Ex. I.

Plaintiff timely appealed the denials by phone. Id. ¶ 23.

On October 24, 2013, Defendant denied the appeals for all dates of service from June 1 to December 21, 2012, on the grounds that it did not have any medical records, and therefore could not determine if " you meet the Blue Shield Life medically necessary criteria for coverage of psychiatric residential treatment." Id. ¶ 24, Ex. J. Plaintiff received five duplicate letters, with dates ranging from November 2013 to March 2014, indicating that the claims for October 1 through December 21, 2012 were still in process awaiting additional information.

Plaintiff called Defendant on March 10, 2014, and spoke to a Blue Shield representative, Faith O. (" Faith"). Faith informed Plaintiff that the information Plaintiff had submitted with his son's medical records and claims had been received, but " had never been coded or entered into the Blue Shield computer, " and instead had sat dormant, despite containing all the information necessary for Blue Shield to process the claims. Id. ¶ 26, Ex. L.

On March 25, 2014 Defendant issued an EOB, addressed to Plaintiff, denying dates of service October 1 through December 21, 2014 for lack of medical necessity. Id. ¶ 27.

Plaintiff's insurance agent, Kent Crawford, contacted Defendant on April 8, 2014 regarding the status of the outstanding claims. Id. ¶ 28. A Blue Shield representative replied by email, informing Plaintiff that the care for June through December 2012 was not covered because it " could have been treated on an outpatient treatment plan." Id. Plaintiff's counsel wrote to Defendant on April 15, 2014, asking for copies of the claim file and plan documents. On April 22, Defendant replied to the dependent son, acknowledging receipt of a grievance and asking him to complete an Authorization for Release of Personal & Health Information Form. Id. ¶ 30. On April 29, however, it changed its position, informing the dependent son that the April 15 letter did not constitute a " grievance, " and that the Customer Service Department would respond. Id. ¶ 31.

Plaintiff filed suit on June 6, 2014, and the Court granted him to leave to file a First Amended Complaint on September 18, 2014 (Dkt. 24). Plaintiff claims that Defendant wrongful denied claims for medical benefits, and that Plaintiff has been directly damaged in the amount of all medical bills and attorneys' costs and fees. Id. ¶ 32-36. Plaintiff also claims that he is entitled to enforce his son's rights under the terms of the plan, and to clarify his son's rights to future benefits under the terms of the plan. Id.

Defendant moves to dismiss on two grounds: (1) that Plaintiff lacks both statutory standing under ERISA and Article III standing, and (2) that the complaint fails to join an indispensable party, Plaintiff's son Nicholas.


Under Federal Rule of Civil Procedure 12(b)(1), a complaint must be dismissed if the court lacks subject matter jurisdiction to adjudicate the claims. Once subject matter jurisdiction is challenged, the burden of proof is placed on the party asserting that jurisdiction exists. Scott v. Breeland, 792 F.2d 925, 927 (9th Cir. 1986) (holding that the party seeking to invoke the court's jurisdiction " bears the burden of establishing that jurisdiction exists"). Accordingly, the court will presume lack of subject matter jurisdiction until the plaintiff proves otherwise in response to the motion to dismiss. Kokkonen v. Guardian Life Ins. Co. of Am., 511 U.S. 375, 377, 114 S.Ct. 1673, 128 L.Ed.2d 391 (1994).

The Court is " not required to accept as true conclusory allegations which are contradicted by documents referred to in the complaint, " Steckman v. Hart Brewing, Inc., 143 F.3d 1293, 1295-96 (9th Cir. 1998), and " [w]e do not ... necessarily assume the truth of legal conclusions merely because they are cast in the form of factual allegations." W. Mining Council v. Watt, 643 F.2d 618, 624 (9th Cir.1981). A jurisdictional challenge under Rule 12(b)(1) may be made either on the face of the pleadings or by presenting extrinsic evidence. White v. Lee, 227 F.3d 1214, 1242 (9th Cir. 2000). Where jurisdiction is intertwined with the merits, we must " assume [ ] the truth of the allegations in a complaint . . . unless controverted by undisputed facts in the record." Warren v. Fox Family Worldwide, Inc., 328 F.3d 1136, 1139 (9th Cir. 2003) (citing Roberts v. Corrothers, 812 F.2d 1173, 1177 (9th Cir. 1987)).

It is appropriate to address the question of standing in deciding a motion to dismiss because " [t]he elements of standing are 'an indispensable part of the plaintiff's case, ' and accordingly must be supported at each stage of litigation in the same manner as any other essential element of the case." Id. at 1140.

A party may move to dismiss a case for failure to join a necessary and indispensable party, as defined by Rule 19. Fed.R.Civ.P. 12(b)(7). The Ninth Circuit has set forth a three-step inquiry to determine whether a case should be dismissed under Rule 12(b)(7). See E.E.O.C. v. Peabody Western Coal Co., 400 F.3d 774, 779-80 (9th Cir. 2005). When seeking dismissal on this basis, the movant bears the burden of adducing evidence in support of the motion. Makah Indian Tribe v. Verity, 910 F.2d 555, 558 (9th Cir. 1990).

First, courts determine " whether an absent party is necessary to the action" under Rule 19(a). Peabody, 400 F.3d at 779; Dawavendewa v. Salt River Project Agric. Improvement & Power Dist., 276 F.3d 1150, 1154-55 (9th Cir. 2002). Second, courts determine whether it is feasible to order that the absent necessary party be joined. Peabody, 400 F.3d at 779. Third, if both the absent party is necessary and joinder is infeasible, then courts must determine, under Rule 19(b), " whether the case can proceed without the absentee, or whether the absentee is an 'indispensable party' such that the action must be dismissed." Id.; Lyon v. Gila River Indian Cmty., 626 F.3d 1059, 1070 (9th Cir. 2010).

A party is " necessary" and must be joined if:

(A) in that person's absence, the court cannot accord complete relief among existing parties; or
(B) that person claims an interest relating to the subject of the action and is so situated that disposing of the action in the person's absence may:
(i) as a practical matter impair or impede the person's ability to protect the interest; or
(ii) leave an existing party subject to a substantial risk of incurring double, multiple, or otherwise inconsistent obligations because of the interest.

Fed.R.Civ.P. 19(a)(1). See also United States v. Bowen, 172 F.3d 682, 688 (9th Cir. 1999). If the third party satisfies the above criteria, the Court must then determine whether joinder is " feasible." See Fed.R.Civ.P. 19(b); Bowen, 172 F.3d at 688. If joinder is not feasible, the Court " must decide whether the absent party is 'indispensable, ' i.e., whether in 'equity and good conscience' the action can continue without the party." See id .

In order to determine whether Rule 19 requires the joinder of additional parties, the court may consider evidence outside of the pleadings. See McShan v. Sherrill, 283 F.2d 462, 464 (9th Cir.1960). The party moving under Rule 12(b)(7) " bear[s] the burden in producing evidence in support of the motion." See Biagro Western Sales, Inc. v. Helena Chem. Co., 160 F.Supp.2d 1136, 1141 (E.D.Cal.2001) ( citing Citizen Band Potawatomi Indian Tribe of Okla. v. Collier, 17 F.3d 1292, 1293 (10th Cir.1994)).


A. Standing

To bring an ERISA claim, a plaintiff must have both statutory standing and constitutional (Article III) standing. Defendant argues that Plaintiff lacks both. This Court disagrees.

1. ERISA Standing

Section 1132 of ERISA confers standing to bring suit on participants, beneficiaries, fiduciaries, or the Secretary of Labor. 29 U.S.C. § 1132 (2014). Specifically, Section 1132(a)(1) " allows a 'participant' in an employee benefit plan to bring a civil action to enforce his rights under the terms of the plan or to enforce the provisions of ERISA." McBride v. PLM Int'l, Inc., 179 F.3d 737, 742 (9th Cir. 1999). Section 1132 (a)(1)(B) states that a civil action may be brought by a participant or beneficiary " 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).

Defendant argues that the plain language " by a participant or beneficiary" is limited by the clause " to recover benefits due to him enforce his rights " so that a participant may only bring a claim on behalf of himself, and may not bring claims on behalf of an adult dependent.

The question presented to the Court is whether a parent who has paid for his adult child's medical bills, where that adult child was a dependent, severely mentally ill, and was a disabled person during all relevant times at issue in the litigation, may recover from an insurer who wrongfully denied claims under the terms of an ERISA policy. Defendant argues that the answer is no, because the parent was under no legal obligation to pay the medical expenses on behalf of his child.

Parties indicate that there is no controlling Ninth Circuit authority, and this Court has not identified any. Thus, the Court must turn to persuasive authority from sister circuits and district courts.

Generally, Courts have found that a participant or beneficiary must bring a claim on their own behalf to claim medical expenses under an ERISA-based claim. See, e.g., Lightfoot v. Principal Life Ins. Co., 2011 WL 2036649, at *1-2 (W.D. Okla. May 24, 2011); Powers v. BlueCross Blue Shield of Illinois, 947 F.Supp.2d 1139, 1144 (D. Colo. 2013).[1] Defendant relies on Lightfoot for the proposition that a Participant may not bring a claim on behalf of an adult beneficiary. In Lightfoot, the plan Principal brought a claim along with his adult dependent son, a participant and beneficiary in the health care benefit plan, to recover funds that he paid for his son's medical expenses. In essence, the Participant argued, " 'benefits due to him' should be construed broadly such that a participant ... can recover benefits for another participant's ... medical expenses that are 'due to him' for equitable reasons such as payment of the other participant's ... medical bills." Lightfoot, 2011 WL 2036649, at *1. The Court rejected this argument. It found that " in light of the express language of § 1132(a)(1)(B) ... based upon the Plan's provisions in this case, David's assertion must fail." Id. Reading the statute so broadly, the court reasoned, would require it to " ignore the phrase 'under the terms of his plan' that immediately follows 'benefits due to him' in § 1132(a)(1)(B)." Id. In rejecting Participant's argument that he had derivative standing it reasoned that " [Plaintiff] has made no allegation, or even any argument, that [his son] has assigned his right to benefits under the Plan to [Plaintiff] or that [he] is the authorized representative or personal representative of [his son]. Further, [his son] is clearly not deceased as he is a co-plaintiff in this case. Accordingly, the Court finds that David does not have standing to bring this action based upon derivative standing, 'authorized representative' standing, or deceased party/personal representative standing." Lightfoot v. Principal Life Ins. Co., No. CIV-11-130-M, 2011 WL 2036649, at *4 (W.D. Okla. May 24, 2011). The parties in that case did not raise, and the Court did not consider, the issue of subrogation, as the son was a co-plaintiff in the case.

In Ray v. PPOM, 2005 WL 1984470 (E.D. Mich. Aug. 9, 2005), another case Defendant relies on, a Participant, the mother of an adult son, brought claims for medical expenses on behalf of her child which she argued were wrongfully denied. The Court found that " A parent of a plan beneficiary, even a parent whose employment is the source of the injured party's claim to benefits, does not have standing in her individual capacity to sue to enforce payment of medical benefits to another party solely on the grounds that [she] would be liable for payment of the medical bills if the plan does not pay them." Id. at *2. The Court rejected the argument to expand coverage to a parent who incurs benefits on behalf of her adult child due in part to the fact " There is no evidence that Beeman, an adult, would be unable to bring a claim on his own behalf. Further, Beeman was not a minor at the time of the accident, thus Plaintiff was not rendered liable for his debts." Id. at *3.[2] In addition " the opinion gives no indication whether the plaintiff had actually paid the expenses in question, or was simply attempting to assert her son's claim jus tertii ." Wills v. Regence Bluecross Blueshield of Utah, No. CIV. 2:07-CV-616BSJ, 2008 WL 4693581, at *9 (D. Utah Oct. 23, 2008) (distinguishing case).

Plaintiff responds that these cases are inapposite, because in all circumstances the beneficiary/child was either capable of bringing suit or had brought suit. Here, Plaintiff argues that he has the right to sue to recover medical expenses incurred by his child as a result of his position as a plan participant and his subrogation of his child's rights to reimbursement.

2. ERISA Derivative Standing

Under ERISA, courts have found derivative standing available to those who are not themselves beneficiaries or participants. For example, assignees of a participant may have standing to bring a federal ERISA claim. See, e.g., Kennedy v. Connecticut General Life Ins. Co., 924 F.2d 698, 13 Employee Benefits Cas. (BNA) 1572, 133 A.L.R. Fed. 591 (7th Cir. 1991) (federal jurisdiction can be asserted over an action by the assignee of a participant, reasoning that the assignee became a participant under ERISA when the participant designated him as a person to receive her plan benefits); Hobbs v. Blue Cross Blue Shield of Alabama, 276 F.3d 1236 (11th Cir. 2001) (physicians' assistants holding valid assignments of benefits held to be parties who have derivative standing to sue on behalf of participants and beneficiaries for unpaid medical benefits). Derivative standing in this instance is based upon the valid standing of a participant or beneficiary who assigned his rights under a plan.

" The other form of derivative standing occurs when the party bringing an action under Section 1132(a)(1)(B) is a successor-in-interest to the original ERISA plan participant or beneficiary." Scott v. Regions Bank, 702 F.Supp.2d 921, 929 (E.D. Tenn. 2010) (collecting cases). Thus, third-parties may sue to recover benefits due to the original ERISA plan participant or beneficiary after that party's death. Id. In Scott, the court considered whether beneficiaries of a trust, where the trust is the named beneficiary of an ERISA covered life insurance policy, have derivative standing to bring an action under Section 1132(a)(1)(B). Scott v. Regions Bank, 702 F.Supp.2d 921, 930 (E.D. Tenn. 2010). Considering derivative standing in the context of assignees and successors-in-interest, the court held that it did. It concluded that " giving the Plaintiffs derivative standing to bring their claim under Section 1132(a)(1)(B) for clarification of their rights to and recovery of the proceeds from their father' life insurance policies would further the goal of ERISA--to protect the interests of the participants and their beneficiaries." Id.

Plaintiff proposes that he has standing under ERISA as a subrogee of his child's rights under the policy, for the purposes of Section 1132(a)(1)(B). Subrogation claims present another facet of derivative standing. Plaintiff relies heavily on Wills v. Regence Bluecross Blueshield of Utah . No. CIV. 2:07-CV-616BSJ, 2008 WL 4693581 (D. Utah Oct. 23, 2008). The claims in Wills were nearly identical to the ones presented here. In Wills, the insurer submitted that " as an adult beneficiary of the Plan, [the adult child] has standing as a plaintiff in her own right to seek benefits due to her as reimbursement of her own expenses, and the fact that [her father] may have personally assumed financial responsibility for those expenses does not afford him a claim under ERISA. Id. at *7. The court disagreed, and held that the plaintiff had standing under ERISA. In so doing, it analogized cases where health care providers or insurers became subrogees of the participant to confer standing to sue for health benefits under ERISA. Id. (citing Allstate Ins. Co. v. Operating Engineers Local 324 Health Care Plan, 742 F.Supp. 952, 956 (E.D. Mich. 1990) (" As a subrogee of an ERISA participant, i.e., plaintiff's insured, the insurer in this Court's opinion has standing to sue under section [1132](a)")). Because the parent in this instance was a participant, and had adopted the rights of his child to sue as a result of subrogation, the court found that he was afforded standing under the statute. Wills, 2008 WL 4693581 at *7.

It is undisputed that Plaintiff is a participant under the Plan. Thus, Plaintiff " is among those parties expressly entitled to bring suit under ERISA." Leeson v. Transamerica Disability Income Plan, 671 F.3d 969, 974 (9th Cir. 2012). In analyzing the subrogation claim, the court must assess whether a plaintiff's subrogation of his child's claims would confer the rights of his son on to him for the purposes of Section 1132 (a)(1)(B). In essence, as a result of subrogation, whether the benefits are " due to him under the terms of his plan." 29 U.S.C. § 1132(a)(1)(B). Consistent with the reasoning in Wills, the court finds that it does. As in Wills, the Court finds that a participant may plead " a plausible claim of injury-in-fact concerning reimbursement 'due to him' as subrogee of [his son's] claim as a result of his own payment of those expenses on [his son's] behalf." Wills, 2008 WL 4693581, at *9.

3. Subrogation

Defendant argues that Plaintiff has not pleaded facts to support a theory of equitable subrogation of the son's interests. This Court disagrees.

" 'Subrogation' ...'is a creature of equity, having for its purpose the working out of an equitable adjustment and the doing of complete and perfect justice between the parties by securing the ultimate discharge of a debt by the person who in equity and good conscience ought to pay it, and preventing the sweeping away of the fund from which in good conscience the creditor ought to be paid." In re Kemmerrer, 114 Cal.App.2d 810, 814, 251 P.2d 345, 347 (1952) (citations omitted).

In California, courts consider several factors in assessing equitable subrogation. " (1) Payment must have been made by the subrogee to protect his own interest. (2) The subrogee must not have acted as a volunteer. (3) The debt paid must be one for which the subrogee was not primarily liable. (4) The entire debt must have been paid. (5) Subrogation must not work any injustice to the rights of others." Caito v. United Cal. Bank, 20 Cal.3d 694, 704, 144 Cal.Rptr. 751, 576 P.2d 466 (1978)(quoting Grant v. de Otte, 122 Cal.App.2d 724, 728, 265 P.2d 952, 955 (1954)).

Given the equitable origins of subrogation, sometimes equitable concerns can override the stated elements of the judge-made doctrine. In re Flamingo 55, Inc., 378 B.R. 893, 912 (Bankr. D. Nev. 2007) aff'd as modified, 646 F.3d 1253 (9th Cir. 2011) (citing Caito, 20 Cal.3d at 705, 576 P.2d at 472, 144 Cal.Rptr. at 757.). " Equitable subrogation is a broad equitable remedy, not limited to circumstances where these five factors are met, but is appropriate whenever 'one person, not acting as a mere volunteer or intruder, pays a debt for which another is primarily liable, and which in equity and good conscience should have been discharged by the latter.'" Han v. United States, 944 F.2d 526, 529 (9th Cir. 1991) (applying California law). " Under California law, a party is considered a volunteer if, in making a payment, it has no interest of its own to protect, it acts without any obligation, legal or moral, and it acts without being requested to do so by the person liable on the original obligation." Morgan Creek Residential v. Kemp, 153 Cal.App.4th 675, 691 n. 11, 63 Cal.Rptr.3d 232 (citing In re Hamada, 291 F.3d 645, 651 (9th Cir. 2002)).

Plaintiff has pled sufficient facts to establish that equitable subrogation may be appropriate. Plaintiff paid for the medical care of his son to ensure that his dependent was properly cared for. Under the circumstances, his actions can be considered involuntary. Here, although (as Defendant emphasizes) there was no legal transfer of the son's financial interests to the Plaintiff, the Plaintiff was not a stranger to this transaction. Plaintiff was in regular direct contact with the insurance company, and indeed, was an insured under the Policy himself. His relationship with his son, and his son's severe mental disability, created a moral obligation for the Plaintiff to act on his son's behalf. See, e.g., Springham v. Kordek, 55 Md.App. 449, 454, 462 A.2d 567, 570 (1983) (children had a moral duty to assure that their mother would continue to have shelter after abandonment by the father); Henry v. Knight, 74 Ind.App. 562, 122 N.E. 675, 678 (1919) (niece held entitled to subrogation for support provided an enfeebled aunt upon default by the uncle due to a strong moral obligation). While Plaintiff was not primarily liable for the debt, Plaintiff paid for his son's treatment. Additionally, Plaintiff has shown that the Defendant communicated directly with him regarding the claims and benefits due under the Policy. As such, it is clear that there would be no unjust outcome as to Defendant. Plaintiff has pleaded facts sufficient to allege that he subrogated his son's claims and may stand in his shoes for the purposes of his son's rights to payment under the Policy.

4. Article III Standing

Defendant also argues that the Plaintiff has not adequately alleged Article III standing.

To establish standing for the purposes of the constitution, there are three elements. " First, the plaintiff must have suffered an 'injury in fact'--an invasion of a legally protected interest which is (a) concrete and particularized, (b) actual or imminent, not 'conjectural' or 'hypothetical. Second, there must be a causal connection between the injury and the conduct complained of--the injury has to be fairly tracable to the challenged action of the defendant, and not the result of the independent action of some third party not before the court. Third, it must be likely, as opposed to merely speculative, that the injury will be redressed by a favorable decision." Lujan v. Defenders of Wildlife, 504 U.S. 555, 112 S.Ct. 2130, 119 L.Ed.2d 351 (1992) (internal citations omitted).

As to the costs incurred paying for his son's past medical expenses, Plaintiff has clearly made this showing. ...

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