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Motion to Dismiss Denied, Asks for Factual Analysis – M.D. Fla.

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  • Motion to Dismiss Denied, Asks for Factual Analysis – M.D. Fla.

    Here’s a new case out of the Middle District of Florida, Mark Atherley v. United Healthcare of Florida, Inc. United Healthcare made a motion to dismiss which the court denies. The first question for the court is whether the defendant is a proper party defendant. The court rules:

    The common thread in cases concerning the de facto plan administrator doctrine is that the Court must engage in a factual analysis before reaching a conclusion as to who may properly be considered the plan administrator. Indeed, the core holding of Hamilton is that in certain circumstances it may be necessary for a court to consider the specific facts of the case rather than granting deference to the designations in the plan document. See 244 F.3d at 824. At the motion to dismiss stage, however, the Court is required to accept Plaintiff’s factual allegations as true and is not permitted to engage in the individualized factual analysis contemplated by Hamilton. See Griffin, 496 F.3d at 1199.

    At least one other court in this district has acknowledged this dilemma. In White v. Aetna Life Ins. Co., the Honorable James S. Moody, Jr., Senior United States District Judge, held that the defendant’s motion to dismiss was premature because determination of the plan administrator ultimately requires a factual analysis not permitted at the motion to dismiss stage. Case no. 8:08-cv-1194-T-30TBM, 2009 WL 909272 at *2-3 (M.D. Fla. 2009). In reaching this conclusion, Judge Moody distinguished the case before him from Baker v. Big Star Division of the Grand Union Company, 893 F.2d 288 (11th Cir. 1990). Judge Moody noted that, whereas in Baker the defendants had moved for summary judgment on the grounds that the defendant was not the plan administrator, in the case before him the defendants were proceeding on the same theory at the motion to dismiss stage. White, 2009 WL 909272 at *3. Judge Moody found that because the court is required to accept the plaintiff’s factual allegations as true at the motion to dismiss stage and Plaintiff had alleged that the defendant in White was the plan administrator, dismissal was not appropriate. Id.

    Similarly here, the defendant has proceeded at the motion to dismiss stage and asks the court to engage in factual analysis where it is prohibited from doing so. Plaintiff alleges that the plan is administered by United. Doc. 1 ¶ 1. The Court must accept Plaintiff’s allegation as true at this stage of the proceedings. Griffin, 496 F.3d at 1199. Accepting Plaintiff’s allegation as true, Count II of Plaintiff’s complaint is sufficient to state a claim on which relief can be granted. See 29 U.S.C. § 1132.
    The court next determines that the plaintiff’s claim for statutory penalties survives.

    Although some items requested by Plaintiff may indeed exceed the scope of 29 U.S.C. § 1024(b)(4), at a minimum Plaintiff requested “a complete, certified copy of the subject insurance policy/plan in effect at the time of the subject Cleveland Clinic medical services” and “[a] copy of the ‘in-network’ provider list pertaining to type of transplant at issue that was/is in effect following the time of the transplant and related services through the present.” Doc. 1 ¶ 28. These documents clearly fall within the broad scope of “other instruments under which the plan is established or operated.” 29 U.S.C. § 1024(b)(4). As such, when accepting Plaintiff’s allegations as true, Count II of Plaintiff’s complaint is sufficient to state a claim on which relief can be granted. See 29 U.S.C. §§ 1024(b)(4), 1132.
    The opinion is attached below.
    Attached Files