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Plaintiff Survives Motion to Dismiss – N.D. Ind.

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  • Plaintiff Survives Motion to Dismiss – N.D. Ind.

    Here’s a new case out of the Northern District of Indiana entitled William Emerick, pro se, v. Blue Cross Blue Shield Anthem. In this matter, the court rules that BCBS’ motion to dismiss should be denied. I believe that the plaintiff got very, very lucky here. The plaintiff is proceeding pro se and since filing his complaint has not responded to anything, much less this motion to dismiss. However, the court does the plaintiff’s work for him and finds that his state law claim for breach of contract should be converted to an ERISA action and not dismissed.

    However, while labeled a “breach of contract” claim under state law, Emerick’s
    complaint adequately sets forth the elements of an ERISA action under 29 U.S.C. § 1132(a)(1)(B), which allows a beneficiary to bring a civil action in federal district court “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.” First, Emerick alleges that he is a beneficiary3 under the policy: “Plaintiff … jointly with his deceased wife … entered into a written health insurance contract with the Defendant” and “Defendant … contracted with the Plaintiff to provide coverage for the medical needs of Plaintiff’s decedent.” [DE 6 at 1] Second, he clearly seeks to recover benefits he believes are due to him under this policy. See generally, id. Because of this, the Court will not dismiss his case simply because he names “breach of contract” as a claim for relief but articulates a cause of action under ERISA. See Bartholet v. Reishauer A.G. (Zurich), 953 F.2d 1073, 1078 (7th Cir. 1992) (explaining that identifying an incorrect legal theory is not fatal where plaintiff brought state breach of contract claim that was actually based on ERISA); see also Johnson v. City of Shelby, 135 S. Ct. 346 (2014) (“Federal pleading rules call for ‘a short and plain statement of the claim showing that the
    pleader is entitled to relief’; they do not countenance dismissal of a complaint for imperfect statement of the legal theory supporting the claim asserted.”) (citation omitted).
    The court also finds that the plaintiff did not miss the contractual statute of limitations because his administrative remedies were not exhausted until after that time limitation had run.

    Here, the policy measures Emerick’s limitations period based on the deadline for filing a claim for benefits, which itself is measured based on the date on which he incurred medical expenses for his wife’s treatment. Under this rubric, and according to Anthem’s calculations, Emerick’s three-year contractual limitations period ended in April 2015. Emerick’s complaint, however, contains no allegations as to whether or when he exhausted the internal review process (or, when his claims became final) that served as a prerequisite to him filing suit. For example, if Emerick challenged Anthem’s response to his claims pursuant to the grievance and appeal process, and those internal procedures did not conclude until after April 2015, then he would certainly have far less than an “unreasonably short” period of time to file a civil suit under Heimeshoff; he would have no time at all to file suit.

    The fact that this information is missing from Emerick’s complaint does not merit dismissal. Timeliness (or lack thereof) is an affirmative defense, and “‘complaints need not anticipate and attempt to plead around defenses.’” Chicago Bldg. Design, P.C. v. Mongolian House, Inc., 770 F.3d 610, 613 (7th Cir. 2014) (quoting United States v. N. Trust Co., 372 F.3d 886, 888 (7th Cir. 2004)). Accordingly, a motion to dismiss based on a failure to comply with a contractual limitations period should be granted only where “‘the allegations of the complaint itself set forth everything necessary to satisfy the affirmative defense.’” See id. (quoting United States v. Lewis, 411 F.3d 838, 842 (7th Cir. 2005)). In other words, dismissal on this ground at the pleading stage is only appropriate when the plaintiff “affirmatively plead[s] himself out of court.” Id.; see also Vinson v. Vermilion Cnty., Ill., 776 F.3d 924, 929 (7th Cir. 2015) (“[A] plaintiff may plead herself out of court when she includes in her complaint facts that establish an impenetrable defense to her claims.”). Here, the complaint is ambiguous as to when Emerick exhausted the policy’s internal review procedures, if at all. Because these factual details remain
    unresolved, the Court cannot address the reasonableness of the applicable contractual limitations period here, as required by Heimeshoff. See Jamison, 2015 WL 6711081, *5 (issues of fact remained as to when plaintiff’s cause of action arose, preventing dismissal for lack of timeliness). Once the parties determine whether and when Emerick completed an internal review of his claims for reimbursement, “they should consider the Supreme Court’s reasonableness requirement as articulated in Heimeshoff.” Id. For the time being, the contents of the complaint do not establish the airtight timeliness defense that Anthem proposes; Emerick did not “plead himself out of court.” Therefore, the motion to dismiss will be denied.
    The opinion is attached below.
    Attached Files