And v. Essentia Health

342 F. Supp. 3d 947
CourtDistrict Court, D. Maine
DecidedSeptember 20, 2018
DocketCivil No. 16-100 (DWF/LIB)
StatusPublished
Cited by19 cases

This text of 342 F. Supp. 3d 947 (And v. Essentia Health) is published on Counsel Stack Legal Research, covering District Court, D. Maine primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
And v. Essentia Health, 342 F. Supp. 3d 947 (D. Me. 2018).

Opinion

DONOVAN W. FRANK, United States District Judge

INTRODUCTION

Plaintiffs Brittany Tovar and Reid Olson brought this suit alleging that Defendants designed and sponsored a health care plan that contained a discriminatory categorical exclusion for all health services related to gender transition, and denied Olson, Tovar's transgender son, coverage for medically necessary care. HealthPartners and Essentia have both moved to dismiss the complaint. For the reasons discussed below, the Court grants in part and denies in part HealthPartners' motion and denies Essentia's motion.

BACKGROUND

Plaintiff Brittany Tovar was a nurse practitioner employed by Defendants Essentia Health and Innovis Health, LLC, d/b/a Essentia Health West (collectively, "Essentia"), from September 24, 2010, until July 29, 2016. (Doc. No. 66 ("Am. Compl.") ¶ 16.) As part of her employee benefits, Tovar was provided health insurance through the Essentia Health Employee Medical Plan (the "Plan"), which is sponsored by Essentia and administered by Defendants HealthPartners, Inc., and HealthPartners Administrators, Inc. (collectively, "HealthPartners," and collectively with Essentia, "Defendants"). (Id. ¶¶ 17, 25.) On October 1, 2014, Tovar's son, Plaintiff Reid Olson, became a beneficiary under the Plan. (Id. ¶ 18.)

In November 2014, Olson was diagnosed with gender dysphoria, which arises when an individual's gender identity differs from the gender assigned at birth.1 (Id. ¶ 19.) According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ("DSM-5"), the symptoms of gender dysphoria include "clinically significant distress or impairment in social, occupational, or other important areas of functioning." (Id. ¶ 21.) Medical treatments such as mental health counseling, hormone therapy, and gender reassignment surgery have been shown to relieve the symptoms of gender dysphoria. (Id. ¶ 22.) Health professionals decided that these treatments were necessary to treat Olson's gender *951dysphoria. (Id. ¶ 34.) Olson's doctor also recommended that Olson begin taking the medications Lupron and Androderm to treat Olson's gender dysphoria. (Id. ¶¶ 43-51, 63-67.)

Tovar and Olson sought coverage for these medical treatments as well as pre-authorization for gender reassignment surgery for Olson through the Plan, but because the Plan at that time categorically excluded coverage of "[s]ervices and/or surgery for gender reassignment," Defendants denied insurance coverage for Olson's treatment and medications. (Id. ¶¶ 23, 33-34, 68.) Tovar appealed the Plan's categorical exclusion of gender reassignment treatments. (Id. ¶¶ 36-41.) HealthPartners denied Tovar's appeal, notifying Tovar of its intent to enforce the terms of the Plan. (Id. ) Tovar incurred out-of-pocket expenses for Androderm, but Plaintiffs decided not to purchase Lupron. (Id. ¶¶ 62, 66.) Defendants later decided to provide coverage for Androderm as a one-time exception and reimbursed Tovar for her out-of-pocket expenses. (Id. ¶ 67.) As a result of the denied coverage, Olson and Tovar suffered emotional and financial harm, and Olson suffered delayed access to medically necessary treatment. (Id. ¶¶ 70-72.)

Essentia requested that HealthPartners remove the exclusion from the Plan starting on January 1, 2016, and HealthPartners did so. (Id. ¶ 73.) On July 29, 2016, Tovar's employment with Essentia ended. (Id. ¶ 16.) Tovar and Olson, however, remained covered under the Plan through October 31, 2016. (Id. ¶ 73.)

In the First Amended Complaint, Plaintiffs have brought identical claims against HealthPartners alleging a violation of Section 1557 of the Patient Protection and Affordable Care Act ("Section 1557"). Olson also brings a Section 1557 claim against Essentia. Essentia and HealthPartners separately move to dismiss.

DISCUSSION

I. Legal Standard

In deciding a motion to dismiss under Rule 12(b)(6), a court assumes all facts in the complaint to be true and construes all reasonable inferences from those facts in the light most favorable to the complainant. Morton v. Becker , 793 F.2d 185, 187 (8th Cir. 1986). In doing so, however, a court need not accept as true wholly conclusory allegations, Hanten v. Sch. Dist. of Riverview Gardens , 183 F.3d 799, 805 (8th Cir. 1999), or legal conclusions drawn by the pleader from the facts alleged, Westcott v. City of Omaha , 901 F.2d 1486, 1488 (8th Cir. 1990). A court deciding a motion to dismiss may consider the complaint, matters of public record, orders, materials embraced by the complaint, and exhibits attached to the complaint. See Porous Media Corp. v. Pall Corp. , 186 F.3d 1077, 1079 (8th Cir. 1999).

To survive a motion to dismiss, a complaint must contain "enough facts to state a claim to relief that is plausible on its face." Bell Atl. Corp. v. Twombly , 550 U.S. 544, 570, 127 S.Ct. 1955, 167 L.Ed.2d 929 (2007). Although a complaint need not contain "detailed factual allegations," it must contain facts with enough specificity "to raise a right to relief above the speculative level." Id. at 555, 127 S.Ct. 1955. As the Supreme Court reiterated, "[t]hreadbare recitals of the elements of a cause of action, supported by mere conclusory statements," will not pass muster under Twombly . Ashcroft v. Iqbal , 556 U.S. 662, 678, 129 S.Ct. 1937, 173 L.Ed.2d 868 (2009) (citing Twombly

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342 F. Supp. 3d 947, Counsel Stack Legal Research, https://law.counselstack.com/opinion/and-v-essentia-health-med-2018.