Bourgeois v. Blue Cross Blue Shield of Massachusetts, Inc.

CourtDistrict Court, D. Massachusetts
DecidedMarch 31, 2021
Docket4:20-cv-40051
StatusUnknown

This text of Bourgeois v. Blue Cross Blue Shield of Massachusetts, Inc. (Bourgeois v. Blue Cross Blue Shield of Massachusetts, Inc.) is published on Counsel Stack Legal Research, covering District Court, D. Massachusetts primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Bourgeois v. Blue Cross Blue Shield of Massachusetts, Inc., (D. Mass. 2021).

Opinion

UNITED STATES DISTRICT COURT DISTRICT OF MASSACHUSETTS

________________________________________________ ) ROY A. BOURGEOIS and ) BOURGEOISWHITE, LLP, ) Plaintiff, ) ) v. ) CIVIL ACTION ) No. 20-40051-TSH ) BLUE CROSS BLUE SHIELD OF ) MASSACHUSETTS, BOSTON HILL ) ADVISORS, LLC, and JOSEPH HAYES, ) Defendants. ) ________________________________________________)

MEMORANDUM OF DECISION AND ORDER March 31, 2021

HILLMAN, D.J.

Background Roy A. Bourgeois (“Bourgeois”) and BourgeoisWhite, LLP (“BourgeoisWhite” and together with Bourgeois, “Plaintiffs”) have filed a complaint against Blue Cross Blue Shield of Massachusetts, Inc. (“BCBS”), Boston Hill Advisors, LLC (“Boston Hill”), and Joseph Hayes (“Hayes” and together with BCBS and Boston Hill, “Defendants”) asserting: (1) that BCBS violated the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C §1132 (Count I); (2) a claim against Boston Hill and Hayes for the breach of contract (Count III); (3) a claim against Boston Hill and Hayes for breach of the covenant of good faith and fair dealing (Count IV); (4) a claim for negligence against Boston Hill and Hayes (Count V); (5) a claim for negligent misrepresentation against Boston Hill and Hayes (Count VI); and (6) a claim against Boston Hill and Hayes for unfair or deceptive acts or practices under Mass. Gen. L. ch. 93A (“Chapter 93A”) (Count VII). Plaintiffs have also filed a claim for preliminary injunction (Count II) seeking to enjoin BCBS from denying Bourgeois health insurance coverage per the terms of his policy.

Plaintiffs’ claims arise out of Bourgeois’ failure to enroll in Medicare Part B coverage after he attained the age of 65. More specifically, Bourgeois is a participant in the Employee Health Benefit Plan (“Plan”) established by his employer, BourgeoisWhite. In August 2019, Bourgeois required emergency coronary artery bypass surgery. BCBS notified Bourgeois that it was refusing to cover all of the the medical expenses because, they were to be covered by Medicare. Bourgeois had not applied for Medicare Part B coverage upon attaining the age of 65 as required by the terms of the Plan. The total surgical costs were approximately $140,000. BCBS refused to cover $47,123.67 of the medical expenses and another $8,548.75 in out-patient services. This Memorandum and Order addresses the following: BCBS’s motion to dismiss

(Docket No. 16); Hayes’ motion to dismiss (Docket No. 26); and Boston Hill’s motion for judgment on the pleadings (Docket No. 32). For the reasons set forth below, those motions are granted, in part and, denied, in part. Plaintiff has also filed a motion to strike Exhibit B from BCBS’ motion to dismiss (Docket No. 25). That motion is denied. Standard of Review The Motion to Dismiss In evaluating a Rule 12(b)(6) motion to dismiss, the court must accept the plaintiff’s well plead facts as true, “drawing all reasonable inferences in the pleader’s favor, and see if they plausibly narrate a claim for relief.” Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570, 127 S.Ct. 1955, 1973 (2007); see also Ruiz v. Bally Total Fitness Holding Corp., 496 F.3d 1, 5 (1st Cir. 2007) (citing Rogan v. Menino, 175 F.3d 75, 77 (1st Cir. 1999)) (holding that the Court must give the plaintiff “the benefit of all reasonable inferences therefrom”). The Court’s plausibility standard maintains that the plaintiff must state a claim where the “[f]actual allegations must be

enough to raise a right to relief above the speculative level.” Twombly, 550 U.S. at 570, 127 S.Ct. 1955. Significantly, the plausibility standard differs from a probability requirement, but “asks for more than a sheer possibility that a defendant has acted unlawfully.” Ashcroft v. Iqbal, 556 U.S. 662, 678, 129 S.Ct. 1937, 1949 (2009) (quoting Twombly, 550 U.S. at 556, 127 S.Ct. 1955). Additionally, the plaintiff’s complaint must contain factual allegations rather than labels and conclusions. Twombly, 550 U.S. at 555, 127 S.Ct. 1955. “The relevant inquiry focuses on the reasonableness of the inference of liability that the plaintiff is asking the court to draw from the facts alleged in the complaint.” Ocasio-Hernàndez v. Fortuño-Burset, 640 F.3d 1, 13 (1st Cir. 2011). When the plaintiff’s well-pleaded facts does not assert “enough heft to show that plaintiff

is entitled to relief”, then dismissal is appropriate. Ruiz Rivera v. Pfizer Pharm., LLC, 521 F.3d 76, 84 (1st Cir. 2008). Motion for Judgment on the Pleadings Rule 12(c) provides that once pleadings are closed, a party may move for judgment on the pleadings. Fed. R. Civ. P. 12(c). “[T]he fate of such a motion will depend upon whether the pleadings, taken as a whole, reveal any potential dispute about one or more of the material facts.” Gulf Coast Bank & Trust Co. v. Reder, 355 F.3d 35, 38 (1st Cir. 2004). The standard of review for a 12(c) motion is identical to that of a 12(b)(6) motion. See Doe v. Brown Univ., 896 F.3d 127, 130 (1st Cir. 2018). It is proper for a court to make a judgment on the pleadings when the complaint fails to show a plausible right to relief. See Villeneuve v. Avon Prods., Inc., 919 F.3d 40, 49 (1st Cir. 2019). Facts Bourgeois’ Coverage and Incurred Medical Expenses

Bourgeois is an employee of BourgeoisWhite, a law firm with less than 20 employees. BourgeoisWhite offers employees a group healthcare insurance plan through BCBS (previously defined as the “Plan”). Hayes acted as an agent of the Plaintiffs in researching, recommending, and obtaining the Plan. Bourgeois has been enrolled in the Plan for several years and has at all times made timely premium payments. On November 25, 2016, Bourgeois turned 65 and enrolled in Medicare Part A, but not Medicare Part B. Bourgeois continued to pay his premiums after turning 65. Boston Hill is Haye’s alleged employer. Boston Hill’s website explicitly states: “If you are still working and have employer-provided health care it makes sense to apply for Medicare part A when you turn 65, but you don't have to enroll in Parts B or D, and there is no penalty.”

None of the Defendants notified Bourgeois of any change in his coverage after he had turned 65. Bourgeois incurred thousands of dollars in medical costs attributable to emergency coronary artery bypass surgery in August 2019. BCBS denied coverage for approximately $55,000 of the medical expenses related to Bourgeois’ surgery. BCBS’s stated reason for refusing to pay these expenses is that they were to be covered by Medicare Part B. Under the terms of the Plan, because BourgeoisWhite has less than twenty employees, Bourgeios was required to enroll in Medicare Part B upon turning 65. After BCBS denied coverage, Bourgeois contacted Hayes who advised him to apply for Medicare Part B and request a retroactive effective date, and then apply to BCBS for an exception request. Hayes further advised Bourgeois that an appeal to BCBS prior to receiving the Medicare Part B retroactive effective date would be futile.

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Bourgeois v. Blue Cross Blue Shield of Massachusetts, Inc., Counsel Stack Legal Research, https://law.counselstack.com/opinion/bourgeois-v-blue-cross-blue-shield-of-massachusetts-inc-mad-2021.