Doering v. National Health Insurance Company

CourtDistrict Court, D. Arizona
DecidedAugust 19, 2022
Docket2:21-cv-02198
StatusUnknown

This text of Doering v. National Health Insurance Company (Doering v. National Health Insurance Company) is published on Counsel Stack Legal Research, covering District Court, D. Arizona primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Doering v. National Health Insurance Company, (D. Ariz. 2022).

Opinion

1 WO 2 3 4 5 6 IN THE UNITED STATES DISTRICT COURT 7 FOR THE DISTRICT OF ARIZONA 8

James M ichael Doering, ) No. CV-21-02198-PHX-SPL ) 9 ) 10 Plaintiff, ) ORDER vs. ) ) 11 ) National Health Insurance Company, et ) 12 al., ) 13 ) ) 14 Defendants. )

15 Before the Court are Defendant LIFE’s 12(b)(6) Motion to Dismiss RICO Counts 16 1 and 2 (Doc. 31) and Defendants National Health Insurance Company’s and National 17 General Holdings Corporation’s Motion to Dismiss (Doc. 38). For the reasons that 18 follow, the Motions will be granted.1 19 I. BACKGROUND 20 On December 23, 2021, Justin W. Fontaine filed a Complaint initiating this matter. 21 (Doc. 1). Mr. Fontaine has since passed away, and the named Plaintiff is now James 22 Michael Doering, acting in his capacity as the personal representative of Mr. Fontaine’s 23 estate. (Doc. 58). Defendant National Health Insurance Company (“National Health”) is a 24 subsidiary of National General Holdings Corporation (“National General”) and offers 25 health insurance throughout the country. (Doc. 1 at 4–5). Defendant Joseph Holm is a 26

27 1 Because it would not assist in resolution of the instant issues, the Court finds the pending motions are suitable for decision without oral argument. See LRCiv. 7.2(f); Fed. 28 R. Civ. P. 78(b); Partridge v. Reich, 141 F.3d 920, 926 (9th Cir. 1998). 1 licensed insurance agent in Arizona who sells National Health policies. (Doc. 1 at 5). He 2 is also the sole member of Defendant Health Insurance Advocates LLC. (Doc. 1 at 5). On 3 August 1, 2019, National Health issued a group Short-Term Limited Duration (“STLD”) 4 health policy to Defendant LIFE Association, Inc., a nonprofit organization that offers 5 various purported benefits to dues-paying members. (Doc. 1 at 5, 18). STLD policies are 6 regulated by the states, as they fall outside the protections of the federal Affordable Care 7 Act (“ACA”). (Doc. 1 at 15). 8 LIFE’s application for the National Health group STLD policy listed its city as 9 Birmingham, Alabama, and so the policy was issued in Alabama and governed by 10 Alabama law. (Doc. 1 at 24). In fact, the Alabama address listed on LIFE’s website, 11 communications, and filings submitted to various state insurance departments is a “virtual 12 office,” from which it has its mail and calls forwarded to its actual Texas office. (Doc. 1 13 at 24–26). Moreover, Plaintiff alleges that a group STLD policy can only be issued to an 14 association if it is maintained for a purpose other than obtaining insurance, but that LIFE 15 is in fact maintained for the purpose of obtaining insurance despite its contrary 16 representations to state regulators. (Doc. 1 at 17, 26). Plaintiff alleges that these 17 misrepresentations to state regulators have allowed Defendants to “evade state 18 regulation,” “forum shop for the most insurer-friendly state law,” and “price their 19 products well below those offered on the ACA’s exchanges.” (Doc. 1 at 3). 20 On December 15, 2020, Mr. Holm completed an application for National’s STLD 21 policy on behalf of Mr. Fontaine and his then-wife, Kelly Fontaine, through a phone call 22 with Ms. Fontaine. (Doc. 1 at 6–7). In response to a question about whether the applicant 23 has received medical care for drug or alcohol abuse in the last five years, Mr. Holm 24 marked “No.” (Doc. 1 at 9). Plaintiff alleges that that Mr. Holm never actually asked Ms. 25 Fontaine that and other questions, as Ms. Fontaine would have answered “Yes” due to 26 Mr. Fontaine’s prior treatment for alcohol abuse. (Doc. 1 at 9). The application was 27 approved and the Fontaines were insured under the group STLD policy beginning 28 January 1, 2021. (Doc. 1 at 10). 1 On February 20, 2021, Mr. Fontaine was in a severe motorcycle accident and was 2 transported to a hospital by air ambulance for treatment for multiple serious injuries. 3 (Doc. 1 at 11). He timely submitted insurance claims for the resulting medical expenses, 4 and National Health pre-approved his medical care related to the accident. (Doc. 1 at 11). 5 National Health then requested Mr. Fontaine’s past medical records and began a 6 comprehensive investigation of his medical history. (Doc. 1 at 12). On May 12, 2021, 7 National Health denied Mr. Fontaine’s claims and rescinded his STLD policy retroactive 8 to its effective date. (Doc. 1 at 12). National Health explained that based on his medical 9 records, the question on the application about alcohol abuse should have been answered 10 “Yes,” which would have made him ineligible for coverage. (Doc. 1 at 12). As a result, 11 Plaintiff incurred more than $600,000 in medical expenses. (Doc. 1 at 35). 12 Plaintiff’s Complaint alleges six counts: (1) violation of 18 U.S.C. § 1962(c) of the 13 Racketeer Influenced and Corrupt Organizations Act (“RICO”) against Defendants 14 National Health, National General, and LIFE; (2) violation of 18 U.S.C. § 1962(d) of 15 RICO against National Health, National General, and LIFE; (3) breach of the duty of 16 good faith and fair dealing against National Health and National General; (4) insurance 17 fraud pursuant to A.R.S. § 20-443 against National Health, National General, Mr. Holm, 18 and Health Insurance Advocates LLC; (5) violation of the Arizona Consumer Fraud Act 19 against National Health, National General, Mr. Holm, and Health Insurance Advocates 20 LLC; and (6) insurance agent negligence against Mr. Holm and Health Insurance 21 Advocates LLC. (Doc. 1). Mr. Holm and Health Insurance Advocates LLC have 22 answered the Complaint (Doc. 29), but National Health, National General, and LIFE now 23 move to dismiss the claims against them pursuant to Federal Rule of Civil Procedure 24 (“Rule”) 12(b)(6). (Docs. 31, 38). 25 II. LEGAL STANDARD 26 To survive a Rule 12(b)(6) motion to dismiss, “a complaint must contain sufficient 27 factual matter, accepted as true, to ‘state a claim to relief that is plausible on its face.’” 28 Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009) (quoting Bell Atl. Corp. v. Twombly, 550 U.S. 1 544, 570 (2007)). A claim is facially plausible when it contains “factual content that 2 allows the court to draw the reasonable inference” that the moving party is liable. Id. 3 Factual allegations in the complaint should be assumed true, and a court should then 4 “determine whether they plausibly give rise to an entitlement to relief.” Id. at 679. Facts 5 should be viewed “in the light most favorable to the non-moving party.” Faulkner v. ADT 6 Sec. Servs., Inc., 706 F.3d 1017, 1019 (9th Cir. 2013). 7 Moreover, under Rule 9(b), “[i]n alleging fraud or mistake, a party must state with 8 particularity the circumstances constituting fraud or mistake.” Such allegations must be 9 “specific enough to give defendants notice of the particular misconduct which is alleged 10 to constitute the fraud charged so that they can defend against the charge and not just 11 deny that they have done anything wrong.” Semegen v. Weidner, 780 F.2d 727, 731 (9th 12 Cir. 1985). 13 III. DISCUSSION 14 a. RICO (Counts I and II) 15 Defendants argue that Plaintiff’s RICO claims should be dismissed for two 16 reasons: (1) they are barred by the McCarran-Ferguson Act, 15 U.S.C.

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Doering v. National Health Insurance Company, Counsel Stack Legal Research, https://law.counselstack.com/opinion/doering-v-national-health-insurance-company-azd-2022.