H.H. v. Aetna Ins. Co.

342 F. Supp. 3d 1311
CourtDistrict Court, S.D. Florida
DecidedDecember 12, 2018
DocketCASE NO. 18-80773-CV-MIDDLEBROOKS
StatusPublished
Cited by11 cases

This text of 342 F. Supp. 3d 1311 (H.H. v. Aetna Ins. Co.) is published on Counsel Stack Legal Research, covering District Court, S.D. Florida primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
H.H. v. Aetna Ins. Co., 342 F. Supp. 3d 1311 (S.D. Fla. 2018).

Opinion

DONALD M. MIDDLEBROOKS, UNITED STATES DISTRICT JUDGE

THIS CAUSE comes before the Court upon Defendant Aetna Insurance Company's *1315("Aetna") Motion to Dismiss (DE 22), filed August 8, 2018. Plaintiffs filed a response on August 31, 2018 (DE 27), and Defendant filed a reply on September 17, 2018 (DE 30). For the reasons set forth below, Defendant's Motion is granted.

I. BACKGROUND

Plaintiffs initiated this lawsuit on June 14, 2018. (DE 1). Plaintiff H.H. filed by and through his father, J.H., and Plaintiff V.G. filed by and through her father, C.G. (Id. at 1). Plaintiffs asserted claims under the Employee Retirement Income and Security Act ("ERISA"), 29 U.S.C. ¶¶ 1001 - 1191c, and under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Act of 2008 (the "Parity Act"), 29 U.S.C. § 1185a. (Id. )

A. Plaintiff H.H.

Plaintiff H.H. was covered by his father J.H.'s employer-sponsored health insurance plan, which was underwritten and administered by Aetna. (Id. ¶¶ 8, 19). On March 29, 2016, upon the recommendation of his therapist, H.H. went to Open Sky Wilderness Therapy ("Open Sky"), an intermediate mental health treatment program in Durango, Colorado. (Id. ¶¶20-21). H.H. had for years had mental health issues such as anxiety, depression, and suicidal ideation, and he had unsuccessfully undergone outpatient treatment, hospitalization, and other therapies. (Id. ) He was treated at Open Sky from March 29, 2016 to June 29, 2016, and his father paid $45,105 for such treatment. (Id. ¶ 24).

On October 29, 2016, Aetna denied the claims submitted for H.H.'s treatment at Open Sky. (Id. ¶ 25). J.H. appealed Aetna's decision, and Aetna affirmed it on May 20, 2017. (Id. ¶ 26). J.H. invoked Aetna's second level of appeal, and Aetna again affirmed its denial of the claims on August 17, 2017. (Id. ¶ 27). After J.H.'s second appeal was denied, he had exhausted Aetna's mandatory internal appeal process. (Id. )

H.H. brings three claims: first, for plan enforcement under ERISA (Count 1); second, for violating the Parity Act (count 2); and third, for equitable relief under ERISA for Aetna's violation of the Parity Act (Count 3). (Id. ¶¶ 47-65). H.H. initiated this lawsuit in his individual capacity and as representative of a class of people "who are covered under any ERISA-governed health benefit plan fully-insured by Aetna Life that covered mental or nervous disorders or substance abuse care and who required treatment at one or more licensed residential treatment centers during the applicable class period." (Id. ¶ 36). On October 30, 2018, H.H. informed the Court that he no longer sought to proceed with this matter as a class action and is instead only pursuing his claims on an individual basis. (DE 46).

B. Plaintiff V.G.

Plaintiff V.G. was insured under her father C.G.'s employer-sponsored health insurance, which was administered by Aetna. (DE 1 ¶¶ 7, 12). Upon the advice of her therapist, V.G. went to Aspiro Group, Inc. ("Aspiro"), a wilderness therapy program in Mount Pleasant, Utah, on March 6, 2016. (Id. ¶ 12-13). V.G. had already unsuccessfully undergone outpatient treatment and other therapies for her mental health issues such as attention-deficit/hyperactivity disorder ("ADHD"), autism, and suicidal ideation. (Id. ) V.G. was treated at Aspiro from March 6, 2016 to May 4, 2016, for which C.G. paid $28,500. (Id. )

On March 9, 2016, Aetna denied the claims submitted for V.G.'s treatment at Aspiro. (Id. ¶ 18). C.G. appealed Aetna's decision, and Aetna affirmed it on October 22, 2016. (Id. ) C.G. appealed the decision for a second time, and Aetna again affirmed it on January 26, 2017. (Id. ) At that *1316point, C.G. had exhausted Aetna's required internal appeals procedure.

V.G. brings two claims for plan enforcement under ERISA against Aetna (Count 4-5). (Id. ¶¶ 66-74). V.G. initially brought this action on her own behalf and on behalf of a class of people "who are covered under any ERISA-governed self-insured health benefit plan (1) with similar mental health and substance abuse grants and exclusions to the plan covering V.G. (2) that is administered by Aetna Life and (3) who required treatment at one or more licensed wilderness therapy programs during the applicable class period." (Id. ¶ 36). V.G. notified the Court on October 30, 2018 that she no longer sought to proceed with this matter as a class action and is instead only pursuing her claims on an individual basis. (DE 46).

II. LEGAL STANDARD

A motion to dismiss under Rule 12(b)(6) challenges the legal sufficiency of a complaint. Fed. R. Civ. P. 12(b)(6). When reviewing a motion to dismiss, a court must view the complaint in the light most favorable to the plaintiff and must take the factual allegations stated therein as true. Morgan v. Christensen, 582 Fed. Appx. 806, 809 (11th Cir. 2014). According to Rule 8(a), a complaint need only contain "a short and plain statement of the claim showing that the pleader is entitled to relief." Fed. R. Civ. P 8(a)(2). This standard requires more than bare allegations or conclusions by the plaintiff. The factual assertions must be sufficient to allow a court to draw a reasonable inference that the defendant is liable for the alleged misconduct. Morgan, 582 Fed. Appx. at 809 (quoting Bell Atlantic Corp. v. Twombly, 550 U.S. 544, 555, 127 S.Ct. 1955, 167 L.Ed.2d 929 (2007) ).

III. DISCUSSION

A. ERISA Violations

"[B]enefits payable under an ERISA plan are limited to the benefits specified in the plan." Sanctuary Surgical Centre, Inc. v. UnitedHealth Group, Inc., 2013 WL 149356, at *3 (S.D. Fla. Jan. 14, 2013). To state a plausible claim under ERISA, then, a plaintiff "must 'provide the court with enough factual information to determine whether the [services] were indeed covered services under the plan.' " Id. (quoting Stewart v. Nat'l Educ. Ass'n,

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342 F. Supp. 3d 1311, Counsel Stack Legal Research, https://law.counselstack.com/opinion/hh-v-aetna-ins-co-flsd-2018.