O.F., individually and on behalf of M.F. v. HEALTH CARE SERVICE CORPORATION, doing business as BLUE CROSS BLUE SHIELD OF TEXAS

CourtDistrict Court, N.D. Illinois
DecidedMarch 31, 2026
Docket1:25-cv-00127
StatusUnknown

This text of O.F., individually and on behalf of M.F. v. HEALTH CARE SERVICE CORPORATION, doing business as BLUE CROSS BLUE SHIELD OF TEXAS (O.F., individually and on behalf of M.F. v. HEALTH CARE SERVICE CORPORATION, doing business as BLUE CROSS BLUE SHIELD OF TEXAS) is published on Counsel Stack Legal Research, covering District Court, N.D. Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

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O.F., individually and on behalf of M.F. v. HEALTH CARE SERVICE CORPORATION, doing business as BLUE CROSS BLUE SHIELD OF TEXAS, (N.D. Ill. 2026).

Opinion

UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

O.F., individually and on behalf of M.F.,

Plaintiff, NO. 1:25-CV-00127

v. Judge Edmond E. Chang

HEALTH CARE SERVICE CORPORATION, doing business as BLUE CROSS BLUE SHIELD OF TEXAS,

Defendant.

MEMORANDUM OPINION AND ORDER

O.F.’s daughter M.F. received mental-health treatment from two facilities in Utah. R. 1, Compl. ¶¶ 1, 4.1 After O.F.’s claims for insurance coverage were denied, he brought this suit against Health Care Service Corporation (which does business as Blue Cross Blue Shield of Texas), the entity that administered the relevant bene- fits plans. Id. ¶¶ 2, 5; R. 23, Def.’s Br. at 2. O.F. alleges violations of the Employment Retirement Income Security Act of 1974 (commonly known as ERISA), 29 U.S.C. § 1132(a), and the Mental Health Parity and Addiction Equity Act of 2008, id. § 1185a(a)(3).2 Compl. ¶¶ 9, 49–94. Blue Cross now moves to dismiss the Complaint for failure to state a claim. R. 22, Def.’s Mot.; Def.’s Br. at 1. For the reasons explained

1Citations to the record are “R.” followed by the docket entry number and, if needed, a page or paragraph number.

2This Court has subject matter jurisdiction over this case under 29 U.S.C. § 1132(e)(1) and 28 U.S.C. § 1331. in this Opinion, the current complaint is dismissed, though the dismissal is without prejudice for now and with leave to amend. I. Background

O.F. and M.F. are a father-daughter duo who live in Texas and are covered by health-insurance plans administered by Blue Cross over the course of two years. Compl. ¶¶ 1–2, 4–5. Seeking mental-health treatment, M.F. was admitted to two fa- cilities in Utah (Aspiro Wilderness Adventure Therapy and later La Europa Acad- emy) during various times from October 2021 to December 2022. Id. ¶¶ 4, 10, 26. O.F. submitted claims to Blue Cross for both periods of inpatient treatment. Id. ¶¶ 11, 27. Blue Cross ultimately denied O.F.’s claims. Compl. ¶ 5. For M.F.’s treatment

at Aspiro, Blue Cross denied O.F.’s claim because Aspiro provided “behavioral health outdoor/wilderness services” that were excluded under the plans from the coverage of “residential treatment center[s]” and from “behavioral health services.” Id. ¶¶ 24–25. As for La Europa, Blue Cross explained that a facility would be considered a residen- tial treatment center only if there was 24-hour nursing, a service that was unavaila- ble at La Europa. Id. ¶¶ 32–33.

II. Legal Standard Under Federal Rule of Civil Procedure 8(a)(2), a complaint generally need only include “a short and plain statement of the claim showing that the pleader is entitled to relief.” Fed. R. Civ. P. 8(a)(2). This short and plain statement must “give the de- fendant fair notice of what the claim is and the grounds upon which it rests.” Bell Atl.

2 Corp. v. Twombly, 550 U.S. 544, 555 (2007) (cleaned up).3 The Seventh Circuit has explained that this rule “reflects a liberal notice pleading regime, which is intended to ‘focus litigation on the merits of a claim’ rather than on technicalities that might

keep plaintiffs out of court.” Brooks v. Ross, 578 F.3d 574, 580 (7th Cir. 2009) (quoting Swierkiewicz v. Sorema N.A., 534 U.S. 506, 514 (2002)). At the same time, the Su- preme Court instructs that “[d]etermining whether a complaint states a plausible claim for relief will ... be a context-specific task ....” Ashcroft v. Iqbal, 556 U.S. 662, 679 (2009). The Seventh Circuit has drawn a context-dependent distinction between relatively straightforward employment discrimination claims versus more complex claims. Swanson v. Citibank, N.A., 614 F.3d 400, 404–05 (7th Cir. 2010).

“A motion under Rule 12(b)(6) challenges the sufficiency of the complaint to state a claim upon which relief may be granted.” Hallinan v. Fraternal Ord. of Police of Chi. Lodge No. 7, 570 F.3d 811, 820 (7th Cir. 2009). “[A] complaint must contain sufficient factual matter, accepted as true, to state a claim to relief that is plausible on its face.” Iqbal, 556 U.S. at 678 (cleaned up). These allegations “must be enough to raise a right to relief above the speculative level.” Twombly, 550 U.S. at 555. The

allegations that are entitled to the assumption of truth are those that are factual, rather than mere legal conclusions. Iqbal, 556 U.S. at 678–79.

3This Opinion uses (cleaned up) to indicate that internal quotation marks, alterations, and citations have been omitted from quotations. See Jack Metzler, Cleaning Up Quotations, 18 Journal of Appellate Practice and Process 143 (2017).

3 III. Analysis Consistent with the treatment of factual allegations at the pleading stage, Blue Cross does not contest the alleged facts for purposes of its motion to dismiss. Def.’s

Br. at 2 n.2. And the parties agree that ERISA governs the plans. Compare Compl. ¶ 3, with Def.’s Br. at 5–9. But the parties disagree on whether the wilderness pro- gram at Aspiro and the residential program at La Europa are covered, as a matter of law, by O.F.’s plans. Def.’s Br. at 5–9; R. 29, Pl.’s Resp. at 8–11. Within this claim, O.F. suggests that Blue Cross’s procedurally inadequate denial furnishes an inde- pendent basis for relief. Pl.’s Resp. at 10–11. And if the programs are not covered, O.F. argues that the exclusion of either violates the Parity Act. Pl.’s Resp. at 11–16.

The Court will take each argument in turn. To do so, the Court considers O.F.’s health-insurance plans, as described in the 2021 and 2022 benefits booklets. Blue Cross attaches copies of the booklets to its mo- tion to dismiss, R. 23-1, Exh. 1, 2021 Benefits Booklet; R. 23-1, Exh. 2, 2022 Benefits Booklet, and because the terms of the plans are central to O.F.’s claims, the Court considers them at the pleading stage, Esco v. City of Chicago, 107 F.4th 673, 678–79

(7th Cir. 2024). O.F. acknowledges that the relevant terms are the same in both book- lets, Pl.’s Resp. at 3 n.5, so for convenience’s sake, the Court will refer to just the 2021 version of the plans. A. ERISA The threshold question is the proper standard of review for the ERISA claim. Typically, claimants prefer that federal courts give de novo review to plan 4 determinations (which are usually rejections of claims) rather than grant discretion to the plan administrator. Here, however, O.F. contends that the plans give Blue Cross discretion to interpret terms and benefits, so Blue Cross would have deference

under the familiar arbitrary-and-capricious standard. Compl. ¶¶ 51–52, 58; Pl.’s Resp. at 10–11. Applying that deference here might help O.F. because he asserts that the plan made various procedural mistakes during its consideration of his claim; in contrast, de novo review renders the plan’s past procedural steps as largely unim- portant.

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O.F., individually and on behalf of M.F. v. HEALTH CARE SERVICE CORPORATION, doing business as BLUE CROSS BLUE SHIELD OF TEXAS, Counsel Stack Legal Research, https://law.counselstack.com/opinion/of-individually-and-on-behalf-of-mf-v-health-care-service-ilnd-2026.