Rogers v. UnitedHealth Group, Inc.

144 F. Supp. 3d 792, 2015 U.S. Dist. LEXIS 144795, 2015 WL 6462716
CourtDistrict Court, D. South Carolina
DecidedOctober 26, 2015
DocketNo. 2:15-cv-01736-DCN
StatusPublished
Cited by9 cases

This text of 144 F. Supp. 3d 792 (Rogers v. UnitedHealth Group, Inc.) is published on Counsel Stack Legal Research, covering District Court, D. South Carolina primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Rogers v. UnitedHealth Group, Inc., 144 F. Supp. 3d 792, 2015 U.S. Dist. LEXIS 144795, 2015 WL 6462716 (D.S.C. 2015).

Opinion

ORDER

DAVID C. NORTON, UNITED STATES DISTRICT JUDGE

This matter comes before the court on defendants UnitedHealth Group, Inc., United Healthcare Services, Inc., and United Healthcare, Inc.’s (collectively “United”) motion to dismiss pursuant to Federal Rule of Civil Procedure 12(b)(6). For the reasons set forth below, the court grants' in part and denies in part United’s motion.

I. BACKGROUND

Plaintiff Thomas D. Rogers (“Tom”) entered into a contract for health care coverage (“Group Plan”) with United1 as part of his employment with Richardson, Patrick, Westbrook, and Brickman LLC. Compl. ¶ 8; Id. Ex. A. Tom has suffered from kidney disease for much of his adult life. Id. ¶ 10. In early 2014, Tom’s doctor recommended a new drug therapy to treat his nephritis. Id. ¶ 11. Tom experienced complications from the new treatment and developed an infection. Id. ¶ 12. On May 23, 2014, Tom was admitted to the hospital where he was diagnosed with septicemia on May 28, 2014. Id. After spending two weeks in the hospital, Tom’s physicians “encouraged [him] to move to a rehabilitation facility to continue his treatment, given the critical nature of his condition and the ongoing need for multiple dialysis treatments each week.” Id. ¶ 14.

In accordance with the terms of the Group Plan, Tom sought pre-approval from United for coverage of his rehabilitative care. Id. ¶ 15. United denied Tom’s request for coverage, believing he could receive in-home treatment. Id. ¶ 16. At the time, Tom “could not negotiate stairs, needed mobility assistance, [] was still receiving constant medication ... and [ ] was recovering from severe septicemia with an already-compromised immune system.” Id. Tom again sought pre-approval for coverage at an alternate rehabilitation facility called Vibra. Id. ¶ 18. United rejected Tom’s second request. Id. ¶ 19. [795]*795Tom’s physicians “agreed that an acute inpatient care facility was the best option to prevent possible fatal complications.” Id. ¶ 18. Tom decided to receive rehabilitative treatment at Vibra for approximately one week from June 10, 2014 until June 17, 2014. Id. ¶ 20.

On June 10, 2014, the first day of Tom’s stay at Vibra, United notified Tom by letter of the results of its peer-to-peer review of Tom’s physician’s decision to refer him to Vibra. Id. ¶ 21; Compl. Ex. B. United’s reviewing physician determined that it was not medically necessary for Tom to be admitted to Vibra and therefore refused to pay any claims from that provider. Id. ¶ 21. The original bill for the care Tom received from Vibra was $24,164.65, but Tom negotiated a lower rate three months after his discharge. Id. ¶ 22. Tom paid Vibra a total of $11,795.00. Id.

In its letter notifying Tom of the results of the peer-to-peer review, United gave Tom the opportunity to request the information United reviewed in making its decision regarding coverage, including “copies of all documents, records, health benefit plan provisions, internal rules, guidelines and protocols and any other relevant information” relied upon in making its decision. Id. ¶ 23; Ex. B, at 2. Tom sent both a written request for all information and documents relied upon and the requisite signed release to United on July 22, 2014. Compl. Ex. C. Tom claims that United failed to respond to his request. Compl. ¶ 25. Tom’s attorney sent a second written request for the documents on September 25, 2014. Compl. Ex. D. Tom claims that the only response he received from United was a “cryptic fax” sent on September 29, 2014 “stating that a fax received by United did not include an ORS/Secondary barcode sheet, a detail neither explained in the cryptic fax nor requested pursuant to the June 10, 2014, letter setting forth the necessary steps for requesting details of the denial of coverage.” Compl. ¶ 26.

Tom and plaintiff Victoria A. Rogers (“Ms.Rogers”) (collectively “the Rogers”) filed the present action on April 21, 2015. The Rogers bring the following claims: (1) Employee Retirement Income Security Act (“ERISA”) violation pursuant to 29 U.S.C. § 1132(a)(1)(B); (2) injunctive relief under ERISA pursuant to 29 U.S.C. § 1132(a)(3); (3) breach of fiduciary duty pursuant to 29 U.S.C. § 1109; (4) breach of contract; (5) breach of implied covenant of good faith and fair dealing; and (6) negligence. United filed a motion to dismiss on June 5, 2015. The Rogers filed a response in opposition to United’s motion on June 22, 2015. United filed a reply on July 2, 2015. The motion to dismiss has been fully briefed and is now ripe for the court’s review.

II. STANDARD

Under Federal Rule of Civil Procedure 12(b)(6), a party may move to dismiss for “failure to state a claim upon which relief can be granted.” When considering a Rule 12(b)(6) motion to dismiss, the court must accept the plaintiffs factual allegations as true and draw all reasonable inferences in the plaintiffs favor. See E.I. du Pont de Nemours & Co. v. Kolon Indus., 637 F.3d 435, 440 (4th Cir.2011). But “the tenet that a court must accept as true all of the allegations contained in a complaint is inapplicable to legal conclusions.” Ashcroft v. Iqbal, 556 U.S. 662, 678, 129 S.Ct. 1937, 173 L.Ed.2d 868 (2009).

On a motion to dismiss, the court’s task is limited to determining whether the complaint states a “plausible claim for relief.” Id. at 679, 129 S.Ct. 1937. A complaint must contain sufficient factual allegations in addition to legal conclusions. Although Rule 8(a)(2) requires only a “short and plain statement of the claim showing that [796]*796the pleader is entitled to relief,” “a formulaic recitation of the elements of a cause of action will not do.” Bell Atl. Corp. v. Twombly, 550 U.S. 544, 555, 127 S.Ct. 1955, 167 L.Ed.2d 929 (2007). The “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, 129 S.Ct. 1937 (quoting Twombly, 550 U.S. at 570, 127 S.Ct. 1955). “Facts pled that are ‘merely consistent with’ liability are not sufficient.” A Soc’y Without a Name v. Virginia, 655 F.3d 342, 346 (4th Cir.2011) (quoting Iqbal, 556 U.S. at 678, 129 S.Ct. 1937).

III. DISCUSSION

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
144 F. Supp. 3d 792, 2015 U.S. Dist. LEXIS 144795, 2015 WL 6462716, Counsel Stack Legal Research, https://law.counselstack.com/opinion/rogers-v-unitedhealth-group-inc-scd-2015.