Sellers v. Anthem Life Ins. Co.

316 F. Supp. 3d 25
CourtCourt of Appeals for the D.C. Circuit
DecidedJune 6, 2018
DocketCivil Action No. 16–2428 (TJK)
StatusPublished
Cited by7 cases

This text of 316 F. Supp. 3d 25 (Sellers v. Anthem Life Ins. Co.) is published on Counsel Stack Legal Research, covering Court of Appeals for the D.C. Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Sellers v. Anthem Life Ins. Co., 316 F. Supp. 3d 25 (D.C. Cir. 2018).

Opinion

TIMOTHY J. KELLY, United States District Judge

Plaintiffs Joseph Sellers, Jr., and Richard McClees serve as trustees of the SMART Voluntary Short Term Disability Plan (the "VSTD Plan" or "Plan"). The VSTD Plan is an employee welfare benefit plan regulated under the Employee Retirement Income Security Act of 1974 ("ERISA"), Pub. L. No. 93-406, 88 Stat. 829. The Plan offers short-term disability benefits to certain rail and bus workers. From January 2010 through March 2016, Defendant Anthem Life Insurance Company ("Anthem") underwrote disability insurance that the VSTD Plan provided, and processed claims for benefits.

*30Plaintiffs contend that Anthem overcharged the VSTD Plan for those insurance services. In the instant lawsuit, they bring claims against Anthem for violations of ERISA's prohibited-transaction provisions, as well as claims for breach of contract and unjust enrichment. Anthem has moved to dismiss under Federal Rules of Civil Procedure 12(b)(1) and 12(b)(6). ECF No. 15; see also ECF No. 15-1 ("Def.'s Br."); ECF No. 17 ("Pls.' Opp'n"); ECF No. 18 ("Def.'s Reply"). For the reasons set forth below, the motion will be GRANTED IN PART and DENIED IN PART . Plaintiffs' ERISA claims will be dismissed for failure to state a claim. Plaintiffs' claims for breach of contract and unjust enrichment, however, will be allowed to proceed.

I. Factual and Procedural Background

The VSTD Plan was founded in October 2009 and was originally sponsored by the United Transportation Union ("UTU"). ECF No. 14 ("Am. Compl.") ¶5, 7. In 2012, UTU merged into another union, the International Association of Sheet Metal, Air, Rail, and Transportation Workers ("SMART"). Id. 8. In 2014, Plaintiffs Sellers and McClees were appointed by SMART as trustees of the VSTD Plan, taking the seats formerly held by two UTU-appointed trustees, Malcolm Futhey (UTU's former president) and John Lesniewski. Id. ¶10, 74.

Under both UTU and SMART, the VSTD Plan has provided short-term disability benefits to plan participants, who work for railroad and commuter-bus companies. Id. 12. The schedule of benefits differs for rail and bus employees. Id. 13. Nonetheless, the essential features of the benefits are the same: the Plan offers short-term disability insurance to eligible employees, and premiums are automatically deducted from plan participants' paychecks unless they affirmatively opt out of coverage. See id. ¶14-15.

The Plan engaged Anthem to provide short-term disability insurance to participating rail employees starting on January 1, 2010. Id. 18. The Plan paid Anthem the premiums deducted from participants' paychecks, and Anthem underwrote the benefits and processed claims. Id. ¶18, 22. Anthem offered its services through a series of one-year contracts. Id. 45. In 2011, Anthem, arguing that it was not being adequately compensated, successfully negotiated with the Plan for higher premiums starting in 2012. Id. 31. Anthem also "separately negotiated premiums to provide [short-term disability] benefits to bus industry participants" starting in 2012. Id. 32.

Plaintiffs allege that Anthem "knowingly receiv[ed] excessive compensation" during the period from 2012 through 2014. Id. ¶44-45. Specifically, they allege that the difference between the premiums Anthem received and the claims it paid ranged from $3.7 million to $7.1 million during those three years, representing "profit margins" of 26.2% to 49.8%. Id. ¶34-43. Plaintiffs also complain that, while Anthem was all too eager to seek premium increases when its profits were supposedly low, Anthem did not offer lower premiums when its profits were high. Id. 44.

Plaintiffs allege that Anthem, in addition to charging unreasonable premiums, also engaged in another form of misconduct. Specifically, they allege that Anthem paid "kickbacks," disguised as commissions, to a former UTU employee named Edward Carney from 2010 through 2013. See id. ¶61-81. During the period in question, Carney allegedly had "no business relationship with Anthem or the VSTD Plan." Id. 61. Nonetheless, Anthem allegedly paid Carney hundreds of thousands of dollars per year from the premiums it received.

*31Id. ¶62-65. Plaintiffs claim that Anthony Martella, who worked for a company that sold insurance to SMART members and "was in the position to steer the commission business to Carney," helped "to orchestrate the payments from Anthem to Carney" (although how, exactly, is unclear). Id. ¶71-72. In return, Carney allegedly passed on tens of thousands of dollars from the "kickbacks" he received to Martella. Id. ¶66-70, 73. Plaintiffs also allege that, in 2011, Carney "slipped $2,000 into the coat pocket of then president of the UTU, Malcolm Futhey," who was also a trustee of the Plan at the time. Id. 74. Plaintiffs allege that the payments from Anthem to Carney "were not reasonable commissions" and "increased, dollar for dollar, the amount of the premiums paid by VSTD." Id. ¶77-78.

After taking office as trustees of the Plan in 2014, Plaintiffs sought to negotiate better rates. See id. 51. Anthem responded by proposing what Plaintiffs characterize as a risksharing arrangement. Id. 53. Until that point, Anthem had borne the risk of loss in the event that claims exceeded premiums. Id. Anthem offered a deal under which Plaintiffs would pay higher premiums but receive quarterly refunds of 50% of the difference between premiums received and claims paid. Id. Plaintiffs evidently disliked this proposal but claim that, since it was too late to consider other offers, they accepted it by letter dated January 30, 2015. See id. 55 & Ex. A. Plaintiffs allege that Anthem nonetheless failed to make any of the refund payments required under the agreement. Id. 60.

According to Plaintiffs, Anthem subsequently took the view that the January 2015 letter had not caused a binding contract to form. See id. 92. Anthem sought to continue negotiating, proposing an agreement under which the refunds for 2015 and 2016 would not be paid quarterly, but in a lump sum in 2017. See id. 57. Anthem, for its part, claims that the parties ultimately did reach an agreement providing for a lump sum. See Def.'s Br. at 27. Anthem has provided what it asserts is the binding agreement, although it is signed only by the Plan and not by Anthem. See Def.'s Br. Ex. B (ECF No 15-3).

Plaintiffs assert five counts against Anthem. The first three arise under Section 406(a)(1) of ERISA, 29 U.S.C. § 1106(a)(1), and allege that the payments Anthem received from the Plan constituted unlawful "prohibited transactions." Am. Compl. ¶82-102. Count IV alleges that Anthem breached its contract with the Plan by failing to make the quarterly refund payments that Plaintiffs claim are owed for 2015.

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Bluebook (online)
316 F. Supp. 3d 25, Counsel Stack Legal Research, https://law.counselstack.com/opinion/sellers-v-anthem-life-ins-co-cadc-2018.