Whiting v. AARP & Unitedhealthcare Insurance

637 F.3d 355, 394 U.S. App. D.C. 421, 2011 U.S. App. LEXIS 4485, 2011 WL 781094
CourtCourt of Appeals for the D.C. Circuit
DecidedMarch 8, 2011
Docket10-7049
StatusPublished
Cited by41 cases

This text of 637 F.3d 355 (Whiting v. AARP & Unitedhealthcare Insurance) 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
Whiting v. AARP & Unitedhealthcare Insurance, 637 F.3d 355, 394 U.S. App. D.C. 421, 2011 U.S. App. LEXIS 4485, 2011 WL 781094 (D.C. Cir. 2011).

Opinion

Opinion for the Court by Circuit Judge ROGERS.

ROGERS, Circuit Judge:

Susan Whiting purchased medical insurance from United Healthcare Insurance Company (“United”) after receiving a letter and brochure describing the insurance from the American Association of Retired Persons (“AARP”), of which she is a member. Upon having emergency gall bladder surgery a year later, she submitted her medical bills to United only to be told that inpatient pathology and radiology services were not covered. Although United paid the costs of her surgeon and for ten physician visits and room and board at the hospital, Whiting was left to pay nearly forty thousand dollars in medical bills. She sued AARP and United, on behalf of herself and others, alleging breach of contract, fraud under the D.C. Consumer Protection Procedures Act (“the Consumer Act”), and she also sued AARP for unjust enrichment. The district court dismissed the complaint pursuant to Federal Rule of Civil Procedure 12(b)(6) for failure to state a claim on which relief could be granted. Upon de novo review, see Atherton v. D.C. Office of Mayor, 567 F.3d 672, 681 (D.C.Cir.2009), we affirm.

Applying the meaning that common speech imports to the insurance contract, which is governed by District of Columbia law, we conclude that the contract is not ambiguous. It includes sections on what services are and are not covered and includes notations limiting coverage that are directly relevant to Whiting’s circumstances. But even assuming that a reasonable person would be led astray by the absence of either the word “only” or an explicit exclusion of inpatient radiology and pathology services in the “WHAT IS COVERED ” section, and/or various other provisions in the Certificate of Insurance (“the Certificate”) that do not contain relevant limitations, Whiting’s breach of contract claims fail. The chart contained in the brochure that she received from AARP stated that “only” outpatient pathology and radiation services are covered, a word that in the context in which it appeared can only be understood to exclude non-outpatient services. For similar reasons, her statutory fraud and unjust enrichment claims also fail. Further, the district court *358 did not err in denying Whiting’s motion to take judicial notice of congressional materials or in dismissing the complaint with prejudice.

I.

According to the complaint, in August 2007 Whiting received a marketing letter and promotional materials from AARP on the “AARP Medical Advantage Plan” (“the Plan”), which was characterized as a “bridge” insurance plan underwritten by United targeted at retirees and unemployed AARP members who were not yet eligible for Medicare. The marketing letter included the following statements: The Plan “is for those who are “between jobs, retired early, or find [themselves] needing primary health insurance”; the Plan “is not major medical, yet [it] provides essential health benefits at an affordable price”; the Plan “is a smart option if you need essential health benefits right now”; the Plan offers “the reassurance that comes with knowing that you can see a doctor when you need to, get lab tests, and more ...,” and “provides fixed cash benefits for covered services, including ... [l]ab tests — up to $ XXX per day,” presumably an amount specified in the actual letter sent to Whiting; and the Plan offers three levels of coverage, bronze, silver, and gold, and “plan limitations and exclusions, and additional details on available plan options” are found in the enclosed brochure.

The enclosed brochure included the following statements: The Plan “is not a major medical health plan, but is a good option if you need essential health benefits today at an affordable price. This plan provides valuable benefits that lower total out-of-pocket expenses on covered medical services, and also offers you some- coverage until you qualify for Medicare. You’ll get fixed cash benefits for a wide range of health care expenses — including doctor’s visits, lab tests, prescriptions, and much more”; and AARP members should apply if: (i) “you are without coverage,” (ii) “you need a ‘bridge’ until Medicare,” and (iii) “you need to lower your medical costs.” In addition, a full-page chart contained in the brochure stated that under the bronze, silver, and gold coverage levels, “Hospital Inpatient” benefits include a fixed daily payment. For Gold plan members, this amount is $1,500 per day. Under a subheading marked “Additional Benefits,” the chart stated that the Plan allots a per procedure maximum payment for “Lab/Pathology (Outpatient Only)” and “Radiology (Outpatient Only).” The chart also stated that a separate “Outpatient Hospital Benefit” is subject to an annual payment cap.

Whiting applied for the Plan and selected the gold coverage level. She was successfully enrolled and was issued the Certificate, which provided insureds thirty days “to examine your certificate” and “decide you do not want this coverage” for a full refund. The first page of the Certificate states, in pertinent part:

Benefits are payable as shown in the SCHEDULE OF BENEFITS for the following:

• HOSPITAL INPATIENT STAYS
• HOSPITAL OUTPATIENT SERVICES
• EMERGENCY ROOM/OUTPATIENT OBSERVATION CARE
• SURGERY
• RADIOLOGY SERVICES
• LABORATORY/PATHOLOGY SERVICES
• HEALTH CARE PRACTITIONER SERVICES
• POST-HOSPITAL CARE

In the “WHAT CERTAIN TERMS MEAN ” glossary to the Certificate, “Covered Service(s)” is defined to mean “[s]tays or services incurred while your coverage is in force,” within a standard of care, necessary for prevention or treat *359 ment of a medical condition, and certified by a physician. “Laboratory/Pathology Services” and “Radiology Services” are defined by reference to the Physicians’ Current Procedural Terminology.

The Certificate’s “WHAT IS COVERED ” section states that United will pay for “the following covered stays and services which are not otherwise excluded (see WHAT IS NOT COVERED).” It continues: “If you are confined in a Hospital as an inpatient, the Hospital Inpatient Stay Benefit is payable beginning on the second day of a covered Hospital Inpatient Stay,” as set forth in the Schedule of Benefits. The section further states that “[i]f you incur a charge for a covered outpatient service ... a Hospital Outpatient Benefit is payable” as set forth in the Schedule of Benefits. The section then lists a series of services — none of which were provided to Whiting — covered under the “Hospital Outpatient Benefit.” Separately, the section describes the radiology benefit as follows:

5) Radiology Benefit — If you incur a charge for a Radiology Service performed in an outpatient setting, a Radiology Benefit is payable, up to a maximum of $2,700.00 per procedure.

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Bluebook (online)
637 F.3d 355, 394 U.S. App. D.C. 421, 2011 U.S. App. LEXIS 4485, 2011 WL 781094, Counsel Stack Legal Research, https://law.counselstack.com/opinion/whiting-v-aarp-unitedhealthcare-insurance-cadc-2011.