United States District Court, D. Massachusetts
BRENT S. and ANGIE S., individually and as representatives of the class of similarly situated individuals, Plaintiffs,
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC., Defendant.
MEMORANDUM AND ORDER ON DEFENDANT'S MOTION TO
ALLISON D. BURROUGHS U.S. DISTRICT JUDGE
Brent S. and Angie S., individually and as class
representatives, (collectively, “Plaintiffs”)
bring this action against Defendant Blue Cross Blue Shield of
Massachusetts, Inc. (“Defendant”) to challenge
Defendant's denial of claims for residential treatment of
mental health disorders in adolescents where part of the
treatment services involved an educational component. [ECF
No. 41 (“Amended Complaint” or “Am.
Compl.”) ¶ 1]. The Amended Complaint brings two
claims under the Employee Retirement Income Security Act of
1974 (“ERISA”): a claim for benefits under 29
U.S.C. § 1132(a)(1)(B) and equitable relief pursuant to
29 U.S.C. § 1132(a)(3). [Id. ¶¶
53-58]. Pending before the Court is Defendant's motion to
dismiss pursuant to Federal Rule of Civil Procedure 12(b)(6).
[ECF No. 60]. For the following reasons, Defendant's
motion to dismiss [ECF No. 60] is DENIED.
following facts are drawn from the Complaint, the
well-pleaded allegations of which are taken as true for the
purposes of evaluating the motion to dismiss. See Ruivo
v. Wells Fargo Bank, N.A., 766 F.3d 87, 90 (1st
Cir. 2014). Defendant maintains that their policies exclude
mental health residential treatment services that have an
educational component based on the following language (the
Some examples of services and programs that are not covered
by this health plan are: services that are performed in
educational . . . settings[.] . . . These types of noncovered
programs may be in residential or nonresidential settings.
They may include therapeutic elements and/or clinical staff
services as well as vocational, educational, problem solving,
and/or recreational activities. These programs may have
educational accreditation. The staff may include some
licensed mental health providers who may provide some
therapy. No. benefits are provided for any services furnished
along with one of these non-covered programs. For example, no
benefits are provided for therapy and/or psychotherapy
furnished along with one of these non-covered programs.
[Am. Compl. ¶ 18]. The policies also contain the
following exception: “No benefits are provided for
exams, evaluations, or services that are performed solely for
educational or developmental purposes. The only exceptions
are for . . . treatment of mental conditions for enrolled
dependents who are under age 19[.]” [Id.
son, Jake, suffered from mental illness and substance abuse
and began receiving treatment for his mental health
conditions at Ashcreek Ranch Academy (“Ashcreek
Ranch”) when he was 17 years old. [Id.
¶¶ 24-32]. Ashcreek Ranch is a licensed residential
treatment program in Washington County, Utah. [Id.
¶ 24]. Defendant denied coverage for Jake's
treatment at Ashcreek Ranch because it was “a
residential treatment [sic] and boarding school” and
thus “not a covered type of provider” under
Plaintiffs' plan. [Id. ¶ 37]. Plaintiffs
exhausted their ERISA pre-litigation appeal options and paid
out of pocket for Jake's treatment. [Id. ¶
38]. Plaintiffs allege that, on information and belief, more
than 100 insured adolescents covered by Defendant's
policies have had similar claims improperly denied.
[Id. ¶ 42].
STANDARD OF REVIEW
evaluate a Rule 12(b)(6) motion to dismiss for failure to
state a claim, the Court must accept as true all well-pleaded
facts, analyze those facts in the light most hospitable to
the plaintiff's theory, and draw all reasonable
inferences from those facts in favor of the plaintiff.
U.S. ex rel. Hutcheson v. Blackstone Med., Inc., 647
F.3d 377, 383 (1st Cir. 2011). To avoid dismissal, a
complaint must set forth “factual allegations, either
direct or inferential, respecting each material element
necessary to sustain recovery under some actionable legal
theory.” Gagliardi v. Sullivan, 513 F.3d 301,
305 (1st Cir. 2008) (citation omitted). The plaintiff's
obligation to articulate the basis of her claims
“requires more than labels and conclusions.”
Bell Atlantic Corp. v. Twombly, 550 U.S. 544, 555
(2007). The facts alleged, when taken together, must be
sufficient to “state a claim to relief that is
plausible on its face.” A.G. ex rel. Maddox v.
Elsevier, Inc., 732 F.3d 77, 80 (1st Cir. 2013) (quoting
Twombly, 550 U.S. at 570). “A claim has facial
plausibility when the plaintiff pleads factual content that
allows the court to draw the reasonable inference that the
defendant is liable for the misconduct alleged.”
Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009)
Count One: Claim for Benefits under 29 U.S.C. §
One asserts a claim for benefits under 29 U.S.C. §
1132(a)(1)(B) and alleges that Defendant's denial of
coverage for Jake's mental health care at Ashcreek Ranch
violates the terms of Plaintiffs' ERISA-governed
insurance policy. [Am. Compl. ¶¶ 53-56]. Defendant
contends that Count One should be dismissed because (i)
Plaintiffs do not allege that the room and board charges from
Ashcreek Ranch qualify for coverage under the plan; (ii)
Plaintiffs fail to allege a violation of ERISA based on the
denial of benefits because, even in the absence of the
Recreational Exclusion, services at Ashcreek Ranch would not
have been covered by the plan; and, (iii) Plaintiffs have not
sufficiently alleged a breach of fiduciary duty. [ECF No. 61
at 7]. Plaintiffs respond that each of these arguments
“is more appropriately raised in a motion for summary
judgment under the standards as implemented for ERISA welfare
benefits litigation in this Circuit” because
“[w]ithout an agreed upon record for the Court to act,
dismissal is premature.” [ECF No. 67 at 3, 7].
Defendant argues in reply that motions to dismiss “are
appropriate, and are often granted, in ERISA welfare-benefit
cases” and that an ERISA case does not need to reach
summary judgment when a plaintiff “fail[s] to state a
plausible claim at the pleading stage.” [ECF No. 70 at
correctly asserts that ERISA welfare-benefit cases are not
outside the scope of Rule 12(b)(6). See
[id.]; Fed.R.Civ.P. 12(b)(6). The instant case,
however, is not analogous to scenarios in which Rule 12(b)(6)
motions have been granted in ERISA welfare-benefit cases in
this district. See, e.g., Brenner v. Metro. Life
Ins. Co., No. 11-cv-12096-GAO, 2013 WL 1337367, at *2
(D. Mass. Mar. 29, 2013) (overruling objection to
recommendation to dismiss claim under § 1132(a)(1)(B)
because dismissal was proper where claim sought
“extra-contractual relief that is unavailable”
under the statute); Thiffault v. Butler Home Prod.,
Inc., No. 05-cv-40011-FDS, 2006 WL 240189, at *2 (D.
Mass. Jan. 5, 2006) (granting employer's motion to
dismiss § 1132(a)(1)(B) claim because complaint did not
allege that employer administered the ERISA plan);
Andrews-Clarke v. Lucent Techs., Inc., 157 F.Supp.2d
93, 99-103 (D. Mass. 2001) (dismissing complaint alleging
ERISA claims on the basis of res judicata).
has also provided the Court with supplemental authorities,
including a recent similar case from this district,
Cotten v. Blue Cross & Blue Shield of Massachusetts
HMO Blue, Inc., No. 16-cv-12176-RGS, 2018 WL 6416813 (D.
Mass. Dec. 6, 2018). [ECF Nos. 71, 71-1]. The lawsuit in
Cotten, brought by parents who enrolled their
children in “wilderness therapy programs” to
address substance abuse and mental health issues and were
denied insurance coverage for these programs, concerned the
same Recreational Exclusion as is at issue here. See
Cotten, 2018 WL 6416813, at *1; see also [ECF
No. 71 at 1]. The plaintiffs in Cotten argued that
the wilderness programs were improperly excluded from
coverage because they were not “custodial care.”
Cotten, 2018 WL 6416813, at *2. Judge Stearns
disagreed and dismissed the claim under § 1132(a)(1)(B).
Id. He ...