Jeremiah Redstone, M.D., as an authorized representative and attorney-in-fact of his patient D.R., and Wayne Lee, M.D., as an authorized representative and attorney-in-fact of his patient C.F., on behalf of themselves and on behalf of all others similarly situated v. Aetna, Inc. and Aetna Life Insurance Company

Summary

The United States District Court for the District of New Jersey denied Aetna’s motion to dismiss an amended putative class action complaint involving reimbursement for out-of-network breast reconstruction services under Aetna’s National Advantage Program. The court held that the plaintiffs adequately alleged an entitlement to benefits under ERISA § 502(a)(1)(B) based on mandatory plan-summary language concerning payment of a pre-negotiated rate. The court also allowed the plaintiffs’ claims for injunctive and other equitable relief under ERISA § 502(a)(3) to proceed.

Holdings

1. The amended complaint plausibly stated a claim under ERISA § 502(a)(1)(B) because the mandatory NAP language in the plan summaries permitted an inference that plaintiffs had a legally enforceable right to payment at the applicable pre-negotiated rates and that Aetna improperly failed to pay those rates.
2. The § 502(a)(3)(A) claim for injunctive relief and the § 502(a)(3)(B) claim for appropriate equitable relief survived the motion to dismiss.
3. The court could not consider Aetna's declaration because it was extraneous to and not relied on in the amended complaint; the Multiplan Agreement did not warrant dismissal even assuming it could be considered.

Questions Presented

1. Whether the amended complaint plausibly alleged an enforceable entitlement to benefits under ERISA § 502(a)(1)(B) based on the plan summaries' NAP provisions.
2. Whether the claims for injunctive and other equitable relief under ERISA § 502(a)(3) should be dismissed as duplicative or because the § 502(a)(1)(B) claim failed.
3. Whether the court could consider the Multiplan Agreement and a declaration submitted by Aetna in connection with the motion to dismiss.

Disposition

other