DocketNumber: Docket 16-3526; August Term 2017
Judges: Hall, Pooler, Wesley
Filed Date: 4/12/2018
Status: Precedential
Modified Date: 10/19/2024
Group insurance policies, unlike individual insurance policies, are contracts for the benefit of third parties. Under a group insurance program, a central entity-the group-enters into a contract with an insurance provider and acts as the policyholder. Members of the group are the third-party beneficiaries of that contract. Typically, state law defines what entities may issue group insurance policies, and group members are almost always employees of a company or members of an organization formed for purposes other than obtaining insurance coverage. See, e.g.,
Group insurance is desirable to insurers because the larger pool of insureds reduces the insurer's risk and eliminates administrative costs. In theory, group members also benefit from enrollment in group policies for two primary reasons. First, insurers pass on the lower cost of insurance to insureds in the form of reduced premiums. Second, insureds do not need to negotiate with insurers or shop around for the best insurance policy because the group, as the policyholder, presumptively serves that role. See id .
In addition to limiting what entities may issue group policies, New York requires an eligible group to obtain approval from a regulatory agency before offering group insurance. See
BACKGROUND
I. The HealthExtras Program
In 1997, HealthExtras, Inc., created a group insurance program that offered $1,000,000 or $1,500,000 accidental permanent and total disability coverage, plus *570$2500 emergency accident and sickness medical expense coverage ("HealthExtras Program"). HealthExtras advertised and sold policies to consumers through marketing agreements with banks and companies that issued credit cards, including American Express, Citibank, Capital One, J.C. Penney, Sears, and Conoco Phillips. The banks and credit card companies solicited cardholders to enroll in the HealthExtras Program by sending flyers with their customers' monthly credit card bills, by direct mail, or by telephone. The flyers included images of the late actor Christopher Reeve, statements by Mr. Reeve endorsing the HealthExtras Program, and brief descriptions of the HealthExtras policies.
If a cardholder expressed interest in the HealthExtras Program, the marketing agent mailed them a program description encouraging them to enroll and reminding them that HealthExtras "was created to provide families with financial security" because sometimes "lives change in an instant, like Christopher Reeve's." Joint App. A-38. Cardholders who chose to enroll did so by agreeing to a monthly charge on their credit card bill. Because HealthExtras is not a licensed insurer or broker, however, it contracted with defendants Stonebridge, TransAmerica, and Federal to underwrite and issue the disability insurance.
Defendants issued the policies to HealthExtras, the policyholder, as group and blanket accident disability and medical expense insurance, and the enrolled card holders became group members. The policies, however, narrowly circumscribed the kinds of injury or illness under which policy holders could recover.
II. The Complaint and Motion to Dismiss
Plaintiffs commenced the present class action in the United States District Court for the Southern District of New York (Gardephe, J. ) in March 2015. Although the members of plaintiffs' putative class did not suffer qualifying losses or make claims for coverage under their policies, plaintiffs argue that they are entitled to reimbursement of the premiums and fees they paid defendants, as well as enhanced damages. Their complaint alleges quasi-contract claims based on violations of New York Insurance Law, claims based on violations of New York consumer protection laws, and common-law fraud claims.
First , plaintiffs allege that defendants sold them insurance coverage that was void ab initio because the policies (1) "were not issued to eligible entities" as that term is defined in New York Insurance Law §§ 4235 and 4237 ; (2) "were not filed with and approved by the Superintendent of New York's Department of Insurance, violating
Alternatively, plaintiffs allege that even if their coverage was not void ab initio , it was voidable for illegality. Plaintiffs argue New York Insurance Law is intended to protect them from illegal insurance contracts and that defendants were enriched at their expense when they failed to comply with the law. For their quasi-contract claims, plaintiffs seek reimbursement of fees and premiums they paid to defendants.
Second , plaintiffs allege violations of New York General Business Law §§ 349 and 350, which prohibit unfair or deceptive trade practices and false advertising, respectively. Specifically, the complaint alleges that defendants sent marketing materials discussing the "nature and benefits of the HealthExtras Program" and written certificates of insurance that "falsely[ ] represented that the Policies ... were legal under New York law" and "provided real and valuable insurance coverage." Joint App. A-87, A-92. Plaintiffs also allege that defendants failed to disclose certain material facts and thereby misrepresented the nature of the insurance coverage they sold to plaintiffs.
Third , plaintiffs allege that defendants committed common-law fraud, fraud in the inducement, or aiding and abetting fraud. The complaint alleges that defendants knew statements in their marketing materials *572were false because defendants in general are charged with knowing the terms of New York Insurance Law and these defendants knew that the subject policies did not comply. See Pasternack v. Lab. Corp. of Am. Holdings ,
Defendants filed a joint motion to dismiss pursuant to Federal Rules of Civil Procedure 9(b), 12(b)(1), and 12(b)(6). They argued the District Court lacked subject-matter jurisdiction over plaintiffs' action because plaintiffs could not demonstrate an injury in fact as required for Article III standing. Specifically, defendants' position is that New York's savings statute,
The District Court granted defendants' motion to dismiss for lack of standing; it did not reach any other grounds for dismissal.
DISCUSSION
We review de novo the District Court's decision to dismiss plaintiffs' complaint for lack of standing pursuant to Federal Rule of Civil Procedure 12(b)(1), "construing the complaint in plaintiff[s'] favor and accepting as true all material factual allegations contained therein." Crupar-Weinmann , 861 F.3d at 79 (internal quotation marks omitted). "Where, as here, a case is at the pleading stage, the plaintiff[s] must clearly allege facts demonstrating each element [of standing]." Spokeo, Inc. v. Robins , --- U.S. ----,
"Standing to sue is a doctrine rooted in the traditional understanding of a case or controversy. The doctrine developed in our case law to ensure that federal courts do not exceed their authority as it has been traditionally understood."
The injury-in-fact requirement "helps to ensure that the plaintiff has a 'personal stake in the outcome of the controversy.' " Susan B. Anthony List v. Driehaus , --- U.S. ----,
To establish injury in fact, a plaintiff need only show that he or she suffered an invasion of a legally protected interest that is concrete and particularized. Spokeo ,
Plaintiffs have standing. First, with respect to their quasi-contract claims, they argue they paid premiums for disability and medical expense insurance policies that are illegal under New York law and are therefore void ab initio or, in the alternative, voidable. Accepting plaintiffs' allegations as true and assuming they would be successful on the merits-as we must for purposes of our threshold jurisdictional analysis, Crupar-Weinmann , 861 F.3d at 79 -they have articulated a concrete, economic injury: payment of premiums on a void or voidable insurance policy.
According to defendants, plaintiffs lack standing to assert their quasi-contract claims because application of the savings statute would provide, in essence, an affirmative defense by requiring the insurers to honor the allegedly illegal policies had plaintiffs filed claims; in other words, plaintiffs were not injured because their claims are meritless. That argument, however, asks us to do what we cannot: decide the merits of the claim en route to determining its justiciability. See Mashantucket Pequot Tribe ,
*575Plaintiffs have met that burden by alleging harm in the form of premium payments on illegal policies, and they have standing to pursue their quasi-contract claims irrespective of the fact that defendants propose a reading of a statute that would, if accepted, undermine the merits of plaintiffs' claims. See
Second, plaintiffs have standing to pursue their statutory and common-law fraud claims. Both categories of claims allege that defendants misrepresented the nature of the HealthExtras policies by failing to disclose that they were not issued in compliance with New York law and in so doing, induced plaintiffs to purchase the policies at an inflated price.
The District Court's resolution of this case is problematic for an additional reason. The New York statute upon which the defendant-insurers rely, § 3103(a), has never been interpreted by a New York state court or the New York Court of Appeals as precluding an insured from bringing a claim against an insurer for a refund of premiums paid for an illegal policy.
Without commenting on the merits of plaintiffs' arguments, we note that the statute appears to have been enacted with the purpose of protecting insureds, not insurance companies. See, e.g., Bersani v. Gen. Acc. Fire & Life Assur. Corp.,
The Eighth Circuit reached a similar conclusion in another case involving HealthExtras and a class of plaintiffs that had not suffered qualifying losses or made claims for coverage under the policies. See Graham v. Catamaran Health Sols. LLC , 16-1161,
On appeal, the Eighth Circuit rejected that argument and held that the named plaintiff had standing to pursue two classes of claims. First, as to the theory that the HealthExtras policies were void ab initio , the court noted that the defendants' argument depended on the merits of the underlying claim. Id. at *4. Ignoring the defendants' statutory argument and looking instead to the plaintiff's allegations, the court concluded that "if the policy is deemed void ab initio due to non-compliance with state law," the plaintiff would have suffered an injury in fact. Id. Second, as to allegations of injury even if the policies were not void, the Eighth Circuit held that the plaintiff had standing because his claims sought "a refund of all or at least some portion of premiums paid." Id.
We agree with the Eighth Circuit's reasoning. "Standing analysis does not permit consideration of the actual merits of a plaintiff's claim." Id. Whether the policies were void ab initio , whether the savings statute rendered them valid, and whether plaintiffs overpaid for the policies are questions that "go[ ] to the merits, not the threshold standing analysis." Id. Plaintiffs have alleged concrete and particularized harms for all of their claims, and for the purposes of Article III, they have therefore *577alleged sufficient facts to establish the elements of standing.
CONCLUSION
The District Court erred when it dismissed plaintiffs' claims for lack of standing. For the foregoing reasons, the opinion and order of the District Court granting defendants' motion to dismiss for lack of standing is VACATED and the case is REMANDED for further proceedings.
For example, one of the solicitations read:
Financial Security. You're covered with $1.5 Million if an accident leaves you permanently disabled.... The American Express Accidental Disability Plan provides you with $1.5 million in one lump sum if you are permanently disabled as the result of an accident and can't return to work. For only $9.95 a month, you can help guarantee your financial security now and in the future.... With the American Express Accidental Disability Plan you can prevent a personal tragedy from becoming a financial tragedy. Enroll now, and for only $9.95 a month, you can rest assured that you are protected.
Joint App. A-161.
On January 25, 2018, this Court received notice from plaintiffs' counsel indicating that they had reached a settlement agreement with defendant-appellant Federal and that the parties "intend to seek the dismissal of this appeal as to Federal pursuant to Federal Rule of Appellate Procedure 42(b)." Dkt. No. 155. However, this Court has not received a dismissal agreement as required by F.R.A.P. 42(b) and until such an agreement is docketed and a dismissal order entered, Federal will remain a party to the appeal. Additionally, HealthExtras contracted with National Union and Virginia Surety to underwrite disability and medical expenses insurance, respectively, but those entities entered into a global settlement with plaintiffs and are not parties to this appeal. Plaintiffs have also either settled with or withdrawn their claims against HealthExtras (now known as Catamaran Health Solutions, LLC), Virginia Surety Company, and American International GroupAIG.
For example, the disability policies defined "Loss" as "total and permanent Loss of Use" of "both hands or both feet" or "one hand and one foot," "total and permanent Loss of sight in both eyes," "total and permanent Loss of speech," or "total and permanent Loss of hearing in both ears." Joint App. A-64. "Loss of Use," in turn, was restricted to "actual severance through or above a wrist or ankle or total paralysis of a limb or limbs which is determined by a competent medical authority to be permanent, complete and irreversible." Id.
For example, plaintiffs claim that defendants failed to disclose that they participated in a program in which unsuspecting credit card holders and others were targeted for what appeared to be beneficial low-cost group insurance policies, but what were in fact illegal and valueless policies. Joint App. A-88, A-89. Ultimately, therefore, plaintiffs' statutory claims are also dependent on a determination that the underlying policies were in fact in violation of New York law.
The savings statute provides:
[A]ny policy of insurance or contract of annuity delivered or issued for delivery in this state in violation of any of the provisions of this [New York Insurance Law] chapter shall be valid and binding upon the insurer issuing the same, but in all respects in which its provisions are in violation of the requirements or prohibitions of this chapter it shall be enforceable as if it conformed with such requirements or prohibitions.
...
In any action to recover under the provisions of any policy of insurance or contract of annuity delivered or issued for delivery in this state which the superintendent is authorized by this chapter to approve if in his opinion its provisions are more favorable to policyholders, the court shall enforce such policy or contract as if its provisions were the same as those specified in this chapter unless the court finds that its actual provisions were more favorable to policyholders at the date when the policy or contract was issued.
In their motion to dismiss, defendants also argued that plaintiffs did not plead fraud with sufficient particularity under Federal Rule of Civil Procedure Rule 9(b), that they failed to state a claim upon which relief could be granted under Federal Rule of Civil Procedure Rule 12(b)(6), and that all of their claims are time-barred.
Reading the complaint in the light most favorable to plaintiffs, Crupar-Weinmann v. Paris Baguette Am., Inc. ,
The court treated plaintiffs' claims for deceptive acts and false advertising as alleging plaintiffs were harmed because they would have had to sue before defendants would cover a qualifying injury. These allegations, the court concluded, were conclusory and conjectural because plaintiffs never suffered qualifying injuries or filed claims that defendants might have rejected. Gonzales , 15-2259,
Because the District Court dismissed the case before extensive discovery, the full amount of the class-wide award plaintiffs are pursuing is not clear. However, counsel for plaintiffs estimated at oral argument that in New York State, members of the putative class had paid between $10,000,000 and $20,000,000 in premiums on their HealthExtras policies. See Oral Argument at 20:14, Gonzales v. Nat'l Union Fire Ins. Co. , 16-3526 (2d Cir. Nov. 14, 2017), http://www.ca2.uscourts.gov/decisions/isysquery/75bf6584-4fbc-4c8b-9668-29d46d963694/91-100/list/.
For example, in Carver , a recipient of public benefits won $10,000 in the New York State lottery.
Specifically, the pleadings allege that defendants knew or should have known that the HealthExtras policies (1) were not issued to eligible entities under New York Insurance Law §§ 4235 and 4237, (2) were never approved by the Superintendent of New York's Department of Insurance, in violation of New York Insurance Law § 3201(b)(1), and (3) lacked provisions required by New York Insurance Law § 3221(a). Joint App. A-83. Defendants did not disclose these alleged deficiencies in their marketing materials, and plaintiffs therefore argue that they purchased illegal coverage that no reasonable person with full knowledge of the nature of the coverage would have selected. See
We mean no criticism of a very able District Court judge. He does not have the power to ask a New York court its views on the statute or its application to claims like plaintiffs'. See
The statute is written in terms of "enforcing" the illegal terms of a policy. See, e.g. ,