Lydia Mallon v. Trover Solutions Inc

NOT PRECEDENTIAL
UNITED STATES COURT OF APPEALS
FOR THE THIRD CIRCUIT
_____________
No. 14-3189
_____________
LYDIA MALLON,
on behalf of herself and all others similarly situated,
Appellant
v.
TROVER SOLUTIONS INC., D/B/A HEALTHCARE RECOVERIES, INC.,
INDEPENDENCE BLUE CROSS; QCC INSURANCE COMPANY
_______________
On Appeal from the United States District Court
for the Eastern District of Pennsylvania
(District Court No. 2-11-cv-00326)
District Judge: Honorable R. Barclay Surrick
_______________
Submitted Pursuant to Third Circuit LAR 34.1(a)
January 23, 2015
Before: RENDELL, SMITH, and KRAUSE, Circuit Judges.
(Filed: May 19, 2015)
_______________
OPINION*
_______________
*
This disposition is not an opinion of the full Court and pursuant to I.O.P. 5.7
does not constitute binding precedent.
KRAUSE, Circuit Judge.
Appellant Lydia Mallon brought a putative class action contesting the Appellees’
subrogation rights under a health insurance plan and seeking declaratory and injunctive
relief pursuant to §§ 502(a)(1)(B) and 502(a)(3) of the Employee Retirement Income
Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1132(a)(1)(B), (a)(3). Mallon was injured
in a car accident and received tort damages from a third-party driver, after which
Appellees sought reimbursement of the benefits paid under the health insurance plan.
Although Mallon contested the Appellees’ subrogation rights under the plan, she
ultimately paid the reimbursement and brought this action. The District Court dismissed
the complaint for failure to exhaust administrative remedies. For the reasons set forth
below, we will affirm.1
A plaintiff is required to exhaust administrative remedies prior to bringing an
ERISA action to recover benefits under a plan. See Harrow v. Prudential Ins. Co. of Am.,
279 F.3d 244, 252 (3d Cir. 2002). However, exhaustion is not required for claims arising
from substantive statutory provisions of ERISA, such as claims for breach of fiduciary
duties in violation of §§ 404-406. See id. at 253; Zipf v. Am. Tel. & Tel. Co., 799 F.2d
889, 891-92 (3d Cir. 1986). Mallon argues that she was not required to exhaust
1
We have jurisdiction under 28 U.S.C § 1291. We exercise plenary review over a
district court’s decision to grant a motion to dismiss. Ballentine v. United States, 486
F.3d 806, 808 (3d Cir. 2007). We review de novo the legal standard a district court
applies to its exhaustion determination, but review for abuse of discretion a district
court’s decision whether exhaustion is required. See Cottillion v. United Ref. Co., 781
F.3d 47, 53 (3d Cir. 2015).
2
administrative remedies because she claims a breach of fiduciary duty, in violation of
§§ 404(a)(1)(A) and (D), rather than a denial of benefits due, in violation of § 502(a).
We have held that where “plaintiffs claim that their ERISA plan wrongfully sought
reimbursement of previously paid health benefits, the claim is for ‘benefits due.’” Levine
v. United Healthcare Corp., 402 F.3d 156, 163 (3d Cir. 2005); see also Wirth v. Aetna
U.S. Healthcare, 469 F.3d 305, 308-09 (3d Cir. 2006). Mallon’s argument that Wirth and
Levine are inapplicable because they addressed jurisdictional disputes rather than
exhaustion is unavailing in light of our clear and direct statement that a subrogation claim
is for benefits due. See Levine, 402 F.3d at 163.
Nor are we persuaded by Mallon’s argument that she alleged a breach of fiduciary
duty, rather than a claim for benefits due, because she also disputed the manner in which
the Appellees attempted to collect the reimbursement of the benefits paid. Mallon’s
claims rest on her allegations that the Appellees improperly sought reimbursement of
medical benefits paid under the terms of the plan. She “cannot circumvent the exhaustion
requirement by artfully pleading benefit claims as breach of fiduciary duty claims.”
Harrow, 279 F.3d at 253-54 (3d Cir. 2002) (holding that exhaustion is required when the
facts alleged do not present a breach of fiduciary duty claim independent of a benefits
claim).
Mallon next argues that, even if she were required to exhaust administrative
remedies, exhaustion was satisfied because Appellees failed to meet the notice
requirements for an adverse benefits determination. Under ERISA, plan administrators
must “provide adequate notice in writing to any participant or beneficiary whose claim
3
for benefits under the plan has been denied.” 29 U.S.C. § 1133(1). The notice should
set forth the specific reasons for the denial; the plan provisions on which the
determination is based; a description of any additional material or information necessary
for the claimant to perfect a claim and a description of why such material or information
is necessary; and a description of the plan’s review procedures and applicable time limits,
including a statement of the claimant’s right to bring civil action under § 502(a). 29
C.F.R. § 2560.503-1(g)(i) to (iv). The purpose of this notice requirement is to ensure that
participants understand and can challenge a benefits decision, and to provide participants
with the information necessary to perfect their claim. See Miller v. Am. Airlines, Inc.,
632 F.3d 837, 852 (3d Cir. 2011).
We agree with the District Court that the Appellees substantially complied with
the notice requirements. See Brogan v. Holland, 105 F.3d 158, 165-66 (4th Cir. 1997).
On October 11, 2007, the Appellees forwarded to Mallon’s counsel a letter explaining
that, under the benefits plan, the Appellees had a right to pursue subrogation as a self-
funded plan under ERISA. The Appellees also forwarded to counsel “The Personal
Choice Health Benefits Program,” setting forth both the Appellees’ subrogation rights
and the procedures and timeline for filing an administrative complaint and appeal.
Accordingly, the District Court did not abuse its discretion when it held that, in light of
all the communications between Mallon’s counsel and the Appellees, Mallon was
sufficiently aware of the reason for the adverse benefit determination and the steps
necessary to perfect her claim under the plan.
4
Finally, Mallon argues that exhaustion was satisfied because there were no
administrative remedies available to resolve subrogation disputes. Relying on a narrow
reading of the administrative procedures outlined in the benefits program, Mallon argues
that, because the description of administrative appeals gives as examples “contract
exclusions and non-covered benefits, exhausted benefits, and claims payment issues,”
subrogation issues cannot be addressed by the available administrative procedures. J.A.
at 211. However, administrative appeals under the benefits program cover “disputes or
objections regarding a Claims Administrator decision that concerns coverage terms.” Id.
Mallon’s objection to a decision regarding the terms of her coverage, i.e. that the benefits
she received are subject to a subrogation lien, could have been addressed by the available
administrative remedies. See Levine, 402 F.3d at 163 (claims arising from collections of
subrogation liens are benefits claims). Moreover, the benefits program outlines a
complaint procedure by which plan participants can lodge any complaint with the Claims
Administrator. The District Court, therefore, did not abuse its discretion when it held that
Mallon was required to exhaust available administrative remedies before filing suit.
Accordingly, we will affirm.
5