United States District Court, M.D. Florida, Fort Myers Division
MIRANDO, UNITED STATES MAGISTRATE JUDGE.
matter comes before the Court upon review of Defendant United
Healthcare of Florida Inc.'s (“United”)
Motion to Dismiss Count II of Plaintiff's Complaint and
Incorporated Memorandum of Law (“Motion to
Dismiss”). Doc. 11. Plaintiff filed a response in
opposition. Doc. 14. The Court, having reviewed
Defendant's motion and the relevant pleadings, finds that
Defendant's motion is due to be denied.
an action for recovery of benefits (Count I) and
administrative penalties (Count II) under the Employment
Retirement Income Security Act of 1974 (“ERISA”),
29 U.S.C. §§ 1000-1461, alleging United improperly
denied Plaintiff's claim for health insurance benefits.
According to the Complaint and exhibits thereto,
Plaintiff, Mark Atherley, was an employee of Southwest
Florida Maritime, Inc. (“SWFM”) during the
relevant time period. Doc. 1 ¶ 7. Plaintiff was covered
by a health insurance plan offered by SWFM and administered
by United. Id. While insured under his
employer's plan, Plaintiff required a liver transplant.
Id. at ¶ 8. United authorized the procedure and
referred Plaintiff to Tampa General Hospital for treatment.
In March 2015, however, the hospital told Plaintiff that he
would not be a part of their transplant program, but he could
try again in six months. Id. Plaintiff was expected
to live only four months without the necessary liver
United's patient advocate, Plaintiff requested that
United find an alternative in-network provider. Id.
at ¶ 9. The advocate suggested a hospital in Orlando,
but the Orlando hospital failed to communicate with Plaintiff
for about one month. Id. After Plaintiff's
failed attempts to reach either the provider in Orlando or
his United advocate, Plaintiff set out on his own to find a
transplant provider. Id. Plaintiff located the
Cleveland Clinic in Weston, Florida. Id.
Plaintiff alleges the Cleveland Clinic is now a part of
United's network, at the time of Plaintiff's
procedure apparently it was not. Id. at 4, n.3.;
see also Id. ¶ 10. Cleveland Clinic billed
United for the procedure, and while United made some partial
payments, it refused to cover approximately $290, 000 of the
cost of Plaintiff's transplant, so Plaintiff paid for the
transplant himself. Id. ¶ 11; see also
Id. at 5 n.5. United then refused to indemnify Plaintiff
for his out-of-pocket costs. Id. ¶ 11.
Plaintiff tried to obtain documentation and information
regarding Plaintiff's plan and the disputed procedure,
but United either refused to provide the documentation, or
belatedly provided only partial documentation. Id.
¶ 18. After attempts at pre-suit resolution also failed,
Plaintiff initiated this action. Id. ¶ 19.
Rule 8(a)(2), Federal Rules of Civil Procedure, a complaint
must contain a “short and plain statement of the claim
showing that the pleader is entitled to relief.”
Fed.R.Civ.P. 8(a)(2). This obligation requires “more
than labels and conclusions, and formulaic recitation”
of facts to survive a 12(b)(6) motion to dismiss. Bell
Atlantic Corp. v. Twombly, 550 U.S. 544, 555 (2007).
“[The] factual allegations must be
“plausible” and “enough to raise a right to
relief above the speculative level.” Id. When
evaluating a motion to dismiss, the Court accepts as true all
factual allegations set forth in the complaint and the
attached exhibits. Griffin Industries, Inc. v.
Irvin, 496 F.3d 1189, 1199 (11th Cir. 2007). “A
copy of a written instrument that is an exhibit to a pleading
is part of the pleading for all purposes.” Fed.R.Civ.P.
10(c). “[T]he Court may dismiss a complaint pursuant to
Federal Rule of Civil Procedure 12(b)(6) when, on the basis
of a dispositive issue of law, no construction of the factual
allegations will support the cause of action.”
Marshall Cnty. Bd. Of. Educ. V. Marshall Cnty. Gas
Dist., 992 F.2d 1171, 1174 (11th Cir. 1993) (citing
Executive 100, Inc. v. Martin Cnty., 992 F.2d 1536,
1539 (11th Cir. 1991)).
argues that Count II fails to state a claim on which relief
can be granted because: (1) United is a claims administrator
of the plan rather than a plan administrator under ERISA;
and, (2) the documents requested by Plaintiff are not subject
to statutory penalties.
Whether United Healthcare is a claims administrator of the
plan rather than a plan administrator under ERISA.
II of Plaintiff's Complaint is a claim for administrative
penalties under 29 U.S.C. § 1132(c)(1) and 29 C.F.R.
§ 2575.502c-1. Collectively, these statutes give a plan
administrator thirty days to respond to a request for
information from a plan beneficiary or participant, and
provide for a penalty of $110.00 per day for each day beyond
the thirty days in which the plan administrator does not
respond to the request. See 29 U.S.C. §
1132(c)(1); 29 C.F.R. § 2575.502c-1. Only requests for
certain specified documents are included under 29 U.S.C.
§ 1132(c)(1) and 29 C.F.R. § 2575.502c-1, and only
plan administrators are subject to the administrative
penalties found in these statutes. See Id. Defendant
argues that it is not a plan administrator as defined by
these statutes and, as such, Plaintiff has failed to state a
claim on which relief can be granted.
correctly asserts that in order to be subject to
administrative penalties under ERISA, Defendant must be an
“administrator.” Doc. 11 at 2; 29 U.S.C. §
1132(c)(1). An “administrator” under ERISA is
“the person specifically so designated by the terms of
the instrument under which the plan is operated, ” or
in the absence of such a designated person, the plan sponsor.
29 U.S.C. § 1002 (16)(A)(i-ii). The Eleventh Circuit has
distinguished an “administrator” under ERISA,
commonly referred to as a plan administrator, from a
“claims administrator, ” a third-party service
provider engaged to provide administrative services on behalf
of the plan sponsor. Smiley v. Hartford Life and Acc.
Ins. Co., 610 F. App'x 8 (11th Cir. 2015).
Hamilton v. Allen-Bradley Co., Inc., the Eleventh
Circuit recognized that although ERISA contemplates the plan
document may name a plan administrator, the plan document is
not necessarily dispositive; and it may be necessary to
consider “the factual circumstances surrounding the
administration of the plan, even if these factual
circumstances contradict the designation in the plan
document.” 244 F.3d 819, 824 (11th Cir. 2001). This is
commonly referred to as the de facto plan
administrator doctrine. The de facto plan
administrator doctrine has been employed in cases where an
employer establishes an ERISA plan and then engages a
third-party service provider to administer claims, while
retaining at least partial control over the claims
administration process. See, e.g.,
Hamilton, 244 F.3d at 824 (finding that an employer
retained sufficient control to be considered a plan
administrator where it required employees to obtain
applications for disability from its human resources
department); see also Rosen v. TRW, Inc., 979 F.2d
191, 193-94 (11th Cir. 1992) (holding that an employer can be
liable for ERISA violations if it is administering the plan,
even where not designated as the plan administrator in the
plan document). Where, however, a plaintiff has attempted to
use the doctrine to shift responsibility under ERISA to a
third-party service provider who was not specifically
designated as the plan administrator, the Eleventh Circuit
generally has rejected the argument. See, e.g, Oliver v.
Coca Cola Co., 497 F.3d 1181, 1193-94 (11th Cir. 2007)
reh'g granted, opinion vacated in part on other
grounds, 506 F.3d 1316 (11th Cir. 2007) and adhered
to in part on reh'g, 546 F.3d 1353 (11th Cir. 2008).
common thread in cases concerning the de facto plan
administrator doctrine is that the Court must engage in a
factual analysis before reaching a conclusion as to who may
properly be considered the plan administrator. Indeed, the
core holding of Hamilton is that in certain
circumstances it may be necessary for a court to consider the
specific facts of the case rather than granting deference to
the designations in the plan document. See 244 F.3d
at 824. At the motion to dismiss stage, however, the Court is
required to accept Plaintiff's factual ...