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Fritzky v. Aetna Health

September 2, 2009

RE: RICHARD FRITZKY
v.
AETNA HEALTH, INC., ET AL



The opinion of the court was delivered by: William J. Martini Judge

MARTIN LUTHER KING JR. FEDERAL BLDG. & U.S. COURT HOUSE 50 WALNUT STREET, P.O. BOX 419 NEWARK, NJ 07101-0419 (973) 645-6340

LETTER OPINION

Dear Litigants:

This matter comes before the Court on a Motion to Dismiss brought by Defendants Aetna Health, Inc. ("Aetna") and Dr. Ira Klein, M.D. ("Klein") pursuant to Rule 12(b)(6) of the Federal Rules of Civil Procedure. Fed. R. Civ. P. 12(b)(6). Specifically, Defendants argue that Plaintiff's complaint fails to state a claim for which relief can be granted, because all of Plaintiff's claims are preempted by the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§ 1001 et seq. ("ERISA"). Oral argument was held on August 26, 2009. For the reasons stated below, Defendant's Motion to Dismiss is GRANTED without prejudice.

BACKGROUND

In March 2005, Plaintiff was employed as the Chief Executive Officer of the Meadowlands Regional Chamber of Commerce ("MRCC"). (Pl.'s Cmplt.¶ 1). At that time, the MRCC entered into a Small Group Health Maintenance Organization Point of Service Contract (the "Plan" or the "Contract") with Defendant Aetna. (Pl.'s Cmplt.¶ 2). Pursuant to the Plan, Aetna was obligated to provide services and pay benefits to Plaintiff as part of Plaintiff's employment relationship with MRCC. (Pl.'s Cmplt.¶ 3). However, the Plan's coverage was limited to benefits that Aetna determined to be "medically necessary and appropriate."*fn1 Plaintiff was covered by the Plan at all times relevant to this action. The Plan meets the statutory definition of an "employee welfare benefit plan" under ERISA. 29 U.S.C. § 1002(1).

Beginning in October 2005, Plaintiff was diagnosed with a series of medical conditions including sepsis secondary to disseminated meningococcemia. (Pl.'s Cmplt.¶ 6). During his hospitalization, Plaintiff suffered from multiple "collateral conditions" that required the amputation of several fingers and toes and one leg. (Id.). Later that same month, Plaintiff was transferred to a different hospital and then to various rehabilitative care facilities. (Pl.'s Cmplt.¶ 7). He was re-admitted to the hospital on June 12, 2006. (Pl.'s Cmplt.¶ 8). Upon his discharge in late June 2006, Plaintiff's treating physician recommended acute rehabilitation. (Pl.'s Cmplt.¶ 10). However, through its medical designee Dr. Ira Klein ("Klein"), Aetna determined that acute rehabilitation was not medically necessary and denied the request for coverage. (Pl.'s Cmplt.¶ 13). Instead, Aetna approved coverage for subacute rehabilitative care. (Pl.'s Cmplt.¶ 11). Plaintiff alleges that Klein's determination that Plaintiff would not benefit from acute care amounted to a wrongful denial of benefits for medically recommended treatment. (Pl.'s Cmplt.¶ 19).

Plaintiff began receiving the subacute care on June 29, 2006. (Pl.'s Cmplt.¶ 12). Approximately seven weeks after the initial determination, Aetna reversed its decision and found that Plaintiff was entitled to acute care. (Pl.'s Cmplt.¶ 16). Plaintiff's condition deteriorated, and on August 24, 2006, he was readmitted to the hospital to undergo amputation of his remaining leg.*fn2 (Pl.'s Cmplt.¶ 15). Plaintiff alleges that the amputation was rendered necessary as a result of Defendants' wrongful failure to grant him acute rehabilitative care in June 2006. (Pl.'s Cmplt.¶ 23).

Plaintiff initially filed his Complaint in New Jersey state court on October 9, 2008. The Complaint contains seven counts: (1) breach of contract; (2) breach of the covenant of good faith and fair dealing with respect to the contracts made with MRCC and its employees; (3) breach of fiduciary duties owed to Plaintiff; (4) wrongful preclusion from the pursuit of day to day affairs and wrongful failure to provide documentation;*fn3 (5) unjust enrichment; (6) breach of the covenant of good faith and fair dealing; and (7) tortious interference with medical care. Plaintiff also requested compensatory, consequential, and exemplary damages, punitive damages, damages for pain and suffering, costs, and a jury trial.

On November 18, 2008, Defendants removed the action to this Court, based upon federal question jurisdiction arising out of ERISA. Presently before the Court is Defendants' motion to dismiss the complaint for failure to state a claim for which relief can be granted, pursuant to Fed. R. Civ. P. 12(b)(6), on the grounds that Plaintiff's claims are completely preempted under ERISA § 502(a), 29 U.S.C. § 1132(a).

ANALYSIS

I. Standard of Review

In deciding a motion to dismiss under Fed. R. Civ. P. 12(b)(6), all allegations in the complaint must be taken as true and viewed in the light most favorable to the plaintiff. See Warth v. Seldin, 422 U.S. 490, 501 (1975); Trump Hotels & Casino Resorts, Inc. v. Mirage Resorts Inc., 140 F.3d 478, 483 (3d Cir. 1998). Further, when considering a 12(b)(6) motion to dismiss, a court may take into account only the complaint, exhibits attached to the complaint, matters of public record, and undisputedly authentic documents if the plaintiff's claims are based upon those documents. See Pension Benefit Guar. Corp. v. White Consol. Indus., 998 F.2d 1192, 1196 (3d Cir. 1993). If, after viewing the allegations in the complaint in the light most favorable to the plaintiff, it appears that no relief could be granted "under any set of facts that could be proved consistent with the allegations," a court may dismiss a complaint for failure to state a claim. Hishon v. King & Spalding, 467 U.S. 69, 73 (1984).

Although a complaint does not need to contain detailed factual allegations, "the 'grounds' of [the plaintiff's] 'entitlement to relief' requires more than labels and conclusions, and a formulaic recitation of the elements of a cause of action will not do." Bell Atlantic Corp. v. Twombly, 127 S.Ct. 1955, 1965, 167 L.Ed. 2d 929 (2007). Thus, the factual allegations must be sufficient to raise a plaintiff's right to relief above a speculative level. See id. at 1964-65. Furthermore, although a court must view the allegations as true in a motion to dismiss, it is "not compelled to accept ...


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