United States District Court, D. Utah, Central Division
FRANCISCO S., individually and as guardian of M.S. a minor, Plaintiff,
AETNA LIFE INSURANCE COMPANY and WORLD BANK GROUP MEDICAL INSURANCE PLAN, Defendants.
MEMORANDUM DECISION AND ORDER GRANTING IN PART AND
DENYING IN PART DEFENDANTS' MOTION TO DISMISS (ECF NO.
J. Furse United States Magistrate Judge.
Life Insurance Company (“Aetna”) and the World
Bank Group Medical Insurance Plan (collectively “the
Aetna Defendants”) move the Court to dismiss
Plaintiff Francisco S.'s Complaint “with prejudice
and on the merits.” (Defs.' Mot. to Dismiss
(“Mot.”) 1, ECF No. 14.) The Aetna Defendants
argue this Court should dismiss Mr. S.'s claims with
prejudice because the International Organizations Immunities
Act, 22 U.S.C. § 288 et seq, (the
“Immunities Act”), shields the World Bank from
suit. (Id. at 4-6.) The Aetna Defendants further
assert this Court lacks subject matter jurisdiction over Mr.
S.'s ERISA claim because the World Bank Group Medical
Insurance Plan (the “Plan”) qualifies as a
governmental plan exempt from coverage under the Employee
Retirement Income Security Act of 1974 (“ERISA”).
(Id. at 6-7.) Lastly, the Aetna Defendants contend
this Court should dismiss Mr. S.'s claims against Aetna
because Aetna does not insure the benefits under the Plan and
therefore lacks privity of contract with Mr. S. (Id.
at 7-8.) Having considered the parties' briefing and oral
argument, the Court GRANTS I N PA R T and DENIES IN PART the
Aetna Defendants' Motion to Dismiss for lack of subject
AND PROCEDURAL HISTORY
January 3, 2018, Mr. S. filed the Complaint alleging the
Aetna Defendants violated 29 U.S.C. § 1132(a)(1)(B) when
they failed to pay for his daughter's medically necessary
treatment. (Compl. ¶¶ 54-60, ECF No. 2.) Taking the
factual allegations in the Complaint as true, Kan. Penn
Gaming, LLC v. Collins, 656 F.3d 1210, 1214 (10th Cir.
2011) (citing Bell Atl. Corp. v. Twombly, 550 U.S.
544, 555 (2007)), the following facts provide the background
for this decision.
participates in the Plan; his daughter M. is a beneficiary.
(Compl. ¶ 6, ECF No. 2.) Aetna “is the third-party
claims administrator for the Plan” who “denied
claims for coverage in connection with mental health care
provided to M.” (Id. at ¶ 8.)
received mental health treatment from Outback Therapeutic
Expeditions (“Outback”) and New Haven Residential
Treatment Center (“New Haven”). (Id. at
¶ 7.) Aetna denied coverage for M.'s treatment at
Outback as not medically necessary because M. “was
‘not actively suicidal, violent, manic, psychotic,
severely depressed, or otherwise in crisis.'”
(Id. at ¶¶ 24-25.) Mr. S. alleges Aetna
violated ERISA “when it denied his appeal”
because it “did not give him specific information or
cite to the medical records Aetna used to justify the denial
of M.'s treatment.” (Id. at ¶ 27.)
Aetna continued to uphold its denial of M.'s treatment at
Outback on the same basis throughout the internal appeal
process. (Id. at ¶ 32.)
also denied coverage for M.'s subsequent treatment at New
Haven because M. did not have “a realistic plan and
intent to commit suicide”, and thus she could receive
treatment “at a less intensive level of care or in
another setting.” (Id. at ¶ 34.) Mr. S.
alleges Aetna violated ERISA's claims processing
regulations when it “neglected to provide him with
specific references to the medical records that they had used
to determine that M.'s care was not medically
necessary.” (Id. at ¶ 41.) Additionally,
Aetna failed “to provide the names and qualifications
of the reviewers involved in the decision to deny
care.” (Id.) Aetna upheld its denial of
M.'s treatment at New Haven on the same basis as its
original denial throughout the internal appeal process
(id. at ¶ 51), and Mr. S. filed suit alleging
Aetna breached its fiduciary duties “when it failed to
comply with its obligations under 29 U.S.C. § 1104 and
29 U.S.C. § 113 3 to act solely in the interest of the
Plan participants and beneficiaries for the exclusive purpose
of providing benefits to them and to provide a full and fair
review of [his] claims” and 29 U.S.C. §
1104(a)(1)(D) “when it failed to discharge it duties
‘in accordance with the documents and instruments
governing the Plan.'” (Id. at ¶¶
March 26, 2018, the Aetna Defendants filed their Motion to
Dismiss for lack of jurisdiction pursuant to Federal Rule of
Civil Procedure 12(b)(1) and for failure to state a claim
pursuant to Federal Rule of Civil Procedure 12(b)(6). (Mot.,
ECF No. 14.) On April 23, 2018, Mr. S. filed his Memorandum
in Opposition to the Aetna Defendants' Motion. (Pls.'
Mem. in Opp'n to Defs.' Mot. to Dismiss
(“Opp'n”), ECF No. 16.) On May 5, 2018, the
parties filed a stipulated motion seeking leave for Mr. S. to
submit a supplemental memorandum on the sole issue of the
World Bank's immunity from suit and also extending the
time for the Aetna Defendants to file their Reply memorandum
in support of their Motion to Dismiss. (Stip. Mot. for
Pls.' to Submit a Supp. Mem. & to Extend the Deadline
for Defs.' Reply Mem. (“Stip. Mot.”) 1-2, ECF
No. 21.) The Court granted the parties' stipulated motion
on May 10, 2018 (Order Granting Stip. Mot. for Pls. to Submit
a Supp. Mem. & to Extend the Deadline for Defs.'
Reply Mem., ECF No. 23), and Mr. S. filed his supplemental
memorandum on May 11, 2018. (Pl.'s Supp. Mem., ECF No.
24.) On May 24, 2018, the Aetna Defendants filed their Reply.
(Reply Mem. in Supp. of Defs.' Mot. to Dismiss
(“Reply”), ECF No. 25.)
October 11, 2018, the Court held a hearing on the Motion
where the Court heard argument and ordered the parties to
submit supplemental briefing on the limited issue that, in
the event the Court dismisses Mr. S.'s Complaint, whether
the Court should dismiss his Complaint with or without
prejudice. (See Minute Entry, ECF No. 27.) During
the hearing, the parties submitted a copy of the Summary Plan
Description. (Medical Insurance Plan: Summary Plan
Description (“Summary Plan Description”), ECF No.
28.) On November 26, 2018, the Aetna Defendants filed their
supplemental brief. (Defs.' Supp. Briefing re: Mot. to
Dismiss (“Defs.' Supp. Brief”), ECF No. 33.)
On November 30, 2018, Mr. S.'s filed his brief (Pl.'s
Supp. Briefing Re: Mot. to Dismiss (“Pl.'s Supp.
Brief”), ECF No. 34.)
motion to dismiss brought pursuant to Federal Rule of Civil
Procedure 12(b)(1) challenges the court's subject matter
jurisdiction. “Subject-matter jurisdiction involves a
court's authority to hear a given type of case.”
Radil v. Sanborn W. Camps, Inc., 384 F.3d 1220, 1224
(10th Cir. 2004). Federal district courts “have limited
subject matter jurisdiction and may only hear cases
‘when empowered to do so by the Constitution and by act
of Congress.'” Id. at 1225 (quoting 16
James Wm. Moore, Moore's Fed. Practice §
108.04(2) (3d ed. 2003)). The party asserting jurisdiction
bears the burden of establishing subject matter jurisdiction.
Penteco Corp. Ltd. P'ship-1985A v. Union Gas Sys.,
Inc., 929 F.2d 1519, 1521 (10th Cir. 1991) (“Since
federal courts are courts of limited jurisdiction, there is a
presumption against  jurisdiction, and the party invoking
federal jurisdiction bears the burden of proof.”)
(citing Basso v. Utah Power & Light Co., 495
F.2d 906, 909 (10th Cir. 1974)).
can challenge subject matter jurisdiction either facially or
factually. See Merrill Lynch Bus. Fin. Servs., Inc. v.
Nudell, 363 F.3d 1072, 1074 (10th Cir. 2004). A
“facial attack on the complaint's allegations as to
subject matter jurisdiction questions the sufficiency of the
complaint.” Holt v. United States, 46 F.3d
1000, 1002 (10th Cir. 1995) (citing Ohio Nat'l Life
Ins. Co. v. United States, 922 F.2d 320, 325 (6th Cir.
1990)). “In reviewing a facial attack on the complaint,
a district court must accept the allegations in the complaint
as true.” Id. (citing Ohio Nat'l,
922 F.2d at 325.) A factual attack goes “beyond
allegations contained in the complaint and challenge[s] the
facts upon which subject matter jurisdiction depends.”
Holt, 46 F.3d at 1003. “When reviewing a
factual attack on subject matter jurisdiction, a district
court may not presume the truthfulness of the complaint's
factual allegations.” Id. “A court has
wide discretion to allow affidavits, other documents, and a
limited evidentiary hearing to resolve disputed
jurisdictional facts under Rule 12(b)(1). … In such
instances, a court's reference to evidence outside the
pleadings does not convert the motion to a Rule 56
motion.” Id. (internal citations omitted)
(citing Wheeler v. Hurdman, 825 F.2d 257, 259 n. 5
(10th Cir. 1987)).
The Court Lacks Jurisdiction over Mr. ...