benefit plan, governed by and subject to the provisions of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001 et seq. (Amended Complaint, paras. 2-3.)
Defendant J.C. Penney Company Inc. Voluntary Employees' Beneficiary Association ("J.C. Penney Plan") is a single employer trust fund and an employee health and welfare benefit plan, also governed by and subject to the provisions of ERISA. (Amended Complaint, para. 4.) Defendant Aetna Life Insurance Company, a Delaware corporation authorized to engage in business in Illinois, administers the J.C. Penney Plan. (Amended Complaint, para. 11.)
The Trustees filed their Complaint in this action after the J.C. Penney Plan denied benefits for certain medical expenses incurred by infant Brittani Louis at Woman's Hospital Foundation and Children's Hospital (collectively the "Hospitals") in Louisiana. The Hospitals are also named as defendants in plaintiffs' Amended Complaint.
Defendants J.C. Penney Plan and Woman's Hospital have moved to dismiss the Amended Complaint on the ground that plaintiffs lack standing to assert the claims of the Amended Complaint. For the reasons set forth below, the motion to dismiss will be granted.
It is well settled that in considering a motion to dismiss a court must take the well-pleaded factual allegations of the complaint as true, and dismissal is appropriate only if it is beyond doubt that the plaintiff can prove no set of facts consistent with the allegations of the complaint which would entitle plaintiff to relief. Conley v. Gibson, 355 U.S. 41, 2 L. Ed. 2d 80, 78 S. Ct. 99 (1957).
The well-pleaded factual allegations set forth in the Amended Complaint depict the following scenario:
On or about December 5, 1988 Marlene Aikens gave birth to her daughter, Brittani Louis at Woman's Hospital Foundation in Baton Rouge, Louisiana. Brittani was born prematurely and was diagnosed as having respiratory disease syndrome, bronchopulmonary dysplasia and "stenoid dependency." (Amended Complaint, para. 10.) Her condition required and continues to require hospital and medical care and treatment. Brittani received treatment at Woman's Hospital Foundation and was later transferred to and received treatment at Children's Hospital in New Orleans, Louisiana. Brittani's medical expenses at Woman's Hospital Foundation total at least $ 139,882.98: her expenses at Children's Hospital total at least $ 131,922.59. (Amended Complaint, para. 22.)
Jeffrey Louis is Brittani's father. He and Brittani's mother have never been married, but lived together prior to and at the time of Brittani's birth. (Amended Complaint, para. 12.) Jeffrey Louis and his daughter Brittani were and are beneficiaries of the CSS Fund, pursuant to which they are entitled to certain medical and hospital benefits, subject to the terms and conditions contained in the CSS Fund's plan document. (Amended Complaint, para. 13.)
The Amended Complaint alleges that at all times relevant to this action, Ms. Aikens and Brittani "were and are beneficiaries entitled to receive, among other things, specified medical and hospital benefits for covered illnesses from the J.C. Penney Plan." (Amended Complaint, para. 11.) The Trustees contend that the J.C. Penney Plan and its administrator Aetna unreasonably refused to pay benefits on behalf of Brittani. (Amended Complaint, para. 19.) Aetna, according to the allegations of the pleading, has asserted that Ms. Aikens failed to enroll Brittani in the J.C. Penney Plan within the eligibility period. Aetna also denied coverage under the late enrollment exception provided in the J.C. Penney Plan because of Ms. Aiken's failure to demonstrate her daughter's insurability. (Amended Complaint, para. 18.) Ms. Aikens appealed Aetna's determination (Amended Complaint, para. 19): defendants have asserted that this appeal was denied subsequent to the filing of the Trustees' complaint in this court. (J.C. Penney Mem. in Opposition, p. 3, n.3.)
The Trustees contend that, under the terms of the CSS Fund Plan Document, the J.C. Penney Plan is Brittani's primary insurance carrier. Accordingly, the Trustees assert, the CSS Fund is only the excess carrier. (Amended Complaint, para. 21.) "Because of the J.C. Penney Plan's failure to assume its responsibility to provide primary benefits to or on behalf of Brittani Louis," the pleading alleges, "the [CSS] Fund will be obligated to pay the hospital and medical benefits incurred on her behalf." (Amended Complaint, para. 20.)
The Trustees rely on sections 5.01, 5.02 and 5.03 of the CSS Fund's Plan Document to support their contention that the J.C. Penney Plan is the primary insurer of Brittani's medical expenses. These provisions of the Plan Document provide as follows:
Section 5.01 PRIORITY OF COVERAGE WHERE COVERED INDIVIDUAL COVERED BY ANOTHER PLAN