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Carolina Zalduondo v. Aetna Life Insurance Company

February 27, 2012


The opinion of the court was delivered by: Royce C. Lamberth, Chief Judge


This is an ERISA suit, involving a plaintiff suing an insurance company for denying a claim for benefits under a health plan. Before the Court are defendant's Motion [6] to Dismiss the Amended Complaint and plaintiff's Motion [9] to File a Sur-Reply. Upon consideration of the motions, oppositions, replies, the entire record in this case, and the applicable law, the Court will grant in part and deny in part defendant's Motion [6] to Dismiss the Amended Complaint and deny plaintiff's Motion [9] to File a Sur-Reply.


The plaintiff in this case is Carolina Zalduondo, who has had problems with one of her hips. Am. Compl. [5] ¶13, Mar. 14, 2011. In August 2009, she decided to pursue a surgical treatment for her hip problem. As an employee of an advertising agency in the D.C. area, she participated in her employer's health care plan. Id. ¶4--9. Aetna Life Insurance Company ("Aetna") is the service provider for that plan, pre-certifying medical services received by plan participants and adjudicating coverage and payment claims. Id. ¶9.

Only health care services provided by certain physicians within Aetna's network are covered by Ms. Zalduondo's plan, and she was allegedly unable to locate successfully an "in-network" physician who was capable of performing the surgery she required. Id. at ¶13. She called Aetna, seeking information regarding what steps she would have to take to get the services of a particular out-of-network physician ("Dr. Wolff") covered by the plan. Id. ¶14. She was told that to get his services covered, she first had to demonstrate that Aetna's network was deficient. Id. ¶16. It's unclear what sort of showing Ms. Zalduondo made to Aetna or what sort of review was undertaken, but in a letter dated September 1, 2009, Aetna denied her request to have Dr. Wolff's services treated as in-network services under the plan. Id. ¶17.

On September 11, 2009, Ms. Zalduondo received a letter from Aetna denying her request that the company pre-certify the surgical procedure she was planning to have. Id. ¶21. She again called Aetna, apparently to dispute Aetna's decision, and the company arranged a telephone call between Dr. Wolff and the doctor from Aetna who had originally denied her pre-certification request. Id. ¶22--24. That call took place on September 14, 2009, only two days before Ms. Zalduondo had scheduled her surgery. Id. ¶¶24, 28. While it's unclear what transpired during this call, following Ms. Zalduondo's surgery on September 16, 2009, Aetna notified her that the surgery would not be covered for various reasons. Id. ¶29--30. Her dispute with Aetna about the sufficiency of its physician network persisted, however, with Aetna stating that she could have been adequately treated in-network by two physicians other than Dr. Wolff, id. ¶30, and Ms. Zalduondo maintaining that these physicians weren't qualified to perform her surgery. Id. ¶31-- 32.

She brought suit in this Court*fn1 against Aetna in October 2010 for violations of the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001 et seq. Her Amended Complaint brings two claims. First, she brings a claim for improper denial of benefits ("Claim 1") under 29 U.S.C. § 1132(a)(1)(B), which authorizes civil suits by plan participants to recover benefits due under a plan and to enforce participants' rights under a plan. Am. Compl. [5] ¶38-- 43. She alleges, in Claim 1, that Aetna failed to fully and fairly review her claim, failed to provide her with information regarding the bases of its decision to deny her claim, and violated a certain Department of Labor regulation that requires the "fiduciary" of a group health plan, in deciding an appeal of an adverse benefit determination based at least in part upon a medical judgment, to consult with a "health care professional who has appropriate training and experience . . . ." Am. Compl. [5] ¶¶ 40, 42--43 (citing 29 C.F.R. § 2560.503-1(h)(3)(iii)).

Her second claim ("Claim 2") is for breach of fiduciary duties. Id. ¶44--49 (citing 29 U.S.C. § 1132(a)(2)). She alleges that Aetna breached its fiduciary duties by failing to communicate with her properly about the availability of in-network providers, misrepresenting services covered by the plan, failing to inform her of the reasons for denying coverage of her outof-network physician, and misrepresenting the qualifications of the company's in-network physicians. Id. ¶44--48. As to Claim 1, Ms. Zalduondo wants Aetna to pay her benefit claims at the in-network rates for Dr. Wolff "and all physicians and specialists who treated" her; to pay for "the specific procedures" performed by Dr. Wolff "and the anesthesiologist and surgical assistants involved" in the surgery; and to pay her attorney's fees and expenses. Id. at 9. As to Claim 2, she seeks declarations that the plan's administration is inconsistent with the plan documents and with regulations governing the claims appeal process. Id.

In February 2011, Aetna filed a Motion to Dismiss [4] 1, Feb. 25, 2011, but Judge Howell denied it as moot because Ms. Zalduondo amended her complaint a couple of weeks later. In March 2011, Aetna filed the instant Motion, seeking dismissal of Ms. Zalduondo's Amended Complaint. Def.'s Mot. Dismiss [6] 1, Mar. 31, 2011. Aetna's Motion to Dismiss became ripe at the end of April 2011. However, to bring to the Court's attention a recent Supreme Court decision with (purportedly) some bearing on its review of Aetna's Motion to Dismiss, Ms. Zalduondo filed a Motion to File a Sur-Reply at the end of May 2011. Pl.'s Mot. File Sur-Reply [9] 1, May 26, 2011.


A motion to dismiss is appropriate when a complaint fails "to state a claim upon which relief can be granted." Fed. R. Civ. P. 12(b)(6). To overcome this hurdle, a complaint must contain "a short and plain statement of the claim showing that the pleader is entitled to relief, in order to give the defendant fair notice of what the . . . claim is and the grounds upon which it rests." Bell Atl. Corp. v. Twombly, 550 U.S. 544, 555 (2007) (internal quotations omitted). The Court must "accept as true all of the factual allegations contained in the complaint," Atherton v. District of Columbia, 567 F.3d 672, 681 (D.C. Cir. 2009), and grant a plaintiff "the benefit of all inferences that can be derived from the facts alleged." Kowal v. MCI Commc'ns Corp., 16 F.3d 1271, 1276 (D.C. Cir. 1994). However, the Court may not "accept inferences drawn by plaintiffs if such inferences are unsupported by the facts set out in the complaint." Id. In other words, "only a complaint that states a plausible claim for relief survives a motion to dismiss." Ashcroft v. Iqbal, 129 S. Ct. 1937, 1950 (2009); see also Atherton, 567 F.3d at 681.


ERISA was enacted as a comprehensive regulation of private employee benefit plans for the purpose of protecting their participants and beneficiaries. See Aetna Health Inc. v. Davila, 542 U.S. 200 (2004); Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41 (1987). To enforce compliance with ERISA and the terms of ERISA plans, the statute authorizes participants or beneficiaries of such plans to bring suit in federal court to recover benefits due under the terms of their plans or to enforce their rights under such plans. See 29 U.S.C. § 1132(a)(1)(B). Participants or beneficiaries may also sue, via § 1132(a)(2), for "appropriate relief" under § 1109, which establishes personal liability for an ERISA fiduciary for breaches of fiduciary duties that result in losses to the plan. See 29 U.S.C. § 1109(a). Finally, plan beneficiaries or participants may sue under § 1132(a)(3) to enjoin violations of ERISA or of the terms of an ERISA plan, or to obtain "other appropriate equitable relief" to redress or enforce such violations. Id. § 1132(a)(3).

While ERISA does not explicitly require exhaustion of administrative remedies, the D.C. Circuit has held (alongside most other circuits) that plaintiffs seeking to recover benefits under ERISA plans must exhaust available administrative remedies under those plans before bringing a lawsuit in federal court. Commc'ns Workers of Amer. v. Amer. Tel. & Tel. Co., 40 F.3d 426, 431--32 (D.C. Cir. 1994); see also Dorsey v. Jacobson Holman, PLLC, 707 F. Supp. 2d 21, 27 (D.D.C. 2010). The exhaustion requirement applies to claims for benefits as well as claims for breach of fiduciary duty, Dorsey, 707 F. Supp. 2d at 27 (citing Simmons v. Wilcox, 911 F.2d 1077, 1081 (5th Cir. 1990)), and "prevents premature or unnecessary judicial interference with plan administrators." Cox v. Graphic Commc'ns Conference of Int'l Bhd. of Teamsters, 603 F. Supp. 2d 23, 29 (D.D.C. 2009). Furthermore, requiring plan participants to exhaust their administrative remedies enables plan administrators to manage plans efficiently, correct ...

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