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Hoover v. Harvard Pilgrim Healthcare, Inc.

United States District Court, D. New Hampshire

May 9, 2016

Randall Hoover et al.
v.
Harvard Pilgrim Healthcare, Inc., et al. Opinion No. 2016 DNH 192

MEMORANDUM ORDER

Joseph N. Laplante United States District Judge

This insurance coverage action requires the court to apply the limitations period in a health care coverage plan. Plaintiffs Randall Hoover and Barbara Hoover sued to recover costs associated with the treatment of their son, Gary Hoover, after defendant United Behavioral Health, Inc. denied their claim under Mrs. Hoover’s employer-provided health care plan. This court has jurisdiction over this matter under 28 U.S.C. § 1332 (diversity) because the plaintiffs are New Hampshire citizens, all defendants are citizens of other states, and the amount in controversy exceeds $75, 000.

The defendants have moved to dismiss the complaint, see Fed. R. Civ. P. 12(b)(6), arguing that the Hoovers’ suit is time-barred by the terms of the insurance plan. Even if it were not barred, defendants argue, the Hoovers have failed to state a claim for breach of the covenant of good faith and fair dealing. Concluding that the facts as set out by the complaint demonstrate that plaintiffs failed to meet the plan’s two-year deadline for filing a lawsuit to recover benefits, the court grants defendants’ motion.

I. Applicable legal standard

To survive a motion to dismiss under Rule 12(b)(6), the plaintiff must state a claim to relief by pleading “factual content that allows the court to draw the reasonable inference that the defendant is liable for the misconduct alleged.” Martinez v. Petrenko, 792 F.3d 173, 179 (1st Cir. 2015) (quoting Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009)). “Granting a motion to dismiss based on a limitations defense is entirely appropriate when the pleader’s allegations leave no doubt that an asserted claim is time-barred.” LaChapelle v. Berkshire Life Ins. Co., 142 F.3d 507, 509 (1st Cir. 1998). In ruling on such a motion, the court accepts as true all well-pleaded facts set forth in the complaint and draws all reasonable inferences in the plaintiff’s favor. See, e.g., Martino v. Forward Air, Inc., 609 F.3d 1, 2 (1st Cir. 2010). The court “may consider not only the complaint but also facts extractable from documentation annexed to or incorporated by reference in the complaint and matters susceptible to judicial notice.” Rederford v. U.S. Airways, Inc., 589 F.3d 30, 35 (1st Cir. 2009).

II. Background

The following summary of the facts takes the approach described above, drawing all inferences in the plaintiffs’ favor. Plaintiffs Randall and Barbara Hoover bring this action as next friends of their son, Gary Hoover.[1] Barbara’s employer, the University System of New Hampshire, provided the Hoovers’ health care benefits plan through Harvard Pilgrim.[2] By agreement with Harvard Pilgrim, UBH managed the plan’s mental health and substance abuse benefits, including determining whether costs associated with Harvard Pilgrim members’ use of mental health and substance abuse services would be covered by the plan.

Gary has been diagnosed with Schizotypal Personality Disorder and Alcohol Use Disorder. Upon the recommendation of his outpatient mental health service providers, Gary was admitted to WestBridge Community Services in Manchester, New Hampshire on November 1, 2012. According to the complaint, WestBridge is the only residential facility in New Hampshire that treats both alcohol addiction and mental health symptoms like Gary’s.

Harvard Pilgrim’s network of approved providers did not, however, include WestBridge. Under the Hoovers’ policy, Harvard Pilgrim would pay benefits to out-of-network providers only in emergencies or if no in-network provider offered the services required. Before Gary was admitted, Barbara called UBH, which informed her that it would cover treatment by an out-of-network provider “[i]f a network provider is not within thirty miles of your residence . . . .” Complaint (document no. 1-1) ¶ 30. WestBridge’s billing department also contacted UBH, and was told that UBH authorized Gary’s treatment at WestBridge and that “[m]uch of the invoiced charges would be paid . . . .” Id. ¶¶ 33, 35.

When WestBridge submitted its first invoice, however, UBH denied coverage on the grounds that Gary could obtain in-patient mental health services at Concord Hospital, an in-network provider. Id. ¶¶ 37-38. The plaintiffs allege that Concord Hospital could not meet Gary’s needs because it provides only short-stay crisis stabilization mental health services and outpatient substance abuse services, whereas Gary’s prior mental health providers determined that Gary required a long-term dual diagnosis residential service. WestBridge can provide that service but, according to the complaint, Concord Hospital cannot. Id. ¶ 39.

Plaintiffs’ policy provided for an expedited appeal process, of which the plaintiffs availed themselves. After consulting with Gary’s doctor at WestBridge, and after a review of his appeal by a consultant psychiatrist, Harvard Pilgrim affirmed the denial of benefits on November 12, 2012.

More than two years later, on February 18, 2015, the Hoovers filed their complaint in Strafford County Superior Court, asserting a single claim for breach of the covenant of good faith and fair dealing. Defendants timely removed the action to this court. Defendants now move to dismiss, see Fed. R. Civ. P. 12(b)(6), arguing that plaintiffs’ suit is time-barred under the terms of the benefits plan and, further, that plaintiffs have failed to plead facts necessary to state a claim for relief under the implied covenant of good faith and fair dealing.

III. Analysis

When resolving a motion to dismiss based on a limitations defense, the court must consider “whether the complaint and any documents that properly may be read in conjunction with it show beyond doubt that the claim asserted is out of time.” Rodi v. S. New England Sch. of Law, 389 F.3d 5, 17 (1st Cir. 2004). The relevant plan provision states: “Any legal action against the Plan for failing to provide Covered Benefits must be brought within two years of the denial of any benefit.”[3] Plan Handbook (document no. 7-3) at 51. At oral argument, plaintiffs conceded the enforceability of the 2-year limitation period.[4] Plaintiffs further conceded that their claim, though dressed as one for a breach of the implied covenant of good faith and fair dealing, is a “legal action against the Plan for failing to provide Covered Benefits.”[5] The court therefore turns its attention to ...


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