Seventh Circuit: Plaintiffs Seeking Plan Benefits Need Not Cite Specific Plan Provisions to Survive Motions to Dismiss

Dr. Griffin, a dermatologist and surgeon, was assigned the right under her patient’s health plan to “pursue claims for benefits, statutory penalties, [and] breach of fiduciary duty ….” Prior to treating the patient, Dr. Griffin confirmed through a plan representative that the plan would pay “the usual, reasonable, and customary rate” for her services, as specified in the plan document. Dr. Griffin then submitted a claim for nearly $8,000, and the plan paid her only about $3,000.

After challenging the plan’s benefits determination by letter, Dr. Griffin brought suit against the plan and its administrators under ERISA, seeking unpaid benefits, equitable relief, and statutory penalties. 29 U.S.C. §§ 1132(a)(1)(B), (a)(3), (c)(1). Dr. Griffin alleged that the Defendants (1) failed to reimburse her at the proper rate; (2) breached their fiduciary duties in failing to abide by the plan’s terms; and (3) failed to provide plan documents and information she requested within 30 days.

The Defendants moved to dismiss Dr. Griffin’s suit. They contended that the doctor was not owed benefits under ERISA because she had failed to identify a specific plan provision entitling her to greater payment, which they urged was required under Clair v. Harris Tr. & Sav. Bank, 190 F.3d 495, 497 (7th Cir. 1999) (“[O]nly benefits specified in the plan can be recovered in a suit under section 502(a)(1)(B).”). The district court agreed and dismissed the claim for benefits. It also dismissed Dr. Griffin’s equitable claim alleging breach of fiduciary duty as duplicative of her claim for benefits, and dismissed her claim for statutory penalties, concluding that such claims were available only to plan “participants or beneficiaries[,]” not their assignees.

On review, the Seventh Circuit reversed the district court’s holding that Dr. Griffin was required to cite a specific plan provision establishing coverage at her billed amount. Relying on the Fifth Circuit’s recent decision in Innova Hospital San Antonio, Limited Partnership v. Blue Cross & Blue Shield of Georgia, Inc., 892 F.3d 719, 729 (5th Cir. 2018), the Seventh Circuit declared that “[P]laintiffs alleging claims under 29 U.S.C. § 1132(a)(1)(B) for plan benefits need not necessarily identify the specific language of every plan provision at issue to survive a motion to dismiss under Rule 12(b)(6).” Dr. Griffin did not need to point to a particular plan provision specifying entitlement to “greater payment,” as such a requirement would “turn notice pleading on its head[,]” especially when the plan failed to provide Dr. Griffin with “information necessary to allege with more detail where the plan’s calculation of the usual and customary rate went astray.” While the Defendants had responded to Dr. Griffin’s request for plan documents and information, they did so six months after her request, and never provided documents used to determine the payment made, such as rate tables or fee schedules.

The Circuit Court also reversed the district court’s dismissal of Dr. Griffin’s claim for statutory penalties. It recognized that an assignee designated to receive benefits is considered a beneficiary under ERISA that can sue for unpaid benefits, suing for benefits requires access to information about those benefits, and “[i]t follows that Dr. Griffin also must be a beneficiary able to sue when she is denied requested information.” Conversely, the Court affirmed the dismissal of Dr. Griffin’s equitable claim for breach of fiduciary duty, as equitable relief was unavailable when 29 U.S.C. § 1132(a)(1)(B) offered damages for the same conduct.