Zoia v. United Health Group Incorporated

Background

Adam Zoia was enrolled in a health insurance plan administered by the defendants. On March 17, 2022, he suffered serious injuries in a skiing accident in Idaho. After initial treatment at Saint Alphonsus Hospital in Boise, an air ambulance transported him on March 22, 2022, to NYU Langone Medical Center, where he underwent multiple surgeries and later received rehabilitation.

Zoia submitted a $611,590 claim for the air transport. The defendants denied the claim, stating that he could have been transferred to a closer hospital and that the transport was not authorized, medically necessary, or covered under the plan’s facility-to-facility transportation criteria. Zoia alleged that the plan covered emergency air ambulance transportation to the nearest hospital where the required emergency care could be performed. He also alleged that NYU Langone was the only facility capable of providing the specialized care he needed.

Zoia asserted one claim under Section 502(a)(1)(B) of the Employee Retirement Income Security Act, which allows a plan participant to sue to recover benefits allegedly owed under a plan. He alleged that the defendants violated that law by refusing to cover the air ambulance expense. He also argued that the court should review the benefits denial without deference because he had not received a full and fair review and had not received a copy of the plan.

Rule 12(b)(6) standard and review standard

The defendants moved to dismiss the Second Amended Complaint under Federal Rule of Civil Procedure 12(b)(6), which tests whether a complaint alleges enough facts to state a legally plausible claim. For this motion, the court treated well-pleaded factual allegations as true but did not accept conclusory assertions as true.

The court held that the plan gave the plan administrator discretionary authority to interpret the plan and determine eligibility. Therefore, the court said the benefits decision ordinarily would be reviewed under the deferential arbitrary-and-capricious standard rather than de novo review, which means the court would consider the issue anew. The court added that the result would be the same even under de novo review because the plan’s uncontested terms were outcome-determinative.

ERISA claim

The parties agreed that emergency air ambulance coverage was limited to transportation to the “nearest hospital” where the required emergency services could be performed. The court accepted that air transportation was medically necessary and that Zoia plausibly alleged that he needed care available at a Level I trauma center.

The court nevertheless found that Zoia had not plausibly alleged that NYU Langone was the nearest facility capable of providing that care. It characterized the assertion that only NYU Langone’s multidisciplinary team could treat him as conclusory and implausible, noting that other Level I trauma centers were closer to Idaho. The court also observed that the complaint did not allege that the transport to NYU Langone was no more costly than transportation to a closer facility providing the same level of care.

Because Zoia had not plausibly alleged that the plan covered transportation to NYU Langone, the court concluded that he had not stated a claim under ERISA Section 502(a)(1)(B). The court did not address all of Zoia’s other arguments, including whether some defendants were improperly joined.

Leave to amend and disposition

Zoia asked for permission to amend if the motion to dismiss was granted. The court denied that request, explaining that Zoia had already amended the complaint twice and had three opportunities to plausibly allege that NYU Langone was the closest hospital able to provide the required emergency services. The court concluded that another amendment would be futile.

The court granted the defendants’ motion to dismiss, denied leave to amend, directed the Clerk to terminate the motion at docket entry 32, and closed the case.