Tsetsekos v. Horizon Blue Cross Blue Shield of New Jersey

Background

Katherine Tsetsekos brought one claim under the Employee Retirement Income Security Act of 1974 (ERISA), seeking benefits under a group health plan administered by Horizon Blue Cross Blue Shield of New Jersey and sponsored by Pfizer, Inc. She alleged that, while vacationing in Greece in July 2022, she suffered a brain aneurysm and seizure and was treated at three hospitals over 28 days. She was later transported by air ambulance to Westchester Medical Center in New York.

Tsetsekos alleged that Horizon wrongfully denied reimbursement for the air ambulance transfer. Horizon’s September 12, 2023 denial stated that the transfer did not satisfy the plan’s requirement that covered transportation be to the nearest hospital with appropriate facilities. Tsetsekos alleged that she appealed and exhausted the plan’s administrative remedies before filing suit.

Plan requirements and motion

The plan covered air ambulance services only if the requirements for ground ambulance coverage were met: an approved ambulance supplier had to provide the transport; ground transportation had to be medically unsafe or inadvisable; and the patient had to be transported to the nearest hospital with appropriate facilities. In addition, the plan required either that other emergency transportation would threaten the patient’s health or survival because of its timing or instability, or that the pickup location was inaccessible by other emergency transportation.

Horizon moved to dismiss under Federal Rule of Civil Procedure 12(b)(6), which permits dismissal when a complaint does not state a legally sufficient claim. To state an ERISA benefits claim, Tsetsekos had to allege facts showing an ERISA plan, entitlement to benefits under the plan, denial of those benefits, and a wrongful denial.

Court’s reasoning

The court held that the complaint did not plausibly allege that the air ambulance transfer satisfied the plan’s coverage requirements. Specifically, the court found that Tsetsekos did not allege facts showing:

- that the air ambulance provider was an approved supplier; - that ground transportation was medically contraindicated, meaning unsafe or inadvisable because of her condition; - that Westchester Medical Center was the nearest hospital with appropriate facilities; or - that the timing or instability of other emergency transportation threatened her health or survival, or that the pickup location could not be reached by other emergency transportation.

The court characterized the allegations that ground transport was infeasible and that COVID-19 restrictions prevented transfer to another European hospital as conclusory. It also found that the complaint did not identify specific medical evidence, nearby facilities, regulations, or other concrete facts showing that appropriate care was unavailable closer to Greece. The court rejected the argument that discovery could supply facts missing from the complaint, explaining that a plaintiff must state a plausible claim before obtaining discovery.

The court also stated that, even if the complaint had been sufficient, the administrative record supported Horizon’s denial. According to the court, multiple medical and benefits professionals concluded that appropriate treatment was available in Greece and that air transportation was not medically necessary. Applying the deferential arbitrary-and-capricious standard discussed in the opinion, the court stated that the record did not support overturning Horizon’s decision.

Disposition

Judge Nelson S. Roman granted Horizon’s motion to dismiss. The court dismissed Tsetsekos’s claims without prejudice and granted her leave to file an amended complaint by October 10, 2025. Horizon was directed to answer or otherwise respond by October 31, 2025, if she filed an amended complaint. If she did not amend within the allowed time, the claims dismissed without prejudice would be deemed dismissed with prejudice and the case would be deemed terminated.

The court also denied Tsetsekos’s demand for a jury trial, holding that an action seeking benefits under ERISA Section 502(a)(1)(B) does not carry a right to a jury trial.