Rois-Mendez v. California Physicians' Service

Background

Alek Rois-Mendez was enrolled in a group employee welfare benefit plan administered by California Physicians' Service, doing business as Blue Shield of California. After he was diagnosed with parotid gland cancer in 2019, physicians at Cedars-Sinai determined that proton beam radiation therapy was the best course of treatment and referred him to California Protons Cancer Therapy Center.

California Protons asked Blue Shield to authorize the treatment in advance. Blue Shield denied the request because it considered proton beam radiation therapy investigational. Blue Shield also denied an expedited appeal, stating that the plan excluded experimental or investigational services. Because of medical urgency, Rois-Mendez began treatment and paid California Protons himself. He later submitted a claim for reimbursement, but had not received a response or reimbursement when he filed his amended complaint.

Rois-Mendez asserted two claims under the Employee Retirement Income Security Act: denial of plan benefits and equitable relief.

Motion to Dismiss

Blue Shield moved to dismiss under Federal Rule of Civil Procedure 12(b)(1), which permits dismissal for lack of subject-matter jurisdiction. Blue Shield argued that Rois-Mendez lacked standing—the required connection between an alleged injury and a remedy available from the court—because Blue Shield had paid California Protons for most of the treatment and had denied the remaining claims for reasons other than the investigational-services exclusion.

The court treated Blue Shield's argument as a factual challenge to jurisdiction and considered evidence beyond the complaint. The court found that Blue Shield did not dispute that it had initially denied prior authorization because the treatment was investigational, later upheld that decision on appeal, or that Rois-Mendez paid California Protons directly. Blue Shield also did not dispute that Rois-Mendez had not received reimbursement for the treatment when the amended complaint was filed.

The court concluded that Rois-Mendez had suffered an injury through his out-of-pocket treatment payments. It further concluded that the injury was fairly traceable to Blue Shield's conduct and likely could be remedied by a favorable court decision. The court therefore denied Blue Shield's motion to dismiss.

Request to Amend

In his opposition brief, Rois-Mendez asked to add claims for intentional interference with contractual relations and violation of his attorneys' equitable lien. The court ruled that a complaint cannot be amended through a brief opposing a motion to dismiss. It denied the request for leave to amend, without prejudice to Rois-Mendez's filing a noticed motion under the Northern District of California's local rules.

Disposition

The court denied Blue Shield's motion to dismiss. It also denied Rois-Mendez's request for leave to amend the First Amended Complaint, without prejudice to filing a noticed motion requesting that leave.