Norman Maurice Rowe, M.D., M.H.A.,L.L.C. v. Aetna Life Insurance Company

Document and procedural posture

The provided document is a letter from Aetna's counsel to Judge Lorna G. Schofield. It asks permission to proceed with a motion to dismiss under Federal Rule of Civil Procedure 12(b)(6), which concerns whether a complaint states a legally sufficient claim. The letter proposes dates for the parties' submissions. It is not a court opinion or order, and it does not show that the court granted, denied, or otherwise ruled on the proposed motion.

Plaintiffs' allegations

The letter states that Norman Maurice Rowe, M.D., M.H.A.,L.L.C. and East Coast Plastic Surgery, P.C. are out-of-network providers with Aetna. Aetna allegedly administered a welfare plan sponsored and funded by the Mason Tenders' District Council Welfare Fund and governed by the Employee Retirement Income Security Act of 1974 (ERISA). The plan provided health insurance coverage to A.V., identified in the letter as a purported patient of the plaintiffs.

According to the complaint as described in the letter, a plaintiffs' employee contacted Aetna to verify benefits before A.V.'s surgery. The plaintiffs alleged that an Aetna representative said Aetna would reimburse the services based on 80% of the reasonable and customary amount. They alleged that this statement created an oral contract or promise, which they accepted when A.V. received breast-reduction surgery on October 6, 2020. The plaintiffs sued for breach of contract, unjust enrichment, promissory estoppel, and fraudulent inducement.

Aetna's proposed grounds for dismissal

Aetna argued that the call occurred on May 22, 2020, rather than July 15, 2020, and that the recording and transcript showed that the representative only relayed benefits available under A.V.'s plan. Aetna maintained that the call did not promise payment for particular services or create a separate contract.

Aetna further argued that ERISA expressly preempts the plaintiffs' state-law claims because those claims relate to the plan and its out-of-network benefit terms. In addition, Aetna contended that the breach-of-contract and promissory-estoppel claims did not adequately allege a clear promise, mutual agreement, contractual intent, or authority for the customer-service representative to promise payment beyond the plan's terms.

Aetna argued that the unjust-enrichment claim failed because the plaintiffs did not confer a benefit on Aetna by providing surgery to A.V. Finally, Aetna argued that the fraudulent-inducement claim failed under the heightened pleading requirements of Rule 9(b), was based on the same alleged conduct as the contract claim, and did not identify a misrepresentation separate from the alleged contract.

Disposition

No disposition appears in the provided text. The document records Aetna's request and arguments, but it does not state that Judge Schofield ruled on the proposed motion to dismiss.