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United States Court of Appeals for the First Circuit
January 31, 2022, Decided
THOMPSON, Circuit Judge. Plaintiffs S.R. and T.R. are the parents of N.R., who was four years old at the start of our story. The family had health insurance through T.R.'s employment at defendant Raytheon Company. Raytheon enlisted defendant United Healthcare to administer this health insurance plan (simply called the "Plan" from here on out) and assigned defendant William Bull to be the Plan's administrator. Everyone seemed happy with this arrangement until United Healthcare refused to pay for N.R.'s speech therapy. After S.R. and T.R. could not get United Healthcare to change its mind, the family sued for various violations of the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001, et seq. The district court dismissed the case in full, buying into the defendants' representations of how the Plan works too much for this stage in the litigation. Ever mindful that all well-pleaded factual allegations in the complaint are accepted as true when reviewing a motion to dismiss, we affirm as to Count 1, and reverse and remand as to the remaining counts. See Ezra Charitable Tr. v. Tyco Int'l, Ltd., 466 F.3d 1, 6 (1st Cir. 2006) (in addition to accepting well-pleaded factual allegations in the complaint, we also construe reasonable inferences in favor of the plaintiffs).
Relevant Details of the Plan
The [*3] Plan includes a list entitled "Exclusions," and explains that "[t]he [United Healthcare] plans do not cover any expenses incurred for services, supplies, medical care, or treatment relating to, arising out of or given in connection with [those excluded services.]" Among those excluded expenses are "[h]abilitative services for maintenance/preventive treatment" and "speech therapy for non-restorative purposes."
The "Exclusions" list also includes a nested sub-list of "mental health (including Autism Spectrum Disorder (ASD) services)/substance-related and addictive disorders services [that] are not covered[.]" That "mental health" list includes the following relevant text:
Full case includes Shepard's, Headnotes, Legal Analytics from Lex Machina, and more.
2022 U.S. App. LEXIS 2735 *; __ F.4th __; 2022 WL 278537
N.R., by and through his parents and guardians, S.R. and T.R., individually and on behalf of all others similarly situated, and derivatively on behalf of the Raytheon Health Benefits Plan, Plaintiff, Appellant, v. RAYTHEON COMPANY; RAYTHEON HEALTH BENEFITS PLAN; WILLIAM M. BULL, Defendants, Appellees.
Prior History: [*1] APPEAL FROM THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MASSACHUSETTS. Hon. Richard G. Stearns, U.S. District Judge.
Parity, benefits, speech therapy, mental health, documents, fiduciary, disorder, habilitative, district court, plan administrator, allegations, motion to dismiss, non-restorative, terms of the plan, substance use, defendants', diagnosis, coverage, violates, medical necessity, limitations, restore, terms, deny coverage, guidelines, losses, breach of fiduciary duty, fiduciary duty, instruments, provisions
Pensions & Benefits Law, Civil Litigation, Causes of Action, Failures to Respond, Suits to Recover Plan Benefits, Remedies, Equitable Relief, Injunctions, Civil Procedure, Appeals, Standards of Review, De Novo Review, Pleadings, Complaints, Requirements for Complaint, Defenses, Demurrers & Objections, Motions to Dismiss, Failure to State Claim, Business & Corporate Compliance, Mental Health Parity Act, Pensions & Benefits Law, Mental Health Parity Act, Public Health & Welfare Law, Medicaid, Coverage, Pharmaceutical Services, Fiduciary Responsibilities, Plan Administration, Adherence to Plan, Breach of Fiduciary Duty, Consolidated Omnibus Budget Reconciliation Act, Enforcement, Fiduciaries, Fiduciary Liability, Personal Liability, ERISA, Standing, Damages, Extracontractual Damages, Disclosure, Notice & Reporting, Required Reports, Summary Plan Descriptions, Governments, Legislation, Interpretation