United States District Court, E.D. Pennsylvania
April 5, 2004.
JONATHAN WIRTH, individually and on behalf of all others similarly situated
AETNA U.S. HEALTHCARE
The opinion of the court was delivered by: HARVEY BARTLE, III, District Judge
Defendant Aetna Health, Inc. ("Aetna") (improperly denominated by
plaintiff as Aetna U.S. Healthcare) moves to dismiss the first amended
class action complaint ("complaint")*fn1 for failure to state a claim
upon which relief can be granted under Rule 12(b)(6) of the Federal Rules
of Civil Procedure.
Plaintiff Jonathan Wirth alleges various state law claims against Aetna
in connection with a health care agreement under which he is a
beneficiary. This action was originally filed in the Court of Common
Pleas of Bucks County, Pennsylvania and then removed to this court. We
denied plaintiff's motion to remand on the ground that this court has
subject matter jurisdiction under the doctrine of complete preemption. We
determined that plaintiff's claims relate to an employee benefit plan
within the scope of § 502(a)(1)(B) of the Employee Retirement Income
Security Act ("ERISA") even though we may still apply state insurance law due to the savings clause of § 514(b)(2)(A) of
ERISA. 29 U.S.C. § 1132(a)(1)(B) and 1144(b)(2)(A); Wirth v. Aetna U.S.
Healthcare, Civ.A. No. 03-5406 (E.D. Pa. Feb. 9, 2004).
For present purposes we accept as true all well-pleaded facts. In re
Rockefeller Ctr. Props. Secs. Litig., 311 F.3d 198, 215 (2002). We may
also consider "an undisputedly authentic document that a defendant
attaches as an exhibit to a motion to dismiss if the plaintiff's claims
are based on the document." Pension Benefit Guar. Corp. v. White Consol.
Indus., Inc., 998 F.2d 1192, 1196 (3d Cir. 1993), cert. denied,
510 U.S. 1042 (1994).
According to the complaint, Plaintiff sustained injuries as a result of
an automobile accident. Aetna, a health maintenance organization ("HMO"),
paid part of the medical benefits for his injuries under the provisions
of a health care agreement with his father's employer. After plaintiff
obtained a settlement from the tortfeasor, Aetna asserted a lien against
the proceeds in order to obtain reimbursement for its expenditures on his
behalf. He subsequently paid Aetna $2,066.90 to release the lien. He now
seeks declaratory, injunctive, and monetary relief against Aetna for its
allegedly wrongful conduct.
No one disputes that the terms of Aetna's health care agreement
authorize the lien in question. Rather, plaintiff maintains that such
liens violate Pennsylvania's Motor Vehicle Financial Responsibility Law ("MVFRL"), which reads in pertinent
In actions arising out of the maintenance or use of a
motor vehicle, there shall be no right of subrogation
or reimbursement from a claimant's tort recovery with
respect to workers' compensation benefits, benefits
available under section 1711 (relating to required
benefits), 1712 (relating to availability of benefits)
or 1715 (relating to availability of adequate limits)
or benefits paid or payable by a program, group
contract or other arrangement whether primary or
excess under section 1719 (relating to coordination of
75 Pa. Cons. Stat. Ann. § 1720.
Aetna moves to dismiss the complaint on the ground that HMOs are exempt
from the anti-subrogation provisions of § 1720 under a provision of
the Pennsylvania Health Maintenance Organization Act ("HMO Act"). This
a health maintenance organization operating under the
provisions of this act shall not be subject to the
laws of this State now in force relating to insurance
corporations engaged in the business of insurance nor
to any law hereafter enacted relating to the business
of insurance unless such law specifically and in exact
terms applies to such health maintenance
organization. For a health maintenance organization
established, operated, and maintained by a
corporation, this exemption shall apply only to the
operations and subscribers of the health maintenance
Pa. Stat. Ann. tit. 40, § 1560(a) (emphasis added).
Section 1720 of the MVFRL is "a law hereafter enacted" since it was
adopted later in time than § 1560(a) of the HMO Act. It is also a law
"relating to the business of insurance." No less an authority than the
United States Supreme Court has ruled in FMC Corp. v. Holliday, 498 U.S. 54, 61 (1990), that "Section 1720
directly controls the terms of insurance contracts by invalidating any
subrogation provisions that they contain. . . . It does not merely have
an impact on the insurance industry; it is aimed at it." Moreover, there
is nothing in § 1720 which "specifically and in exact terms applies" to
HMOs. Consequently, as a result of § 1560(a), § 1720 does not abrogate
the subrogation provisions of the Aetna healthcare agreement. The lien
against plaintiff for reimbursement of his medical benefits was valid,
and he is not entitled to the return of the $2,066.90.
Whether or not, as plaintiff contends, HMOs like Aetna have an unfair
competitive advantage under Pennsylvania law is a matter properly
addressed by the Commonwealth's General Assembly, not this court. See
DiGreqorio v. Keystone Health Plan East, 840 A.2d 361, 370 n.3 (Pa.
Plaintiff's claims for breach of contract, unjust enrichment, bad faith
insurance practices, and for declaratory, injunctive, and monetary relief
are all dependent on his argument that § 1720 invalidated Aetna's
lien against his motor vehicle tort recovery. Since his premise is
without merit, his claims fail as a matter of law.
The motion of defendant to dismiss plaintiff's first amended class
action complaint will be granted.
AND NOW, this day of April, 2004, for the reasons set forth in the
accompanying Memorandum, it is hereby ORDERED that the motion of
defendant Aetna Health, Inc. (improperly denominated by plaintiff as
Aetna U.S. Healthcare) to dismiss plaintiff's first amended class action
complaint is GRANTED.