United States District Court, E.D. Texas, Sherman Division
AMY WHITLEY, INDIVIDUALLY AND AS NEXT FRIEND TO L.K.W. and L.Q.W.
DR PEPPER SNAPPLE GROUP, INC., DR PEPPER SNAPPLE GROUP HEALTH PLAN, and ADMINISTRATIVE COMMITTEE
MEMORANDUM OPINION AND ORDER
L. MAZZANT UNITED STATES DISTRICT JUDGE
before the Court is Defendant Dr Pepper Snapple Group, Inc.
(“Dr Pepper”), Dr Pepper Snapple Group Health
Plan, and the Dr Pepper Snapple Group, Inc. Administrative
Committee's (collectively, “Defendants”)
Motion to Dismiss Plaintiff's First Amended Complaint.
(Dkt. #10). After considering the relevant pleadings, the
Court grants in part and denies in part Defendants'
lawsuit concerns Defendants' alleged erroneous denial of
coverage for treatment of Plaintiff Amy Whitley's
(“Whitley”) sons', L.K.W. and L.Q.W., autism
spectrum disorder. From August 2015 through January 2016,
Whitley inquired into whether her healthcare plan (“the
Plan”) covered treatments for autism. During this time,
Defendants gave Whitley conflicting information as to whether
the Plan covered L.K.W.'s Applied Behavior Analysis
(“ABA”) treatment, including different variations
of the Summary Plan Description. For example, Whitley
received a 2013 Summary Plan Description that did not contain
an ABA treatment exclusion provision, but received a 2016
Summary Plan Description that did.
January 2016, L.K.W.'s ABA treatment provider requested a
pre-service claim determination (“L.K.W.'s First
Claim”) to determine whether the Plan covered
L.K.W.'s ABA therapy. Defendants denied coverage, and
Plaintiff appealed Defendants' decision. On July 26,
2016, Defendants issued a final administrative denial.
September 21, 2016, Plaintiff filed a second pre-service
claim for L.K.W.'s ABA therapy (“L.K.W.'s
Second Claim”). Defendants again denied coverage
issuing a final administrative denial on May 9, 2017.
on February 16, 2017, Plaintiff filed a pre-service claim for
L.Q.W.'s ABA therapy (“L.Q.W.'s Initial
Claim”). Like Plaintiff's previous claims,
Defendants denied coverage and issued a final administrative
denial on May 24, 2017.
April 28, 2016, Whitley filed suit in state court alleging Dr
Pepper violated, among other things, the Americans with
Disabilities Act by denying coverage for L.K.W.'s autism
treatment. On May 31, 2016, Dr Pepper removed Whitley's
state court action to federal court. Whitley v. Dr Pepper
Snapple Group, Inc., 4:16-CV-362-ALM, Dkt. #1 (E.D. Tex.
May 31, 2016) (“Whitley I”).
Subsequently, on January 19, 2017, Whitley filed this lawsuit
(“Whitley II”) alleging Defendants
wrongfully denied both of her sons coverage for ABA therapy
in violation of the Employee Retirement Income Security Act
of 1974 (“ERISA”) and the Pete Domenici Mental
Health Parity and Addiction Equity Act
(“MHPAEA”). On July 20, 2017, the Court
consolidated Whitley I and Whitley II for
purposes of discovery and trial. (Whitley I, Dkt.
April 26, 2017, Defendants filed their motion to dismiss
Plaintiff's First Amended Complaint pursuant to Federal
Rule of Civil Procedure 12(b)(6). (Dkt. #10). Specifically,
Defendants allege Plaintiff's claims are untimely and
Plaintiff failed to exhaust administrative remedies prior to
filing suit. Plaintiff filed her response on May 17, 2017.
(Dkt. #12). Defendants filed their reply (Dkt. #22) on June
7, 2017, and Plaintiff filed her sur-reply (Dkt. #23) on June
Federal Rules of Civil Procedure require that each claim in a
complaint include a “short and plain statement . . .
showing that the pleader is entitled to relief.”
Fed.R.Civ.P. 8(a)(2). Each claim must include enough factual
allegations “to raise a right to relief above the
speculative level.” Bell Atl. Corp. v.
Twombly, 550 U.S. 544, 555 (2007).
12(b)(6) motion allows a party to move for dismissal of an
action when the complaint fails to state a claim upon which
relief can be granted. Fed.R.Civ.P. 12(b)(6). When
considering a motion to dismiss under Rule 12(b)(6), the
Court must accept as true all well-pleaded facts in
plaintiff's complaint and view those facts in the light
most favorable to the plaintiff. Bowlby v. City of
Aberdeen, 681 F.3d 215, 219 (5th Cir. 2012). The Court
may consider “the complaint, any documents attached to
the complaint, and any documents attached to the motion to
dismiss that are central to the claim and referenced by the
complaint.” Lone Star Fund V (U.S.), L.P. v.
Barclays Bank PLC, 594 F.3d 383, 387 (5th Cir. 2010).
The Court must then determine whether the complaint states a
claim for relief that is plausible on its face.
‘“A claim has facial plausibility when the
plaintiff pleads factual content that allows the [C]ourt to
draw the reasonable inference that the defendant is liable
for the misconduct alleged.'” Gonzalez v.
Kay, 577 F.3d 600, 603 (5th Cir. 2009) (quoting
Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009)).
“But where the well-pleaded facts do not permit the
[C]ourt to infer more than the mere possibility of
misconduct, the complaint has alleged-but it has not
‘show[n]'-‘that the pleader is entitled to
relief.'” Iqbal, 556 U.S. at 679 (quoting
Iqbal, the Supreme Court established a two-step
approach for assessing the sufficiency of a complaint in the
context of a Rule 12(b)(6) motion. First, the Court should
identify and disregard conclusory allegations, for they are
“not entitled to the assumption of truth.”
Iqbal, 556 U.S. at 664. Second, the Court
“consider[s] the factual allegations in [the complaint]
to determine if they plausibly suggest an entitlement to
relief.” Id. “This standard
‘simply calls for enough facts to raise a reasonable
expectation that discovery will reveal evidence of the
necessary claims or elements.'” Morgan v.
Hubert, 335 F. App'x 466, 470 (5th Cir. 2009)
(citation omitted). This evaluation will “be a
context-specific task that requires the reviewing [C]ourt to
draw on its judicial experience and common sense.”
Iqbal, 556 U.S. at 679.
“[t]o survive a motion to dismiss, a complaint must
contain sufficient factual matter, accepted as true, to
‘state a claim to relief that is plausible on its