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Woska v. Health Care Service Corporation

United States District Court, W.D. Oklahoma

February 20, 2018

ANTHONY WOSKA, et al., Plaintiffs,



         Before the Court is Defendants' Motion to Dismiss [Doc. No. 7], which is brought pursuant to Rule 12(b)(6), Federal Rules of Civil Procedure. Plaintiffs have responded to the Motion [Doc. No. 16], and Defendants have replied [Doc. No. 19]. The matter is fully briefed and at issue.


         Physicians at Oklahoma Procure Management, d/b/a Procure Proton Therapy Center (Procure) recommended that Plaintiff Anthony Woska (Woska) undergo proton beam radiotherapy to treat his prostate illness. At all times relevant to this action, Woska was married to Plaintiff Debbie Woska[1] and insured under an insurance policy issued by Defendants Health Care Service Corporation (HCSC) and Blue Cross Blue Shield of Oklahoma (BCBS). Defendants denied Woska's claims for benefits relating to the proton therapy, and upheld the denial after multiple appeals by Woska. Woska claims Defendants' denial constitutes breach of contract, breach of the duty of good faith and fair dealing, negligence per se, and tortious interference with his business relationship with Procure. Defendants also refused to approve Procure's requests for authorization relating to the proton therapy treatment. Procure, likewise, contends that Defendants' refusal to authorize and pay for Woska's proton therapy constituted a breach of contract, breach of the duty of good faith and fair dealing, and an attempt to drive Procure from the medical marketplace.

         Defendants move to dismiss Plaintiffs' Petition on the grounds that (1) Woska has failed to establish any purported breach; (2) Woska fails to allege sufficient facts to establish a bad faith denial; (3) Woska's negligence per se action fails as a matter of law because he fails to identify any statutes, regulations, or code provisions that were violated; (4) Woska's tortious interference claim fails because he fails to allege interference with a contract between him and Procure; (5) Procure fails to allege sufficient facts to state a claim for relief; and (6) The complaint fails to assert any cause of action on behalf of Plaintiff Debbie Woska.


         Pursuant to the seminal decisions of Bell Atlantic Corp. v. Twombly, 550 U.S. 544 (2007) and Ashcroft v. Iqbal, 556 U.S. 662 (2009), to survive a motion to dismiss, a complaint must contain enough allegations of fact, taken as true, “to state a claim to relief that is plausible on its face.” Khalik v. United Air Lines, 671 F.3d 1188, 1190 (10th Cir. 2012) (quoting Twombly, 550 U.S. at 570).[2] Under this revised standard, “the mere metaphysical possibility that some plaintiff could prove some set of facts in support of the pleaded claims is insufficient; the complaint must give the court reason to believe that this plaintiff has a reasonable likelihood of mustering factual support for these claims.” Robbins v. Oklahoma, 519 F.3d 1242, 1247 (10th Cir. 2008) (quoting Ridge at Red Hawk, L.L.C. v. Schneider, 493 F.3d 1174, 1177 (10th Cir. 2007) (emphasis in original)). The “plausibility” standard announced in Twombly and Iqbal is not considered a “heightened” standard of pleading, but rather a “refined standard, ” which the court of appeals has defined as “refer[ring] to the scope of the allegations in a complaint: if they are so general that they encompass a wide swath of conduct, much of it innocent, then the plaintiffs have not nudged their claims across the line from conceivable to plausible.” Khalik v. United Air Lines, 671 F.3d 1188, 1191 (10th Cir. 2012) (citing Kansas Penn Gaming, LLC v. Collins, 656 F.3d 1210, 1214 (10th Cir. 2011); Robbins, 519 F.3d at 1247.

         The Tenth Circuit has further noted that the nature and specificity of the allegations required to state a plausible claim will vary based on context. Robbins, 519 F.3d at 1248. “Thus … the Twombly/Iqbal standard is ‘a middle ground between heightened fact pleading, which is expressly rejected, and allowing complaints that are no more than labels and conclusions or a formulaic recitation of the elements of a cause of action, which the Court stated will not do.' ” See id. at 1247. Accordingly, in deciding Twombly and Iqbal, there remains no indication the Supreme Court “intended a return to the more stringent pre-Rule 8 pleading requirements.” Khalik, 671 F.3d at 1191 (citing Iqbal, 556 U.S. at 678). It remains true that “[s]pecific facts are not necessary; the statement need only ‘give the defendant fair notice of what the ... claim is and the grounds upon which it rests.' ” Erickson v. Pardus, 551 U.S. 89, 93 (2007) (quoting Twombly, 550 U.S. at 555); Khalik, 671 F.3d at 1192 (“Twombly and Iqbal do not require that the complaint include all facts necessary to carry the plaintiff's burden.”) (quoting al-Kidd v. Ashcroft, 580 F.3d 949, 977 (9th Cir. 2009)).

         Lastly, “[w]hile the 12(b)(6) standard does not require that Plaintiff establish a prima facie case in [the] complaint, the elements of each alleged cause of action help to determine whether Plaintiff has set forth a plausible claim.” Khalik, 671 F.3d at 1191 (citing Swierkiewicz v. Sorema N.A., 534 U.S. 506, 515 (2002)).


         I. Anthony Woska

         A. Breach of Contract

         To state a claim for breach of contract under Oklahoma law, a plaintiff must sufficiently plead the following elements: (1) the existence of a contract, (2) the defendant's breach of that contract, and (3) damages the plaintiff suffered as a result of the breach. Digital Design Group, Inc. v. Information Builders, Inc., 2001 OK 21, ¶ 33, 24 P.3d 834, 843; Coen v. SemGroup Energy Partners G.P., LLC, 2013 OK CIV APP 75, ¶ 32, 310 P.3d 657, 666.

         Defendants contend Woska has not alleged sufficient facts to state a plausible claim for breach of contract because he has not identified the terms of an existing contract that would allow the Court to draw a reasonable inference that BCBS is liable for any breach. See Mot. at 4. The Court disagrees. In ruling on a motion to dismiss for failure to state a claim, the Court assumes as true all well-pled facts and views them in a light most favorable to the plaintiff. Brokers' Choice of America, Inc. v. NBC Universal, Inc., 757 F.3d 1125, 1135-36 (10th Cir. 2014). Here, the Petition alleges that Plaintiff had in force and effect an insurance policy issued by Defendants. Petition, ¶ 24 [Doc. No. 1-2]. It alleges proton therapy treatment was expressly-or should have been-a covered service under the policy's provisions. Petition at ¶¶ 24, 40. The Petition further alleges that Defendants wrongfully breached the policy by refusing to provide ...

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