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Gray v. Aetna Life Inc. Co.

United States District Court, M.D. Alabama, Southern Division

December 18, 2018

CANTRICE GRAY Plaintiff,
v.
AETNA LIFE INSURANCE COMPANY, Defendant.

          REPORT AND RECOMMENDATION

          DAVID A. BAKER UNITED STATES MAGISTRATE JUDGE

         Plaintiff, Cantrice Gray, sues Defendant, Aetna Life Insurance Company, (“Aetna”) in a single-count complaint seeking to enforce her rights and recover benefits as the beneficiary to supplemental life insurance benefits under a policy of group life insurance issued by Aetna. (Doc. 1). All claims are brought pursuant to the Employee Retirement Income Security Act of 1974, as amended, 29 U.S.C. § 1001, et seq. (“ERISA”). This matter is before the Court on Aetna's motion to dismiss. (Doc. 11). Plaintiff filed a response in opposition (Doc. 14) and Defendant replied (Doc. 18). The court heard argument on August 7, 2018. For the reasons that follow, the Magistrate Judge recommends that Aetna's motion to dismiss be granted.

         I. JURISDICTION

         The court has subject matter jurisdiction over this dispute pursuant to 28 U.S.C. § 1331. Personal jurisdiction and venue are not contested by the parties, and the court finds sufficient basis in the record to support both. See 28 U.S.C. § 1391. On August 13, 2018, the above-styled matter was referred for review and recommendation by United States District Judge Emily C. Marks. (Doc. 24); see also 28 U.S.C. § 636(b); Rule 72, Fed. R. Civ. P.; United States v. Raddatz, 447 U.S. 667 (1980); Jeffrey S. v. State Board of Education of State of Georgia, 896 F.2d 507 (11th Cir. 1990).[1]

         II. BACKGROUND AND STATEMENT OF FACTS [2]

         On January 29, 2018, Plaintiff Cantrice Gray (“Gray”) filed a Complaint against Defendant Aetna under ERISA, claiming she is the beneficiary of proceeds of a policy of insurance issued to Bennie Joe Willis, Jr., who was employed by Performance Food Group, Inc. (“PFG”) (Doc. 1). Subsequent to Willis' hire by PFG, he requested Supplemental Life Insurance coverage in the amount of $126, 000 under the group life insurance policy made available to PFG employees through a benefit plan issued by Aetna (“the Plan”). Id. ¶ 7. Because the request was made more than sixty days after his eligibility date, Aetna required Willis to submit evidence of good health which he submitted via an Evidence of Insurability Statement to Aetna on December 22, 2014. Id. ¶ 8. Aetna approved the application and issued the Supplemental Life Insurance coverage under the Plan effective on January 1, 2015. Id. Gray alleges that while the Supplemental Life Insurance coverage was in force, Willis died from injuries sustained in an automobile accident on January 5, 2016. Id. ¶ 9.

         Aetna paid benefits to Gray in the amount of $42, 129.05 under the Basic Life Coverage of the Policy and $178, 000 under the Accidental Life Insurance Coverage of the Policy. Id. ¶ 12. Gray demanded Aetna pay the Supplemental Life insurance benefits under the policy, but Aetna denied Gray's claim on May 9, 2017. Id. ¶¶ 11, 13. Gray attaches to her Complaint a copy of the May 9, 2017 letter from Aetna to her denying her claim for Supplemental Life insurance benefits. (Doc. 1-1). Based on Aetna's review of Willis' medical records, Aetna concluded that full disclosure did not occur on the Evidence of Insurability submitted by Willis with his application for insurance. Id. at 4. Aetna states that had his medical conditions been disclosed, his application for Supplemental Life insurance benefits would have been denied under its Medical Underwriting guidelines. Id. The letter advised that in order to have the denial reviewed, the written request seeking review “must be mailed or delivered within 60 days following receipt of this explanation.” Id. at 5.

         On October 5, 2017, Gray, through counsel, challenged the denial of her benefits and requested information from Aetna. (Doc. 1, ¶ 14). She attaches a copy of the October 5 letter to her complaint. (Doc. 1-2). On October 19, 2017, Aetna requested a signed authorization in order to release Willis' medical records. (Doc. 1, ¶ 15). Gray's counsel forwarded the signed authorization on October 27, 2018. Id. ¶ 16. Gray alleges that Aetna did not respond to her lawyers' letters of October 5 and 27, nor did it provide the requested information. Id. ¶ 18. She asserts that Aetna violated the Plan and the ERISA statute in failing to review her claim on appeal. Id. ¶ 19. She alleges she has exhausted all of her claim remedies or exhaustion is otherwise futile. Id. ¶ 21.

         In a single-count complaint, she seeks to enforce her rights under the Plan as regulated by ERISA. (Doc. 1). She alleges that Aetna's actions in denying her benefits was wrongful and she seeks $126, 000 in Supplemental Life insurance benefits, interest on past due benefits, and any other relief available. Id. ¶¶ 22-28.

         Aetna moves to dismiss Gray's complaint for failure to timely appeal and exhaust her administrative remedies. (Doc. 11).[3] Aetna contends that Gray's claim is barred for failing to timely appeal the denial of her claim. It further asserts that her arguments of futility and that her claim should be deemed exhausted do not otherwise save her claim.

         In response, Gray submits that the court has discretion to determine whether to apply the exhaustion requirement. (Doc. 14 at 2). Where, as here, Aetna controlled the Plan documents and denied Gray access to them, she argues the court should exercise its discretion to not require the exhaustion requirement be met given she was denied meaningful access to the Policy's procedures and Aetna's basis for denial of her claim. Id. at 8-14.

         III. STANDARD OF REVIEW

         Federal Rule of Civil Procedure 8 provides that a complaint must contain “a short and plain statement of the claim showing that the pleader is entitled to relief.” Fed.R.Civ.P. 8(a)(2). The pleader must allege “enough facts to state a claim to relief that is plausible on its face.” Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007). “[D]etailed factual allegations” are not required, but mere “labels and conclusions” or “a formulaic recitation of the elements of a cause of action” are not enough. Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009). On a motion to dismiss under Federal Rule of Civil Procedure 12(b)(6), a court “accept[s] the allegations in the complaint as true and constru[es] them in the light most favorable to the plaintiff.” Hill v. White, 321 F.3d 1334, 1335 (11th Cir. 2003).

         IV. ...


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