United States District Court, M.D. Pennsylvania
November 29, 2005.
JANET SCOTT, Plaintiff,
AETNA LIFE INSURANCE COMPANY, et. al., Defendants.
The opinion of the court was delivered by: A. CAPUTO, District Judge
Presently before the Court are Defendant Aetna Life Insurance
Company's Motion for Summary Judgment (Doc. 30) and Plaintiff
Janet Scott's Motion for Summary Judgment (Doc. 35). For the
reasons set forth below, the Court will grant Defendant's motion
and deny Plaintiff's motion. The Court has jurisdiction over this
matter pursuant to 28 U.S.C. § 1331.
Plaintiff enrolled herself and her spouse in a life insurance
plan ("the Plan") governed by the Employee Retirement Income
Security Act, 29 U.S.C. §§ 1001, et seq., ("ERISA").
Plaintiff's employer, Thomson Education Direct ("Thomson"),
administered the plan. (Doc. 31, Ex. 1, Aetna-00033.) Defendant
Aetna administered claims under the Plan. Id.
On September 15, 1997, Plaintiff elected "spouse coverage" in
the amount of $60,000.00 for her husband. (Doc. 31, Ex. 2.) Under
the terms of the Plan, the maximum amount for a spouse may not
exceed twice the employee's annual earnings after being rounded
to the next higher $10,000. (Doc. 31, Ex. 1, Aetna-00030.) Furthermore, one can become insured with respect to a dependant
for an amount of Life Insurance in excess of $35,000 only if one
submits evidence of that dependent's good health to Aetna and
such evidence is approved by Aetna. Id. Plaintiff did not meet
either of these requirements upon electing coverage for her
husband in the amount of $60,000.00, however, Plaintiff submitted
evidence that premiums were deducted from her paychecks by
Thomson for this level of coverage. (Doc. 31, Ex. 7,
On October 13, 2001, Plaintiff and Mr. Scott divorced. (Doc. 11
¶ 11.) Plaintiff informed her employer, Thomson, that the divorce
was finalized. (Doc. 37 ¶ 8.) Plaintiff, however, did not inform
Aetna directly of the change in her marital status. Plaintiff
submitted evidence that Thomson told her that her former
husband's insurance would continue through December 31, 2001.
(Doc. 37 ¶ 9; Doc. 31, Ex. 7, Aetna-00064.) Thomson also
continued to deduct premiums from Plaintiff's paycheck for life
insurance for Mr. Scott through the end of December, 2001. (Doc.
31, Ex. 4, Aetna-00066.)
Mr. Scott died suddenly on December 27, 2001. (Doc. 31, Ex. 5,
Aetna-00086.) Following Mr. Scott's death, Plaintiff submitted a
claim to Aetna for life insurance benefits. (Id. at Ex. 3,
Aetna 00056-57.) Aetna denied Plaintiff's claim for benefits
after it determined that Mr. Scott ceased to be an eligible
dependent as of the date that Mr. and Mrs. Scott's divorce became
final. (Id. at Ex. 6, Aetna-00062.) Plaintiff appealed the
denial of her claim.
On February 5, 2002, the Aetna claims examiner authored the
DC INDICATED THAT DECEDENT WAS DIVORCED FROM THE
EMPLOYEE JANET SCOTT CALLED CLAIRE AT PH OFFICE . . .
TALKED TO HER ABOUT COVERAGE SHE INDICATED THAT
ALTHOUGH EE WAS DIVORCED THE HR AREA HAD NOT BEEN NOTIFIED AND THE LOCATION WHERE EE WORKS THOUGHT THAT
COVERAGE WOULD CONTINUE FOR 90 DAYS TOLD HER THAT
TO THE BEST OF MY KNOWLEDGE COVERAGE WOULD HAVE ONLY
BEEN IN FORCE TO 30 DAYS AFTER DIVORCE. ALSO CHECKED
WITH CONVERSION UNIT TO SEE IF THEY HAD APPLIED TO
CONVERT THE SPOUSE COVERAGE AT THE TIME OF THE
DIVORCE PER PH THEY WERE DIVORCED IN OCTOBER 2001
NOTHING WAS RECV'D IN CONVERSIONS PH WANTS TO
RELEASE TO EXAMINER TO SEE IF PAYMENT CAN BE MADE.
(Doc. 37 ¶ 12; Doc. 36, Ex. 1.) Following further investigation,
Aetna upheld the denial of Plaintiff's claim. Id.
Plaintiff then filed the present suit pursuant to ERISA, which
was removed to this Court on March 23, 2004. (Doc. 1.) On June
10, 2004, Plaintiff filed an Amended Complaint. (Doc. 11.) On
August 31, 2004, the Court granted a Motion to Dismiss
Plaintiff's employer, Thomson, from suit. (Doc. 23.) On June 30,
2005, Defendant Aetna filed a motion for summary judgment. (Doc.
30.) Plaintiff filed a motion for summary judgment on July 15,
2005. (Doc. 35.) Both motions are fully briefed and ripe for
Summary judgment is appropriate if "the pleadings, depositions,
answers to interrogatories, and admissions on file, together with
the affidavits, if any, show that there is no genuine issue as to
any material fact and that the moving party is entitled to a
judgment as a matter of law." FED. R. CIV. P. 56(c). A fact is
material if proof of its existence or nonexistence might affect
the outcome of the suit under the applicable substantive law.
See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). Where there is no material fact in dispute, the moving party
need only establish that it is entitled to judgment as a matter
of law. Where, however, there is a disputed issue of material
fact, summary judgment is appropriate only if the factual dispute
is not a genuine one. See id. at 248. An issue of material fact
is genuine if "a reasonable jury could return a verdict for the
nonmoving party." Id.
Where there is a material fact in dispute, the moving party has
the initial burden of proving that: (1) there is no genuine issue
of material fact; and (2) the moving party is entitled to
judgment as a matter of law. See CHARLES ALAN WRIGHT & ARTHURR.
MILLER, FEDERAL PRACTICE AND PROCEDURE: CIVIL 2D § 2727 (2d ed.
1983). The moving party may present its own evidence or, where
the nonmoving party has the burden of proof, simply point out to
the Court that "the nonmoving party has failed to make a
sufficient showing of an essential element of her case." Celotex
Corp. v. Catrett, 477 U.S. 317, 323 (1986).
All doubts as to the existence of a genuine issue of material
fact must be resolved against the moving party, and the entire
record must be examined in the light most favorable to the
nonmoving party. See White v. Westinghouse Elec. Co.,
862 F.2d 56, 59 (3d Cir. 1988). Once the moving party has satisfied its
initial burden, the burden shifts to the nonmoving party to
either present affirmative evidence supporting its version of the
material facts or to refute the moving party's contention that
the facts entitle it to judgment as a matter of law. See
Anderson, 477 U.S. at 256-257.
The Court need not accept mere conclusory allegations, whether
they are made in the complaint or a sworn statement. Lujan v.
Nat'l Wildlife Fed'n, 497 U.S. 871, 888 (1990). In deciding a motion for summary judgment, "the judge's
function is not himself to weigh the evidence and determine the
truth of the matter but to determine whether there is a genuine
issue for trial." Anderson, 477 U.S. at 249.
1. Standard of Review
Defendant argues it is entitled to an "arbitrary and
capricious" standard of review as detailed in Firestone Tire &
Rubber Co. v. Bruch, 489 U.S. 101 (1989) and Pinto v. Reliance
Standard Life Insurance Co., 214 F.3d 377 (3d Cir. 2000).
Plaintiff counters that the Court is required to review the
denial of her claim under a de novo standard of review. Because
I find that even under a de novo standard of review Defendant
is entitled to summary judgment, I will review Plaintiff's claim
de novo without further determination of the appropriate
2. Plaintiff's Claim
Pursuant to 29 U.S.C. § 1132(a)(1)(B), a claimant may bring a
civil action to recover benefits due to her under the terms of
her plan. In the present case, Plaintiff seeks to recover life
insurance benefits for her ex-husband. Plaintiff argues that the
Plan is ambiguous because it does not expressly state that
"spousal coverage" terminates after a divorce, and she should
therefore be entitled to benefits. Plaintiff points to the
alleged confusion of her employer, Thomson, as well as Aetna's
claim examiner in support of her contention that the Plan is
ambiguous. For the reasons set forth below, I disagree and find
that the language of the Plan is clear as to Mr. Scott's
ineligibility for coverage under the Plan. In interpreting the terms of an ERISA plan, the Court examines
the plan documents as a whole and, if they are unambiguous,
construes them as a matter of law. See Kemmerer v. ICI Americas
Inc., 70 F.3d 281, 288-89 (3d Cir. 1995). In interpreting the
"provisions of a plan governed by ERISA, terms `must be given
their plain meanings, meanings which comport with the
interpretation given by the average person.'" Int'l Union,
United Auto., Aero. & Agric. Implement Workers v. Skinner Engine
Co., 15 F. Supp. 2d 773, 780 (W.D. Pa. 1998) (citing Wickman v.
Northwestern Nat'l Ins. Co., 908 F.2d 1077, 1084 (1st Cir.
1990), cert. denied, 498 U.S. 1013 (1990)). A term is ambiguous
if it is subject to reasonable alternative interpretations. Id.
at 780. However, if upon review, a court can find "but one
reasonable interpretation, then a fortiori there can be no
ambiguity." Id. (citing Curcio v. John Hancock Mut. Life Ins.
Co., 33 F.3d 226, 231 (3d Cir. 1994)).
In the present case, the Plan's "Summary of Coverage" states
under the section titled "Dependents" that:
You may cover your:
wife or husband
(Doc. 31, Ex. 1, Aetna-00026.)
Further, under the section "Termination of Coverage" the Plan
states, in relevant part, that:
A dependent's coverage will terminate at the first
to occur of:
When such person is no longer a defined
(Doc. 31, Ex. 1, Aetna-00046-47.)
Even under a de novo standard of review, I find the Plan's
language to be unambiguous. By the literal terms of the Plan, insurance on Mr.
Scott ceased when he ceased to be Plaintiff's husband. The Plan
specifically states that a dependent's coverage terminates when
the person is no longer a defined dependent. Dependent is defined
in the Plan, in relevant part, as your "wife or husband." Upon
divorce, Mr. Scott was no longer Plaintiff's husband. As I can
find only one reasonable interpretation, the language of the Plan
is not ambiguous as to Mr. Scott's ineligibility for coverage
following the finalization of his divorce.
In support of her argument, Plaintiff relies on Lewis v. Cox
Enter., Inc., No. 94-2792, 1995 WL 321754 (E.D. La. May 24,
1995). In Lewis, a company representative told the plaintiff
that he could maintain coverage for his ex-spouse, and continued
to deduct premiums for the insurance for over two years after the
plaintiff's divorce. The policy language in Lewis was identical
to the language here. The court found that the term "defined
dependent" was ambiguous, and that the language could be
construed in favor of coverage. As previously stated, I find the
Plan's language to be clear and unambiguous in the instant case,
and I therefore decline to follow Lewis.
As there is no genuine issue of material fact as to Mr. Scott's
ineligibility for coverage under the Plan, Plaintiff's motion for
summary judgment will be denied and Defendant's motion for
summary judgment will be granted.
The Plan is not ambiguous and there is no genuine is of
material fact as to Mr. Scott's ineligibility for coverage under
the Plan. Therefore, Aetna properly denied Plaintiff's claim for
life insurance benefits for her ex-husband. Plaintiff's motion
for summary judgment will be denied and Defendant's motion for
summary judgment will be granted.
An appropriate Order will follow. ORDER
NOW, this 29th day of November, 2005, IT IS HEREBY
(1) Defendant Aetna Life Insurance Company's Motion for Summary
Judgment (Doc. 30) is GRANTED.
(2) Plaintiff Janet Scott's Motion for Summary Judgment (Doc.
35) is DENIED.
(3) The Clerk of Court shall mark this case CLOSED.
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