United States District Court, W.D. Pennsylvania
J. Schwab United States District Judge
DeSue (“Plaintiff”) brings this action against
Aetna Life Insurance Co., the Bank of America
(“BOA”) Corporate Benefits Committee, and the
Bank of America Long Term Disability Plan
(“Defendants”), alleging violations of the
Employee Retirement Income Security Act of 1974
(“ERISA”), 29 U.S.C. § 1001 et seq.
Currently pending before this Court is Defendants' Motion
to Dismiss Count II of the Amended Complaint, along with a
brief in support. Doc. nos. 18-19. Plaintiff filed a Response
thereto. Doc. no. 27. Defendant filed a Reply. Doc. no. 28.
This matter is ripe for review.
initiated this action on October 31, 2016, by filing a
three-count Complaint against Defendants. Doc. no. 1. On
January 3, 2017, Defendants filed a Motion to Dismiss Counts
II and III. Doc. no. 11. Plaintiff responded by filing a
two-count Amended Complaint, in which she asserts claims for
denial of benefits under 29 U.S.C. § 1132(a)(1)(B), and
breach of fiduciary duty under 29 U.S.C. § 1132(a)(3).
Doc. no. 16.
worked for BOA from October 10, 2011, through August 7, 2013,
during which time she was insured “under a group long
term disability insurance policy (the ‘Group
Policy') underwritten and administered by Aetna.”
Id. ¶ 7. The Group Policy provides benefits to
any participant who cannot “perform the material duties
of [her] own occupation, solely because of: disease or
injury” for up to 18 months. Id. ¶ 9.
After 18 months, the Group Policy provides benefits only if
the participant cannot “work at any reasonable
August 2013, Plaintiff stopped working and was approved for
FMLA leave and short term disability benefits, which lasted
through February 2, 2014. Id. ¶¶ 12-13.
She alleges, however, that throughout that period,
“Aetna terminated [her] benefits, forcing her to appeal
in order to reinstate benefits payments on at least three
occasions.” Id. ¶ 16. “[T]he
terminations and delays caused [her] employment with BOA to
be terminated and caused a loss of [medical and life]
insurance coverage.” Id.
her short term disability expired, Plaintiff sought long term
benefits under the Plan. Id. ¶ 17. Aetna
initially denied her claim, but that decision was overturned
on appeal on June 24, 2014, so “benefits were paid
effective February 6, 2014 and continued through August 5,
2015” - i.e., for the full, 18-month “own
occupation” period. Id. ¶¶ 21-23. In
the meantime, Plaintiff claims that Aetna “stop[ed] and
start[ed] her benefits and ma[de] it difficult for her to get
needed medical treatment, because she had no income to pay
for medical insurance[.]” Id. ¶ 40. More
specifically, Plaintiff alleges that “Aetna terminated
[her] benefit effective January 16, 2015, due to insufficient
‘evidence of an impairment severe enough that would
prevent [her] from performing the material duties of [her]
occupation[, ]'” but “[b]enefits were
reinstated in February 2015 ‘as a courtesy' and
then terminated again on February 17, 2015[.]”
Id. The next month, Plaintiff was advised that
“Aetna had placed her file ‘on hold' while
waiting to obtain medical records, rather than continuing to
pay benefits until records were received and reviewed, a
delay caused by Aetna's own failure to pay an invoice for
the records, and then advised her that she was required to
appeal in order to overturn the decision[.]”
Id. In April 2015, Aetna withheld benefits while it
“sent [Plaintiff's] file for a ‘full file
review' from a clinician, a review which had not been
undertaken even though there was evidence in the file of
ongoing impairment . . . [B]enefits were reinstated as of
February 2015, and authorized through August 2015[.]”
2015, Aetna began to consider whether Plaintiff was
restricted from working in any occupation and thus entitled
to a continuation of benefits. Id. ¶ 40. On
July 29, 2015, Aetna terminated Plaintiff's benefits
after concluding that she could perform full-time sedentary
work; her appeal was denied on February 18, 2016.
Id. ¶ 27. Plaintiff alleges that “Aetna
rendered its decision before receiving additional information
from [her] which it invited her to submit[.]”
Id. ¶ 39. “Due to the interruption and
loss of her benefits, ” Plaintiff claims that she was
“forced to forego medical insurance, which she could
not afford, she lost her life insurance, and she was forced
to borrow money, incur interest and draw on her retirement
savings to meet her basic living expenses.”
Id. ¶ 58.
relief, Plaintiff seeks “all benefits due under the
Plan from August 2015 to the date of judgment[.]”
Id. at 15. She also seeks to “[e]njoin
Defendants to provide a procedure for full and fair review of
adverse determinations under the Plan in accordance with 29
U.S.C. § 1133” and “to discharge their
fiduciary duties in accordance with 29 U.S.C. § 1104,
” as well as “restitution or surcharge to
disgorge Defendants' unjust enrichment in wrongfully
delaying and denying benefits and/or to make Plaintiff whole
for losses, including[, ] but not limited to[, ] harm
suffered for the delay in getting medical treatment, the loss
of income and interest incurred on loans to pay for basic
living expenses, the loss of retirement savings, loss of life
insurance and payment of attorneys' fees caused by
Aetna's violation of 29 U.S.C. § 1133 and breach of
fiduciary duty[.]” Id. at 16.
Standard of Review
survive a motion to dismiss under Rule 12(b)(6), a complaint
must allege “enough facts to state a claim for relief
that is plausible on its face.” Bell Atl. Corp. v.
Twombly, 550 U.S. 544, 570 (2007). “The District
Court must accept the complaint's well-pleaded facts as
true, but may disregard any legal conclusions.”
Fowler v. UPMC Shadyside, 578 F.3d 203, 210 (3d Cir.
2009) (citation omitted). “Threadbare recitals of the
elements of a cause of action, supported by mere conclusory
statements, do not suffice.” Iqbal, 556 U.S.
motion raises one issue: whether Plaintiff should be
permitted to simultaneously pursue claims under §
1132(a)(1)(B) for denial of benefits ...