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Desue v. Aetna Life Insurance Co.

United States District Court, W.D. Pennsylvania

February 9, 2017

JOANNE DESUE, Plaintiff,


          Arthur J. Schwab United States District Judge

         I. Introduction

         Joanne 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.

         II. Background

         Plaintiff 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.

         Plaintiff 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 occupation.” Id.

         In 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.

         After 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[.]” Id.

         In May 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.

         As 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.

         III. Standard of Review

         To 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. at 678.

         IV. Discussion

         Defendants' motion raises one issue: whether Plaintiff should be permitted to simultaneously pursue claims under § 1132(a)(1)(B) for denial of benefits ...

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