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Hansel v. Aetna Life Insurance Co.

United States District Court, E.D. Pennsylvania

June 25, 2018

WILLIAM HANSEL, Plaintiff,
v.
AETNA LIFE INSURANCE CO., et al., Defendants.

          MEMORANDUM OPINION

          Mitchell S. Goldberg, J.

         Plaintiff William Hansel brings claims under the civil enforcement provision of the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1132(a)(1)(B), against Defendants Aetna Life Insurance Company (“Aetna”) and Lincoln National Life Insurance Company (“Lincoln”), seeking disability benefits under an employee benefits plan. Aetna has moved to dismiss Plaintiff's Amended Complaint pursuant to Federal Rule of Civil Procedure 12(b)(6) for failure to state a claim.[1] Because I find Aetna's arguments to be factual, Defendant's Motion to Dismiss is premature. I will therefore deny the Motion.

         I. FACTUAL BACKGROUND

         The Amended Complaint sets forth the following facts:[2]

         From December 1, 2015 until mid-2016, Plaintiff was an employee of Anexinet Corporation (“Anexinet”), who provided Plaintiff with a disability insurance plan governed by ERISA and sponsored by third-party insurers. Lincoln was the plan's sponsor prior to March 1, 2016, and Aetna sponsored it from March 1 onward. The terms of the Aetna policy are described in a “Booklet-Certificate” that Plaintiff attached to his Amended Complaint.[3] The policy offered short-term and long-term disability benefits. (Am. Compl. ¶¶ 1-3, 7-16.)

         On February 26, 2016, Plaintiff alleges that he “went out of work with severe anxiety and depression, and exacerbation of his bi-polar disorder.” He “was non-functional to the point of not being able to leave his home.” On March 4, 2016, Plaintiff was admitted to a treatment center. Since then, Plaintiff has been under the ongoing supervision of a physician. At the time Plaintiff filed his Complaint, he was still unable to work. (Id. ¶¶ 17-21.)

         On March 4, 2016, Plaintiff applied to Aetna for short-term disability benefits. Aetna denied coverage because it concluded that Plaintiff's disability started on February 26, 2016- the day of his first absence from work-four days before the Aetna coverage period began on March 1, 2016. Plaintiff then applied to Lincoln, which also denied coverage, based on, among other reasons, its conclusion that Plaintiff's disability did not begin until March 4, 2016, the date Plaintiff first sought treatment. This date was four days after the Lincoln coverage period ended on February 29, 2016. (Id. ¶¶ 25-29.)

         Plaintiff did not apply to either Lincoln or Aetna for long-term disability benefits. Under both insurer's policies, a participant is not eligible for long-term disability before exhausting short-term disability. Plaintiff alleges that, given both insurers' positions that he was not eligible for short-term disability, applying for long-term disability would have been futile. (Id. ¶¶ 46-49, 57-59.)

         Plaintiff filed suit in this Court on August 31, 2017, seeking an award of short-term and long-term disability benefits from both insurers, a declaration of his future right to receive long-term disability benefits, and attorney's fees and costs. (Id. ¶¶ 83, 102.)

         II. STANDARD OF REVIEW

         To survive a motion to dismiss pursuant to Federal Rule of Civil Procedure 12(b)(6), a complaint must “contain sufficient factual matter, accepted as true, to ‘state a claim for relief that is plausible on its face.'” Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009) (quoting Bell Atlantic Corp. v. Twombly, 550 U.S. 544, 570 (2007)). The plausibility standard requires more than a “sheer possibility that a defendant has acted unlawfully.” Id. To determine the sufficiency of a complaint under Twombly and Iqbal, a court must take the following three steps: (1) the court must “take note of the elements a plaintiff must plead to state a claim;” (2) the court should identify the allegations that, “because they are no more than conclusions, are not entitled to the assumption of truth;” and (3) “where there are well-pleaded factual allegations, [the] court should assume their veracity and then determine whether they plausibly give rise to an entitlement for relief.” Burtch v. Milberg Factors, Inc., 662 F.3d 212, 221 (3d Cir. 2011) (alterations and citations omitted). Plaintiff's claims are analyzed below under this standard.

         III. ANALYSIS

         ERISA permits a plan beneficiary to bring an action “to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan.” 29 U.S.C. § 1132(a)(1)(B). To succeed in such an action, a plaintiff must show that he was owed benefits under the plan and that benefits were wrongly denied. Manning v. Sanofi-Aventis, U.S. Inc., No. 3:11-cv-1134, 2012 WL 3542284, at *3 (M.D. Pa. Aug. 14, 2012). Additionally, the plaintiff must first have exhausted administrative remedies under the plan or show that exhaustion would be futile. Berger v. Edgewater Steel Co., 911 F.2d 911, 916 (3d Cir. 1990).

         Aetna argues that Plaintiff has not plausibly alleged an entitlement to relief because the undisputed facts show that: (a) Plaintiff's disability began before the start of the Aetna policy, putting it outside the policy's coverage; (b) even if Plaintiff was not disabled before the start of the policy, his absence from work delayed coverage until after he became disabled; and (c) Plaintiff has not ...


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