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Swanson v. Aetna Life Insurance Co.

United States District Court, D. Colorado

January 5, 2016

ALICE E. SWANSON, Plaintiff,
v.
AETNA LIFE INSURANCE COMPANY; Defendant.

ORDER ON MOTION TO DISMISS

WILEY Y. DANIEL, SENIOR UNITED STATES DISTRICT JUDGE

I. INTRODUCTION AND BACKGROUND

THIS MATTER is before the Court on Defendants’ Motion to Dismiss (ECF No. 9), filed on June 16, 2015. A response was filed on July 7, 2015, and a reply was filed on July 17, 2015. Subsequent to the motion being fully briefed, the parties filed a Stipulation of Dismissal with Prejudice of Bank of America Corporation and Bank of America Benefit Plan from the Second Claim for Relief (see ECF No. 19). That stipulation was received and accepted by the Court on August 26, 2015. Plaintiff then filed a Supplemental Citation of Authority in Response to Defendants’ Motion to Dismiss (see ECF No. 20). Defendants then filed a Motion to Supplement the Motion to Dismiss (ECF No. 26), on September 14, 2015, in light of the subsequent filings beyond the time that the motion was fully briefed. A response to that motion was filed on October 5, 2015, and a reply was filed on October 15, 2015. Accordingly, there are two pending motions before the Court - the Defendants’ Motion to Dismiss (ECF No. 9), and the Defendants’ Motion to Supplement the Motion to Dismiss (ECF No. 26).

By way of background, this case arises out of Plaintiff’s claim for Accidental Death and Personal Loss (“ADPL”) benefits pursuant to an employee welfare benefits plan governed by the Employee Retirement Income Security Act, 29 U.S.C. § 1001 et seq, (“ERISA”). Plaintiff alleges that she is entitled to the ADPL benefits due to the death of her spouse, who was a participant under the benefits plan. The plan was issued to Bank of America, designating Aetna as the claims administrator and Bank of America as the plan administrator. Aetna approved the Plaintiff’s claim for basic life and supplemental life insurance benefits, but denied her claim for ADPL benefits, claiming that her spouse’s death was not a covered loss under the terms of the plan. Plaintiff filed an administrative appeal, and Aetna affirmed the original denial. Plaintiff brings two claims for relief in her amended complaint: the first for benefits under 29 U.S.C. § 1133(2) and the second for penalties under 29 U.S.C. § 1132(c)(1). She seeks declaratory relief, actual damages, attorney’s fees and other costs, including expert witness fees.

Defendants’ Motion to Dismiss argues that Plaintiff’s Amended Complaint fails to state a claim upon which relief can be granted. They claim that under the statutory provision cited by the Plaintiff in her first claim, there is no right to a substantive cause of action. For Plaintiff’s second claim, they claim that the statutory provision cited by the Plaintiff only allows a claim for penalties to be brought against a plan administrator, not a claims administrator, and since the Plaintiff only requested documents of Aetna (the claims administrator), the claim cannot stand.

While Plaintiff refers to disputed and undisputed facts in her response to the motion to dismiss, at this stage I must “accept all well-pleaded facts” in the complaint “as true and view them in the light most favorable” to the party asserting the claim. Jordan-Arapahoe, LLP v. Bd. Of Cnty Comm’rs, 633 F.3d 1022, 1025 (10th Cir. 2011). Plaintiff alleges that after her husband died in January of 2013, she submitted a timely claim for accidental death benefits under the benefits plan. Pl.’s Compl., ECF No. 4, p. 3; see also the Group Accident and Health Insurance Policy, attached to the motion as Exhibit A; and the Schedules of Life Insurance, Dependents Life Insurance, Accidental Death and Personal Loss, and Dependents Accidental Death and Personal Loss, attached to the motion as Exhibit B.[1]

Plaintiff alleges that she received a letter from Aetna on April 29, 2013, denying ADPL benefits. Pl.’s Compl., ECF No. 4, p. 3. Plaintiff states that she requested documentation from Aetna on May 17, 2013 and June 26, 2013, including a certified copy of the policy and the documents used in determining the denial. Plaintiff contends that she made these requests based on language in the denial letter from Aetna, stating that it would produce “upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to your claim for benefits.” Id. Plaintiff made additional requests on November 18, 2013, March 3, 2014, March 14, 2014, and November 19, 2014. Id. at 4-5. Aetna provided a copy of the policy and “incomplete copies of purported computer notes” on November 21, 2014. Id. at 5.

Under Plaintiff’s first claim of relief, she alleges that she has not been provided “a full and complete copy of the claim record, all documents, records and other information relevant to the claim.” Id. She further claims that Aetna “was operating under a conflict of interest in making its decision to deny accidental death benefits, ” claiming that Aetna’s denial decisions were “made by undisclosed representatives of Aetna, ” and that “Aetna has refused to fully disclose or identify the decision maker, their qualifications or what additional information or opinions were considered, despite requests for same by Plaintiff.” Id. at 6. She also contends that Aetna failed to have “rules, criteria, guidelines, protocols, manuals or other documents of that nature in place or that complied with ERISA for the review and handling of Plaintiff’s claim.” Id. She claims that the Defendants failed to adequately investigate or consider medical evidence regarding the accidental nature of her husband’s death. Id. at 6-7. Plaintiff also claims that she was denied a full and fair review of the ADPL claim. Id. at 8.

Under her second claim of relief, Plaintiff claims that the Defendants have “delayed or failed to produce other instruments under which the Plan is established” and that they “intentionally and without basis delayed and failed to produce upon request all documents, records and other information relevant to Plaintiff’s claim for benefits” as well as those generated during the appeal process. Id. at 9. She notes that under 29 U.S.C. § 1132(c)(1)(B), she is entitled to the statutory penalty of $110 per day for each of the violations she identified in her Amended Complaint. Id.

II. ANALYSIS

A. Standard of Review

In reviewing a motion to dismiss, the court must “accept all well-pleaded facts as true and view them in the light most favorable” to the party asserting the claim. Jordan-Arapahoe, LLP, 633 F.3d at 1025. To survive a motion to dismiss under Rule 12(b)(6), the party asserting the claim “must allege that ‘enough factual matter, taken as true, [makes] his claim for relief ... plausible on its face.’” Id. (quotation and internal quotation marks omitted). “A claim has facial plausibility when the [pleaded] factual content [ ] allows the court to draw the reasonable inference that the defendant is liable for the misconduct alleged.’” Id. (quotation omitted).

Thus, a party asserting a claim “must include enough facts to ‘nudge[] his claims across the line from conceivable to plausible.’” Dennis v. Watco Cos., Inc., 631 F.3d 1303, 1305 (10th Cir. 2011) (quotation omitted). Conclusory allegations are not sufficient to survive a motion to dismiss. Gallagher v. Shelton, 587 F.3d 1063, 1068 (10th Cir. 2009). “[A]lthough a statute of limitations bar is an affirmative defense, it may be resolved on a Rule 12(b)(6) motion to dismiss when the dates given in the complaint make clear ...


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