Meyer v Group Long Term Disability Plan et al

Filing 19

ORDER denying 14 Defendants' Motion to Dismiss for Failure to State a Claim. Entered by Chief Judge James E. Shadid on 10/10/2017. (RT, ilcd)

E-FILED

Tuesday, 10 October, 2017 12:05:48 PM
Clerk, U.S. District Court, ILCD
IN THE
UNITED STATES DISTRICT COURT
CENTRAL DISTRICT OF ILLINOIS
PEORIA DIVISION
SHERRY MEYER,
Plaintiff,
v.

Case No. 1:16-cv-01282-JES-JEH

GROUP LONG TERM DISABILITY
PLAN FOR EMPLOYEES OF EDWARD
D. JONES & CO., L.P. and HARTFORD
LIFE AND ACCIENTAL INSURANCE
COMPANY,
Defendant.

ORDER
Now before the Court is the Defendants’ Motion to Dismiss for Failure to State a Claim.
(D. 14). 1 The Defendants have filed a Memorandum in Support of their Motion (D. 15) as well
as a Reply (D. 18) in the wake of the Plaintiff’s Response (D. 16). For the reasons set forth
below, the Defendants’ Motion is DENIED. 2
BACKGROUND
The Plaintiff, Sherry Meyer, filed her Complaint in this case on July 27, 2016. (D. 1).
She brings her claim under the Employee Retirement Income Security Act of 1974, 29 U.S.C. §
1132(a)(1)(B) (“ERISA”). The Plaintiff was employed by Edward Jones & Co. L.P. (“Jones”).
Defendant Hartford Life and Accidental Insurance Company (“Hartford”) insured an employee
welfare benefit plan (“the Plan”) sponsored by Jones under ERISA. If a Jones employee became
disabled while insured by the Plan, the Plan provided coverage for long-term disability benefits

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Citations to the Docket in this case are abbreviated as “D. __.”
The Court notes that the Defendants’ Motion has been ripe since November 2, 2016 when they filed their Reply.
The Court apologizes for any delay it has caused in resolving this matter more promptly.

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to eligible participants and beneficiaries. To qualify, employees must be disabled for ninety
continuous days, continue to have a disability after ninety days, and submit a proof of loss to
Hartford. The Plaintiff was a participant in the Plan. She also had insurance under the Plan and
was able to decide all eligibility and benefits questions.
The Plaintiff worked full-time for Jones until November 1, 2013, when she submitted a
long term disability benefit claim for her condition of major depressive disorder. Hartford
approved her claim solely on the grounds of her depressive disorder. Around March 2015, the
Plaintiff’s treating physician notified Hartford that the Plaintiff was released to return to work
full-time, with no restrictions. Hartford terminated her benefits because her health condition was
no longer functionally impairing according to her treating physician. Hartford told her that in
order for her to be considered for benefits, she had to demonstrate that she had a physical
condition preventing her from performing her occupational duties. Hartford explained that long
term disability benefits were denied because it had a lack of medical information regarding a
physical condition. Hartford offered Meyer two options: 1) she could perfect her claim by
providing the necessary information, or 2) if she disagreed with their determination, she could
appeal it without providing the requested information. Hartford listed the necessary information
that the Plaintiff was required to provide.
In her Complaint, the Plaintiff claims that she suffers from cervicobrachial syndrome,
fibromyalgia, chronic fatigue syndrome, neuritis, widespread pain, sleep disturbance, and
fatigue. She claims her conditions continue to prevent her from completing all of her job duties,
including lifting and working more than 28 hours per week. The Plaintiff asserts that she
provided Hartford with notice on April 6, 2015 that she was disabled, as defined by the Plan.

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On May 7, 2015, Hartford notified the Plaintiff that after a review, she was determined to
be not disabled. The Plaintiff was given the option of submitting an appeal of the decision to the
Hartford Appeal Unit. On June 2, 2015, the Plaintiff sent medical records and claim forms from
two doctors to the Appeal Unit. On August 11, 2015, Hartford denied her benefits. The Plaintiff
claims that she exhausted all administrative remedies available to her under the Plan and,
pursuant to Section 502(a) of ERISA, she is entitled to bring this action.
The Defendants now move to dismiss the Plaintiff’s Complaint. They argue that the
Plaintiff’s June 2 letter cannot be characterized as an appeal. As such, the Defendants assert that
the Plaintiff did not follow the Plan’s appeal procedure, did not exhaust her administrative
remedies as required under ERISA, and did not appeal Hartford’s disability determination within
180 days. The Defendants further contend that the Plaintiff does not sufficiently plead
exhaustion of administrative remedies or plead that she appealed Hartford’s claim determination.
Therefore, the Defendants assert, the Plaintiff’s Complaint should be dismissed with prejudice.
LEGAL STANDARD
In reviewing the Defendants’ Motion to Dismiss pursuant to Federal Rule of Civil
Procedure 12(b)(6), the Court accepts the Plaintiff’s factual allegations as true. Erickson v.
Pardus, 551 U.S. 89, 94 (2007). Allegations stated in the form of legal conclusions, however, are
insufficient to survive a motion to dismiss. McReynolds v. Merrill Lynch & Co., Inc., 694 F.3d
873, 885 (7th Cir. 2012). A complaint must contain a short and plain statement of the plaintiff’s
claim, sufficient to show entitlement to relief and to notify the defendants of the allegations against
them. Fed. R. Civ. P. 8(a)(2); Bell Atl. Corp. v. Twombly, 550 U.S. 544, 555-57 (2007). This
standard is met if the plaintiff describes in sufficient factual detail enough to suggest a right to

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relief beyond a speculative level. Id.; Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009); EEOC v.
Concentra Health Srvs., 496 F.3d 773, 776 (7th Cir. 2007).
More specifically, a complaint must go beyond “mere labels and conclusions” to contain
“enough to raise the right to relief above the speculative level.” G&S Holdings, LLC v. Cont’l
Cas. Co., 697 F.3d 534, 537-38 (7th Cir. 2012). In short, “the plaintiff must give enough details
about the subject-matter of the case to present a story that holds together. In other words, the
court will ask itself could these things have happened, not did they happen.” Swanson v.
Citibank, N.A., 614 F.3d 400, 404 (7th Cir. 2010) (emphasis in original).
ANALYSIS
The Defendants argue that the Plaintiff failed to exhaust her administrative remedies
under ERISA. Specifically, they claim that the Plaintiff’s failure to follow the applicable claims
procedures and exhaust administrative remedies cannot be cured because the Plan’s 180 day
deadline for appealing a claim denial passed before the Plaintiff filed her Complaint. Hartford
alleges it told the Plaintiff: “[i]f you wish to perfect your claim, please submit the required
information to [Penny Mccormick’s] attention.” (D. 15 at pg. 3). Hartford also informed the
Plaintiff: “you may submit an appeal of our decision to the Appeal Unit” if she was unable or did
not wish to provide that information. Id. According to the Defendants, the Plaintiff did not
submit an appeal or allege that she submitted an appeal. Rather, on June 2, 2015, the Plaintiff
sent a handwritten cover letter to the attention of Mccormick, stating the following:
Hi—Enclosed are my medical records and claim forms from two doctors. Please
advise regarding my disability income asap. EDJ [Employer] still has me on parttime, irregular schedule[sic.] leave of absence. My rheumatologist only wants me
to work 28 or less hours a week.

Id. at pg. 4.

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The Defendants state that Mccormick completed the original claim review and in an
August 11, 2015 letter, informed the Plaintiff that her claim was denied and that she had a right
to appeal. The letter also informed the Plaintiff that her appeal must be submitted within 180
days from the receipt of the denial letter and advised that she could bring a civil action under
Section 502(a) of ERISA if she appeals and Hartford again denies her claim. Id.
The Defendants also allege that the Plan lays out the requisite claim procedures,
including an explanation that a claimant must exhaust administrative remedies once a claim is
denied. Id. According to the Defendants, the Plaintiff’s Complaint does not allege that she
requested an appeal of her claim or that it was within the 180-day appeal deadline. The
Defendants argue that the Plaintiff did not specifically request an appeal in her June 2, 2015
letter, which indicated that she was submitting additional proof of loss, not an appeal. Id. at 8. If
it had been an appeal, Hartford argues, someone other than Mccormick would have reviewed the
Plaintiff’s claim. Also, if considered an appeal, the submission would have been directed to be
filed with the appeal department.
In making their argument, the Defendants acknowledge that the Plaintiff used the appeal
unit’s address, but point out that her letter was addressed to Mccormick, following the
instructions for perfecting her claim, rather than following the instructions for an appeal.
Further, they highlight that nothing in her June 2, 2015 letter stated that she disagreed with the
May 7, 2015 letter and that the Plaintiff did not request a review or give notice that she disagreed
with the May 7, 2015 letter or the August 11, 2015 letter. The Defendants emphasize that the
Plaintiff’s sole argument is that she used the P.O. Box address for the appeals unit, and thus, the
submission is an appeal. They maintain that “a communication to a claims administrator does

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not constitute an appeal if it does not clearly request an appeal of a claim decision.” (D. 18 at pg.
4).
The Plaintiff argues that she exhausted her administrative remedies prior to the
commencement of this suit. (D. 16 at pg. 3, citing Ex. A of her Complaint). She points to the
Plan’s claims procedures that state “as part of your appeal . . . you may submit written
comments, documents, records and other information relating to your claim.” Id. The Plaintiff
contends that her June 2nd letter was an appeal of Hartford’s May 7th adverse benefit
determination, as she mailed her June 2, 2015 letter and records to the address that Hartford’s
May 7, 2015 benefits determination instructed her to do. Id. at 4-5. She construes the second
adverse benefit determination on August 11, 2015 to be in response to her June 2 appeal.
The Plan allows Hartford to request further proof before it makes a benefit determination,
but only allows Hartford to consider appeals after the adverse benefit determination. (D. 1 at pp.
32-33). The May 7th letter gave the Plaintiff the option to provide further proof of loss or
simply submit an appeal of its determination. Id. at pp. 45-49. Therefore, the Plaintiff argues,
this provided her with two avenues for appeal and she exhausted her administrative remedies.
Alternatively, even if Hartford failed to follow the Plan’s claims procedures, she argues she
should be deemed to have exhausted her administrative remedies because Hartford failed to
follow the Plan’s claims procedures. (D. 16 at pg. 9).
The Defendants respond to the contention that Harford did not follow the Plan’s claim
and appeals procedures by explaining that if the Plaintiff submitted additional evidence to perfect
her claim, the May 7th letter would not be considered an adverse benefit decision and the claim
review would be extended. (D. 18 at pg. 4). They argue that this is consistent with the Plan. Id.

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The Defendants cite to several decisions in support of their argument. These cases, however, are
distinguishable from the case at bar.
For example, in Orr—one of the cases cited by the Defendants—the family of a deceased
policy holder was denied benefits because an exclusion applied to the benefits. Orr v. Assurant
Employee Benefits, 786 F.3d 596 (7th Cir. 2015). Specifically, any death resulting directly or
indirectly from intoxication fell under the exclusion. The Orrs sent two letters to the insurance
company that denied the benefits. They did not, however, follow the steps as provided in the
policy. The policy set forth a two level review. The court ultimately granted summary judgment
against the Orrs because they failed to exhaust their administrative remedies and the Seventh
Circuit affirmed. Id. at 601.
The Orrs argued that the insurance company attempted to layer additional appeal levels
into the claims review process. However, as the Seventh Circuit stated, the Orrs represented that
they had more documentation to send in support of their second appeal. Id. at 602. Instead of
finishing the second level of review, the Orrs filed suit. Accordingly, they failed to exhaust the
proper administrative remedies before filing suit. In the case presently before the Court, there is
not yet any clear indication that the Plaintiff failed to exhaust administrative remedies as
required.
For purposes of a motion to dismiss, complaints are construed in the light most favorable
to the plaintiff, well-pleaded factual allegations are taken as true, and all reasonably-drawn
inferences are drawn in favor of the plaintiff. See Albright v. Oliver, 510 U.S. 266, 268 (1994);
Hishon v. King & Spalding, 467 U.S. 69 (1984); Lanigan v. Village of East Hazel Crest, 100
F.3d 467 (7th Cir. 1997); M.C.M. Partners, Inc. v. Andrews-Bartlett & Assoc., Inc., 62 F.3d 967,
969 (7th Cir. 1995); Early v. Bankers Life & Cas. Co., 959 F.2d 75 (7th Cir. 1992).

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Viewing the Complaint in a light most favorable to the Plaintiff, the Plaintiff has
sufficiently alleged that her June 2, 2015 letter to Hartford constituted an appeal. Here, the
plaintiff actually sent documentation requested by Hartford as “necessary for a determination of
[Meyer’s] claim[.]” (D. 16 at pg. 6, citing exhibits from her Complaint). Further, she mailed the
June 2 letter to the correct P.O. Box for the appeals department. Meanwhile, Hartford provided
two avenues, i.e. told the Plaintiff to provide additional information for Hartford to consider an
appeal or simply rely on information provided prior to Hartford’s adverse benefits determination.
The Plaintiff responded to Hartford’s instructions. Her response was, arguably, an attempt at
appealing Hartford’s determination of her disability. As the Plaintiff points out, the Plan stated
that the policy holder could also “submit written comments, documents, records and other
information relating to your claim.” (D. 16 at pg. 8, citing Ex. A of her Complaint). These
policy provisions, coupled with the Plaintiff’s response, sent to the proper address for appeals,
allows the Complaint to survive the Defendants’ Motion to Dismiss.
CONCLUSION
For the foregoing reasons, the Defendants’ Motion to Dismiss for Failure to State a Claim
(D. 14) is DENIED.
It is so ordered.
Entered on October 10, 2017

_s/James E. Shadid_________
James E. Shadid
Chief United States District Judge

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