Warmbrodt v. Reliance Standard Life Insurance Company

Filing 12

MEMORANDUM AND ORDER re: 2 MOTION to Dismiss Case filed by Defendant Reliance Standard Life Insurance Company. IT IS HEREBY ORDERED that defendant's motion to dismiss (#2) is GRANTED. Signed by District Judge Stephen N. Limbaugh, Jr on 10/12/16. (CSG)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
EASTERN DIVISION
JOSEPH WARMBRODT,
Plaintiff,
vs.
RELIANCE STANDARD LIFE INS. CO.,
Defendant.

)
)
)
)
)
)
)
)
)

No. 4:16-cv-70 SNLJ

MEMORANDUM and ORDER
Plaintiff Joseph Warmbrodt filed this action under the Employee Income Security
Act of 1974, 29 U.S.C. § 1001, et seq. (“ERISA”), to recover benefits he alleges are due
under an employee welfare benefit plan. The defendant is Reliance Standard Insurance
Company (“Reliance”), which provides coverage for certain employees of St. Anthony’s
Medical Center under an employee welfare benefit plan (“Plan”). Reliance has moved to
dismiss the complaint (#2). The motion has been fully briefed and is now ripe for
disposition.
I.

Background
For the purposes of defendant’s motion to dismiss, the facts pleaded in the

complaint are presumed true. Plaintiff was employed by St. Anthony’s Medical Center
as a full-time registered nurse when he was diagnosed with multiple myeloma, a cancer
that forms in bone marrow. Plaintiff underwent a course of chemotherapy beginning on
July 4, 2011 and underwent a bone marrow transplant on December 9, 2011. He applied
for Long Term Disability (“LTD”) benefits from Reliance and received such benefits
1

under the Plan beginning on September 18, 2011 and ending on April 18, 2015. Reliance
sent plaintiff a letter dated April 5, 2015 advising him that his benefits were ending and
setting forth the proper procedure for appealing Reliance’s determination.
Plaintiff appealed the decision to end his LTD benefits on October 13, 2015.
Reliance responded that it had conducted an initial review of the information in the claim
file and that it had requested additional medical records from plaintiff’s medical
providers. The letter further stated --- according to the Complaint, which did not attach
the letter --- that Reliance was required “to reach a decision within 45 days of receipt of
the request for appeal” but that, if Reliance needed additional information, Reliance could
“request up to an additional 45 days to complete the appeal process.” (Cmplt. ¶ 17.)
Reliance requested an independent medical evaluation on December 3, 2015, 54
days after plaintiff submitted his appeal. The evaluation was scheduled for December 18,
but it was scheduled to take place in Cincinnati, Ohio. Plaintiff lives in Missouri. On
December 9, Reliance advised plaintiff’s attorney that the evaluation would be
rescheduled. Then, on December 15, 2015, Reliance advised plaintiff that the evaluation
would take place on January 18, 2016.
The 90-day deadline for Reliance to make a claim determination on plaintiff’s
appeal expired on January 11, 2016. Plaintiff filed this action on January 15, 2016. At
that time, Reliance had not decided plaintiff’s appeal. He claims he is entitled to
payment of long-term disability benefits in the amount of $1,307.96 per month until his
65th birthday, plus interest for the time he was wrongfully denied benefits. He claims
Reliance wrongfully discontinued payment of those benefits, wrongfully failed to make a
decision on his appeal in a timely manner, and wrongfully failed to process his claims in
a manner consistent with ERISA regulations or the language of the Plan. Defendant has
2

moved to dismiss plaintiff’s claims because plaintiff filed this lawsuit before the appeal
process was complete and because plaintiff did not appear for his medical evaluation.
Defendant seeks dismissal with prejudice of plaintiff’s complaint or, in the alternative,
the opportunity to conduct the independent medical evaluation and complete the appeal
process.
II.

Legal Standard
The purpose of a Rule 12(b)(6) motion to dismiss for failure to state a claim is to

test the legal sufficiency of a complaint so as to eliminate those actions “which are fatally
flawed in their legal premises and deigned to fail, thereby sparing litigants the burden of
unnecessary pretrial and trial activity.” Young v. City of St. Charles, 244 F.3d 623, 627
(8th Cir. 2001) (citing Neitzke v. Williams, 490 U.S. 319, 326-27 (1989)). “To survive a
motion to dismiss, a claim must be facially plausible, meaning that the ‘factual content. . .
allows the court to draw the reasonable inference that the defendant is liable for the
misconduct alleged.’” Cole v. Homier Dist. Co., Inc., 599 F.3d 856, 861 (8th Cir. 2010)
(quoting Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009)). The Court must “accept the
allegations contained in the complaint as true and draw all reasonable inferences in favor
of the nonmoving party.” Id. (quoting Coons v. Mineta, 410 F.3d 1036, 1039 (8th Cir.
2005)). However, “[t]hreadbare recitals of the elements of a cause of action, supported
by mere conclusory statements,” will not pass muster. Iqbal, 556 U.S. at 678.
III.

Discussion
At the outset, the Court notes that the defendant has attached numerous documents

in support of its motion to dismiss. Plaintiff objects. However, “[w]hen deciding a
motion to dismiss, a court may consider the complaint and documents whose contents are
alleged in a complaint and whose authenticity no party questions, but which are not
3

physically attached to the pleading.” Kushner v. Beverly Enters., Inc., 317 F.3d 820, 821
(8th Cir. 2003) (quoting In re Syntex Corp. Sec. Litig., 95 F.3d 922, 934 (9th Cir. 1996));
see also Miller v. Redwood Toxicology Lab., Inc., 688 F.3d 928, 931 (8th Cir. 2012)
(noting that courts additionally consider “matters incorporated by reference or integral to
the claim” for a motion to dismiss) (quoting 5B Charles Alan Wright & Arthur R. Miller,
Federal Practice and Procedure § 1357 (3d ed. 2004)). Plaintiff observes that defendant
“selectively” attached documents to its motion and that it is not appropriate to consider
only part of the administrative record to determine defendant’s motion. (#10 at 2.) As an
example, plaintiff notes that defendant has not included as an exhibit the “Final Appeal
Denial” letter, which was issued after Reliance was served with the complaint. However,
that letter was not referred to in the complaint because it did not yet exist, and defendant
included only documents referred to in the complaint. Plaintiff’s objections are
overruled.
Defendant maintains that plaintiff’s suit should be dismissed because he failed to
exhaust his administrative remedies before filing his complaint. “ERISA does not
contain an express requirement that employees exhaust contractual remedies prior to
bringing suit.” Wert v. Liberty Life Assur. Co. of Boston, 447 F.3d 1060, 1062 (8th Cir.
2006) (citing Conley v. Pitney Bowes, 34 F.3d 714, 716 (8th Cir.1994)). However, the
Eighth Circuit recognizes a “judicially-created” exhaustion requirement when “a
contractual review procedure that is in compliance with 29 U.S.C. § 1133 and 29 C.F.R.
§ 2560.503-1(f) and (g)” is available to the claimant. Id. That is, this “exhaustion
requirement applies so long as the employee has notice of the procedure, even if the plan,
insurance contract, and denial letters do not explicitly describe the review procedure as
mandatory or as a prerequisite to suit.” Id. Here, the plaintiff did have notice of the
4

appeal procedure --- it was explained in the denial letter sent to him on April 5, 2015.
(#3-2 at 4.) Although plaintiff appears to believe that the plan document itself needed to
include such information, the plain language of Wert makes clear that if the employee has
notice of the review procedure, that is sufficient. Wert, 447 F.3d at 1062. The legal
entity referred to as the “plan” must notify the employee of review procedures, but that
information is not required to be in the plan document. See 29 U.S.C. § 1102(b).
Plaintiff clearly failed to exhaust his administrative remedies by filing his lawsuit
while his appeal was still open. Reliance had 90 days to make a decision after receiving
the appeal on October 13, 2015 --- until January 11, 2016. However, the deadline was
tolled pursuant to 29 C.F.R. § 2560.503-1(i)(4), which allows for tolling in the event that
the Plan requires further information necessary to deciding a claim. Defendant wrote to
plaintiff’s counsel on November 10, 2015 regarding its need for additional information
and also stated that the appeal was tolled from the date of the request until the
information was received. Defendant states that the information it sought was received
on November 25, 2015, extending the appeal deadline from January 11 to January 26,
2016. In addition, the appeal deadline was extended when, on November 23, 2015,
defendant informed plaintiff that an independent medical examination (“IME”) was
required. Defendant’s letter stated that it would “toll the statutory time frames for
rendering an appeal determination pending completion of the examination and receipt of
the physician’s report....” (#3-6 at 2.) Because the IME was scheduled and then
rescheduled for January 18, 2016, the deadline for an appeal decision was at least after
that date. Plaintiff filed his complaint on January 15, before even appearing for the IME.
Defendant also suggests that plaintiff’s lawsuit may be dismissed for his failure to
cooperate in that defendant posits that plaintiff filed the lawsuit just days before the
5

scheduled IME in order to avoid appearing for the examination. Although the timing of
plaintiff’s filing is suspicious, the Court declines defendant’s invitation. In addition,
defendant asks the Court to dismiss plaintiff’s claim with prejudice in light of plaintiff’s
allegedly late appeal request. Because the circumstances of the allegedly-late filed
appeal request are not properly before the Court, the Court again declines defendant’s
request. The Court will dismiss plaintiff’s complaint, without prejudice, to allow
defendant to conduct the independent medical examination it reasonably requested from
plaintiff in the first place. In addition, the Court will consider a motion and
accompanying evidence to support any claim for fees and costs incurred by defendant in
defending this prematurely-filed lawsuit.
Accordingly,
IT IS HEREBY ORDERED that defendant’s motion to dismiss (#2) is
GRANTED.
Dated this 12th day of October, 2016.

STEPHEN N. LIMBAUGH, JR.
UNITED STATES DISTRICT JUDGE

6