Deas v. Prudential Insurance Company Of America
Filing
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ORDER granting in part 7 Motion to Dismiss and dismissing the case without prejudice. Signed by Honorable David C Norton on April 26, 2018.(cban, )
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF SOUTH CAROLINA
CHARLESTON DIVISION
Cheryl Deas,
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Plaintiff,
vs.
Prudential Insurance of America,
Defendant.
No. 2:17-cv-03016-DCN
ORDER
This matter comes before the court on Prudential Insurance Company of
America’s (“Prudential”) Motion to Dismiss, ECF No. 7. For the reasons set forth below,
the court grants in part the motion and dismisses the case without prejudice.
I. BACKGROUND
Cheryl Deas (“Deas”) filed this suit asking the court to grant her the long term
disability benefits she claims to be entitled to under the Employee Retirement Income
Security Act (“ERISA”). Compl. ¶ 3. Deas was employed at the Summerville Medical
Center until May 2015, and claims to have been provided with long term disability
insurance coverage through a plan (“the Plan”) insured by Prudential and administered by
HCA, Inc. (“HCA”). Id. ¶ 4. Deas alleges that she became disabled and had to cease
working, and that she filed a claim for disability benefits in March 2017. Id. ¶¶ 5–6.
She alleges that Prudential has failed to reach a decision on her claim in a timely manner
in violation of 29 C.F.R. §2560.503-1. Deas claims that this violation allows the court to
proceed with the instant action as though she has fully exhausted all of her administrative
remedies. She asks the court to declare, pursuant to 29 U.S.C. § 1132(a)(1)(B), that she
is entitled to the benefits under the Plan.
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Deas filed suit on November 7, 2017. ECF No. 1. On December 27, 2017,
Prudential filed a motion to dismiss. ECF No. 7. On January 19, 2018, Deas filed her
response in opposition, ECF No. 11, and on January 25, 2018, Prudential filed its reply.
The motion has been fully briefed and is ripe for the court’s review.
II. STANDARD
Under Federal Rule of Civil Procedure 12(b)(6), a party may move to dismiss for
“failure to state a claim upon which relief can be granted.” When considering a Rule
12(b)(6) motion to dismiss, the court must accept the plaintiff’s factual allegations as true
and draw all reasonable inferences in the plaintiff’s favor. See E.I. du Pont de Nemours
& Co. v. Kolon Indus., 637 F.3d 435, 440 (4th Cir. 2011). But “the tenet that a court
must accept as true all of the allegations contained in a complaint is inapplicable to legal
conclusions.” Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009). On a motion to dismiss, the
court’s task is limited to determining whether the complaint states a “plausible claim for
relief.” Id. at 679. Although Rule 8(a)(2) requires only a “short and plain statement of
the claim showing that the pleader is entitled to relief,” “a formulaic recitation of the
elements of a cause of action will not do.” Bell Atl. Corp. v. Twombly, 550 U.S. 544,
555 (2007). The “complaint must contain sufficient factual matter, accepted as true, to
‘state a claim to relief that is plausible on its face.’” Iqbal, 556 U.S. at 678 (quoting
Twombly, 550 U.S. at 570). “Facts pled that are ‘merely consistent with’ liability are not
sufficient.” A Soc’y Without a Name v. Virginia, 655 F.3d 342, 346 (4th Cir. 2011)
(quoting Iqbal, 556 U.S. at 678).
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III. DISCUSSION
Deas filed this action asking the court to grant her benefits under the Plan because
she claims that Prudential has failed to reach a decision on her insurance claim in a timely
manner, and thus her claim is deemed to be denied under 29 C.F.R. § 2560.503-1. Under
that provision, “[i]n the case of a claim for disability benefits, the plan administrator shall
notify the claimant, in accordance with paragraph (g) of this section, of the plan’s adverse
benefit determination within a reasonable period of time, but not later than 45 days after
receipt of the claim by the plan.” 29 C.F.R. § 2560.503-1(f)(3). This section also allows
for an extension of the notification deadline if “necessary due to matters beyond the
control of the plan” and if the administrator notifies the claimant of the need for the
extension. Id. The federal regulations also provide that if a plan administrator fails to
follow these timing requirements, “the claimant is deemed to have exhausted the
administrative remedies available under the plan . . . [and] is entitled to pursue any
available remedies” under 29 U.S.C. § 1132. 29 C.F.R. § 2560.503-1(l)(2). Section
1132, the civil enforcement provision of ERISA, allows a participant or beneficiary to
bring a civil 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).
Deas filed her claim with Prudential in March 2017. If Prudential intended to
deny her claim, then it should have notified her of this within 45 days after receiving her
claim or notified her of the 30-day extension for processing her claim. There is no
evidence in the complaint or from Prudential that anyone notified Deas of the adverse
decision on her claims application, let alone informed her that a decision would take
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longer than 45 days.1 Thus, because it appears that Prudential failed to follow the claims
procedure, Deas is warranted in bringing the case currently before the court to obtain her
benefits under the plan.
Prudential moves to dismiss Deas’s action because she did not make a timely
claim for benefits under the applicable ERISA plan. Mot. Dism. at 1. Prudential argues
that because Deas failed to submit a timely claim, she has not exhausted her pre-suit
administrative remedies as required under ERISA and the Plan, and thus her complaint
should be dismissed with prejudice. Id.
The Plan sets the following time limitations on filing a claim for benefits:
We encourage you to notify us of your claim as soon as possible, so that a
claim decision can be made in a timely manner. Written notice of a claim
should be sent within 30 days after the date your disability begins.
However, you must send Prudential written proof of your claim no later than
90 days after your elimination period ends. If it is not possible to give proof
within 90 days, it must be given no later than 1 year after the time proof is
otherwise required except in the absence of legal capacity.
1
The only information before the court about this is in Deas’s response to the
motion to dismiss, in which she states that:
“By August 2017, Plaintiff had not received a decision on her long-term
disability claim, and Plaintiff wrote a letter to Defendant on August 9, 2017
requesting status. By September 21, 2017, Plaintiff had not received a
response to her August 9, 2017 letter from Defendant. She again wrote a
letter to Defendant requesting the status of her long-term disability claim.
Defendant, again, ignored Plaintiff’s letter . . . .”
Pl.’s Resp. at 2. As discussed on page 6, the court cannot on a motion to dismiss consider
facts not raised in the complaint but raised for the first time in response to the motion to
dismiss.
However, the court need not rely solely on Deas’s response to the complaint for
this information. Prudential does not claim anywhere that it did issue an adverse decision
to Deas. Additionally, Deas’s complaint is based on the provisions in 29 C.F.R. §
2560.503-1, which allow a claim to be deemed denied if the plan administrator does not
notify the applicant of its adverse decision in a timely manner. Thus, the court assumes
for the purposes of the motion to dismiss that the plan administrator never sent a notice of
denial of benefits to Deas.
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The claim form is available from your Employer, or you can request a claim
form from us. If you do not receive the form from Prudential within 15 days
of your request, send Prudential written proof of your claim without waiting
for the form.
Plan, ECF No. 7 Ex. A, at 29. 2 As Prudential notes, the elimination period under
the Plan begins on the date of the claimant’s disability onset and lasts 147 days. Id. at 1.
Under these deadlines, Deas was required to submit proof of her claim to Prudential at
the very latest one year and 237 days after her disability began.3 Deas alleges that she
became disabled in May 2015, but does not specify the day. Compl. ¶ 4. Giving Deas
the benefit of assuming that her disability onset date was May 31, 2015, she was required
to submit proof of her claim by January 23, 2017 at the latest—one year and 237 days
after May 31, 2015. According to the complaint, Deas filed her claim for benefits in
March 2017. Id. ¶ 6. Taking as true the facts alleged in the complaint—because Deas
2
On a motion to dismiss, the court considers “the complaint in its entirety, as well
as other sources courts ordinarily examine when ruling on Rule 12(b)(6) motions to
dismiss, in particular, documents incorporated into the complaint by reference, and
matters of which a court may take judicial notice.” Tellabs, Inc. v. Makor Issues &
Rights, Ltd., 551 U.S. 308, 322 (2007); see Bailey v. Virginia High Sch. League, Inc.,
488 F. App’x 714, 715–16 (4th Cir. 2012) (“In deciding whether a complaint will survive
a motion to dismiss, a court evaluates the complaint and any documents attached or
incorporated by reference.”). In addition to considering “documents that are explicitly
incorporated into the complaint by reference [ ] and those attached to the complaint as
exhibits . . . we may consider a document submitted by the movant that was not attached
to or expressly incorporated in a complaint, so long as the document was integral to the
complaint and there is no dispute about the document’s authenticity.”
Here, the Plan was not included in or attached to the complaint; it was submitted
to the court as an attachment to Prudential’s motion to dismiss. Yet, because the
complaint explicitly references the Plan several times and because the terms of the Plan
are integral to resolving Deas’s action and no one disputes the document’s authenticity,
the court will utilize the Plan that Prudential submitted in its consideration of the motion
to dismiss.
3
The 147-day elimination period, plus 90 days after the elimination period ends,
plus the extra year if required = one year and 237 days from the disability onset date.
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did not submit her claim within the deadlines set by the Plan, her current suit before this
court to grant her benefits under the Plan should be dismissed.
In her response to the motion to dismiss, Deas alleges for the first time that she
wrote to HCA in September 2016, requesting any long term disability plans and claim
forms necessary for her to make a claim for those benefits. Pl.’s Resp. at 2. She argues
that she never received a response and that in January 2017 she wrote another letter to
HCA requesting the information, to which HCA responded on February 14, 2017 with
the requested information. Id. In her response to the motion to dismiss, Deas raises for
the first time the argument that her letter to HCA in September 2016 constituted a
“reasonable procedure for filing a long term disability claim.” Id. at 8, citing 29 C.F.R. §
2560.503-1(e). She argues that this was submitted before the January 23, 2017 deadline
and thus the court should consider her insurance claim as timely. Deas then argues, again
for the first time, that the court should equitably toll the deadline because she was
“induced or tricked by [her] adversary’s misconduct into allowing the filing deadline to
pass,” due to HCA’s failure to respond to any of her letters requesting claim information
until February 14, 2017. Id. at 9, citing Gayle, 401 F.3d at 22.
The court cannot consider these arguments on a motion to dismiss if they or the
facts upon which they are based were not raised in the complaint, as “the complaint may
not be amended by the briefs in opposition to a motion to dismiss.” Mylan Labs., Inc. v.
Akzo, N.V., 770 F.Supp. 1053, 1068 (D. Md. 1991) (quoting Car Carriers, Inc. v. Ford
Motor Co., 745 F.2d 1101 (7th Cir. 1984)). The court in Marsh v. Virginia Dept. of
Transp., 2014 WL 6833927, at *8 (W.D. Va. Dec. 3, 2014) reasoned that to allow a
plaintiff to assert new claims by raising them in his brief in opposition to the motion to
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dismiss “would mean that a party would unilaterally amend a complaint at will, even
without filing an amendment, and simply by raising a point in a brief.” The court agrees.
None of the factual or legal allegations around this estoppel-based argument, or regarding
the letters to HCA, are found in the original complaint. The court therefore cannot
consider any of these allegations in resolving the motion to dismiss. Thus, the court grant
grants in part Prudential’s motion to dismiss and dismiss the case without prejudice,
allowing Deas the opportunity to re-file her claim with a complaint that fully incorporates
the facts and arguments she raises in her response to the motion to dismiss.
IV. CONCLUSION
Based on the above, the court grants in part the motion dismiss and dismisses
Deas’s case without prejudice.
AND IT IS SO ORDERED.
DAVID C. NORTON
UNITED STATES DISTRICT JUDGE
April 26, 2018
Charleston, South Carolina
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