Ausler v. Aetna Life Ins. Co.
| Decision Date | 04 March 2019 |
| Docket Number | Case No. 4:18-CV-00315 JAR |
| Parties | TIFFANY AUSLER, Plaintiff, v. AETNA LIFE INSURANCE CO, Defendant. |
| Court | U.S. District Court — Eastern District of Missouri |
This matter is before the Court on Defendant Aetna Life Insurance Company's ("Aetna") Motion to Dismiss. (Doc. 10.) Plaintiff Tiffany Ausler has filed a response in opposition (Doc. 19), and Aetna has replied (Doc. 23).
Plaintiff makes the following allegations (see Docs. 1, 19): Plaintiff was employed by Boeing Corporation as a software engineer for more than thirteen years. As a Boeing employee, Plaintiff was eligible for the company's short-term disability ("STD") and long-term disability ("LTD") compensation plans, which are administrated by Aetna and subject to the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001-1461. Aetna provided Boeing employees with a plan brochure1 detailing things like eligibility requirements, thebenefits claims process, and how to appeal from a denial. (Doc. 10-2 at 37-151 (see also, Doc. 10-1 (The Boeing Company Master Welfare Plan)).) It notes that Aetna serves as the plan's "service representative," with the authority to approve or deny disability claims and to review denials on appeal. (Id. at 61)
The plan brochure is divided into thirteen sections, including Section 1 - Eligibility and Enrollment; Section 2 - Short-Term Disability Plan; Section 3 - Long-Term Disability Plan; and Section 9 - Claims and Appeals. (Doc. 10-2 at 43.) Section 1 of the plan brochure defines who is eligible for Boeing's seven employer-sponsored benefits plans.2 (Doc. 10-2 at 40.) Initial eligibility determinations are made by the Boeing Service Center and appeals are considered by Boeing's Employee Benefit Plans Committee. (Id. at 121-22.) Section 2 of the plan brochure explains that STD benefits are available if an employee becomes disabled as a result of a pregnancy-related condition, accidental injury, or illness. (Id. at 61.) If an employee is disabled for twenty-six weeks, she "may be eligible for benefits under the [LTD] plan." (Id.) Section 3 of the plan brochure explains the amount and duration of LTD benefits. (Id. at 67-76.) On page 3-10, the brochure explains how to claim LTD benefits:
(Id. at 76.)
Section 9 is divided into four subsections with headings set apart in bold letters. (Doc. 10-2 at 116.) The first subsection begins:
(Id. at 117.) Next is Benefit Claims Process, which includes a procedure for filing a claim for benefits and appealing if your claim is denied. (Id.) After that is Eligibility Claims Process, again explaining how to file a claim and appeal a denial. (Id. at 112.) The fourth and final subsection states:
On December 1, 2014, Plaintiff submitted a claim for STD and LTD benefits, claiming total disability and providing documentation from her medical provider in support. (Doc. 11-1 at 1.) Upon review, Aetna notified plaintiff by letter "that the evidence does not support disability as defined by your group policy" and denied Plaintiff's STD claim. (Id. at 2.) In addition, Aetna denied Plaintiff's LTD claim because she "[had] not met the 26 [week] waiting period." (Id.)
Plaintiff appealed Aetna's denial of STD benefits. (Doc. 11-2.) In a letter dated February 27, 2015, Aetna informed Plaintiff that it agreed with its original determination and denied her appeal. (Id. at 1.) The final paragraph of the letter states:
Plaintiff filed this suit on February 26, 2018—1,095 days after Aetna's appeal letter—alleging that Aetna's denial of both STD and LTD benefits was an abuse of discretion. (Doc. 1.) Aetna argues that Plaintiff's STD claim is time-barred because she did not comply with the 180-day time limit outlined in the plan brochure. (Doc. 10.) Aetna also argues that Plaintiff is barred from seeking LTD benefits because she never pursued them through the plan's required procedure for claiming them. (Id.)
Plaintiff responds that the language of the plan brochure is ambiguous and that, in any event, a 180-day time limit is unreasonably short. (Doc. 19.) In addition, she argues that, once her STD claim was denied, she was ineligible for LTD benefits and that exhaustion was therefore futile. (Id.)
To survive a motion to dismiss under Rule 12(b)(6), "a complaint must contain sufficient factual matter, accepted as true, to 'state a claim to relief that is plausible on its face.'" Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009) (quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007)). A claim is facially plausible "when the plaintiff pleads factual content that allows the court to draw the reasonable inference that the defendant is liable for the misconduct alleged." Id. (citing Twombly, 550 U.S. at 556). "While a complaint attacked by a Rule 12(b)(6) motion to dismiss does not need detailed factual allegations, a plaintiff's obligation to provide the 'grounds' of his 'entitle[ment] to relief' requires more than labels and conclusions, and a formulaic recitation of the elements of a cause of action will not do." Twombly, 550 U.S. at 555, 127 S.Ct. 1955 (alteration in original) (citations omitted). "When ruling on a motion to dismiss [under Rule 12(b)(6)], the district court must accept the allegations contained in the complaint as true and all reasonable inferences from the complaint must be drawn in favor of the nonmoving party." Young v. City of St. Charles, 244 F.3d 623, 627 (8th Cir. 2001).
As noted, Aetna argues that Plaintiff failed to meet the 180-day time period for filing suit after the denial of her appeal, as set out in the plan brochure, and that her denial-of-STD-benefits claim is therefore subject to dismissal as time-barred. (Doc. 10.) In addition, Aetna argues that Plaintiff is barred from advancing her denial-of-LTD-benefits claim because she failed to exhaust the procedure outlined in the plan brochure. (Id.)
Plaintiff argues that the plan brochure is ambiguous. (Doc. 19 at 3-7.) Ordinarily, Missouri law construes ambiguous contract terms in favor of the insured. Brewer v. Lincoln Nat. Life Ins. Co., 921 F.2d 150, 153 (8th Cir. 1990). However, this rule does not apply in ERISAcases. Id. Instead, "courts should construe any disputed language 'without deferring to either party's interpretation.'" Id. (quoting Wallace v. Firestone Tire & Rubber Co., 882 F.2d 1327, 1329 (8th Cir. 1989)). "[T]erms should be accorded their ordinary, and not specialized, meanings." Id. at 154. "[I]f, after applying ordinary principles of construction, giving language its ordinary meaning and admitting extrinsic evidence, ambiguities remain," "a court construing plans governed by ERISA should construe ambiguities against the drafter." Delk v. Durham Life Ins. Co., 959 F.2d 104, 106 (8th Cir. 1992).
Plaintiff argues that the 180-day time limit in the plan brochure refers only to appeals from a denial under the Eligibility Claims Process—decisions by the Boeing Service Center and Boeing's Employee Benefit Plans Committee about whether an employee or dependent is eligible to participate in the company's disability, life, and accident benefit plans. (See Doc. 10-2 at 121-123.) Plaintiff argues that there is no doubt she is eligible to participate in the STD plan and that therefore the relevant provision is found under the Benefit Claims Process heading. (Doc. 19; Doc. 10-2 at 117-121.) In that subsection, no specific deadline for filing a civil lawsuit is given; the brochure promises only to provide written notice that includes, among other things, a "[s]ummary of your right to additional appeals or legal action." (See Doc. 10-2 at 117-121.) The letter informing Plaintiff that her appeal had been denied warns her to "check your plan brochure or summary plan description to see if it gives you the time frame to file a lawsuit." (Doc. 19.) Plaintiff argues that because the Benefit Claims Process subsection does not include a time limit, the 180-day deadline applies only to eligibility claims.
The Court finds that there are multiple instances in which the plan brochure's plain language unambiguously shows that the 180-day deadline is not limited to eligibility claims. First, Section 9...
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