Martinez v. Prudential Ins. Co. of Am.
| Citation | 594 F.Supp.3d 827 |
| Decision Date | 27 September 2021 |
| Docket Number | Civil Action No. 7:21-CV-00123 |
| Parties | Jose M. MARTINEZ, Plaintiff, v. PRUDENTIAL INSURANCE COMPANY OF AMERICA, et al., Defendants. |
| Court | U.S. District Court — Southern District of Texas |
Mark Anthony Di Carlo, Attorney at Law, Corpus Christi, TX, for Plaintiff.
Robert L. Galligan, Alexandro Benavides, Jones, Galligan, Key & Lozano, L.L.P., Weslaco, TX, for Defendants.
ORDER GRANTING IN PART AND DENYING IN PART DEFENDANTS' MOTION TO DISMISS PLAINTIFF'S COMPLAINT AND DENYING PLAINTIFF'S MOTION FOR JUDGMENT AND SANCTIONS
Now before the Court is "Defendants' Motion to Dismiss Plaintiff's Complaint" ("Defendants' Motion") (Dkt. No. 7) filed by Prudential A/K/A D/B/A The Prudential Company of America Disability Management Service A/K/A D/B/A Prudential Services Company of America ("Prudential") and American Electric Power Service Corporation ("AEPSC") (collectively "Defendants") and "Plaintiff's Amended Motion for Default Judgment Plaintiff's Amended Motion for Judgment on the Pleadings and/or Response and Objections to Defendant's Response and Objections to Defendants' Motion to Dismiss Plaintiff's Complaint" ("Plaintiff's Motion") (Dkt. No. 15) filed by Plaintiff Jose M. Martinez. After considering the two motions and their responsive briefings (Dkt. Nos. 10, 11, 18), the Court is of the opinion that Defendants' Motion (Dkt. No. 7) should be GRANTED IN PART AND DENIED IN PART and Plaintiff's Motion (Dkt. No. 15) should be DENIED for the following reasons.
Plaintiff filed suit on April 2, 2021, alleging Defendants wrongfully denied him long term disability. (Dkt. No. 1).1 Plaintiff alleges that he is the beneficiary of an "American Electric System Long Term Disability Plan" (the "Plan") with Prudential. Id. at p. 2 ¶ 1. The Plan is a welfare benefit plan providing long-term disability benefits. (Dkt. No. 22 at p. 185).2 Plaintiff was employed by American Electric Power ("AEP") from January 1981 to April 2019. (Dkt. No. 1 at p. 8 ¶ 19).3 Plaintiff believes he paid into "disability" throughout his employment. Id. at p. 9 ¶ 20.
AEPSC is the plan sponsor and administrator. (Dkt. No. 1 at p. 2 ¶ 2); (Dkt. No. 22 at p. 184). AEPSC "has the authority to control, administer and manage the operation of the plan." (Dkt. No. 1 at p. 23 ¶ 66); (Dkt. No. 22 at p. 184). AEPSC and its subsidiaries and affiliates adopted the Plan with the purpose to benefit its employees. (Dkt. No. 1 at p. 23 ¶ 66); (Dkt. No. 22 at p. 184). The Plan is governed by the laws of the State of Ohio, except to the extent it is preempted by federal law. (Dkt. No. 1 at p. 22 ¶ 65); (Dkt. No. 22 at p. 184).
Under the Plan, a full-time employee who is disabled for 1,040 hours or longer can receive up to 60% of his or her base pay through the Plan. (Dkt. No. 22 at p. 169). Eligible employees are automatically enrolled for this "Employer-provided 60% of pay base benefits" under the Plan. Id. at p. 170. AEPSC pays the full cost of the base Plan coverage that provides up to 60% of the base pay coverage. Id. Employees, as of January 1, 2014, have the option to supplement the employer-provided base plan by purchasing an additional benefit equal to 10% of their base pay. Id. at p. 169.
AEPSC has the authority, responsibility, and discretion to determine eligibility to participate in the Plan. Id. at 180. AEPSC appointed the "AEP Recovery Center to make initial determinations of eligibility and an internal LTD Appeals Committee to consider appeals of adverse eligibility determinations made by the AEP Recovery Center." Id. Prudential is the Plan's claims administrator. Id.
After a claimant files a claim for benefits, the claimant will be advised of the determination within forty-five days after receipt of the claim either "by AEP Recovery Center (with regard to eligibility determinations) or Prudential (with regard to other benefit determinations)." (Dkt. No. 1 at p. 27 ¶ 70); (Dkt. No. 22 at p. 180). The period can be extended by thirty days if the reviewer determines that it is necessary and notifies the claimant. (Dkt. No. 1 at p. 7 ¶ 17, p. 27 ¶¶ 70-70.1); (Dkt. No. 22 at p. 180). If a decision cannot be made within the thirty-day extension, the reviewer can extend the period for an additional thirty days provided he or she notifies the claimant. (Dkt. No. 1 at p. 7 ¶ 17); (Dkt. No. 22 at p. 180).
If a claimant disagrees with a determination as to his or her eligibility, the claimant can submit a request in writing to the AEP LTD Plan Appeal Committee and formally request an appeal. (Dkt. No. 22 at p. 181). "The AEP Plan Appeal committee has full discretion and authority to determine eligibility under the plan[.]" (Dkt. No. 1 at p. 8 ¶ 18). If a claimant disagrees with any other type of benefit determination, he or she can submit a written request to Prudential and formally request an appeal. (Dkt. No. 22 at p. 181). "Prudential has full discretion and authority to determine eligibility for benefits and for continued benefits and both have full discretion and authority to construe and interpret all terms and provisions of the plan." (Dkt. No. 1 at p. 8 ¶ 18). Both the AEP LTD Plan Appeal Committee and Prudential "have full discretion and authority to construe and interpret all terms and provisions of the plan." Id.
A claimant has 180 days from receiving a notice of an adverse benefit determination to file an appeal. (Dkt. No. 1 at p. 64 ¶ 160); (Dkt. No. 22 at p. 182). If a claimant is not satisfied with Prudential's decision regarding an appeal on an issue that doesn't involve eligibility under the Plan, then the claimant can submit an additional review, or a "voluntary second level appeal," within sixty days after he or she receives notice of determination of the first level appeal. (Dkt. No. 22 at p. 183).
Plaintiff applied for long term disability on April 16, 2019. (Dkt. No. 1 at p. 27 ¶ 70.1). Prudential acknowledged that it received Plaintiff's claim for benefits on May 2, 2019. (Dkt. No. 22 at p. 158). In a May 14, 2019 letter, Prudential's claim reviewer requested additional information from Plaintiff. (Dkt. No. 1 at p. 27 ¶ 70.1); (Dkt. No. 22 at p. 216-17).4 Prudential sent a letter on May 30, 2019, stating that it needed additional information to determine benefits under the Plan. (Dkt. No. 1 at p. 34 ¶ 93); (Dkt. No. 22 at p. 254-55). Prudential "requested"5 an extension of time on June 18, 2019. (Dkt. No. 1 at p. 8 ¶ 17.1, p. 57 ¶ 146) (Dkt. No. 22 at p. 438-39).
On June 14, 2019, Jennifer Sullivan of Prudential sent a letter to Mr. Juan Briones, PA. Id. at p. 53-56 ¶ 138-143; (Dkt. No. 22 at p. 428-29, 433-34). The letter stated that Sullivan is a registered nurse but did not indicate that she is a claims manager. (Dkt. No. 1 at p. 53 ¶ 139, p. 55 ¶ 142.1); (Dkt. No. 22 at p. 428-29, 433-34).
Plaintiff was denied long term disability on July 17, 2019. (Dkt. No. 1 at p. 63-64 ¶ 160); (Dkt. No. 22 at p. 465). The denial letter mentioned that Prudential did not receive a response from Briones to the letter Sullivan sent on June 14, 2019. (Dkt. No. 1 at p. 64 ¶ 160); (Dkt. No. 22 at p. 466). Plaintiff was informed that he had a right to appeal within 180 days of July 17, 2019. (Dkt. No. 1 at p. 64 ¶ 160); (Dkt. No. 22 at p. 467). The letter stated the appeal must be made in writing. (Dkt. No. 22 at p. 467). Prudential called Plaintiff to advise him of the denial and appeal rights. Id. at p. 470. Plaintiff filed a first level appeal, which was denied on July 17, 2019. (Dkt. No. 1 at p. 2 ¶ 3).
Plaintiff's counsel requested claim documents on August 30, 2019, and October 10, 2019.6 Id. at p. 65 ¶ 163; (Dkt. No. 22 at p. 480-81, 486-87). Prudential spoke to Plaintiff's counsel and informed counsel that it requires Plaintiff's signed authorization to release information on August 30, 2019. (Dkt. No. 22 at p. 483). Plaintiff's counsel sent Prudential signed authorization on August 30, 2019. Id. at p. 484. Prudential sent the information to Plaintiff's counsel on October 10, 2019. Id. at 488-91. Plaintiff received "a long term disability plan and summary plan on November 4, 2019." Id. at p. 5 ¶ 13.1. This plan did not include a list of acronyms. Id. at p. 21 ¶ 61.1.
Plaintiff filed a second level of appeal on February 12, 2020. Id. at p. 2 ¶ 4; (Dkt. No. 22 at p. 496). A letter dated February 12, 2020, from Plaintiff's counsel to Prudential states that he received the claim file on November 4, 2019, and that the claim file was incomplete and inadequate. (Dkt. No. 1 at p. 65-69 ¶ 165); (Dkt. No. 22 at p. 496-500). The letter states, (Dkt. No. 22 at p. 496).
Prudential sent a letter to Plaintiff's counsel on February 20, 2020, notifying Plaintiff that the appeal was untimely since the deadline to file an appeal was January 27, 2020. (Dkt. No. 1 at p. 70 ¶ 169); (Dkt. No. 22 at p. 524-25). The letter acknowledges that Plaintiff requested the claim file before the appeal deadline but stated that the request for the claim file is not a request for an appeal. (Dkt. No. 22 at p. 525).
Plaintiff's counsel sent a letter to Prudential on February 27, 2020, acknowledging receipt of the denial letter and again requesting all documents in the claim file. (Dkt. No. 1. at p. 71 ¶ 170); (Dkt. No. 22 at p. 536). Plaintiff's counsel, again, requested further documentation regarding Plaintiff's Prudential claim file on July 31, 2020. (Dkt. No. 2 at p. 1). Plaintiff received the list of acronyms on August 5, 2020. (Dkt. No. 1 at p. 21 ¶ 61.1, p. 75 ¶ 173.12).
Plaintiff takes issue with multiple actions or omissions by the Defendants. Id. at p. 72-87 ¶¶ 173-173.49. Ultimately, Plaintiff asserts claims under the...
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