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SANFILIPPO v. PROVIDENT LIFE AND CAS. INS. CO.

January 4, 2002

LEELAWATI SANFILIPPO, PLAINTIFF,
V.
PROVIDENT LIFE AND CASUALTY INSURANCE CO. AKA PROVIDENT COMPANIES, INC. AKA UNUMPROVIDENT CORP., DEFENDANT.



The opinion of the court was delivered by: Swain, District Judge.

MEMORANDUM OPINION AND ORDER

Plaintiff Leelawati Sanfilippo ("Plaintiff") brings this action against defendant Provident Life and Casualty Insurance Company, a/k/a Provident Companies, Inc., a/k/a UnumProvident Corporation ("Defendant").*fn1 Plaintiffs complaint pleads this case as a breach of insurance contract action, with jurisdiction premised on diversity of citizenship pursuant to 28 U.S.C. § 1332. Before the Court is Defendant's motion to dismiss the complaint pursuant to Rule 12(b)(6) of the Federal Rules of Civil Procedure. Defendant contends that Plaintiffs state law cause of action is preempted by the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq. ("ERISA"), and that any ERISA cause of action based on the facts plead in the complaint would be barred on account of Plaintiffs failure to exhaust administrative remedies. Both parties have approached this motion as one for summary judgment, asking the Court to consider matters outside the pleadings.*fn2 The Court, having considered the proffered additional materials, thus treats this Federal Rule of Civil Procedure Rule 12(b)(6) motion as one for summary judgment. See Fed.R.Civ.P. 12(b). The Court has jurisdiction of this matter pursuant to 28 U.S.C. § 1332 and, to the extent ERISA issues are implicated, 29 U.S.C. § 1132 and 28 U.S.C. § 1331.

The Court has considered thoroughly all submissions and arguments related to this motion and the decision to be rendered reflects such consideration. For the following reasons, Defendant's motion for summary judgment is granted.

BACKGROUND

The Court finds that there is no genuine dispute as to the following material facts. Plaintiff obtained long term disability coverage through her employer, Wyckoff Heights Medical Center ("Wyckoff"). (Statement of Undisputed Facts Pursuant to Local Rule 56.1, at ¶ 1. ("Def.'s Stmt")).*fn3 Defendant issued a group policy ("Policy") to Wyckoff Heights Medical Center. The Policy provides long term disability insurance coverage for eligible employees of Wyckoff. (Def.'s Stmt at ¶ 2; Am. Compl. at ¶ 9.) The Policy was issued pursuant to an application by Wyckoff, and reflects benefit design criteria set forth on the application. (Ex. 1 to Def.'s Reply to Pl.'s Mem. of Law in Opp'n to Def.'s Mot. to Dismiss; Provident Life and Casualty Insurance Company Voluntary Group Long Term Disability Insurance Certificate, Ex. 2 to Mem. of Law in Supp. of Def.'s Mot. to Dismiss.) Wyckoff agreed to the terms of the Policy and agreed to pay the premiums due thereunder to Defendant. (Ex. 2 to Def.'s Reply to Pl.'s Mem. of Law in Opp'n to Def.'s Mot. to Dismiss.) Plaintiff was, at all relevant times, an eligible employee under the Policy. (Def.'s Stmt at ¶ 3; Am. Compl. at ¶ 10.) The Policy provides coverage in the event a covered person becomes disabled. (Def.'s Stmt at ¶ 4; Am. Compl. at ¶ 11.) The Policy document prepared for distribution to employees is labeled "Your Long Term Disability Benefit" and "Wyckoff Heights Medical Center." (Provident Life and Casualty Insurance Company Voluntary Group Long Term Disability Insurance Certificate, Ex. 2 to Mem. of Law in Supp. of Def.'s Mot. to Dismiss.) It includes claims procedures and a notice of ERISA rights, as well as language purporting to reserve to the plan sponsor the right to "terminate, suspend, withdraw, amend or modify the Plan . . . at any time." (Id. at 22.)

On June 30, 1995, Plaintiff made a claim for disability benefits under the Policy. (Def.'s Stmt at ¶ 8.) Plaintiff was disabled from working as a registered nurse due to injuries sustained while on duty. (Id. at 9.) Defendant began paying benefits to Plaintiff on or about October 1995 and continued to pay such benefits through approximately June 1998. (Def.'s Stmt at ¶¶ 10,18; Am. Compl. at ¶ 22.) The October 2, 1995 letter notifying Plaintiff of the approval of her benefit claim included the statement: "Your Long Term Disability claim will receive payment consideration . . . as required by the group plan." (Ex. 4 to Mem. of Law in Supp. of Def.'s Mot. to Dismiss.)

Defendant's June 15, 1998 letter notifying Plaintiff of the discontinuation of her benefits detailed the reasons for Defendant's termination of the benefits, explained the disability definitions in the Policy, pointed out the availability of jobs Plaintiff could perform in her geographic area, and included in its first paragraph a reference to "the Long Term Disability Plan at Wyckoff Medical Center." The letter concluded as follows:

IF YOU DISAGREE WITH OUR DETERMINATION, YOU MAY SUBMIT A WRITTEN REQUEST FOR RECONSIDERATION, ACCOMPANIED BY DOCUMENTS OR RECORDS FROM YOUR PHYSICIAN IN SUPPORT OF YOUR APPEAL. ALL OF THE INFORMATION YOU WISH TO USE FOR YOUR APPEAL MUST BE RECEIVED IN OUR OFFICE WITHIN 60 DAYS AFTER THE DATE OR RECEIPT OF THIS LETTER. ANY INFORMATION RECEIVED AFTER 60 DAYS WILL NOT BE CONSIDERED.
This is an Employee Retirement Income Security Act of 1974 (ERISA) qualified plan under which you have certain rights including the right to appeal. If you have a group Long Term Disability Insurance Plan Booklet, this law is explained therein.

(Letter dated June 15, 1998 from David Hooks to Plaintiff, Ex. 7 to Mem. of Law in Supp. of Def.'s Mot. to Dismiss.) (Bold and capitalization in original.) The appeal language is consistent with the corresponding language in the claims procedure section of the Policy document, which provides that if a claim is denied, and the covered person does not agree with determination, any "appeal must be made within sixty (60) days of the date of receipt of the letter denying the claim." (Provident Life and Casualty Insurance Company Voluntary Group Long Term Disability Insurance Certificate at 21, Ex. 2 to Mem. of Law in Supp. of Def.'s Mot. to Dismiss.) The Policy also provides that "[n]o action at law or in equity may be brought until 60 days after" a claimant gives proof of loss and has exhausted all appeals. (Id. at 22.) Plaintiff did not pursue an appeal or submit further documents within the 60-day period.

On February 17, 2000, Plaintiffs attorney wrote to Defendant, requesting that Plaintiffs claim be reopened. (Def.'s Stmt ¶ 23.) Defendant has not disputed Plaintiffs assertion in her affidavit:

That I applied for continued benefits from Provident but was unable to pursue it further due to all that is necessary to appeal a claim; after I had an attorney on the case it was possible for him to try for me to get the benefits; that I have not been my usual self as a result of injuries and things I would have done before or even tried to do I am no longer able to do.

(Aff. in Opp'n to Def.'s Mot. For Dismissal Or Summ. J. ...


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