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Gassiott v. Prudential Insurance Co. of America

October 6, 2009

WILLIAM GASSIOTT, PLAINTIFF,
v.
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA AND AICPA LIFE INSURANCE/DISABILITY PLANS COMMITTEE, DEFENDANTS.



The opinion of the court was delivered by: John F. Keenan, United States District Judge

OPINION AND ORDER

Plaintiff William Gassiott ("Gassiott") has brought this action for breach of contract seeking to recover under an insurance policy issued to him by Defendants The Prudential Life Insurance Company ("Prudential") and the AICPA Life Insurance/Disability Plans Committee ("AICPA"). Defendants now move for judgment on the pleadings pursuant to Federal Rule of Civil Procedure 12(c), arguing that Plaintiff's suit is barred by the insurance policy's contractual statute of limitations. For the reasons set forth below, their motion is granted.

I. BACKGROUND

Gassiott is a Certified Public Accountant insured under the American Institute of Certified Public Accountants Long Term Disability Insurance Policy issued by Prudential. (Compl. ¶ 11). This policy provides for monthly payments in the event of Gassiott's total disability. (Compl. ¶ 12). Under the terms of the policy, in order to receive disability benefits, an insured is required to submit written proof of loss to Prudential "within ninety days after: (1) the end of each month or lesser period for which Prudential is liable under the coverage, if the coverage provides for payment at such periodic intervals; or (2) the date of the loss, in the case of any other coverage." (Martin Decl., Ex. B). If Prudential declines to pay insurance benefits after receiving the initial proof of loss, the insured is entitled to appeal the denial internally up to three times. Each internal appeal must be submitted within 180 days of receipt of the claim denial, and Prudential then has 45 days (or 90 days if additional time is required) to render a decision on the appeal. (Martin Decl., Exs. D, E). The insured is also entitled to bring legal action against Prudential to recover benefits, but the insurance policy specifies that:

No action at law or in equity shall be brought to recover under the Group Policy prior to the expiration of sixty days after written proof of the loss upon which claim is based has been furnished as required above. No such action shall be brought more than three years after the expiration of the time within which proof of such loss is required. (Martin Decl., Ex. B).

The Complaint alleges that Gassiott became disabled on February 1, 2004. (Compl. ¶ 17). In July and August of 2004, he submitted proof of loss to Prudential requesting disability benefits because fibromyalgia and chronic fatigue prevented him from performing his accounting duties. (Compl. ¶ 19; Martin Decl., Ex. C). The proof of loss included an Attending Physician Statement dated August 11, 2004 and a personal statement dated August 18, 2004 in which Gassiott reported his symptoms and inability to work. (Martin Decl., Ex. C). On November 5, 2004, Prudential denied Gassiott's claim because the medical information provided "did not support a disability based on objective medical evidence." (Compl. ¶ 25).

On August 31, 2005, Gassiott, represented by counsel, filed his first internal appeal challenging Prudential's denial of his claim. (Compl. ¶ 27). In his appeal, Gassiott submitted additional medical reports detailing his treatment for fibromyalgia, chronic fatigue, tension headaches, Epstein Barr virus, rheumatoid arthritis, Chorean Disease and/or Huntington's Disease. (Compl. ¶ 28). He also submitted personal statements further explaining how his symptoms affected his quality of life and ability to perform his job. (Compl. ¶ 31). On October 17, 2005, Prudential issued a decision upholding its denial of Gassiott's disability claim based on its review of the medical evidence provided, as well as its direct observation of Gassiott playing golf and performing other activities inconsistent with his reported functional abilities. (Compl. ¶ 32; Martin Decl., Ex. E).

On October 27, 2006, Gassiott filed his second internal appeal challenging Prudential's denial of his claim. (Compl. ¶ 37). He submitted additional medical reports, including neurological and cognitive function evaluations, and a determination by the Social Security Administration that he is impaired. (Compl. ¶¶ 38-42). On June 6, 2007, Prudential again upheld its denial of Gassiott's disability claim, stating that the insured "has not provided credible and reliable data to support his reported degree of impairment and accordingly . . . he does not meet the definition of total disability." (Compl. ¶ 44; Martin Decl., Ex. F). Prudential noted that this was its final decision and that no further appeals would be entertained. (Martin Decl., Ex. F).

On August 20, 2008, Gassiott initiated the current suit against Prudential challenging the denial of his disability benefits.

II. DISCUSSION

A. Rule 12(c)

Rule 12(c) of the Federal Rules of Civil Procedure provides that "[a]fter the pleadings are closed - but early enough not to delay trial - a party may move for judgment on the pleadings." Fed. R. Civ. P. 12(c). The standard for granting a Rule 12(c) motion for judgment on the pleadings is identical to that of a Rule 12(b)(6) motion to dismiss the complaint for failure to state a claim upon which relief may be granted. Cleveland v. Caplaw Enters., 448 F.3d 518, 521 (2d Cir. 2006). The court must accept the complaint's factual allegations as true and draw all inferences in the plaintiff's favor. Id. In deciding this motion, the court's function "is merely to assess the legal feasibility of the complaint, not to assay the weight of the evidence which might be offered in support thereof." Geisler v. Petrocelli, 616 F.2d 636, 639 (2d Cir. 1980). Therefore, a complaint will be dismissed where it fails to set forth sufficient facts to state a claim for relief that is "plausible on its face." Bell Atlantic Corp. v. Twombly, 550 U.S. 544, 570 (2007).

The court limits its review to the factual allegations in the complaint, documents attached to the complaint or incorporated therein by reference, and documents that are integral to the complaint and upon which the complaint "solely relies." See Roth v. Jennings, 489 F.3d 499, 509 (2d Cir. 2007); Rothman v. Gregor, 220 F.3d 81, 88 (2d Cir. 2000); Cortec Indus., Inc. v. Sum Holding L.P., 949 F.2d 42, 47-48 (2d Cir. 1991). These include the AICPA Long Term Disability Income Plan document, Plaintiff's proof of loss submission, and Prudential's claim denial letters dated November 5, ...


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