The opinion of the court was delivered by: Charles J. Siragusa United States District Judge
This is an action brought pursuant to ERISA, to recover benefits under two employee welfare plans. Now before the Court is Defendants' motion to dismiss pursuant to Federal Rule of Civil Procedure ("FRCP") 12(b)(6) (Docket No. [#7]). The application is granted.
Peggy A. Hall ("Plaintiff") is the widow of William D. Hall ("Mr. Hall"). Mr. Hall was employed by Eastman Kodak ("Kodak") from 1968 until he retired in May 1992. On February 20, 2006, almost fourteen years after his retirement, Mr. Hall died of malignant mesothelioma, caused by his exposure to asbestos while he was employed at Eastman Kodak. Plaintiff subsequently applied for benefits under two Kodak employee welfare benefit plans: the Kodak Occupational Accidental Death Insurance Plan ("KOADI" or "the Accidental Death Plan") and the Kodak Medical Assistance Plan ("KMA" or "the Medical Assistance Plan"). With regard to the KMA plan, Plaintiff applied for benefits under the provision concerning "SE7/Survivors," discussed further below.
The KOADI plan pays a specified death benefit for qualifying employees. KOADI states that while an employee is a "Workers' Compensation Recipient," he is considered an employee "for all purposes under the Plan." KOADI Plan § 2.10. The plan defines covered injuries, in pertinent part, as follows: 7.01 On-the-Job Injuries
The benefits will be payable in the event that an Employee sustains a bodily injury in the course of his employment with the Company and, within 1 year of the injury, dies as a direct result of the injury. Even if these conditions are not met, the insurance will be paid if death benefits have been determined to be payable under a Workers' Compensation Law because of a death resulting from an injury within one year of the injury. ([#7-4] at 10). However, the plan specifically excludes coverage for "[d]eath which is caused wholly or partly, directly or indirectly, by disease, or bodily or mental infirmity." Id. (Plan § 7.03). The KOADI Plan Summary similarly states: Plan benefits will be payable if you suffer an accidental bodily injury while working at a Participating Company . . . and, within one year of the accident, you die as a direct result of that injury. Plan benefits are also payable if death benefits have been determined to be payable under a Workers' Compensation Law because the death resulted from an injury within one year of the injury. For purposes of the plan, an injury is 'accidental' only if the injury was the result of a sudden incident. It does not include injury or death caused directly or indirectly, or wholly or partly, by . . . your physical or mental illness[.]
The KMA plan, in pertinent part, pays a portion of a survivor's
health-care insurance costs, where the deceased employee's death
qualifies for the aforementioned death benefit under KOADI.*fn1
KMA defines an "SE7/Survivor," as "a person (1) who is the
Survivor of a decedent who was an Employee at the time of death, (2)
where the decedent died on or after January 1, 1993, and (3) where the
decedent died as a result of an occupational accident qualifying the
person for benefits under the [KOADI]." (Obstarczyk Decl., Ex. H). KMA
plan states that an employee who is a Workers' Compensation recipient
"shall be treated as an Employee for all purposes under the Plan." KMA
Plan § 3.25.
Regarding the submission of claims, at the time of Mr. Hall's death, KOADI stated that a claim could be "submitted at any time after the Subscriber's death." Obstarczyk Decl., Ex. A, § 8.02. In July 2006, Kodak issued a "Benefits Update," which announced a change in the claims and appeals procedures under the KOADI and KMA plans. ([#7-4] at 35-36). The document indicates that all "routine" KOADI claims must be filed "[w]ithin one year from the date of death," and that "other" KOADI claims must be filed "[w]ithin 60 days from the date or should have known that there is an issue, dispute, problem or other claim with respect to the plan." Id. at 40. Additionally, the Benefits Update stated that all lawsuits relating to the subject plans must be filed by the earlier of either 90 days after an appealed claim is denied, or 90 days after a plan representative clearly denies a claim. Id. at 36. The Benefits Update also stated that the new deadlines became effective on August 1, 2006, and that claims that arose prior to that date would be subject "to the earlier of the deadline that would have applied under the plan involved prior to its amendment or the deadline described in this summary." Id. at 36.
As noted earlier, Mr. Hall died on February 20, 2006. On March 31, 2006, Kodak sent Plaintiff a letter summarizing the benefits available to her as a surviving spouse. The letter did not mention the KOADI or KMA plans. ([#7-4]). On April 14, 2006, Plaintiff, by her attorney, sent a letter to Kodak's "Plan Administrator," indicating that Mr. Hall's death was from malignant mesothelioma, caused by his exposure to asbestos while working for Kodak. ([#7-4] at 59). The letter also noted, inter alia, that a Worker's Compensation case had been filed on behalf of Mr. Hall. Additionally, the letter stated that "the 'occupational accident' provision" should provide Plaintiff with full health insurance coverage, since Mr. Hall died from occupational disease.*fn2 *fn3 Plaintiff maintains that this letter functioned as a claim for benefits under both KOADI and KMA. Complaint ¶ 20.
On June 9, 2006, Kodak representative John Littwitz ("Littwitz") sent a response, indicating that Plaintiff would have to pay a portion of her monthly health insurance premium, since, "Occupational Accidental Death benefit coverage is not relevant to health care coverage." ([#7-4] at 62). Littwitz stated that Plaintiff could appeal his decision by writing a letter to the Plan Administrator, within 90 days of the date of his letter.
On August 28, 2006, Plaintiff wrote to Kodak's Plan Administrator, and indicated that she was "responding to [Littwitz's] letter dated June 9, 2006." ([#7-4] at 65). Plaintiff stated that she qualified as an "SE7 survivor," since Mr. Hall had been found eligible for Worker's Compensation death benefits. In that regard, Plaintiff referred to KOADI, stating: "Number 7 of the Kodak Occupational Accidental Death Insurance Plan document states, even if conditions are not met the insurance will be paid if death benefits have been determined to be payable under Workers Compensation." ([#7-4] at 65).
On October 5, 2006, Plaintiff's attorney wrote to the Plan Administrator, stating that Plaintiff was entitled to receive a benefit under KOADI, because Mr. Hall had been diagnosed with work-related malignant mesothelioma in June 2005, and died "less than one year after his injury was diagnosed." ([#7-4] at 70) (emphasis added). On December 22, 2006, Littwitz responded by letter, stating that Kodak had received Plaintiff's October 5, 2006 correspondence and was reviewing the case. Complaint ¶ 23. On March 20, 2007, Plaintiff wrote to Kodak seeking an update on her KOADI and KMA claims, and requesting copies of documents pertaining to those claims. ([#7-4] at 79, 81-82). Plaintiff also stated that she had never received a determination concerning her KOADI claim. ([#7-4] at 82). On June 15, 2007, Kodak representative Kim Chesher ("Chesher") wrote to Plaintiff, indicating that Kodak had received Plaintiff's October 5, 2006, letter, but that ...