United States District Court, W.D. Tennessee, Eastern Division
ORDER GRANTING IN PART AND DENYING IN PART DEFENDANT'S MOTION TO DISMISS CLAIMS AGAINST FRED'S INC. WELFARE PLAN AND FRED'S SHORT TERM DISABILITY PLANS AND CERTAIN CLAIMS AGAINST AETNA LIFE INSURANCE COMPANY
J. DANIEL BREEN, Chief District Judge.
This matter was brought by the Plaintiff, Patricia Flatt, on March 19, 2014 against Aetna Life Insurance Company of Hartford, Connecticut a/k/a Aetna, Inc. ("Aetna"); Fred's Inc. Welfare Plan and Fred's Short Term Disability Plan (sometimes collectively referred to as the "Plans"), alleging wrongful denial of long-term disability ("LTD") benefits and short-term disability ("STD") benefits, breach of fiduciary duty and refusal to supply requested information pursuant to the Employee Retirement Income Security Act (ERISA), 29 U.S.C. §§ 1001 et seq., as well as breach of contract under Tennessee state law. Before the Court is the Defendants' motion to dismiss Plaintiff's claims against the Plans as well as certain claims against Aetna under Rule 12(b)(6) of the Federal Rules of Civil Procedure. (D.E. 14.)
STANDARD OF REVIEW
The Rule permits a court to dismiss a complaint for "failure to state a claim upon which relief can be granted." Fed.R.Civ.P. 12(b)(6). The court is to accept all well-pleaded factual allegations as true and construe the complaint in the light most favorable to the plaintiff. Wilson v. HSBC Bank, N.A., ___ F.Appx. ___, 2014 WL 6463020, at *2 (6th Cir. Nov. 19, 2014). The complaint "must contain sufficient factual matter, accepted as true, to state a claim to relief that is plausible on its face." Marie v. Am. Red Cross, ___ F.3d ___, 2014 WL 5905003, at *14 (6th Cir. Nov. 14, 1014) (quoting Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009)) (internal quotation marks omitted).
The following facts have been alleged by the Plaintiff. At all times relevant to this litigation, Flatt was a full-time employee of Fred's Inc. and eligible for both LTD and STD benefits under the Plans, group insurance policies entered into between Fred's Inc. and Aetna for the welfare and benefit of Fred's Inc. employees and in which Plaintiff was a plan participant. Aetna served as the fiduciary and claims administrator of the Plans. Flatt was employed by Fred's Inc. for approximately fifteen years before she became disabled and unable to perform the essential functions of her job as a certified pharmacy technician on January 7, 2012.
She applied for STD benefits under the Plans on or about January 11, 2012. Her medical providers were identified to Aetna and disability-supporting medical records, including imaging studies, reports, etc., were made available to the insurer for its review and consideration. Aetna's initial review of Flatt's STD claim found that disability was supported. Specifically, the insurer concluded, based on the medical information provided, that she was experiencing a "combination of issues" and that she was disabled under the Plans. Her STD payments were scheduled to commence on January 23, 2012.
On February 20, 2012, Aetna found Flatt was "unable to maintain gainful employment" and extended her benefits through March 9, 2012 on grounds that it was "reasonable to support [her] claim for this period due to diagnosis and job physical demand level of medium. Clinical information [received] preclude[d] [her] from being able to perform [the] essential duties of [her] job." The insurer further determined that Flatt "ha[d] job requiring mental clarity and some [physical] demands such as moderate lifting. [Plaintiff] ha[d] multiple complaints, [a] long standing issue of back pain combined with current exacerbation of mental nervous complaints and it [was] reasonable that due to the [combination] of these issues, [Flatt] would be unable/[it would be] unsafe to perform her job duties." Her benefits were terminated, however, effective March 9, 2012 due to a lack of clinical documentation to support her inability to perform essential occupation functions. Plaintiff immediately appealed the denial of benefits.
On or about July 20, 2012, Aetna sent a letter to Flatt, advising that, upon review of her STD benefits application, the contractual guidelines and her medical file, her claim approval was extended through July 13, 2012. However, her benefits were again terminated effective July 14, 2012 due to a lack of medical evidence to support her inability to perform the material duties of her job.
Claim notes of Aetna dated August 3, 2012 reflect that "objective/clinical findings support ongoing disability" and that Flatt was disabled under the Plans. The notes further stated that it was "reasonable to support claim for this period due to diagnosis and job physical demand level of medium. Clinical information received preclude[d] employee from being able to perform essential duties of [her] job." Nevertheless, Aetna advised her by letter that, based on contractual guidelines and the medical information on file, her claim for STD benefits beyond July 14, 2012 was denied. Flatt's benefits were not reinstated and she never received benefits to which she was entitled from July 14 through July 22, 2012.
Plaintiff appealed the denial on August 27, 2012. Around November 12, 2012, Flatt was informed by the insurer that its original decision to deny benefits effective July 14, 2012 had been upheld due to a lack of medical evidence to support the claim and advised her that she had exhausted all appeal rights with respect to the denial of STD benefits.
Flatt's eligibility for LTD benefits began on July 23, 2012, following her maximum benefit period for STD benefits, and Aetna's consideration of her claim for LTD benefits commenced on July 25, 2012. According to the terms of the Plans, once a "Test of Disability" is met, monthly benefits become payable after the "elimination period" expires. This period in Flatt's case was the first 180 days of her disability.
The Plaintiff claims that, as her disability began on January 9, 2012, her LTD benefits became payable after the elimination period expired on July 6, 2012. As was the case with her STD benefit claims, Flatt's physician information and supporting medical records were provided to Aetna. On August 14, 2012, Aetna advised her that it had denied her claim for LTD benefits on grounds that the medical documentation provided failed to support her claim and because she was not under the active care of a provider. Plaintiff appealed the denial and, on November 12, 2012, the insurer informed her ...