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HEROUX v. HUMANA INSURANCE COMPANY

June 8, 2005.

MAUREEN HEROUX, Plaintiff,
v.
HUMANA INSURANCE COMPANY, a corporation, and THE DUVAL GROUP, LTD., an Illinois Corporation, and THE "DUVAL GROUP PLAN," an unnamed employee welfare plan, Defendants.



The opinion of the court was delivered by: JOAN H. LEFKOW, District Judge

MEMORANDUM OPINION AND ORDER

Plaintiff, Maureen Heroux ("Heroux"), filed a six-count Second Amended Complaint against defendants, Humana Insurance Company ("Humana"), The Duval Group Ltd. ("Duval"), and the Duval Group Plan, alleging violations of the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. §§ 1101 et seq. Humana has moved pursuant to Rule 12(b)(6), Fed.R.Civ.P., to dismiss Counts I and III of Heroux's Second Amended Complaint for failure to state a claim upon which relief may be granted. The court has jurisdiction over the claims pursuant to 28 U.S.C. § 1331 and 29 U.S.C. § 1132. For the reasons set forth below, defendant's motion is granted in part and denied in part.

MOTION TO DISMISS STANDARDS

  A motion to dismiss under Federal Rule of Civil Procedure 12(b)(6) challenges the sufficiency of the complaint for failure to state a claim upon which relief may be granted. General Elec. Capital Corp. v. Lease Resolution Corp., 128 F.3d 1074, 1080 (7th Cir. 1997). Dismissal is appropriate only if it appears beyond a doubt that the plaintiff can prove no set of facts in support of its claim that would entitle it to relief. Conley v. Gibson, 355 U.S. 41, 45-46 (1957); Kennedy v. Nat'l Juvenile Det. Ass'n, 187 F.3d 690, 695 (7th Cir. 1999). In ruling on the motion, the court accepts as true all well pleaded facts alleged in the complaint, and it draws all reasonable inferences from those facts in favor of the plaintiff. Jackson v. E.J. Brach Corp., 176 F.3d 971, 977 (7th Cir. 1999); Zemke v. City of Chicago, 100 F.3d 511, 513 (7th Cir. 1996).

  ALLEGATIONS OF THE COMPLAINT*fn1

  I. Background

  Heroux was employed by Duval from February 14, 1998 until April 19, 2002. (Second Amended Complaint at ¶ 6, hereinafter "¶ ___"). As part of her employment with Duval, Heroux received health insurance coverage consisting of medical and drug coverage for illness or injury through the Duval Group Plan (the "Plan"). (¶ 7). The Plan is an employee welfare plan within the meaning of ERISA, adopted by Duval prior to April 2002. (¶ 3). Duval is the Plan's fiduciary and administrator under ERISA. (¶ 5).

  Upon Heroux's departure from her employment with Duval, Duval purported to offer Heroux a three-month severance package that continued her health insurance benefits. (¶ 6). Duval led Heroux to believe that upon her leaving her employment, her medical insurance was being continued under the provisions of the Consolidated Omnibus Budget Reconciliation Act ("COBRA"). (¶ 10). In order to maintain her health insurance coverage, Heroux made regular payments amounting to over $4,000 to Duval from the end of her employment through and including April of 2003. (¶¶ 11, 21).

  In a letter dated April 10, 2003, Duval specifically requested payment from Heroux for insurance. (Compl. Ex. B).*fn2 The letter informed Heroux that her health insurance coverage was expiring on April 30, 2003 and that Duval had not yet received payment for the month of April. Id. The letter notified Heroux that if Duval did not receive payment by April 15, 2003, Duval would end the policy effective March 31, 2003. Id. Duval wrote a check in the amount of $445.00 on April 11, 2003, which Duval cashed on April 18, 2003. (Compl. Ex. C).*fn3 Duval paid for Heroux's share of its group insurance policy through April 2003. (¶ 12).

  II. The Relationship Between Humana and the Plan

  Initially, the Group Insurance Policy (the "Policy") for the Plan identified Humana's predecessor, Employee Health Insurance Company, as its "Administrator."*fn4 (¶ 4). The Policy defined "Administrator" as "[Humana], who performs administrative functions for the Policyholder." (Def. Motion to Dismiss, Ex. A at Duval 0006).

  On June 1, 2000, the Policy was amended to redefine Humana as "Insurer" and "Trust Administrator."*fn5 (Def. Motion to Dismiss, Ex. A at Duval 0023-24). "Insurer" was defined as follows:
[Humana] in its capacity as administrator for claims determination and ERISA claims review fiduciary exercising its discretionary authority to: (1) interpret policy provisions; (2) make decisions regarding eligibility for coverage and benefits; and (3) resolve factual questions relating to coverage and benefits. [Humana] shall not be construed to be a fiduciary of the plan other than as described in this definition. [Humana] is not the Plan Administrator of the plan as that term is defined by ERISA.
(Def. Motion to Dismiss, Ex. A at Duval 0024). "Trust Administrator" was defined as Humana "in its capacity of performing administrative functions for the Policyholder." (Def. Motion to Dismiss, Ex. A at Duval 0024). Plaintiff alleges that Humana had authority to control and manage operation and administration of the Plan, in addition to possessing the discretion to grant or deny claims. (¶ 4). Plaintiff further alleges that Duval relied upon Humana's expertise in the control and management of operation of the Plan, thereby rendering Humana a fiduciary under ERISA. (¶ 4).

  III. Heroux's Claims Against Humana

  The cover pages of the Certificate of Insurance for the health insurance provided under the Plan to Heroux state that Duval is the employer, Heroux is the employee, and that the policyholder is the Trustee of the Employers Health Insurance Benefits Trust. (¶ 8). The certificate does not state the name of the subject plan. (¶ 8). During her employment with Duval, Heroux did not receive a summary plan description document, which is required under ERISA § 1022(b) to be provided and to include identification of the Plan. (¶ 9). Heroux received no other document while employed at Duval that identified the Plan. (¶ 9). Duval had informed Humana of Duval's representations to Heroux regarding Heroux's severance package and COBRA coverage. (¶ 23). In a letter dated March 21, 2003, Humana approved back surgery and related services for Heroux as medically necessary and approved under Heroux's insurance plan. (Compl. Ex. D). Relying upon this letter, Heroux had back surgery at a cost in excess of $140,000 in April 2003. (¶¶ 14, 21). After April 30, 2003, Duval claimed that Heroux's insurance coverage had expired prior to April 2003 and attempted to return the ...


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