United States District Court, N.D. Illinois, Eastern Division
Mark D. Debofsky, Marie Erin Casciari, Daley, Debofsky & Bryant, Chicago, IL, for Plaintiff.
Amanda A. Sonneborn, Megan E. Troy, Seyfarth Shaw LLP, Chicago, IL, for Defendant.
MEMORANDUM OPINION & ORDER
JOAN B. GOTTSCHALL, District Judge.
Defendant The Prudential Insurance Company of America (" Prudential" ) moves to dismiss Plaintiff James Ayotte's Complaint pursuant to Federal Rule of Procedure 12(b)(6). Ayotte sued Prudential pursuant to §§ 502(a)(1)(B) and (g) of the Employee Retirement Income Security Act of 1974 (" ERISA" ), 29 U.S.C. §§ 1132(a)(1)(B) and (g). He seeks benefits allegedly due to him under a long-term disability policy (" the Plan" ), provided to employees of ISI Telemanagement Solutions, Inc. (" ISI" ), which was issued, underwritten, funded, and administered by Prudential. Prudential argues that the Complaint must be dismissed because an ERISA suit pursuant to § 1132(a)(1)(B) may be brought only against the Plan itself. The court holds that, despite the general rule that an ERISA plaintiff seeking benefits must sue the plan, Prudential is a proper party to Ayotte's suit. Prudential's motion to dismiss is denied.
According to the Complaint, Ayotte worked for ISI as vice president of engineering. He was forced to cease working on February 27, 2009, due to chronic headaches. On March 2, 2009, he began receiving benefits under a long-term disability policy underwritten and administered by Unum, ISI's disability insurance provider at the time. Ayotte attempted to return to full-time work on January 4, 2010, but was able to do so only until February 26, 2010. Ayotte worked part-time at ISI from
March 1, 2010, until August 24, 2010, when he was forced to cease work entirely. Ayotte then began receiving full long-term disability benefits from Prudential, which had replaced Unum as ISI's disability insurance provider. Ayotte alleges that the Plan issued and administered by Prudential is an " employee welfare benefit plan," as defined by 29 U.S.C. § 1002(1), and that incident to his employment with ISI, Plaintiff received coverage under the Plan as a " participant," as defined by § 1002(7).
On September 27, 2011, Prudential notified Ayotte that it was terminating his long-term disability benefits effective October 1, 2011. Ayotte appealed that decision internally, and Prudential upheld its decision based on file reviews performed by nonexamining physicians. Ayotte then filed this suit against Prudential. He seeks an order reinstating his long-term disability benefits and further seeks to recover benefits that have accrued from October 1, 2011, to the present, along with interest on all overdue benefits.
Attached to Ayotte's Complaint is a copy of the Plan, called a " Group Insurance Contract for Short and Long Term Disability Coverage." The Plan states that the " Contract Holder" is " PruValue Insurance Benefits Trust." A section entitled " Certificate of Coverage" states that Prudential " welcomes you to the plan" and gives Prudential's address. (Compl. Ex. 1 (Plan) 6, ECF No. 1.) A " General Provisions" section defines the following terms: " You means a person who is eligible for Prudential coverage. We, us, and our means the Prudential Insurance Company of America." ( Id. at 7.)
Under the terms of the Plan— which is also referred to as the " Prudential plan" ( id. at 31)— Prudential approves applications for coverage, receives disability claims, determines whether someone is disabled under the terms of the Plan, evaluates eligibility for benefits, and provides benefits payments. The Plan defines the term " Payable claim" as " a claim for which Prudential is liable under the terms of the Group Contract." ( Id. at 45.) A Summary Plan Description attached to the Plan states that Prudential " as Claims Administrator has the sole discretion to interpret the terms of the Group Contract, to make factual findings, and to determine eligibility for benefits. The decision of the Claims Administrator shall not be overturned unless arbitrary and capricious." ( Id. )
II. LEGAL STANDARD
A motion to dismiss pursuant to Rule 12(b)(6) should be granted if the plaintiff fails to " state a claim to relief that is plausible on its face." Ashcroft v. Iqbal,556 U.S. 662, 678, 129 S.Ct. 1937, 173 L.Ed.2d 868 (2009) (citing Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570, 127 S.Ct. 1955, 167 L.Ed.2d 929 (2007)). The factual allegations in a complaint must " raise a right to relief above the speculative level." Twombly, 550 U.S. at 555-56, 127 S.Ct. 1955; see also Swanson v. Citibank, N.A., 614 F.3d 400, 404 (7th Cir.2010) (" [P]laintiff must give enough details about the subject-matter of the case to present a story that holds together." ). For purposes of a motion to dismiss, the court takes all facts alleged in the complaint as true and draws all reasonable inferences from those facts ...