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Coontz v. Metropolitan Life Insurance Co.

United States District Court, W.D. Kentucky, Bowling Green Division

September 22, 2017

JENNITH COONTZ
v.
METROPOLITAN LIFE INSURANCE COMPANY PLAINTIFF DEFENDANT

          MEMORANDUM OPINION AND ORDER

          Greg N. Stivers, Judge United States District Court.

         This matter comes before the Court on Defendant's Motion to Dismiss, or in the alternative, Motion to Remand (DN 7), Defendant's Motion for Extension of Time to File Reply (DN 11), and Plaintiffs Motion to Strike Reply as Untimely Filed (DN 14). For the following reasons, Defendant's Motion to Dismiss is DENIED, Defendant's Motion for Extension of Time to File Reply is GRANTED, and Plaintiffs Motion to Strike Reply as Untimely Filed is DENIED

         I. BACKGROUND

         Plaintiff Jennith Coontz ("Coontz") was employed at American Greetings Corporation. (Notice Removal Ex. A, at 2, DN 1-2 [hereinafter Compl.]). As part of her employment, Coontz had accidental death and dismemberment ("AD&D") benefits through two plans: the American Greetings Corporation Personal Accidental Death and Dismemberment Plan and the American Greetings Corporation Voluntary Accidental Death and Dismemberment Plan (collectively the "Plan"), which were both issued by Defendant Metropolitan Life Insurance Company ("MetLife"). (Def's Mot. Dismiss Ex. 1, DN7-1).

         On May 4, 2016, Coontz submitted to MetLife a claim for AD&D benefits based on the loss of sight in her right eye. (Compl. ¶ 12). On July 7, 2016, MetLife issued an initial denial of Coontz's claim for benefits on the basis that the "loss of sight was contributed to by the complications arising from the treatment of the lung surgery, therefore, under the terms of the Plan the loss was not the direct result of an accidental injury." (Compl. ¶ 14; Def's Mot. Dismiss Ex. 2, DN 7-3). Further, MetLife determined that even if the loss of sight had been the result of an accident, a Plan exclusion precluded payment "for any loss caused or contributed to by . . . physical or mental illness or infirmity, or the diagnosis or treatment of such illness or infirmity." (Def's Mot. Dismiss Ex. 2).

         With regard to the "Notice of Benefit Determination on Appeal, " the Plan provides that an appeal decision must be rendered within 60 days of receipt of the appeal. (Def's Mot. Dismiss Ex. 1, at 49-50, DN 7-1). This 60-day period can be extended for an additional 60 days "if the claims administrator both determines that special circumstances require an extension of time for processing the claim, and notifies the covered person (or authorized representative), before the initial sixty (60) day period expires, of the special circumstances requiring the extension of time and the date by which the claims administrator expects to render a determination." (Def's Mot. Dismiss Ex. 1, at 49-50). Further, the Plan requires not only a first appeal, but a "second-level appeal" before suit can be initiated. (Def's Mot. Dismiss Ex. 1, at 50). In particular, the Plan provides:

If the covered person is not satisfied with the outcome of the appeals procedure, the covered person has the right to bring a civil action under section 502 (a) of the Employee Retirement Income Security Act of 1974. The covered person may not initiate a legal action against the plan until the covered person has completed the [sic] both the initial and second level appeal process.

(Def's Mot. Dismiss Ex. 1 at 50).

         By letter dated July 15, 2016, Coontz appealed MetLife's decision. (Compl. ¶ 17). On August 16, 2016, she supplemented her appeal with additional information. (Compl. ¶ 19).

         MetLife advised Plaintiff by letter dated August 25, 2016, (the "Extension Letter") that it was "continuing to review [her] appeal dated August 16, 2016." (Compl. ¶ 20; Def's Mot. Dismiss Ex. 3, at 1, DN 7-4). MetLife further advised that "[i]t will be necessary for us [MetLife] to obtain additional information; therefore, completion of your [Coontz's] appeal will be delayed for a short period of time." (Compl. ¶ 20; Def's Mot. Dismiss Ex. 3). Finally, the Extension Letter advised Coontz that "[w]e will notify you of our findings for ERISA use: within sixty (60) days of receiving the necessary information." (Compl. ¶ 20; Def's Mot. Dismiss Ex. 3, at 1).

         Although MetLife had not ruled on Coontz's initial appeal, she filed this action in Casey Circuit Court on December 13, 2016. (Compl. ¶ 22). MetLife subsequently removed the case to this Court. (Notice Removal, DN 1). MetLife has now moved to dismiss the case arguing that Coontz failed to exhaust her administrative remedies before filing suit. (Def's Mot. Dismiss, DN 7). This matter is ripe for adjudication.

         II. JURISDICTION

         This Court has "original jurisdiction of all civil actions arising under the Constitution, laws, or treaties of the United States." 28 U.S.C. § 1331.

         III. DISCUSSION

         A. MetLife's Motion to Dismiss

         MetLife has moved to dismiss the Complaint on the basis that Coontz failed to exhaust her administrative remedies and alternatively requests remand of this matter to MetLife for completion of the administration record.[1] (Def's Mot. Dismiss 6-10). A complaint is subject to dismissal if it "fail[s] to state a claim upon which relief can be granted." Fed.R.Civ.P. 12(b)(6). When considering a motion to dismiss under Rule 12(b)(6), the Court must construe the complaint in a light most favorable to the nonmoving party, accepting "as true all factual allegations and permissible inferences therein." See Gazette v. City of Pontiac,41 F.3d 1061, 1064 (6th Cir. 1994) (citing Westlake v. Lucas,537 F.2d 857, 858 (6th Cir. 1976)). The nonmoving party, however, must plead more than bare legal conclusions. See Lillard v. Shelby Cty. Bd. of Educ,76 F.3d 716, 726 (6th Cir. 1996). In order to survive a 12(b)(6) motion, "[the] complaint must contain (1) 'enough facts to state a claim to relief that is plausible, ' (2) more than 'a formulaic recitation of a cause of action's elements, ' and (3) allegations that suggest a 'right to relief above a speculative level.'" Tackett v. M & G Polymers, USA, LLC,561 F.3d 478, 488 (6th Cir. 2009) (quoting Bell Ail. ...


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