Albandoz-Betancourt v. Sedgwick Claims Management Services, Inc.
Albandoz-Betancourt v. Sedgwick Claims Management Services, Inc.
Opinion of the Court
MEMORANDUM AND ORDER
Before the Court is the motion for judgment on the pleadings pursuant to Federal Rule of Civil Procedure Rule 12(c) (“Rule 12(c)”) filed by defendant Sedgwick Claims Management Services, Inc. (“Sedgwick”). (Docket No. 39.) For the reasons discussed below, the Court DENIES defendant Sedgwick’s motion.
I. BACKGROUND
A. FACTUAL BACKGROUND
In its complaint, plaintiff Albandoz alleges the following facts, which for the purposes of deciding defendant Sedgwick’s motion, the Court takes as true, Perez-Acevedo v. Rivero-Cubano, 520 F.3d 26, 29 (1st Cir. 2008):
Plaintiff Albandoz began working at Walgreen’s Puerto Rico, Inc. (“Walgreen’s”) as a Staff Pharmacist in January 2005. (Docket No. 1 at p. 2.) One of the benefits offered by Walgreen’s is the Walgreen’s Income Protection Plan for Pharmacists (“the Plan”), which is an employee welfare benefit plan as defined by the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001 et seq. Id. at pp. 2-3. The Plan provides short-term and long-term disability benefits. (Docket No. 17 at p. 2.) Defendant Sedgwick is the claims administrator for the Plan. Id.
When the STD benefits were initially approved, defendant Sedgwick informed plaintiff Albandoz that if she did not recover sufficiently to resume work by the end of the approved period, she would have to provide defendant Sedgwick with updated medical documentation by July 5, 2010. (Docket No. 1 at p. 6.) Plaintiff Albandoz saw Dr. Narvaez-Morell again on June 22, 2010, and the notes he submitted to defendant Sedgwick established that her condition persisted. Id. at pp. 6-7. As a result, plaintiff Albandoz requested an approval of an extension of her disability benefits. Id. at p. 6.
On July 14, 2010, defendant Sedgwick informed plaintiff Albandoz that she did not qualify for continuing benefits and denied her claim. (Docket No. 1 at p. 7.) Plaintiff Albandoz filed her first-level appeál on August 31, 2010, in which she submitted additional information from Dr. Annette Martinez that supported the previous diagnosis. Id at p. 8. On October 14, 2010, defendant Sedgwick denied plaintiff Albandoz’s first-level appeal and advised her of her right to a second-level appeal. Id. at p. 9.
Plaintiff Albandoz filed her second-level appeal on December 29, 2010. (Docket No. 1 at p. 10.) While the second-level appeal was ongoing, plaintiff Albandoz’s healthcare benefits were cancelled,
B. PROCEDURAL HISTORY
On March 2, 2012, plaintiff Albandoz filed her complaint, alleging that defendant Sedgwick (1) violated ERISA section 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B), by denying her disability benefits, and (2) violated the Consolidated Omnibus Budget Reconciliation Act (“COBRA”), 29 U.S.C. § 1166, by failing to provide her with prop
On December 20, 2012, defendant Sedgwick filed a motion for judgment on the pleadings requesting that the Court dismiss plaintiff Albandoz’s ERISA claim for long-term disability (“LTD”) benefits because she failed to plead that she exhausted her administrative remedies for those benefits. (Docket No. 39.) Plaintiff Albandoz opposed defendant Sedgwick’s motion on January 1, 2013, contending that, among other arguments,
II. RULE 12(c) STANDARD
‘When as now, a motion for judgment on the pleadings under [Rule 12(c) ] is employed as a vehicle to test the plausibility of a complaint, it must be evaluated as if it were a motion to dismiss under Federal Rule of Civil Procedure 12(b)(6).” Grajales v. P.R. Ports Auth., 682 F.3d 40, 44 (1st Cir. 2012). When considering a motion pursuant to Rule 12(c), a “court must view the facts contained in the pleadings in the light most favorable to the nonmovant and draw all reasonable inferences therefrom .... ” Perez-Acevedo, 520 F.3d at 29 (quoting R.G. Fin. Corp. v. Vergara-Nuñez, 446 F.3d 178, 182 (1st Cir. 2006)). “[A]n adequate complaint must provide fair notice to the defendants and state a facially plausible legal claim.” Ocasio-Hernandez v. Fortuño-Burset, 640 F.3d 1, 12 (1st Cir. 2011).
When faced with a motion for judgment on the pleadings, “[a] plaintiff is not entitled to ‘proceed perforce’ by virtue of allegations that merely parrot the elements of the cause of action.” Ocasio-Hernandez, 640 F.3d at 9 (quoting Ashcroft v. Iqbal, 556 U.S. 662, 129 S.Ct. 1937, 1950, 173 L.Ed.2d 868 (2009)). Any “[n]on-conclusory factual allegations in the complaint[, however,] must ... be treated as true, even if seemingly incredible.” Id. (citing Iqbal, 129 S.Ct. at 1951). Where those factual allegations “allow[] the court to draw the reasonable inference that the defendant is liable for the misconduct alleged,” the claim has facial plausibility. Id. (citing Iqbal, 129 S.Ct. at 1949). The Court must base its determination on the material submitted as part of the complaint and expressly incorporated within it. See Alt. Energy, Inc. v. St. Paul Fire & Marine Ins. Co., 267 F.3d 30, 33 (1st Cir. 2001). Additionally, the Court “may augment these facts and inferences with data points gleaned from documents incorporated by reference into the complaint, matters of public record, and facts susceptible to judicial notice.” Haley v. City of Boston, 657 F.3d 39, 46 (1st Cir. 2011).
The factual material pled must be sufficient “to raise a right to relief above the speculative level,” and to permit the Court to “draw the reasonable inference that the
III. ANALYSIS
“ERISA is a comprehensive federal statute that governs the rights and responsibilities of parties in relation to employee pension, welfare, and benefit plans.” Madera v. Marsh USA Inc., 426 F.3d 56, 61 (1st Cir. 2005). The statute provides a civil enforcement mechanism for “a participant or beneficiary ... to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan.” 29 U.S.C. § 1132(a)(1)(B).
Generally, “[bjefore a plaintiff asserts an ERISA claim ... he must first exhaust his administrative remedies.” Madera, 426 F.3d at 61. “An employee is not required to exhaust his administrative remedies!, however,] in those instances where it would be futile for him to do so.” Id. at 62. Nevertheless, “[a] blanket assertion, unsupported by any facts, is insufficient to call this exception into play.” Drinkwater v. Metro. Life Ins. Co., 846 F.2d 821, 826 (1st Cir. 1988).
Defendant Sedgwick contends that plaintiff Albandoz failed to plead that she exhausted her administrative remedies for the denial of LTD benefits, and, as a result, her claims for those benefits should be dismissed. (Docket No. 39.) Defendant Sedgwick accurately notes that plaintiff Albandoz failed to plead that she ever requested LTD benefits. (Docket No. 39 at p. 6.) Plaintiff Albandoz did contend, however, that the administrative mechanism for appealing the denial of disability benefits “ha[d] been exhausted.... ” (Docket No. 1 at pp. 1-2.)
As defendant Sedgwick correctly notes, a plaintiffs belief that bringing administrative remedies would be futile is insufficient to call the futility exception into play. (Docket No. 39 at pp. 5-6.) If, however, the plaintiffs belief is accurate — as demonstrated by factual evidence — and exhausting the administrative remedies would, in fact, be futile, then the futility exception is called into play. See Drinkwater, 846 F.2d at 826.
In Drinkwater, the plaintiff contended that the review procedure provided by the defendant was futile because there was “not the slightest possibility that the plan administrator could be objective, unbiased and act in the best interest of the beneficiary” when reviewing the plaintiffs claim. 846 F.2d at 825-26. Because the plaintiff failed to produce evidence, apart from the blanket assertion, to show that the review process would have been futile, the First Circuit Court of Appeals found that the futility exception was not applicable, and accordingly plaintiffs failure to exhaust administrative remedies was not excused. Id. at 826.
In contrast, here plaintiff Albandoz provided the eligibility requirements of the Plan as evidence supporting the assertion that it would have been futile for her to pursue the administrative process for LTD
The Court finds that even if plaintiff Albandoz brought an administrative claim for LTD benefits, her efforts would have been futile because she had already been denied STD benefits and was, therefore, ineligible for LTD benefits. Accordingly, the futility exception applies to plaintiff Albandoz’s failure to plead that she exhausted administrative remedies for LTD benefits. Because defendant Sedgwick’s motion for judgment on the pleadings is based solely on plaintiff Albandoz’s failure to plead that she exhausted administrative remedies for LTD benefits, it is DENIED.
IV. CONCLUSION
For the reasons discussed above, the Court finds that the futility exception applies to plaintiffs failure to plead that she exhausted administrative remedies for LTD benefits. Accordingly, the Court DENIES defendant Sedgwick’s motion for judgment on the pleadings, which is based on plaintiff Albandoz’s failure to plead that she exhausted administrative remedies for LTD benefits.
IT IS SO ORDERED.
. Logan Brown, a second-year student at the Georgetown University Law Center, assisted in the preparation of this Memorandum and Order.
. Plaintiff Albandoz alleges that the cancellation of her healthcare benefits violated the Consolidated Omnibus Budget Reconciliation Act ("COBRA”), 29 U.S.C. § 1166, because defendant Sedgwick "did not notify plaintiff [Albandoz] of her COBRA fights once her employment was deemed terminated.” (Docket No. 1 at p. 17.) Plaintiff Albandoz, however, fails to allege the date when her employment was deemed terminated.
. Because the Court finds that plaintiff Albandoz’s argument that she exhausted the available administrative remedies for disability benefits persuasive, it need not address the other arguments.
. Although plaintiff Albandoz failed to provide the eligibility requirements of the Plan in either its original or amended complaint, the Court includes them in its analysis because the Plan is incorporated by reference in both complaints. See Haley, 657 F.3d at 46.
Reference
- Full Case Name
- Hilda Z. ALBANDOZ-BETANCOURT v. SEDGWICK CLAIMS MANAGEMENT SERVICES, INC.s.
- Status
- Published