In Taylor v. Principal Life Insurance Company, No. 3:24CV603 DRL-SJF, 2024 WL 4381223 (N.D. Ind. Oct. 2, 2024), Indiana Northern District Judge Damon R. Leichty denied Principal Life Insurance Company’s Rule 12(b)(6) Motion to Dismiss Plaintiff’s ERISA claim for accidental death and dismemberment (AD&D) benefits, finding that Plaintiff adequately demonstrated that he lacked meaningful access to review procedures to warrant excusal of the requirement that the claimant first exhaust all administrative remedies.
Plaintiff was riding his motorcycle when it slipped and caught his leg while in operation. He lost his leg from this accident. Plaintiff alleged he was covered for dismemberment under a policy issued by Principal and made a claim under the policy which Principal denied. Principal sought to dismiss the ensuing lawsuit asserting that Plaintiff failed to exhaust administrative remedies prior to filing suit.
In opposition, Plaintiff argued (1) pursuing administrative remedies was futile in that Principal determined that he had been operating his motorcycle with a blood alcohol level (“BAC”) that exceeded the legal limit, and there unidentified “issues of law and fact” that must be addressed by a court; (2) he never had the ERISA plan documents to review its provisions; and (3) the written notice denying benefits did not communicate the procedure for pursuing review. The Court quickly disposed of the first two arguments reasoning that the explicit language of the plan excludes coverage when the BAC exceeds the legal limit, and to the extent that there are other factual issues, which Plaintiff did not deny, administrative review permits the plan fiduciary to revisit these with an eye toward the consistent handling of claims and development of a full factual record for the court later. The Court also concluded that to the extent that Plaintiff claimed he did not have the plan documents, he could have simply asked for them.
The third argument, however, found traction with the Court. Principal argued that the denial letter was not within the four corners of the Complaint and should not be considered on a Motion to Dismiss. The Court, however, found that Plaintiff’s argument that the letter did not contain the requisite language concerning administrative remedies was not inconsistent with the Complaint. Furthermore, ERISA regulations require that written notice adverse to a claimant contain a description of the plan’s review procedures and time limits applicable to such procedures. See 29 C.F.R. § 2560.503-1(f), (g)(1)(iv). In denying Principal’s Motion to Dismiss, the Court explained that if the language was omitted from the denial letter, the process of review was fairly unavailable to Plaintiff under the law.
If your insurer has denied or otherwise limited your life, AD&D or disability insurance claim, contact us for assistance.
*Please note that this blog is a summary of a reported legal decision and does not constitute legal advice. This blog has not been updated to note any subsequent change in status, including whether a decision is reconsidered or vacated. The case above was handled by other law firms, but if you have questions about how the developing law impacts your ERISA benefit claim, the attorneys at Roberts Disability Law, P.C. may be able to advise you so please contact us.
LEAVE YOUR MESSAGE
We know how to get your insurance claim paid. Call today at:
(510) 230-2090