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Linda Blaikie v. Rsight

November 21, 2011


The opinion of the court was delivered by: Richard A. Lazzara United States District Judge


THIS CAUSE comes before the Court on Defendant Aetna Health, Inc.'s Motion for Summary Judgment and supporting memorandum of law (Dkt. 47) and Statement of Undisputed Facts with supporting exhibits (Dkt. 48), Defendant Staffing Concepts, Inc.'s Motion for Summary Judgment and supporting memorandum of law (Dkt. 52), and Plaintiff's Memoranda in Opposition to the Motions (Dkts. 55 & 57) and Statements of Disputed Facts (Dkts. 56 & 58) with supporting exhibits (Dkts. 59, 50, 61, & 62).

Background & Claims

Plaintiff filed this lawsuit on August 28, 2009, based on alleged violations of the Employee Retirement Income Security Act, 29 U.S.C. § 1001, et seq. ("ERISA"), with respect to the continuation of Plaintiff's health benefits through the Consolidated Omnibus Budget Reconciliation Act ("COBRA"), following her termination of employment with Defendant Rsight, Inc. ("RSight") on April 11, 2004.*fn1 This is Plaintiff's second lawsuit against the Defendants, both cases arising from the same event: termination of Plaintiff's medical benefit coverage due to non-payment of premium. Plaintiff was employed by RSight, who had an agreement with Defendant Staffing Concepts, Inc. ("SCI") that included arranging for employee benefits for RSight's employees. Through this arrangement, Plaintiff obtained medical benefit coverage through Defendant's Aetna Health, Inc.'s ("Aetna") health maintenance organization pursuant to a group agreement between Aetna and SCI ("the Plan"). After Plaintiff was no longer working, she became eligible for continuation coverage through COBRA, provided that she timely paid her premiums. Defendants terminated her coverage on September 1, 2004, on grounds that Plaintiff failed to timely pay the premiums.

Plaintiff originally brought three counts against Defendants in this action: breach of fiduciary duty, equitable estoppel, and waiver/estoppel, seeking compensatory damages, attorney's fees, costs, and equitable relief. Plaintiff dropped the claim for breach of fiduciary duty after being served with Defendants' answer and affirmative defenses. (Dkt. 17.) Although Plaintiff couches her claims for relief in equitable terms, the claims actually rest on alleged medical costs for which she seeks reimbursement from Defendants inasmuch as she asserts that Defendants failed to properly account for premium payments paid to continue her COBRA benefits, which resulted in her being terminated from the benefits Plan. Further, she maintains that Defendants should compensate her in an amount equal to the costs of her medical treatment multiplied by the time she would have been eligible to receive COBRA benefits.

Summary Judgment Standard

Defendants seek the entry of summary judgment on grounds that Plaintiff failed to exhaust her administrative remedies prior to commencing suit, that her claims are impermissible under ERISA and refuted by the record evidence, and that Plaintiff's claims are barred by the statute of limitations. Summary judgment is appropriate where there is no genuine issue of material fact. Fed.R.Civ.P. 56(c). Where the record taken as a whole could not lead a rational trier of fact to find for the nonmoving party, there is no genuine issue for trial. Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574 (1986) (citation omitted). On a motion for summary judgment, the court must review the record, and all its inferences, in the light most favorable to the nonmoving party. United States v. Diebold, Inc., 369 U.S. 654, 655 (1962). The Court, having carefully considered the parties' submissions, finds that no genuine issues exist for trial and that Defendants Aetna and SCI. are entitled to the entry of final summary judgment on Plaintiff's claims.


Plaintiff was required to exhaust her administrative remedies, as provided for in the ERISA Plan, prior to commencing suit in federal court. Perrino v. Southern Bell Tel. & Tel. Co., 209 F.3d 1309, 1315 (11th Cir. 2000) (holding that "our law is well-settled that plaintiffs in ERISA actions must exhaust available administrative remedies before suing in federal court") (internal quotation marks omitted); seealsoLanfear v. Home Depot, Inc., 536 F.3d 1217, 1223 (11th Cir. 2008) (holding that "the law is clear in this circuit that plaintiffs in ERISA actions must exhaust available administrative remedies before suing in federal court"). This requirement is to be strictly enforced, with courts recognizing only narrow exceptions based on exceptional circumstances. Perrino, 209 F.3d at 1318. The Eleventh Circuit recognizes exceptions "only when resort to administrative remedies would be futile or the remedy inadequate, or where a claimant is denied meaningful access to the administrative review scheme in place." Id. at 1316 (internal citations and quotation marks omitted). This requirement is based upon several important policy considerations, and has been found to be consistent with Congressional intent. Id. at 1315. As the Eleventh Circuit explained, in Mason v. Continental Group, Inc.:

Compelling considerations exist for plaintiffs to exhaust administrative remedies prior to instituting a lawsuit. Administrative claim-resolution procedures reduce the number of frivolous lawsuits under ERISA, minimize the cost of dispute resolution, enhance the plan's trustees' ability to carry out their fiduciary duties expertly and efficiently by preventing premature judicial intervention in the decision making process, and allow prior fully considered actions by pension plan trustees to assist courts if the dispute is eventually litigated.

763 F.2d 1219, 1227 (11th Cir. 1985). Therefore, when a plaintiff fails to exhaust her administrative remedies, her claims are barred unless one of the exceptions is met. Tindell v. Tree of Life, Inc., 672 F. Supp. 2d 1300, 1306 (M.D. Fla. 2009).

The administrative remedies in this case are found in the Certificate of Coverage ("Certificate"), which is part of the Group Agreement between Aetna and SCI and which provided for the benefits on which Plaintiff sues in this action. (Dkt. 1, Ex A.) The Certificate provides for two levels of appeal before a lawsuit may be initiated. (See id.) Plaintiff was also informed of this appeals process in writing through Aetna's initial notice to Plaintiff acknowledging her lawyer's appeal on her behalf. (See Dkt. 50, Ex. 2, Malone Aff. ¶ 4; Ex. A., February 23, 2006 letter.) Plaintiff failed to exhaust these administrative remedies by not timely requesting a Level II appeal. (See Malone Aff. at ¶ 7; Ex. D.) Plaintiff admits that the Certificate required her to comply with the appeals process as a condition precedent to filing suit. (See Dkt. 50, Ex. 5, Plaintiff's Response to Request for Admission No. 7.) Plaintiff fails to assert any of the narrow exceptions excusing her compliance with the process. As a result, Plaintiff's claims are barred and Aetna's decision in the Level I appeal is final and binding. See Lenoir v. BellSouth Telecommunications, Inc., 2006 WL 2982879 (N.D. Ga. 2006) (holding that failure to comply with Aetna second level appeal requirement resulted in plaintiff's failure to exhaust administrative remedies as condition precedent to ERISA claim); Tindell, 672 F. Supp. 2d at 1306; seealsoPalmeri v. Coca-Cola Company, 2006 WL 2523027 (N.D. Ga. 2006); McPhillips v. Blue Cross Blue Shield of Alabama, 2010 WL 3833950, at *4 (M.D. Ala. 2010) (holding that plaintiff's failure to follow the administrative appeals process spelled out in the group plan demonstrated a failure to exhaust administrative remedies); Noren v. Jefferson Pilot Financial Ins. Co., 2010 WL 1841892, at *1 (9th Cir. 2010) (identifying two-level internal administrative review process required by plan and rejecting bare assertion by plaintiff that a second level appeal would have been futile).

Plaintiff did not claim that requesting a Level II appeal would be futile, would provide an inadequate remedy, or that she was denied meaningful access to the administrative scheme in place. Moreover, any claim of futility is refuted by the fact that Plaintiff initially followed the administrative procedures outlined in the Certificate and completed the first level of appeal, which Aetna denied on March 22, 2006. (See Malone Aff., at ¶5; Ex. B, March 22, 2006 letter.) The availability and utility of the administrative scheme is also evidenced, as Defendants assert, by the fact that Plaintiff attempted to request a Level II appeal, but despite being represented by counsel, being provided a detailed overview of the appeals process, which letter includes a detailed description of the appeals procedure), and being expressly informed in the Level I Appeal Resolution Letter that she had 60 days from the receipt of the same to request a Level II appeal, Plaintiff did not request her Level II appeal until well beyond the 60 day period required under the Certificate. (See Malone Aff., at ¶ 4; ¶ 7; Ex. A, February 23, 2006 letter; Ex. D, September 27, 2006 letter.) Simply put, Plaintiff did not make her request for a Level II appeal until July 20, 2006, nearly 120 days after the March 22, 2006 decision denying the first level appeal. (See id.)

The Court agrees with Defendants that to allow Plaintiff's disregard of the Plan terms governing appeal procedures would not only be contrary to the well-settled law in this circuit, but would be contrary to the purposes for which the exhaustion of remedies requirement is imposed. SeeSpringer v. Wal-Mart Associates' Group Health Plan, 908 F.2d 897, 900 (11th Cir. 1990) (holding that "the very premise of the exhaustion requirement, therefore, is that the right to seek federal court review matures only after that requirement has been appropriately satisfied or otherwise excused."); seealso, Perrino, 209 F.3d at 1318 (holding "therefore, if a reasonable administrative scheme is available to a plaintiff and offers the potential for an adequate legal remedy, then a plaintiff must first exhaust the administrative scheme before filing a federal ...

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