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Ausler v. Aetna Life Insurance Co.

United States District Court, E.D. Missouri, Eastern Division

March 4, 2019

TIFFANY AUSLER, Plaintiff,
v.
AETNA LIFE INSURANCE CO, Defendant.

          MEMORANDUM AND ORDER

          JOHN A. ROSS UNITED STATES DISTRICT JUDGE

         This matter is before the Court on Defendant Aetna Life Insurance Company's (“Aetna”) Motion to Dismiss. (Doc. 10.) Plaintiff Tiffany Ausler has filed a response in opposition (Doc. 19), and Aetna has replied (Doc. 23).

         Background

         Plaintiff makes the following allegations (see Docs. 1, 19): Plaintiff was employed by Boeing Corporation as a software engineer for more than thirteen years. As a Boeing employee, Plaintiff was eligible for the company's short-term disability (“STD”) and long-term disability (“LTD”) compensation plans, which are administrated by Aetna and subject to the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001-1461. Aetna provided Boeing employees with a plan brochure[1] detailing things like eligibility requirements, the benefits claims process, and how to appeal from a denial. (Doc. 10-2 at 37-151 (see also, Doc. 10-1 (The Boeing Company Master Welfare Plan)).) It notes that Aetna serves as the plan's “service representative, ” with the authority to approve or deny disability claims and to review denials on appeal. (Id. at 61)

         1. The Plan Brochure

         The plan brochure is divided into thirteen sections, including Section 1 - Eligibility and Enrollment; Section 2 - Short-Term Disability Plan; Section 3 - Long-Term Disability Plan; and Section 9 - Claims and Appeals. (Doc. 10-2 at 43.) Section 1 of the plan brochure defines who is eligible for Boeing's seven employer-sponsored benefits plans.[2] (Doc. 10-2 at 40.) Initial eligibility determinations are made by the Boeing Service Center and appeals are considered by Boeing's Employee Benefit Plans Committee. (Id. at 121-22.) Section 2 of the plan brochure explains that STD benefits are available if an employee becomes disabled as a result of a pregnancy-related condition, accidental injury, or illness. (Id. at 61.) If an employee is disabled for twenty-six weeks, she “may be eligible for benefits under the [LTD] plan.” (Id.) Section 3 of the plan brochure explains the amount and duration of LTD benefits. (Id. at 67-76.) On page 3-10, the brochure explains how to claim LTD benefits:

How to Submit a Long-Term 1Disability Claim
If you are receiving benefits under the Short-Term Disability Plan and you continue to be disabled, you do not need to submit a claim for long-term disability benefits under this plan.
. . .
If you are not receiving benefits under the Short-Term Disability Plan, you will need to initiate a claim for long-term disability benefits by calling Boeing Total Access at the start of your medical leave.
. . .
You must initiate your claim within 90 days of the date your 26-week waiting period under this plan ends . . . A claim submitted more than one year after your 90-day disability claim-filing period will not be covered unless you are legally incapacitated.

(Id. at 76.)

         Section 9 is divided into four subsections with headings set apart in bold letters. (Doc. 10-2 at 116.) The first subsection begins:

How to Submit a Claim or File an Appeal
This section describes two types of claim review and appeal procedures . . .:
• Benefit claims and appeals.
• Eligibility claims and appeals.

(Id. at 117.) Next is Benefit Claims Process, which includes a procedure for filing a claim for benefits and appealing if your claim is denied. (Id.) After that is Eligibility Claims Process, again explaining how to file a claim and appeal a ...


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