James Mitchell Gunn v. Bluecross Blueshield of Tennessee, Inc.

Chattanooga, Tennessee insurance law lawyer represented the Plaintiff in a bad faith breach of insurance contract case.



Plaintiff was hired by SIAG Aerisyin ("SIAG Aerisyn"), LLC, a producer of steel towers located in Chattanooga, Tennessee, on March 28, 2011 (Admin. R. at 115). SIAG Aerisyin provided Plaintiff healthcare insurance under a Group Policy ("the Plan"), which Defendant administered (id. at 1). Caleeta Beagles, Defendant's Corporate Legal Coordinator, stated in anaffidavit Defendant received notification from SIAG Aerisyn on March 30, 2011, to add Plaintiff as an insured under SIAG Aerisyn's plan (Court File No. 21, Ex. A, ¶ 2) (hereinafter "Beagles Aff."). Accordingly, Defendant enrolled Plaintiff as of April 1, 2011 (Admin. R. at 115-17). Upon enrollment, Plaintiff received a copy of the Plan's Evidence of Coverage, which sets forth the grievance procedure to be followed in the event a dispute arises.



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Legal issue Is a plaintiff's ERISA lawsuit precluded for failure to exhaust administrative remedies when disputing an adverse benefit determination from a healthcare plan?



INSURANCE LAW. ERISA - EXHAUSTION OF REMEDIES. The case addresses whether a plaintiff in an ERISA action must exhaust administrative remedies before filing suit when alleging wrongful denial of healthcare benefits. The court considered whether exceptions to the exhaustion requirement, such as lack of notice or knowledge of grievance procedures, could excuse the plaintiff's failure to exhaust administrative remedies.



INSURANCE LAW. ERISA - SUMMARY JUDGMENT. The court evaluates the propriety of using summary judgment to address a defendant's claim that a plaintiff has failed to exhaust administrative remedies under ERISA, affirming that summary judgment is suitable for such procedural defenses.

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"...Notwithstanding the general reluctance to consider summary judgment motions in ERISA cases, courts have increasingly recognized a summary judgment motion is the proper vehicle for considering a defendant's claim that a plaintiff has failed to exhaust administrative remedies before filing a civil action.,Because a plaintiff's failure to exhaust remedies is typically considered an affirmative defense, Jones v. Bock, 549 U.S. 199, 212 (2007) ("[T]he usual practice under the Federal Rules is to regard exhaustion as an affirmative defense."), such an affirmative defense cannot properly support a motion to dismiss under Rule 12(b)(6), which focuses on the plaintiff's complaint, Zappley, 2010 WL 234713, at *4; Fortner v. Thomas, 983 F.2d 1024, 1028 (11th Cir.1993) ("[G]enerally, theexistence of an affirmative defense will not support a rule 12(b)(6) motion to dismiss for failure to state a claim.")....”



"...Federal law permits an individual covered under an ERISA plan, which the Plan covering Plaintiff was, to bring a civil action "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.",Although not formally codified in the statute, courts have long interpreted ERISA to include an exhaustion requirement....”



"...A court may appropriately exercise its discretion and excuse a plaintiff's failure toexhaust administrative remedies where "resorting to the plan's administrative procedure would simply be futile or the remedy inadequate."...”



Key Phrases - Summary judgment motion - Employee Retirement Income Security Act (ERISA) - Exhaustion of administrative remedies - Evidence of Coverage document - Explanation of Benefits (EOB) notices

Summary judgment granted.