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Tuttle v. The Prudential Insurance Co. of America

United States District Court, D. Connecticut

March 9, 2018

GARY B. TUTTLE, Plaintiff,
v.
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA, Defendant.

          RULING ON DEFENDANT'S MOTION TO DISMISS

          Victor A. Bolden United States District Judge

         Gary Tuttle (“Plaintiff”) filed this lawsuit on January 23, 2018, alleging that the Prudential Insurance Company of America (“Prudential” or “Defendant”), failed to provide him with long term disability benefits. Compl., ECF No. 1. Prudential has now moved to dismiss the Complaint. See Def. Mot. Dismiss, ECF No. 12.

         For the reasons stated below, the motion to dismiss is DENIED.

         I. FACTUAL AND PROCEDURAL BACKGROUND

         A. Factual Allegations

         Mr. Tuttle, a resident of Connecticut, Compl. ¶ 1, worked as a Field Service Representative for CDK Global, Inc., a company based in Illinois. Id. ¶¶ 7-8.

         Prudential, an insurance company incorporated in New Jersey, id. ¶ 2, issued a long term disability group policy (“the policy”) to CDK Global, Inc., for the benefit of CDK Global employees who would, in return, pay premiums to maintain the policy. Id. ¶¶ 8, 12.

         The policy provided “financial protection” for employees by paying a portion of their income “while [they] have a long period of disability.” CDK Global, Inc. Group Contract G- 51856-IL (“Policy”) at 21, Def. Mot. to Dismiss, Ex. A, ECF No. 12-2.[1] An employee's income before any disability determined the amount of disability benefits an employee could receive, and the policy allowed “[i]n some cases, you can receive disability payments even if you work while you are disabled.” Id.

         Prudential's policy included the following definition:

         You are disabled when Prudential determines that:

. you are unable to perform the material and substantial duties of your regular occupation due to your sickness or injury; and
. you are under the regular care of a doctor; and
. you have a 20% or more loss in your monthly earnings due to that sickness or injury. After 24 months of payments, you are disabled when Prudential determines that due to the same sickness or injury:
. you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience; and . you are under the regular care of a doctor.

Id. at 30 (emphasis in original). The policy further defines “material and substantial duties” as those “normally required for the regular performance” of an employee's job and which “cannot be reasonably omitted or modified . . . .” Id.

         The policy also includes several other relevant definitions. Under the policy, regular occupation “means the occupation you are routinely performing when your disability begins.” Id. Regular care is defined as meaning “you personally visit a doctor as frequently as is medically required” and that “you are receiving the most appropriate treatment and care, ” both according to “generally accepted medical standards.” Id. at 31.

         If an individual covered under the policy meets the definition of disability, he or she is entitled to either sixty percent of the monthly earnings or $15, 000, whichever is less. Id. at 33. The policy also specifies several deductible sources of income that might reduce the award. Id. The policy does not cover pre-existing conditions. Id. at 41.

         In order to claim benefits, an employee must follow the claims procedure specified in the policy. A covered employee must submit a claim within 90 days after a set period, accompanied by documentation of the injury, medical care, and earnings. Id. at 46. The policy further provided that an employee “can start legal action regarding your claim 60 days after proof of claim has been given and up to 3 years from the time proof of claim is required, unless otherwise provided under federal law.” Id. at 48. Once filed, Prudential had forty-five days to respond to a claim. Summary Plan Description at 55, Def. Mot. to Dismiss, Ex. A, ECF No. 12-2. If denied, “in whole or in part, [the employee or] authorized representative will receive a written notice” explaining the denial. Id.

         Following that written notice, an employee “may appeal [his or her] denied claim in writing to Prudential within 180 days of the receipt of the written notice of denial or 180 days from the date such claim is deemed denied.” Id. at 56. Prudential would then have an additional forty-five days to respond to the appeal. After the appeal decision was rendered, an employee “may take a second, voluntary appeal” within one hundred and eighty days. The claims policy noted: “Your decision to submit a benefit dispute to this voluntary second level of appeal has no effect on your right to any other benefits under this plan. If you elect ...


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