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Stapperfenne v. Nova Healthcare Administrators

April 17, 2006

WILLIAM STAPPERFENNE AND MARJAREE MAYNE-STAPPERFENNE, PLAINTIFFS,
v.
NOVA HEALTHCARE ADMINISTRATORS, INC., ET AL., DEFENDANTS.



The opinion of the court was delivered by: Kugler, District Judge

Docket Entry No. 4

OPINION

This matter comes before the Court upon motion by Defendants Nova Healthcare Administrators, Inc. ("NOVA") and Sevenson Environmental Services, Inc. ("Sevenson") to dismiss Plaintiffs' Complaint for lack of subject matter jurisdiction and failure to state a claim upon which relief can be granted. See Fed. R. Civ. P. 12(b)(1) and 12(b)(6). For the reasons that follow, the Court will deny the Defendants' motion.

I. BACKGROUND

Plaintiff William Stapperfenne is an employee of Sevenson. On or about October 1, 2000, the Defendants allegedly executed and delivered to William Stapperfenne a health insurance coverage plan ("the Plan") with the group name Sevenson Environmental Service, Group No. 149. The parties agree that the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001, et seq., governs the Plan.

On June 14, 2003, William Stapperfenne married Plaintiff Marjaree Mayne-Stapperfenne. William Stapperfenne contends that shortly thereafter, he added his wife to the Plan as a dependent pursuant to the Dependent Special Enrollment Period clause contained in the Plan agreement. Immediately after adding Plaintiff Marjaree Mayne-Stapperfenne as a dependent, William Stapperfenne allegedly began making additional payments for the additional dependent coverage.

Beginning in July 2003, Plaintiff Marjaree Mayne-Stapperfenne incurred surgical and hospital expenses. The amount of these medical bills totals approximately $20,000. (Compl. ¶ 8.) Plaintiffs purportedly submitted Notices of Claim to the Defendants regarding these expenses and have "performed all of the conditions of the insurance policy required to be performed by the plaintiffs." (Compl. ¶ 7.) However, the Plaintiffs allege that the Defendants have rejected the Plaintiffs' claims for payment. Specifically, Plaintiffs contend that "although due demand has been made by the plaintiffs, the defendants have failed and refused, and still fail and refuse to pay plaintiffs' claim." (Compl. ¶ 9.)

Consequently, on March 15, 2005, Plaintiffs initiated this lawsuit in New Jersey Superior Court, Law Division, Cumberland County. In the original Complaint, Plaintiffs sued NOVA for the alleged denial of coverage under the Plan. On or about September 19, 2005, the Plaintiffs filed an Amended Complaint which added Sevenson as a defendant. Shortly thereafter, on October 11, 2005, NOVA and Sevenson removed the action to this Court on the basis of federal question jurisdiction. In lieu of an answer, NOVA and Sevenson filed the present motion to dismiss on November 9, 2005.

II. STANDARD OF REVIEW

Pursuant to Federal Rule of Civil Procedure 12(b)(6), a complaint may be dismissed for failure to state a claim upon which relief can be granted. Fed. R. Civ. P. 12(b)(6). When reviewing a Rule 12(b)(6) motion to dismiss, the Court must accept as true all factual allegations in the complaint and must provide the plaintiff with the benefit of all inferences that may be fairly drawn from the contents of the complaint. Kost v. Kozakiewicz, 1 F.3d 176, 183 (3d Cir. 1993); Wilson v. Rackmill, 878 F.2d 772, 775 (3d Cir. 1989). The Court may not grant a Rule 12(b)(6) motion to dismiss unless it is certain that no set of facts can be proven that would entitle the plaintiff to relief. Conley v. Gibson, 355 U.S. 41, 45-46 (1957); Milhouse v. Carlson, 652 F.2d 371, 373 (3d Cir. 1981).

In addition, the Court may dismiss a complaint for lack of subject matter jurisdiction pursuant to Federal Rule of Civil Procedure 12(b)(1). District courts have original subject matter jurisdiction over (1) civil actions arising under the Constitution, laws or treaties of the United States and (2) civil actions between diverse parties where the amount in controversy exceeds $75,000 exclusive of interest and costs. See 28 U.S.C. §§ 1331, 1332. In considering a motion to dismiss for lack of subject matter jurisdiction, "the person asserting jurisdiction bears the burden of showing that the case is properly before the Court at all stages of the litigation." Packard v. Provident Nat'l Bank, 994 F.2d 1039, 1045 (3d Cir.1993).

III. DISCUSSION

In the current motion to dismiss, NOVA and Sevenson argue that Plaintiffs have failed to exhaust their administrative remedies as required under the Plan. As a result, the Defendants contend that the Court lacks subject matter jurisdiction over the Plaintiffs' claims, and further, that the Plaintiffs' Complaint fails to state a claim upon which relief can be granted. (Def. Mem. at 3-4.)

In response, the Plaintiffs allege that they did, in fact, exhaust their administrative remedies under the Plan. Plaintiffs contend that they sent multiple, written requests for review of the denial of their claims and that these written requests substantially complied with the appeals procedure outlined in the Plan. (Pl. Opp. at 2.) Alternatively, Plaintiffs argue that it would be futile for them to continue to send requests for review on each and every form denying benefits, because (1) the Defendants have ...


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