Heckle v. Matrix Absence Management, Inc.

CourtDistrict Court, S.D. New York
DecidedDecember 14, 2022
Docket7:21-cv-01463
StatusUnknown

This text of Heckle v. Matrix Absence Management, Inc. (Heckle v. Matrix Absence Management, Inc.) is published on Counsel Stack Legal Research, covering District Court, S.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Heckle v. Matrix Absence Management, Inc., (S.D.N.Y. 2022).

Opinion

UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF NEW YORK ------------------------------------------------------------x ERICA HECKLE, : Plaintiff, : : OPINION AND ORDER v. : : 21 CV 1463 (VB) MATRIX ABSENCE MANAGEMENT, INC., : Defendant. : ------------------------------------------------------------x

Briccetti, J.: Plaintiff Erica Heckle brings this purported class action against defendant Matrix Absence Management, Inc., claiming defendant misclassified her and other “telephonic claims examiners” as exempt from overtime requirements under the New York Labor Law (“NYLL”) and failed to provide proper wage statements in violation of NYLL Section 196. Plaintiff also brings an individual claim alleging defendant misclassified her as exempt from the overtime provisions of the Fair Labor Standards Act. Now pending is plaintiff’s motion for class certification on her NYLL claims and for appointment of class counsel. (Doc. #41). For the following reasons, the motion is GRANTED. The Court has subject matter jurisdiction pursuant to 28 U.S.C. §§ 1331 and 1367. BACKGROUND The parties have submitted briefs and declarations with supporting exhibits, which reflect the following factual background. Defendant is a third-party administrator that processes short-term disability (“STD”) and leave of absence (“LOA”) claims on behalf of companies that provide disability benefits and paid or unpaid leave to their employees. Defendant does not issue insurance policies or fund insurance policies; rather, it reviews claims submitted by its customers’ employees to determine whether such claims should be approved under the customers’ insurance plans. Plaintiff worked as a Telephonic Claims Examiner (“TCE”) in defendant’s Hawthorne, New York, office from November 2010 to November 2020.1 TCEs are responsible for reviewing STD and LOA claims submitted by employees of their assigned customers. Each TCE works on a team of approximately ten to fifteen TCEs who

all report to a common supervisor. A TCE’s job title reflects the type of claims they process: a Claims Examiner-LOA processes only LOA claims; a Claims Examiner-STD processes only STD claims; and a Claims Examiner-AMS2 processes both LOA and STD claims. Each TCE is also assigned a “proficiency” level: level 1, level 2, or senior. Plaintiff’s title was Senior Claims Examiner- AMS. A TCE’s proficiency level depends on how much experience the TCE has and dictates when a supervisor will review the TCE’s decision to approve a claim: a supervisor will review approval decisions by a level 1 TCE that exceed $1,000, approval decisions by a level 2 TCE that exceed $1,500, and approval decisions by a senior TCE that exceed $2,500.

A supervisor reviews all determinations to deny a claim, regardless of the TCE’s proficiency level. A supervisor also audits approximately two claims per month of each TCE they oversee, regardless of proficiency level. An individual TCE will generally handle anywhere from 115 to 300 claims at a time, depending on the type of claims the TCE processes. For example, a TCE who processes only STD claims may handle approximately 125 claims at a time, whereas a TCE who processes only

1 As used in this Opinion and Order, TCE refers to Telephonic Claims Examiners working in defendant’s Hawthorne office, including those who work remotely but report to the Hawthorne office. 2 “AMS” is short for Absence Management Specialist. LOA claims may handle 300 claims at a time, and a TCE who processes both may handle 115 claims at a time. TCEs are not required to have any specific education, licenses, or certifications, although the job description for a Senior Claims Examiner-AMS states a “[c]ollege degree [is] preferred or an equivalent of at least three to five years of claims experience.” (Doc. #62-5 at ECF 3).3

The duties of a TCE depend on whether they are processing a STD or LOA claim, and are set forth in a document entitled Matrix Absence Management, Inc. – Best Practices (Doc. #43-4 (the “Matrix Best Practices”)). TCEs “have autonomy to manage” claims assigned to them (Doc. #62-2 (“Mehiel Dep. Tr.”) 4 at 32), but must make decisions according to the terms of the customer’s insurance policies, applicable law, the Matrix Best Practices, and other standard operating procedures provided to TCEs to guide claims management. TCEs are also provided short “cheat sheets” summarizing each customer’s insurance plan to help TCEs determine claimants’ eligibility under the plan.

The Matrix Best Practices sets forth the steps TCEs should take when reviewing claims and the timelines for completing each step. For example, TCEs must determine, within one business day, whether an incoming claim meets minimum eligibility requirements, and then must notify the claimant and customer within one business day of that determination. If a claim meets minimum eligibility requirements, certain documentation is then collected from the claimant. The TCE reviews the documentation to determine the claimant’s eligibility and checks

3 “ECF __” refers to page numbers automatically assigned by the Court’s Electronic Case Filing system. 4 Citations to “Tr. at _” refer to the page number at the top right-hand corner of each transcript page. for indications of fraud, such as obvious inconsistencies in how a claimant and the claimant’s employer each describe an accident that give rise to a claim. If the documentation supports the claimant’s eligibility, the TCE approves the claim.5 If the documentation is insufficient or late, the Matrix Best Practices dictates how the TCE should

proceed, including how many times the TCE may attempt to reach the claimant or provider, and on what timeframe. To determine the appropriate amount of leave on STD claims, TCEs input the diagnosis code from the claimant’s health care provider into a software programmed with the Official Disability Guidelines, which generates a duration based upon that diagnosis. When a claimant requests leave greater than twice the duration generated by the software, the TCE consults a nurse case manager to determine whether the longer requested leave period is appropriate given the medical information submitted. Plaintiff testified that TCEs defer to the nurse case managers’ determinations, and that TCEs cannot approve a claim with a leave period longer than the dictated duration unless the nurse case manager agrees.

If a TCE determines a claim is ineligible under the applicable policy, they will deny the claim. If the supervisor approves the decision to deny, the TCE prepares a standard denial letter using a template. If a TCE determines a claim is eligible under the policy, they will approve the claim and create a “plan of action,” a benefit worksheet (for STD claims), and an approval letter based on existing templates. (Matrix Best Practices at ECF 5–6). If the claim amount exceeds the limit

5 A TCE reviewing a claim seeking leave under the federal Family Medical Leave Act (“FMLA”) must determine whether the claimant’s condition constitutes a “serious health condition” under the FMLA and whether it substantially interferes with the claimant’s ability to work. (Matrix Best Practices at ECF 10; Doc. #62-3 (“Pl. Dep. Tr.”) at 98–104). for the TCE’s proficiency level, a supervisor must review the TCE’s approval the same day or no later than two days after complete claim information is received. Finally, the TCE maintains contact with the claimant by phone and email regarding the claimant’s anticipated return to work after leave. The Matrix Best Practices dictates what steps

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Amchem Products, Inc. v. Windsor
521 U.S. 591 (Supreme Court, 1997)
Myers v. Hertz Corp.
624 F.3d 537 (Second Circuit, 2010)
Wal-Mart Stores, Inc. v. Dukes
131 S. Ct. 2541 (Supreme Court, 2011)
Comcast Corp. v. Behrend
133 S. Ct. 1426 (Supreme Court, 2013)
Cuevas v. Citizens Financial Group, Inc.
526 F. App'x 19 (Second Circuit, 2013)
Seijas v. Republic of Argentina
606 F.3d 53 (Second Circuit, 2010)
Miles v. Merrill Lynch & Co.
471 F.3d 24 (Second Circuit, 2006)
Roach v. T.L. Cannon Corp.
778 F.3d 401 (Second Circuit, 2015)
Pirelli Armstrong Tire Corp. v. LaBranche & Co.
229 F.R.D. 395 (S.D. New York, 2004)
Damassia v. Duane Reade, Inc.
250 F.R.D. 152 (S.D. New York, 2008)
Charron v. Pinnacle Group N.Y. LLC
269 F.R.D. 221 (S.D. New York, 2010)
In re IndyMac Mortgage-Backed Securities Litigation
286 F.R.D. 226 (S.D. New York, 2012)
Ebin v. Kangadis Food Inc.
297 F.R.D. 561 (S.D. New York, 2014)
Jackson v. Bloomberg, L.P.
298 F.R.D. 152 (S.D. New York, 2014)
Robidoux v. Celani
987 F.2d 931 (Second Circuit, 1993)

Cite This Page — Counsel Stack

Bluebook (online)
Heckle v. Matrix Absence Management, Inc., Counsel Stack Legal Research, https://law.counselstack.com/opinion/heckle-v-matrix-absence-management-inc-nysd-2022.