Martin v. Prudential Insurance Co. of America

776 F. Supp. 1172, 14 Employee Benefits Cas. (BNA) 1866, 1991 U.S. Dist. LEXIS 16165, 1991 WL 230491
CourtDistrict Court, S.D. Mississippi
DecidedMay 7, 1991
DocketJ89-0524(W)
StatusPublished
Cited by6 cases

This text of 776 F. Supp. 1172 (Martin v. Prudential Insurance Co. of America) is published on Counsel Stack Legal Research, covering District Court, S.D. Mississippi primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Martin v. Prudential Insurance Co. of America, 776 F. Supp. 1172, 14 Employee Benefits Cas. (BNA) 1866, 1991 U.S. Dist. LEXIS 16165, 1991 WL 230491 (S.D. Miss. 1991).

Opinion

MEMORANDUM OPINION AND ORDER

WINGATE, District Judge.

In this lawsuit, the plaintiffs seek actual and punitive damages arising from the termination of medical benefits under an employee welfare benefit plan funded by the Service Merchandise Company, Inc., and administered by the Prudential Insurance Company of America. It is undisputed that the employee welfare benefit plan in question is governed by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. § 1001, et seq. 1

The plaintiff’s complaint was removed to this court in accordance with 28 U.S.C. § 1441(b) 2 and § 1446. 3 Jurisdiction is predicated upon 28 U.S.C. § 1331 4 which provides that federal district courts shall have original jurisdiction of all civil actions arising under the Constitution, laws, and treaties of the United States. The federal statutes in question arise under ERISA, 29 U.S.C. § 1001, et seq. 5 On an earlier date, *1174 this case was tried to the court sitting without a jury. Having heard the evidence and arguments of counsel, the court now announces its decision pursuant to Rule 52 of the Federal Rules of Civil Procedure.

FACTS

The plaintiff, Andy Martin, was an employee of Service Merchandise Company and became covered under a policy of medical insurance provided by that company and administered by the Prudential Company of America on December 16,1986. Martin’s wife, Debbie Martin, became covered under the Service Merchandise plan pursuant to being Martin’s dependent. Martin and his wife determined to have a child and relied upon the policy of insurance to cover the medical expenses attending such a decision. Andy Martin terminated his employment with Service Merchandise on July 17, 1987, after his wife had become pregnant. The Service Merchandise health care plan provided that benefits under the plan would terminate once an employee ceased to be an eligible associate, when the plan was discontinued, or when contributions to the plan ceased. The health care plan provided that one could continue medical benefits temporarily if upon termination one had been covered under the plan for at least three months. The plan also provided that continuation of benefits would be permitted only if one did not become covered under another group plan. 6

Martin was notified of the right under the Comprehensive Omnibus Reconciliation Act (COBRA) 7 , Title 29 U.S.C. § 1161(a), to continue coverage at his own expense. Martin elected to continue coverage under COBRA on September 23, 1987. However, when Martin went to work for another employer, WSLI Radio, on October 1, 1987, he voluntarily accepted coverage under that company’s group health plan. This new group plan, administered by Jefferson-Pilot Life Insurance Company, did not cover pre-existing conditions such as the pregnancy of Martin’s wife.

Mrs. Martin suffered complications with her pregnancy. Medical bills totalling $16,-769.24 were incurred. Benefits were paid by the Service Merchandise Health Care Plan for the expenses incurred prior to October 1, 1987, the date Andy Martin obtained coverage under the WSLI Radio plan, but no benefits were paid for expenses incurred after that date. On Febru *1175 ary 10, 1988, Service Merchandise notified Martin of its decision to discontinue coverage effective October 1, 1987.

Martin submitted claims for his wife’s expenses to Jefferson-Pilot Life, but the claims were denied inasmuch as they related to a pre-existing pregnancy. Martin eventually obtained counsel and filed this lawsuit on behalf of himself and his wife in state court on August 15, 1989, against Service Merchandise and Prudential Life Insurance Company. The case was removed to this court within the time prescribed.

The complaint asserts five counts and one alternative count. The primary counts include tortious breach of contract, breach of a fiduciary duty, unfair settlement practices such as misrepresentation of policy provisions, fraud in the inducement, and violations of public policy and the provisions of COBRA. The alternative count deals with alleged violations of ERISA. The parties now agree that ERISA governs the disposition of the case.

THE PLAINTIFFS’ ARGUMENT IN SUPPORT OF COVERAGE UNDER THE SERVICE MERCHANDISE PLAN

Martin and his wife rely upon the Mississippi case of Brown v. Blue Cross & Blue Shield of Mississippi, 427 So.2d 139 (Miss. 1983), which held that a couple who had conceived a child while insured by the defendant’s group policy would continue to be covered for pregnancy benefits even though the group policy was terminated after the onset of the pregnancy. The Mississippi Supreme Court reasoned that the defendant insurance company was es-topped to cancel coverage as a matter of public policy after the onset of the event against which the plaintiffs had sought insurance. The Court cited Keeton, Insurance Law Rights at Variance with Policy Provisions, 83 Harv.L.Rev. 961, 967 (1970), an article on the doctrine of reasonable expectations which concludes that under such an approach plaintiffs facing the circumstances of the Brown case on account of such reasonable expectations should be entitled to continued coverage. Plaintiffs argue that their case has kindred facts and deserves the same outcome since they (the Martins) engineered the pregnancy in reliance on the maternity benefits inherent in the policy and since the pregnancy occurred before Andy Martin terminated his position with defendant Service Merchandise Company.

The Martins additionally argue that es-toppel may be predicated upon the defendants having already paid for some of the expenses incurred. Finally, according to the Martins, the Service Merchandise plan should cover the expenses in question because Debbie Martin obtained no new or additional coverage for her pregnancy when Andy Martin obtained coverage under the WSLI Radio/Jefferson-Pilot Life policy. Therefore, say the Martins, the issue of coverage should be resolved in their favor.

THE DEPENDANTS’ RESPONSE TO THE PLAINTIFFS’ ARGUMENT

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500 N.W.2d 619 (South Dakota Supreme Court, 1993)
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Cite This Page — Counsel Stack

Bluebook (online)
776 F. Supp. 1172, 14 Employee Benefits Cas. (BNA) 1866, 1991 U.S. Dist. LEXIS 16165, 1991 WL 230491, Counsel Stack Legal Research, https://law.counselstack.com/opinion/martin-v-prudential-insurance-co-of-america-mssd-1991.