Oxford Health Insurance, Inc. v. Motherly Love Home Care Services, Inc.

237 F. Supp. 3d 25, 2017 U.S. Dist. LEXIS 60393, 2017 WL 1323775
CourtDistrict Court, E.D. New York
DecidedFebruary 27, 2017
Docket15-cv-385 (SJF)(GRB)
StatusPublished
Cited by2 cases

This text of 237 F. Supp. 3d 25 (Oxford Health Insurance, Inc. v. Motherly Love Home Care Services, Inc.) is published on Counsel Stack Legal Research, covering District Court, E.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Oxford Health Insurance, Inc. v. Motherly Love Home Care Services, Inc., 237 F. Supp. 3d 25, 2017 U.S. Dist. LEXIS 60393, 2017 WL 1323775 (E.D.N.Y. 2017).

Opinion

OPINION AND ORDER

FEUERSTEIN, District Judge:

Plaintiff Oxford Health Insurance, Inc. (“Plaintiff’ or “Oxford”) commenced this action against Defendants Motherly Love Home Care Services, Inc. (“Motherly Love”), Robert Franzese, and Elizabeth Franzese (collectively, “Defendants”), seeking declaratory relief pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et seq., and the Declaratory Judgment Act (“DJA”), 28 U.S.C. § 2201 et seq. See Docket Entry (“DE”) [1]. Presently before the Court is Defendants’ motion to dismiss Plaintiffs Complaint pursuant to Rules 12(b)(1) and 12(b)(6) of the Federal Rules of Civil Procedure, which Plaintiff opposes. DE [19], For the reasons set forth herein, Defendants’ motion is granted.

I. BACKGROUND

Unless otherwise noted, the following facts are drawn from the Complaint, DE [1], and are accepted as true for purposes of the instant motion.

[28]*28A. Factual Background

1. The Parties and Relevant Insurance Coverage

Plaintiff Oxford is a licensed health insurance company, operating under the laws of the State of New York with a principal place of business in Trumbull, Connecticut. Compl. ¶ 1. Defendant Motherly Love is a New York corporation with a principal place of business in Centereach, New York. Id. at ¶ 2. Defendants Robert Franzese (“Robert”) and Elizabeth Franzese (“Elizabeth,” and with Robert, the “Franzeses”) reside in Centereach, New York' and are co-owners of Motherly Love. Id. at ¶¶ 3, 4.

Motherly Love completed Oxford’s New York Small Group (2-50) Application (the “Application”) for group health insurance coverage to commence on January 1, 2014. Id. at ¶7. The Application states, inter alia, “To bé eligible for small group coverage, you must be located in a county, where we offer this Oxford product and have at least 2 but not more than 50 eligible employees.” Id. at ¶9. The Application defines an eligible employee as “[a]ctive permanent employees of the employer and of all subsidiaries or affiliates of a corporate employer who work 20 or. more hours per week and are eligible for health benefits through the employer’s group health plan.” Id. at ¶ 10. In the Application, Motherly Love. represented that.it had three (3) eligible employees. Id. at ¶ 11. Based upon Motherly Love’s Application, Oxford accepted coverage effective January 1, 2014. Id. at 1! 13.

Pursuant to a Certificate of Coverage (the “Certificate”),1 Motherly Love was required to “develop and maintain complete and accurate payroll records,- as well as any other records of .the names, addresses, ages, and social security numbers of all group members covered under [the] Certificate, and any other inforrnation required to confirm their eligibility for coverage.” Id. at ¶ 16. Motherly • Love was required to provide such information to Oxford upon Oxford’s request. Id. The Application further provides:

The Applicant understands that this Application may b'e chosen for an audit to confirm the information provided. Audits may be conducted before or after enrollment. If documents reviewed or submitted during an audit show that the information provided on an application was false or that the group does not meet underwriting requirements, the group will not be enrolled (audit • completed prior to enrollment) or will be terminated (audit completed post enrollment).

Id. at ¶ 12.

2. Oxford’s Attempts to Verify Defendants’ Eligibility

On October 1, 2014, “Oxford requested that [Motherly Love] verify its continued eligibility to participate in the New York Community Rated Small Group Coverage provided by Oxford.”2 Id. at ¶ 17. Oxford advised Motherly Love that “if the information was not provided to Oxford’s satisfaction, coverage would not be renewed.” Id. According to Oxford, Motherly Love “failed to provide all of the information requested.” Id. at ¶ 18.

On October 21, 2014, Oxford requested: (i) “the first page of the [Internal Revenue Services’ Form] 1120 along with the Schedule E, K, or G that identifies the owner(s) names, last 4 [digits], of their [29]*29social security number and their division of ownership from 2013”; and (ii) the “job titles and descriptions and .... the number of hours worked per week for Motherly Love ... for Elizabeth Franzese, Robert Franzese [and] Frank Franzese.” Id. at ¶ 19. In an October 24, 2014 letter in response, Motherly Love wrote, “[b]oth Robert Franzese (9726) and Elizabeth Franzese (8846) due to the nature of the business of pediatric home care work are on call 24 hours per day. Frank Franzese (8937) provides night and weekend ‘on-call’ services 8 hours per day.” Id. at ¶ 20 (internal alteration omitted).

On November 21, 2014, Oxford requested that Motherly Love provide: (i) Quarterly Combined Withholding, Wage Reporting, and Unemployment Insurance Return Forms for the first three (3) quarters of 2014 indicating that Motherly Love reported its employees’ wages to the state; and (h) business records demonstrating that Motherly Love’s employees “worked the required twenty hours per week on a continuous basis.” Id. at ¶21. On November 26, 2014, Oxford received Motherly Love’s- NYS-45 Quarterly Tax Filings, which revealed that Frank Franzese “was not paid any wages in the first three quarters of the 2014 calendar year.” Id. at ¶ 22. According to Oxford, Motherly Love “did not provide any additional information demonstrating that any of its claimed Eligible Employees worked twenty hours per week on a continuous basis.” Id.

In a December 1, 2014 letter, Oxford informed Motherly Love that its coverage would be terminated effective December 31, 2014 because Motherly Love “had failed to meet its obligation to demonstrate that it qualified for group coverage under Oxford’s NY , Community-Rated Small Group Plan.” Id. at ¶ 23. In its December 1, 2014 letter, Oxford wrote:

The Underwriting Requirements require at least one “eligible employee.” An “eligible employee” cannot be an individual business owner or his/her -spouse. Moreover, the “eligible employee" must be an active-permanent employee of the employer working twenty (20) hours or more per week on a continuous basis. You have not provided any objectively verifiable information demonstrating that your company employs an “eligible employee.”

Id. In a December 5, 2014 email to Oxford, Motherly Love “asserted that [its] broker had received confirmation that the policy would be renewed.” Id. at ¶ 24.

On December 9, 2014, Oxford requested that Motherly Love provide: (i) a complete report of the hours that Robert and Elizabeth worked per week for the third quarter of 2014, and (ii) an explanation of Robert and Elizabeth’s job descriptions. Id. at ¶ 25. In response, Motherly Love submitted a joint affidavit from Robert and Elizabeth in which they stated that they worked twenty-four (24) hours per day, seven (7) days per week. Id.

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Cite This Page — Counsel Stack

Bluebook (online)
237 F. Supp. 3d 25, 2017 U.S. Dist. LEXIS 60393, 2017 WL 1323775, Counsel Stack Legal Research, https://law.counselstack.com/opinion/oxford-health-insurance-inc-v-motherly-love-home-care-services-inc-nyed-2017.