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Simonette King, et al v. Aetna Life Insurance Company

July 7, 2011

SIMONETTE KING, ET AL., PLAINTIFFS,
v.
AETNA LIFE INSURANCE COMPANY, AND DOES 1 THROUGH 10, INCLUSIVE, DEFENDANTS.



The opinion of the court was delivered by: Dale S. Fischer United States District Judge

FINDINGS OF FACT AND CONCLUSIONS OF LAW

Having considered the evidence presented by the parties and the arguments of counsel, the Court makes the following findings of fact and conclusions of law.

FINDINGS OF FACT

1. For the time period relevant to this action, Plaintiff Stanley Thomas was an employee of L-3 Communications ("L-3"). See Complaint at ¶ 6.

2. Plaintiffs Simonette and Brandon King (the "Twins") were born on December 22, 1989, to Plaintiff *fn1 Renette King-Thomas, the wife of Stanley Thomas.

3. By virtue of his employment with L-3, Mr. Thomas was eligible to participate in the L-3 Communications Group Health Plan through the L-3 Communication Corporation Aetna Choice POS II Medical Plan, as modified (the "Plan"). Administrative Record ("AR") at 84, 159. The Summary Plan Description ("SPD"), AR at 81-167, is the document provided to the employees that describes the available benefits. AR at 84. The parties agree the SPD constitutes the Plan for the purposes of this proceeding. Rptr. Tr. 10-12.

4. Pursuant to the Managed Care/Administrative Services Contract ("Contract") between L-3 and defendant Aetna Life Insurance Company ("Aetna"), AR at 1, et seq., Aetna provides certain administrative services, including claims administration services and managed care services in connection with the Plan. AR at 1.

5. The Contract provides that Aetna "shall process requests for benefits and pay such benefits using Aetna's normal claim determination, payment and audit procedures . . . in accordance with the terms of the Plan and th[e] Contract." AR at 25.

6. Under the Contract, L-3 assumes "all liability for the funding of benefits under the Plan and Aetna assumes no such liability." AR at 25. In addition, L-3 "has the sole and complete authority to determine eligibility of persons to participate in the Plan." AR at 64.

7. Participation in the Plan is not automatic. The employee must enroll to have coverage. The employee and his dependents can enroll only at times specified in the Plan. AR at 160-62.

8. Step-children who live with the employee full-time are eligible to be enrolled in the Plan. AR at 161.

9. Coverage normally ends when a dependent child (including a step-child) reaches his/her 19th birthday, but children determined to be handicapped are eligible for coverage until age 25 if certain conditions are met. AR at 161-62.

10. Under the Plan, when an employee enrolls his dependents for coverage, he is required to complete the L-3 Dependent Eligibility Questionnaire and provide certain documents to prove that the dependent is eligible. This requirement applies in all circumstances in which an employee may want to enroll the dependent, including when the employee has a qualifying event that allows him to add a dependent during the plan year. AR at 162-63.

11. The Plan affords L-3 the right to confirm any dependent's eligibility at any time. Failure to respond to a request ...


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