In Saini v Cigna Life Insurance Company of New York, plaintiff’s husband drowned in the pool of the apartment complex where they lived. Plaintiff sought coverage from CIGNA for benefits under her deceased husband’s group accident policy, which CIGNA had issued to his late employer. However, in investigation of plaintiff’s claim’s, CIGNA’s expert found that plaintiff’s husband suffered a medical event prior to drowning, and “suffered an acute medical event that resulted in a sudden cardiac death prior to being found face down in the water.”
In turn, CIGNA denied plaintiff’s claim citing an exclusion from coverage in the policy that stated, “Benefits will not be paid for any covered injury or covered loss which, directly or indirectly, in whole or in part, is caused by or results from any of the following: Sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof…”
Plaintiff filed a complaint to include causes of action under declaratory relief and equitable relief under ERISA (Sections 501(a)(1)(B), 501(a)(3)) and damages under New York Law (Section 2601 of the NYSIL and Section 349 of the GBL). CIGNA moved to dismiss plaintiff’s state law claims.
Judge Katherine Polk Failla, United States District Southern District of New York, granted CIGNA’s motion to dismiss the state law claims. First, plaintiff’s claims under NYSIL § 2601 were denied as the law specifically authorizes the New York Superintendent of Financial Services to bring a civil action to recover a money judgment as a penalty for any violation of the New York Insurance Law. Id. § 109(d). Plaintiff’s claims under this section were dismissed as New York Courts have made it clear that § 2601 does not create a private right of action.
Additionally, Judge Failla dismissed plaintiff’s state claims under GBL § 349 as the civil enforcement scheme under ERISA “completely preempts any state-law cause of action that duplicates, supplements, or supplants an ERISA remedy.” In the 2nd Circuit, such a claim is preempted if it is “brought (i) by an individual who at some point in time, could have brought his claim under ERISA § 502(a)(1)(B) and (ii) under circumstances in which ‘there is no other independent legal duty that is implicated by a defendant’s actions.’” The first prong entails a two-part inquiry, under which a court considers (i) whether the plaintiff is the type of party that can bring a claim pursuant to § 502(a)(1)(B), and (ii) “whether the actual claim that the plaintiff asserts can be construed as a colorable claim for benefits pursuant to § 502(a)(1)(B).” Judge Failla stated that within this framework, ERISA preempts plaintiff’s GBL § 349 claim.
The Court is silent was to whether plaintiff had retained an expert to rebut CIGNA’s determination of a cardiac event, as opposed to accidental drowning, which could have potentially altered the Court’s decision on CIGNA’s coverage determination. But given the broad language of the exclusion, we suspect the coverage determination would stand, regardless of a potential rebuttal expert’s conclusions. Thanks to Jonathan Avolio for his contribution to this claim. Please email Brian Gibbons with any questions.