Opinion ID: 171217
Heading Depth: 2
Heading Rank: 2

Heading: Mr. Weber's Claim

Text: Mrs. Weber passed away on September 9, 2003. She was survived by her husband (the Appellee here) and her then 3-year-old son. On behalf of Mr. Weber, an insurance broker named E. Clark James sent GE a death claim for Mrs. Weber's Basic and Voluntary Life Insurance policies on September 23, 2003. Mr. James's letter attached a Notice of Claim Proof of Death form, which Janessa DeVore, Winner's Personnel Manager, completed on September 19, 2003. In that form, Ms. DeVore noted that May 16, 2003, was Mrs. Weber's Date Last Worked on a Full-time Basis and certified under penalty of perjury that the information she supplied was true, correct and complete. Shortly thereafter, on October 13, 2003, GE paid out Mrs. Weber's Basic Life Insurance benefits to Mr. Weber. [1] However, in regard to the Voluntary Insurance benefits, GE requested additional documentation from Winner because Ms. Weber's date of last active service (5/16/03) was so close to the effective date of the Voluntary Life Insurance coverage ... (5/1/03) that GE needed to verify that Mrs. Weber was actively at work, working on a full-time basis, thirty hours or more per week on or after May 1, 2003. Winner duly sent along documentation regarding Mrs. Weber's work at Winner. On October 28, 2003, Winner's Vice-President of National Sales, Sam Youngwirth, sent GE a letter documenting Mrs. Weber's duties as a Winner employee. He attached Winner's Payroll Register for Mrs. Weber from January 1, 2003, to May 31, 2003. Youngwirth also attached a series of e-mails from Mrs. Weber to Ms. DeVore that listed Mrs. Weber's hours worked. In an e-mail entitled Hours worked May 1-15, Mrs. Weber states that she worked 5 hours on Monday May 12, 4 hours on May 13, 5 hours on May 14 and 5 hours on May 15. [2] Despite this documentation, an insurance broker working with Mr. Weber advised GE that he believed that Mrs. Weber had worked up until two weeks prior to her death. GE denied Mr. Weber's claim in a letter dated December 3, 2003. Therein, GE explained that Mrs. Weber was never eligible for the Voluntary Life Insurance coverage because she was not a full-time employee, Actively At Work as defined by the policy at the employer's usual place of business, performing all the duties of her job on a full-time, 30 hour per week basis after the May 1, 2003, effective date for the policy. The denial letter noted that GE based its decision on the documentation it requested from Winner and on the Policy. Having explained the decision to deny the claim, GE invited Mr. Weber to submit any documentation that might alter the determination. Mr. Weber, through counsel, protested the denial in a letter dated August 10, 2004, but submitted no new documentation. [3] GE responded on September 9, 2004. GE maintained that Mrs. Weber's failure to work at least 30 hours a week after May 1, 2003, doomed her claim for coverage. Specifically, GE stated that, [b]ased on the information we have received to date, Ms. Weber did not work at least 30 hours a week, on or after the policy effective date of May 1, 2003, and was not eligible for coverage under the policy. GE thus reiterated the determinative rationale identified in its initial decision.