Fill and Sign the Jury Trial Demand 497328058 Form

IN THE UNITED STATES DISTRICT COURT FOR THE ____________ DISTRICT OF ___________ ___________________ DIVISION NAME OF PLAINTIFF )       ) ) V. ) NO.       ) ) NAME OF DEFENDANT )       ) A MUTUAL INSURANCE COMPANY ) ) JURY TRIAL DEMANDED COMPLAINT This is an action to recover damages due under an employment benefit plan governed by the Employee Retirement Income Security Act ("ERISA") 29 U.S.C. Section 1132. Plaintiffs show the Court the following facts: I. Plaintiff, __________, is an adult resident citizen of __________, ________, __________, ______. II. Defendant, _________, is an adult resident citizen of __________ County, _________, and may be served with process by service upon him at his place of employment at __________, ____________, __________ _______. Defendant, ___________, is a corporation, which may be served with process upon its registered agent, __________, at _____________, _________, __________ _________. Defendant, ___________, a Mutual Insurance Co. is a company established for the purpose of providing health benefits and may be served with process by service upon its registered agent, __________, at __________, _____________, ____________ ________. Defendant, ___________, is sued for violation of duties to pay benefits under ERISA. III. This Court has federal question jurisdiction under 28 USC Section 1331 and under ERISA, 29 U.S.C. Section 1132. Plaintiff asserts claims for independent torts and breach of 1 contract against Defendant ____________ and Defendant ___________. These claims are based on state law and are within this Court's supplemental jurisdiction. Alternatively, if the Court finds they are not properly based upon state law, then Plaintiff asserts federal claims under ERISA. IV. Plaintiff is a former employee of Defendant, ____________, Plaintiff began working for Defendant ___________ in ________ __, ____, who agreed that after one year of employment, Plaintiff would have health insurance. Consistent with this promise, in ____________ __, ____, the anniversary date of her employment, Plaintiff applied for health insurance and was approved for coverage by Defendant, _____________. V. In ____________ __ ____, Plaintiff's physician discovered that she had tumors that must be removed. The following day, Defendant, _, acting through its general manager, Defendant _, terminated Plaintiff. Approximately one month later, Plaintiff had surgery and submitted her medical bills to Defendant ______________, who refused to pay the bills, claiming that her coverage had been canceled "retroactively" based upon instructions from the President of ___________, who is Defendant __________. VI. Defendants, ___________'s and _____________'s causing the insurance to be "canceled" represented a malicious interference with the insurance contract that Plaintiff had with Defendant, _____________. Additionally, this also represented a malicious breach of contract by Defendants, ___________, __________ and _____________ since they had contracted to provide Plaintiff with health insurance. VII. Defendant, ______________, violated its obligations under ERISA and its state law contractual obligations when it canceled Plaintiff's contract despite the agreement to provide insurance coverage. The Plaintiff has incurred over $_____.____ in medical bills for which Defendants are jointly and severally liable. IX. The acts of Defendants, ________________ and ______________, in causing the cancellation of the insurance contract, and in breaching the contract which they had with Plaintiff, represents malicious bad faith tort action and also represents a bad faith refusal to carry out the employment contract with Plaintiff in good faith, and further represents malicious interference with contract. Punitive damages are due against Defendant ______________ under state law. 2 X. The actions of Defendant, _____________, are outrageous, such that punitive damages are due. Plaintiff is aware of decisions holding punitive damages not due under actions regulated under ERISA. However, because of the outrageous nature of this case, and because of the actions of Defendant, __________, are so outrageous that there could not have been any Congressional intent to protect it from punitive damages, Plaintiff makes a good faith argument that previous decisions should be modified or distinguished so as to make punitive damages available in this case, even under ERISA against ___________. XI. Defendants, _____________ and ___________, are liable to Plaintiff on the following theories: 1. Intentionally and maliciously inducing ______________ to breach a contract; 2. Breach of contract, which they had to provide insurance coverage to Plaintiff; 3. Bad faith refusal to carry out the employment contract in good faith, i.e., the tort of bad faith; 4. Malicious misrepresentation of material fact by misrepresenting that insurance coverage would be provided. Defendant, __________, is liable to Plaintiff for breach of contract and for breach of the duties to pay benefits regulated by ERISA. Alternatively, if ERISA be not applicable, then Defendant, ____________, is liable to Plaintiff for breach of contract under state law. PRAYER Plaintiffs pray for actual and punitive damages in an amount to be determined by a jury, and for attorney's fees. Respectfully submitted, ______________________________ 3