United States District Court, W.D. Virginia, Lynchburg Division
K. MOON SENIOR UNITED STATES DISTRICT JUDGE
Norman K. Moon This ERISA disability benefits case is before
the Court on cross-motions for summary judgment based on the
administrative record. Plaintiff Melvin Moore, an engineer by
trade, challenges the termination of his long-term disability
payments. A threshold issue is whether an abuse of discretion
or de novo standard of review applies to defendant
Life Insurance Company of North America's
(“LINA”) decision to cease paying benefits under
an employer ERISA plan. Because the ERISA plan provides LINA
with the discretion to decide claims, the former standard
the merits, there are two issues. One is whether-after
receiving 24 months of disability payments-Plaintiff's
condition prevented him from performing the duties of
“any occupation” he was (or could have reasonably
become) qualified for. The other issue is whether
Plaintiff's disability was caused or contributed to by an
anxiety or depressive disorder, which- under the ERISA
plan-would not have entitled him to disability payments
beyond 24 months. Reviewing LINA's determination for
abuse of discretion, the Court concludes that substantial
evidence supported the termination of benefits. Accordingly,
LINA's motion for summary judgment will be granted,
Plaintiff's motion for summary judgment will be denied,
and this case will be dismissed.
THE APPLICABLE STANDARD OF REVIEW
reviewing the denial of benefits under an ERISA plan, a
court's first task is to consider de novo
whether the relevant plan documents confer discretionary
authority on the plan administrator to make a
benefits-eligibility determination.” Woods v.
Prudential Ins. Co. of Am., 528 F.3d 320, 321-22 (4th
Cir. 2008) (emphasis added). The “default standard of
review is de novo, and . . . an abuse-of-discretion
review is appropriate only when discretion is vested in the
plan administrator.” Id. at 322 (summarizing
Firestone Tire & Rubber Co. v. Brunch, 489 U.S.
101, 115 (1989)). So, while summary judgment requires taking
the record in the light favorable to the nonmovant, courts
“must also evaluate a denial of benefits under an abuse
of discretion standard when . . . an ERISA benefit plan vests
discretionary authority.” Vaughan v.
Celanese Americas Corp., 339 F. App'x 320, 322 (4th
case, there is a disagreement about what constitutes the
“Plan documents.” The record contains an
Appointment of Claim Fiduciary (“ACF”) form.
(AR1973). The ACF appoints LINA as “the designated
fiduciary for the review of benefits under the Plan
identified” as AREVA NP, Inc. The ACF further provides
that, as “Claim Fiduciary, ” LINA “shall be
responsible for adjudicating claims for benefits under the
Plan” and “deciding any appeals of adverse claim
determinations.” And most centrally, it grants LINA
“the authority, in its discretion, to interpret the
terms of the Plan, including the Policies; to decide question
of eligibility for coverage or benefits under the Plan; and
to make any related findings of fact.” Because this
language grants discretion to LINA, the sub-issue reduces to
whether the ACF counts as part of the ERISA Plan, so as to
make its grant of discretionary authority applicable to this
what counts as part of the ERISA plan, however, “is not
always a clear-cut task.” Admin. Comm. of Wal-Mart
Stores, Inc. Associates' Health & Welfare Plan v.
Gamboa, 479 F.3d 538, 542 (8th Cir. 2007). The Supreme
Court has stated bluntly that ERISA's definition of a
plan “is ultimately circular, ” so one “is
thus left to the common understanding of the word
‘plan' as referring to a scheme decided upon in
advance.” Pegram v. Herdrich, 530 U.S. 211,
223 (2000). More precisely, an ERISA plan is “a set of
rules that define the rights of a beneficiary and provide for
their enforcement. Rules governing collection of premiums,
definition of benefits, submission of claims, and resolution
of disagreements over entitlement to services are the sorts
of provisions that constitute a plan.” Id.
definition contemplates, as the Fourth Circuit indicated in
Woods, that there are often multiple documents that
together represent the whole of the plan. Woods, 528
F.3d at 321- 22. “ERISA certainly permits more than one
document to make up a benefit plan's required written
instrument.” Tetreault v. Reliance Standard Life
Ins. Co., 769 F.3d 49, 55 (1st Cir. 2014);
e.g., Pettaway v. Teachers Ins. & Annuity
Ass'n of Am., 644 F.3d 427, 433 (D.C. Cir. 2011);
Silverman v. Teamsters Local 210 Affiliated Health &
Ins. Fund, 761 F.3d 277, 286 (2d Cir. 2014) (compiling
cases); Heffner v. Blue Cross & Blue Shield of Ala.,
Inc., 443 F.3d 1330, 1342-43 (11th Cir. 2006).
“ERISA's statutory text suggests that multiple plan
documents can be legally relevant, ” and “ERISA
sections on fiduciary responsibilities imply that there will
be multiple legally important plan documents.”
Pettaway, 644 F.3d at 433-34. As the Seventh Circuit
has repeatedly observed, “often the terms of an ERISA
plan must be inferred from a series of documents, none
clearly labeled as ‘the plan.'” Larson v.
United Healthcare Ins. Co., 723 F.3d 905, 912 (7th Cir.
2013); Raybourne v. Cigna Life Ins. Co. of N.Y., 576
F.3d 444, 448 (7th Cir. 2009); Health Cost Controls of
Ill., Inc. v. Washington, 187 F.3d 703, 712 (7th Cir.
Court is convinced that the ACF is part of the ERISA Plan.
The Seventh Circuit's decision in Raybourne v.
Cigna, 576 F.3d 444 (7th Cir. 2009) is squarely on
point. There, as here, an insurance company pointed to an
“Appointment of Claim Fiduciary” form as creating
an abuse of discretion standard of review. 576 F.3d at 448.
And there, as here, the ACF granted the insurer “the
authority, in its discretion, to interpret the terms of the
Plan . . . to decide questions of eligibility for coverage or
benefits under the Plan.” Id. That grant of
discretion was also described, like here, in a summary plan
these realities, the claimant-like Plaintiff here-asserted
that the ACF was not a plan document. Raybourne
rejected that assertion. 576 F.3d at 448-49. It reasoned that
an ERISA plan was not limited to the original, underlying
insurance policy. Id. at 448. It observed that the
contents of the SPD affirmed that the ACF was, indeed, part
of the plan. Id.; see also id. at 449
(finding the ACF's “grant of discretion to Cigna is
described in the SPD furnished” to employees.). And the
Seventh Circuit found it “difficult to see how [the
ACF] could be anything other than a plan document, ”
given that it (1) provided the name of the plan and
administrator, (2) was signed by the insurer and plan
representatives, and (3) was retroactively effective to the
date of the underlying insurance policy. Id. at 449;
see AR1973 (ACF), AR53 (insurance policy cover
sheet). In sum, the ACF (both here and in Raybourne)
set forth some of the “rules that define the rights of
a beneficiary and provide for their enforcement, ”
including the “submission of claims and resolution of
disagreements over entitlement to services”; these
“are the sorts of provisions that constitute a
plan.” Pegram, 530 U.S. at 223.
is wrong that CIGNA Corp. v. Amara, 563 U.S. 421
(2011) undercuts Raybourne. All Amara holds
is that the SPD is not, standing alone, a plan document that
can create or override terms of the Plan. Amara, 563
U.S. at 437; see id. at 435-38; Tetreault v.
Reliance Standard Life Ins. Co., 769 F.3d 49, 56 (1st
Cir. 2014); Eugene S. v. Horizon Blue Cross Blue Shield
of N.J., 663 F.3d 1124, 1131 (10th Cir. 2011).
Amara thus has no bearing on
Raybourne's core holding that the ACF is a plan
while the SPD is not itself a plan document, nothing in
Amara forecloses looking at the SPD to help identify
what other documents, like an ACF, do comprise the
Plan. As Raybourne put it, an SPD-as a summary
document-“does not exist in a vacuum . . . . [it]
refers to the [ACF] and explains the discretion that [the
ACF] confers.” 576 F.3d at 449. So too here.
AR2002. See also AR72 (policy rider
stating that LINA has been designated as the “named
fiduciary for deciding claims for benefits under the Plan,
” as well as appeals). Amara does not prohibit
considering the SPD's summary language as probative of
whether some other document, with parallel language,
is part of the plan. After all, one expects the SPD,
as a summary, to reflect the Plan's terms. And if it does
not, only then is Amara implicated, instructing that
the standalone SPD is not part of the Plan.
point bolsters the conclusion that the ACF is part of the
Plan. The ACF states that LINA hears appeals of denied
claims. AR1973, 2002. Plaintiff appealed his denial of
benefits to LINA several times. E.g., AR1410-14,
1317-29, 1301-15. This course of dealing suggests the parties
recognized the ACF as a Plan document. See U.S.
Foodservice, Inc. v. Truck Drivers & Helpers Local Union
No. 355 Health & Welfare Fund, 700 F.3d 743, 750
(4th Cir. 2012).
end, Plaintiff's position reduces to reliance on a
handful of district court opinions that either overread
Amara, misunderstand that an ERISA plan can be
comprised of multiple documents without explicit integration,
or both. E.g., Moran v. Life Ins. Co. of N. Am.
Misericordia Univ., No. 3:CV-13-765, 2014 WL 4251604, at
*4-9 (M.D. Pa. Aug. 27, 2014); Barbu v. Life Ins. Co. of
N. Am., 987 F.Supp.2d 281, 286-89 (E.D.N.Y. 2013). These
decisions are unpersuasive, and the Seventh Circuit's
decision in Raybourne is better reasoned, factually
similar, and consistent with Amara.
abuse of discretion standard “requires a reviewing
court to show enough deference to a primary
decision-maker's judgment that the court does not reverse
merely because it would have come to a different result in
the first instance.” Evans v. Eaton Corp. Long Term
Disability Plan, 514 F.3d 315, 322 (4th Cir. 2008). In
“ERISA cases, the standard equates to
reasonableness.” Id. at 322. The
“administrator's decision is reasonable if it ...