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Moore v. Life Insurance Company of North America

United States District Court, W.D. Virginia, Lynchburg Division

March 23, 2018

Melvin Moore, Plaintiff,
v.
Life Insurance Company of North America, Defendant.

          MEMORANDUM OPINION

          NORMAN K. MOON SENIOR UNITED STATES DISTRICT JUDGE

         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 applies.

         As for 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.

         I. THE APPLICABLE STANDARD OF REVIEW

         “In 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 Cir. 2009).

         In this 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 case.

         Ascertaining 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.

         This 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. 1999).

         The 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.[1] That grant of discretion was also described, like here, in a summary plan document (“SPD”).

         Against 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.

         Plaintiff 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 document.

         Furthermore, 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.[2] 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.[3]

         Another 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).

         In the 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.

         The 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 ÔÇťadministrator's decision is reasonable if it ...


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