United States District Court, D. Maryland
Richard D. Bennett United States District Judge.
Tyeast Pettit ("Plaintiff" or "Pettit")
has brought this action pursuant to Sections 502(a), (e)(1)
and (f) of the Employee Retirement Income Security Act
("ERISA"), 29 U.S.C. §§ 1132(a), (e)(1)
and (f), against Defendant Life Insurance Company of North
America ("Defendant" or "LINA"),
challenging LINA's denial of her claims for life
insurance benefits (Count One) and long-term disability
benefits (Count Two) under an employee benefit
governed by ERISA. Compl., p. 1, ECF No. 1. Currently pending
before this Court is Defendant's Motion for Partial
Summary Judgment Regarding the Standard of Review (ECF No.
18). LINA contends that this Court should review its denial
of benefits for "abuse of discretion." Pettit
argues for "de novo" review. The parties'
submissions have been reviewed, and no hearing is necessary.
See Local Rule 105.6 (D. Md. 2016). For the reasons
that follow, Defendant's Motion for Partial Summary
Judgment Regarding the Standard of Review (ECF No. 18) is
DENIED. Accordingly, benefits determinations made by LINA
under the ERISA Plan at issue in this case shall be reviewed
under the default de novo standard.
ruling on a motion for summary judgment, this Court reviews
all facts and reasonable inferences in the light most
favorable to the nonmoving party. Scott v. Harris,
550 U.S. 372, 378 (2007); see also Hardwick ex rel.
Hardwick v. Heyward, 711 F.3d 426, 433 (4th Cir. 2013).
The facts of this case are as follows:
Tyeast Pettit ("Plaintiff" or "Pettit")
resides in Fruitland, Maryland. Compl., ¶ 3, ECF No. 1.
Pettit worked as a Clinical Manager at Fresenius Medical Care
North America ("Fresenius") until June 1, 2012, at
which time she was unable to continue working "in her
own occupation . . . due to multiple sclerosis that was
initially diagnosed in 2008 with progressive symptoms
including the inability to balance, pain, and fatigue."
Id. at ¶¶ 6-7. As a Fresenius employee,
Pettit was covered by the Fresenius Medical Care Holdings
Plan (the "Plan"), a Massachusetts-based employee
benefit plan governed by the Employee Retirement Income
Security Act ("ERISA"), 29 U.S.C. § 1001,
et seq., and "providing for employee benefits
including long-term disability and waiver of premium for life
insurance coverage." Id. at ¶ 5. Defendant
Life Insurance Company of North America
("Defendant" or "LINA") is the Plan's
administrator and insurer, and conducts its business.
Id. at ¶ 4.
Plan includes two separate policies, a Long-Term Disability
Policy (the "LTD Policy") and a Life Insurance
Policy (the "Life Policy"), both issued and
administered by LINA. See LTD Policy, Def.'s Ex.
1, ECF No. 18-3; Life Policy, Def.'s Ex. 2, ECF No. 18-4.
Both policies include integration clauses, which provide that
"[t]he entire contract will be made up of the Policy,
the application of the Employer, a copy of which is attached
to the Policy, and the applications, if any, of the Employees
[Insureds]." LTD Policy at 21; Life Policy at 25.
Additionally, both policies include procedures for amending
the policies, which provide that "[n]o change in the
Policy will be valid until approved by an executive officer
of the Insurance Company. This approval must be endorsed on,
or attached to, the Policy. No agent may change the Policy or
waive any of its provisions." Id.
policies include an Amendatory Rider, which provides that
"[t]he Plan Administrator has appointed the Insurance
Company [LINA] as the named fiduciary for deciding claims for
benefits under the Plan, and for deciding any appeals of
denied claims." LTD Policy at 26-27; Life Policy at
32-33. Additionally, a separate Appointment of Claim
Fiduciary form ("ACF") defines LINA's
responsibilities as follows:
Claim Fiduciary [LINA] shall be responsible for adjudicating
claims for benefits under the Plan, and for deciding any
appeals of adverse claim determinations. Claim Fiduciary
shall have the authority, in its discretion, to interpret the
terms of the Plan, including the Policies; to decide
questions of eligibility for coverage or benefits under the
Plan; and to make any related findings of fact. All decisions
made by such Claim Fiduciary shall be final and binding on
Participants and Beneficiaries of the Plan to the full extent
permitted by law.
Def.'s Ex. 4, ECF No. 18-6. The ACF further provides that
the "Plan Administrator shall include the foregoing in
Summary Plan Descriptions furnished to Participants. Claim
Fiduciary shall provide Plan Administrator with a form of
Summary Plan Description, based on its standard Certificates
of Insurance, which contains in substance the foregoing, in
addition to a summary of the terms of the Policies."
Id. Accordingly, Certificates of Insurance for both
policies were distributed to Plan participants and provided
The Plan Administrator has appointed the Insurance Company
[LINA] as the named fiduciary for adjudicating claims for
benefits under the Plan, and for deciding any appeals of
denied claims. The Insurance Company shall have the
authority, in its discretion, to interpret the terms of the
Plan, to decide questions of eligibility for coverage or
benefits under the Plan, and to make any related findings of
fact. All decisions made by the Insurance Company shall be
final and binding on Participants and Beneficiaries to the
full extent permitted by law.
Disability Insurance Certificate, Def.'s Ex. 5, p. 17,
ECF No. 18-7; Group Life Insurance Certificate, Def.'s
Ex. 6, p. 21, ECF No. 18-8.
paid Pettit long-term disability benefits through November
27, 2014 under the LTD Policy [Policy #LK0980154]. Compl.,
¶ 8, ECF No. 1. Additionally, Pettit "applied for
and continues to receive Social Security Disability benefits
based upon the finding that she is totally and permanently
disabled from substantial gainful activity."
Id. at ¶ 9. However, via letter dated June 24,
2015, "LINA issued a denial of long-term disability
benefits under [the LTD Policy]." Id. at ¶
14. Pettit also filed a claim for "Waiver of
Premium/Life Insurance benefits" under the Life Policy
[Policy #FLX0980203]. However, "[f]ollowing an initial
denial, which plaintiff timely appealed, [LINA] issued a
final denial dated June 24, 2015 on the basis that ‘we
have not been provided with medical documentation to support
an impairment of functional capacity severe enough to affect
your client's ability to work in any sedentary occupation
at this time.' " Id. at ¶ 10. Pettit
claims that "[LINA's] denial was based upon a
medical review and a functional capacity evaluation that
failed to consider chronic pain, unexpected absences from
work and failed to perform a vocational analysis."
Id. at ¶ 12. "As a result of [LINA's]
denial of the Waiver of Premium/Life Insurance benefits,
" Pettit now claims that she "has not received the
proper coverage since September 26, 2014 to which she is
entitled, and was denied the waiver of premium under the
policy including for life insurance benefits."
Id. at ¶ 13.
has brought the present action, pursuant to 29 U.S.C. §
1132(a)(1)(B), to recover benefits under both the Life and
LTD Policies (Counts One and Two). Id. at
¶¶ 17-28. Additionally, Pettit claims that LINA has
violated 29 U.S.C. §§ 1332(a)(1)(A) and (c)(1) by
failing to provide her with "requested copies of plan
documents, summary plan description, complete claims file and
medical evidence used to deny the claim, and communications
whether by memo, letter or email" (Count Three).
Id. at ¶¶ 29-33. Accordingly, Pettit prays
that this Court award the following relief:
(1) declare that the Defendants are obligated to pay
Plaintiff her past due long-term disability benefits with
reinstatement of long-term disability benefits and the waiver
of premium/life insurance coverage; (2) declare that the
Defendants be assessed and ordered to pay $110 per day for
the failure and/or refusal to provide requested Plan
documents, schedules and policies pursuant to 29 U.S.C.
§1132(c)(1); (3) issue an injunction and declaratory
relief that LINA produce all relevant documents under section
503-1(m)(8) to include not only those documents considered
but also those documents "submitted, considered or
generated" in compliance with (b)(5) that the plan has
been applied consistently to similarly situated claimants,
identify all of the medical and vocational experts whether
relied upon or not, identify the actual reviewer and his or
her credentials, provide internal rules, guidelines and
protocols relied upon or applied in terminating
plaintiff's claim for benefits; and (4) award retroactive
long-term disability benefits and reinstate future benefits;
(5) award Plaintiff the costs of this action, interest, and
reasonable attorneys' fees; and (6) award such other
further and different relief as may be just and proper.
Id. at p. 6-7.
of the Federal Rules of Civil Procedure provides that a court
"shall grant summary judgment if the movant shows that
there is no genuine dispute as to any material fact and the
movant is entitled to judgment as a matter of law."
Fed.R.Civ.P. 56(c). A material fact is one that "might
affect the outcome of the suit under the governing law."
Libertarian Party of Va. v. Judd, 718 F.3d 308, 313
(4th Cir. 2013) (quoting Anderson v. Liberty Lobby,
Inc., 477 U.S. 242, 248 (1986)). A genuine issue over a
material fact exists "if the evidence is such that a
reasonable jury could return a verdict for the nonmoving
party." Anderson, 477 U.S. at 248. When
considering a motion for summary judgment, a judge's
function is limited to determining whether sufficient
evidence exists on a claimed factual dispute to warrant
submission of the matter to a jury for resolution at trial.
Id. at 249.
undertaking this inquiry, this Court must consider the facts
and all reasonable inferences in the light most favorable to
the nonmoving party. Libertarian Party of Va., 718
F.3d at 312; see also Scott v. Harris, 550 U.S. 372,
378 (2007). However, this Court "must not weigh evidence
or make credibility determinations." Foster v.
University of Md.-Eastern Shore, 787 F.3d 243, 248 (4th
Cir. 2015) (citing Mercantile Peninsula Bank v.
French, 499 F.3d 345, 352 (4th Cir. 2007)); see also
Jacobs v. N.C. Administrative Office of the Courts, 780
F.3d 562, 569 (4th Cir. 2015) (explaining that the trial
court may not make credibility determinations at the summary
judgment stage). Indeed, it is the ...