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Pettit v. Life Insurance Co. of North America

United States District Court, D. Maryland

July 11, 2016

TYEAST PETTIT, Plaintiff,
v.
LIFE INSURANCE COMPANY OF NORTH AMERICA, Defendant.

          MEMORANDUM OPINION

          Richard D. Bennett United States District Judge.

         Plaintiff 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[1] (Count Two) under an employee benefit plan[2] governed by ERISA.[3] 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.

         BACKGROUND

         In 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:

         Plaintiff 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.

         The 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.

         Both 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.

         ACF, 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 following:

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.

         Group 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.[4]

         LINA 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.

         Pettit 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.

         STANDARD OF REVIEW

         Rule 56 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.

         In 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 ...


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