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Jill Marcin v. Reliance Standard Life Insurance Company

September 28, 2012

JILL MARCIN, PLAINTIFF,
v.
RELIANCE STANDARD LIFE INSURANCE COMPANY, ET AL., DEFENDANTS.



The opinion of the court was delivered by: Amy Berman JACKSONUnited States District Judge

MEMORANDUM OPINION

Plaintiff Jill Marcin brings this suit against defendants Reliance Standard Life Insurance Company ("Reliance") and Mitre Corporation Long Term Disability Insurance Program ("Mitre") under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001, et seq. Plaintiff challenges the denial of her claim for disability benefits under the long-term disability insurance policy insured by Reliance. The parties have cross-moved for summary judgment [Dkts. # 21 and # 27]. Because Reliance has failed to explain the grounds for its decision denying plaintiff benefits, the Court will remand to Reliance for reconsideration of that decision. Accordingly, plaintiff's motion for summary judgment [Dkt. # 21] is granted in part and denied in part and defendants' cross-motion for summary judgment [Dkt. # 27] is denied.

I. BACKGROUND

A. Mitre's Long-Term Disability Insurance Policy

Plaintiff worked as a multi-discipline systems engineer at Mitre, a non-profit organization that supports federally funded research and development centers with systems engineering and information technology assistance. Pl.'s Mem. at 2; Administrative Record ("A.R.") at 14.*fn1 On January 1, 2005, Reliance issued "Group Long-Term Disability Insurance Policy No. LTD111701" ("the Policy" or "the Plan") to Mitre. A.R. at 14. Defendant Reliance acted as the claims review fiduciary and determined eligibility for benefits for the Policy. A.R. at 14.

In order to be eligible for disability benefits, the Policy required an insured: (1) to be "Totally Disabled as the result of a Sickness or Injury covered by this Policy;" (2) to be "under the regular care of a Physician;" (3) to "ha[ve] completed the Elimination Period;" and (4) to "submit[] satisfactory proof of Total Disability." A.R. at 18. In a provision that can hardly be described as a model of clarity, the Policy defined "Totally Disabled" and "Total Disability" as:

[A]s a result of an Injury or Sickness:

(1) [D]uring the Elimination Period and for the first 24 months for which a Monthly Benefit is payable, an Insured cannot perform the material duties of his/her regular occupation;

a. "Partially Disabled" and "Partial Disability" mean that as a result of an Injury or Sickness an Insured is capable of performing the material duties of his/her regular occupation on a part-time basis or some of the material duties on a full-time basis. An Insured who is Partially Disabled will be considered Totally Disabled, except during the Elimination Period;

b. "Residual Disability" means being Partially Disabled during the Elimination Period. Residual Disability will be considered Total Disability; and

(2) [A]fter a Monthly Benefit has been paid for 24 months, an Insured cannot perform the material duties of any occupation. Any occupation is one that the Insured's education, training or experience will reasonably allow. We consider the Insured Totally Disabled if due to an Injury or Sickness he or she is capable of only performing the material duties on a part-time basis or part of the material duties on a Full-time basis.

A.R. at 10.

The definition of "Total Disability" refers to the "Elimination Period," which is in turn defined by reference to the disability. The term "Elimination Period" is defined as a "period of consecutive days of Total Disability . . . for which no benefit is payable. It begins on the first day of Total Disability." A.R. at 9. The Policy also states that the Elimination Period is "[t]he greater of expiration: 180 consecutive days of Total Disability or the end of The MITRE Corporation's continuation program." A.R. at 7.

Further, the Policy uses the term "Interruption Period," which is defined as:

If, during the Elimination Period, an Insured returns to Active Work for less than 160 hours, then the same or related Total Disability will be treated as continuous. Days that the Insured is Actively at Work during this interruption period will not count towards the Elimination Period.

A.R. at 9. Finally, the term "Actively at Work" is defined as: [A]ctually performing on a Full-time or Part-time basis the material duties pertaining to his/her job in the place where and the manner in which the job is normally performed. This includes approved time off such as vacation, jury duty and funeral leave, but does not include time off as a result of an Injury or Sickness.

Id.

B. Plaintiff's claim for disability benefits

Plaintiff was initially diagnosed with serious medical issues including kidney cancer and portal vein thrombosis in November 2005, and the Administrative Record chronicles in great detail the many doctors' appointments, diagnoses, and medical exams she underwent from 2005 to 2007. See, e.g., A.R. 796--98 (recording plaintiff's diagnosis of enlargement of the spleen and portal vein thrombosis by Dr. Sutherland); A.R. at 863--67 (results of Magnetic Resonance Imaging ("MRI") exam showing worsening of her condition); A.R. at 395--97; 712--15; 791--92; 826--27; 853--55 (diagnosis and treatment of renal cell carcinoma). According to the Administrative Record, August 19, 2007, was the last day plaintiff worked before her disability.

A.R. at 657. Plaintiff indicates that she returned to work briefly in November 2007, although she does not specify a precise date. Id. Reliance estimated that she began part-time work on November 12, 2007. A.R. at 742.

On December 18, 2007, Mitre provided Reliance notice of plaintiff's claim of disability. A.R. at 1482. During the period from mid-November 2007 to mid-February 2008, plaintiff worked a reduced number of hours, which varied based on the particular week. A.R. at 742. On February 15, 2008, plaintiff stopped working altogether. A.R. at 742. On March 25, 2008, plaintiff submitted a written application for disability benefits under the Policy. A.R. at 657--66.

C. Reliance's Denial of the Plaintiff's Claim for Disability Benefits

After considering materials submitted by plaintiff as well as reviews provided by physicians consulted by Reliance, Reliance initially denied plaintiff's claim on June 11, 2008. A.R. at 741--44. The denial was based on the grounds that "the medical records in the file do not support work impairment at date of loss or beyond 11/6/07 when you were released to work status post nephrectomy." A.R. at 743.

Plaintiff appealed the decision on December 29, 2008. A.R. at 996--1028. Reliance denied the appeal on September 29, 2009. A.R. at 111--20. The denial letter sent to plaintiff provided in relevant part:

At the time that [plaintiff] returned to "Active Work" in 11/07, she was still within the "Elimination Period" as it is defined by the Policy for her 8/20.07 dates of loss. Hence, as [plaintiff] was working part-time, the Claims Department was required to add the number of hours that [plaintiff] worked during the "Interruption Period" to the end of her "Elimination Period."

Documentation from the Policyholder confirms [plaintiff] was "Actively at Work" during the following time frame:

Week of Total Hours Worked

11/12/07 to 11/18/07 24 hrs 11/19/07 to 11/25/07 17 hrs 11/26/07 to 12/02/07 26 hrs 12/03/07 to 12/09/07 22 hrs 12/10/07 to 12/16/07 29 hrs 12/17/07 to 12/23/07 28 hrs 12/24/07 to 12/30/07 no work 12/31/07 to 01/06/08 2 hours 01/07/08 to 01/13/08 28 hours 01/14/08 to 01/20/08 no work 01/21/08 to 01/27/08 32 hours 01/28/08 to 02/03/08 24 hours 02/04/08 to 02/10/08 5 hours 02/11/08 to 02/17/08 4 hours 02/18/08 no work A.R. at 114 (emphasis removed). Therefore, according to Reliance:

In [plaintiff]'s situation, given her original work stoppage on 8/20/07, and the "Interruption Period" as explained above, [plaintiff] worked in excess of the specified "160 hours" as of 12/14/07. Therefore, the "Elimination Period" needed to be re-started as of 12/15/07.

Id. (emphasis removed).

The letter continued:

However, as of 2/18/08, when [plaintiff] ceased working entirely, information in the claim file reflects that [plaintiff] was still receiving salary continuation from the Mitre Corporation. Hence, according to the provisions set forth in the group Policy, [plaintiff]'s "Elimination Period" would be satisfied after the greater of 180 days of "Total Disability" beginning 2/18/08, or the last date that she received salary continuation from her employer. It is our position, based on the totality of information in the claim file, that [plaintiff] was capable of ...


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