United States District Court, D. Columbia
Jill Marcin, Plaintiff: Scott Bertram Elkind, LEAD ATTORNEY,
ELKIND & SHEA, Silver Spring, MD USA.
Reliance Standard Life Insurance Company, Mitre Corporation
Long Term Disability Insurance Program, Defendants: Kathryn
Anne Grace, LEAD ATTORNEY, WILSON ELSER MOSKOWITZ EDELMAN &
DICKER, LLP, Mclean, VA USA; Joshua Bachrach, PRO HAC VICE,
WILSON ELSER MOSKOWTIZ EDELMAN & DICKER, LLP, Philadelphia,
BERMAN JACKSON, United States District Judge.
2010, plaintiff Jill Marcin has been engaged in litigation
under the Employee Retirement Income Security Act ("
ERISA" ), 29 U.S.C. § 1001, et seq., with
defendants Reliance Standard Life Insurance Company ("
Reliance" ) and Mitre Corporation Long Term Disability
Insurance Program (" Mitre" ). Reliance denied
plaintiff's claim for disability benefits under the Mitre
plan on two previous occasions, but the Court found in each
case that the denial was not adequately justified, and it
remanded the matter to the insurer for further consideration.
See Marcin v. Reliance Standard Life Ins.
Co., 895 F.Supp.2d 105 (D.D.C. 2012); Mem. Op. & Order
(Apr. 14, 2015) [Dkt. # 43] (" Mem. Op. & Order" )
29, 2015, Reliance notified the Court of its latest final
decision on plaintiff's claims. Defs.' Notice of
Final Decision [Dkt. # 44] (" Notice" ). Based on
its review of the materials plaintiff had submitted, Reliance
concluded for a third time that plaintiff " was capable
of performing all of the material duties of her regular
occupation on a full time basis" when her coverage under
the disability insurance plan ended, and that she was
therefore not entitled to benefits. Ex. A to Defs.'
Notice of Final Decision [Dkt. # 44-1] (" Final
Decision" ) at 8.
the deferential standard of review that applies in this case,
the Court finds that the insurer's decision cannot be
sustained. The record in this case does not contain
substantial support for the insurer's finding that she
was capable of working full-time when she stopped working,
and that is the basis upon which it denied her claim for
benefits. Accordingly, the Court will enter judgment in favor
of the plaintiff. It is important to note, however, that the
Court's entry of judgment for plaintiff is not a judicial
determination that plaintiff was " totally
disabled" at the time she stopped working. Rather, this
decision is limited to the finding that Reliance's denial
of benefits to plaintiff based on its determination that she
was capable of full-time work was not reasonable.
Court detailed the factual background of this case in its
April 14, 2015 Memorandum Opinion and Order, see
Mem. Op. & Order at 1-7, so it will only restate key portions
of that summary below. Plaintiff Jill Marcin was diagnosed
with serious medical conditions, including portal vein
thrombosis and kidney cancer, in November 2005, and she
underwent surgery related to her ailments in the fall of
2007. Marcin, 895 F.Supp.2d at 108. Marcin returned
to work part-time with the approval of her physicians in
early November 2007. Id. at 114. From that time
until mid-February 2008, Marcin worked a reduced number of
hours, which varied based on the particular week.
Id. at 108. She stopped working altogether on
February 15, 2008. Id. She filed a written
application for disability benefits under the Mitre policy on
March 25, 2008, claiming that her last day of work before
becoming disabled had been August 19, 2007. Id.
denied Marcin's claim for disability benefits on June 11,
2008. Id. at 108-09. It affirmed the denial on
September 29, 2009, after considering plaintiff's
administrative appeal. Id.
28, 2010, plaintiff received a fully favorable decision from
the Social Security Administration (" SSA" ), which
concluded that, " [b]ased on the application for a
period of disability and disability insurance benefits filed
on April 14, 2008, the claimant has been disabled under
sections 216(i) and 223(d) of the Social Security Act since
August 20, 2007." Decision, SSA Office of Disability
Adjudication and Review, Pl.'s Ex. Submission [Dkt. # 40]
(" SSA Decision" ) at 5. Plaintiff's counsel
submitted the SSA's decision to Reliance on June 21,
2010. Marcin2 988. Reliance responded on June 24, 2010,
stating that its " internal guidelines only provide[d]
for one administrative appeal," and that, "
[a]ccording to [its] records, this appeal ha[d] already been
provided and [its] decision communicated to [plaintiff] on
September 29, 2009." AR2 0201. For that reason, Reliance
stated that its " previous determination remain[ed]
final" and that it was " unable to further address
[plaintiff's] appeal." Id.
filed a complaint in this Court on October 26, 2010,
Marcin, 895 F.Supp.2d at 112, and both sides moved
for summary judgment. Id. at 107. On September 28,
2012, after a comprehensive review of the evidence and
arguments presented by both sides, see id.
at 114-22, the Court denied defendants' motion and
granted plaintiff's motion in part by remanding the
matter to Reliance. Id. at 123-24.
opinion remanding the case, the Court stated that " the
only question" before it was whether plaintiff "
was unable to work when she stopped" in February 2008,
and it noted that, for plaintiff to prevail, the record had
to show that she became disabled before her coverage under
the Mitre plan expired on March 1, 2008. Marcin, 895
F.Supp.2d at 114. The Court undertook a detailed analysis of
the record and chronology of events, and it concluded that
this was " a very close case." Id. at 122.
The Court observed that although plaintiff plainly suffered
from severe medical conditions, id. at 114, she had
done " little to meet her burden under the policy to
demonstrate that she was disabled" during the relevant
time period. Id. at 122. At the same time, however,
the Court noted that defendants had " failed to point to
much evidence to support the finding" that plaintiff was
not disabled at the relevant time, " even under
a deferential standard of review." Id. "
So," the Court stated, " whether the insurer's
determination was reasonable on this record depends in large
measure on what that determination was and the stated reasons
behind it." Id. at 119.
the Court found that it could not determine whether
Reliance's decision to deny benefits to plaintiff was
reasonable because it was not clear what the grounds for that
decision were. Id. at 122. The Court explained:
While the Court's review of Reliance's decision is
highly discretionary, Reliance still must provide enough
evidence to support a finding that the decision was
reasonable and supported by the record. In order to make that
finding, it is essential that the Court understand what the
decision was: what did the plan administrator find and what
were the grounds for that decision? Based on the record
submitted by Reliance, particularly the letter it sent
plaintiff denying the claim for benefits, the Court cannot
answer those questions. While the discussion of
plaintiff's medical condition is not difficult to follow,
it is not clear how Reliance plugged those facts into the
rubric established under the Policy.
Id. (internal citation omitted). The Court went on
to detail several aspects of the decision that were
ambiguous. Id. at 122-23. The Court then remanded
the case to Reliance with instructions " to reconsider
its denial of benefits and to explain specifically how the
[disability insurance] Policy applies to the evidence in the
record, which section of the Policy is controlling, and
whether the decision [to deny plaintiff benefits] is based on
findings of Total Disability, Partial Disability, or Residual
Disability." Id. at 123.
issued a letter to plaintiff reiterating its decision to deny
her claim for disability benefits on January 7, 2013. AR2
0202 [Dkt. # 24]. The letter indicated that Reliance's
decision was based on the same information it had considered
previously -- plaintiff's claim file and the opinions of
Reliance's own medical consultants. See AR2
0205. In addition, the denial letter relied on a new report
by a vocational specialist, who had been commissioned to look
at whether plaintiff was partially disabled based on the
medical records. AR2 0205-06.
28, 2013, plaintiff submitted voluminous materials to
Reliance in an attempt to appeal the January 2013 denial of
benefits, including another copy of the Social Security
Administration's decision awarding plaintiff disability
benefits, see Marcin2 at 988-95, and a new report
from another vocational specialist. See Marcin2 at
4490-501. On July 24, 2013, Reliance declined to consider
plaintiff's appeal, stating again that plaintiff had
already received the one appeal to which she was entitled
under its internal guidelines. AR2 0208.
filed a second complaint in this Court on August 28, 2013,
challenging the January 2013 denial of disability benefits.
Compl. [Dkt. # 1].
November 15, 2013, plaintiff filed a " motion to
establish claim record and standard of review."
Pl.'s Mot. to Establish Claim Record [Dkt. # 12] ("
Claim Record Mot." ); Mem. of P. & A. in Supp. of Claim
Record Mot. [Dkt. # 12-1] (" Claim Record Mem." ).
In that motion, plaintiff asked the Court: (1) to rule that
the materials she had submitted with her attempted
administrative appeal of Reliance's January 7, 2013
decision were part of the record before the Court; and (2) to
alter the standard of review in this case from " abuse
of discretion" to de novo in view of what she
contended was defendants' record of violations under
ERISA. Claim Record Mem. at 24-25. Defendants took the
position that because plaintiff was not entitled to appeal
the January 2013 denial of benefits, the materials she
submitted with her attempted appeal were not part of the
record in this case. Defs.' Mem. of P. & A. in Opp. to
Claim Record Mot. [Dkt. # 13] at 9-12. Defendants also argued
that the standard of review should not change. Id.
April 16, 2014, the Court granted plaintiff's motion in
part and denied it in part in a ruling from the bench.
See Tr. of Status Hr'g (Apr. 16, 2014) ("
Status Hr'g Tr." ) at 7. First, the Court held that
the materials plaintiff had submitted to Reliance with her
appeal would be part of the record in this case. Id.
at 6-7. It noted that Reliance itself had expanded the record
by relying on a new vocational report in its January 7, 2013
decision, and that plaintiff had submitted additional
materials in response to that decision. Id. at 6.
The Court also deemed Reliance's refusal to consider
plaintiff's appeal to be a denial of the appeal.
Id. at 6-7. Finally, the Court found that plaintiff
had not shown any bad faith or malfeasance on the part of
defendants, and it held that the deferential standard of
review would continue to apply. Id. at 5.
moved for summary judgment on July 29, 2014. Defs. Reliance
Standard Life Ins. Co. & the Mitre Corp. Long Term Disability
Ins. Program's Mot. for Summ. J. [Dkt. # 30] ("
Defs.' Mot." ); Mem. of P. & A. in Supp. of
Defs.' Mot. [Dkt. # 30] (" Defs.' Mem." ).
On February 24, 2015, the Court issued an order granting
defendants' motion for summary judgment in part,
resolving two of the issues presented. Order (Feb. 24, 2015)
[Dkt. # 37]. First, after considering plaintiff's
argument that her coverage under the Mitre policy ended much
later than March 1, 2008, the Court affirmed its previous
finding that plaintiff ceased to be covered by the Mitre
disability insurance policy on March 1, 2008. Id. at
3-4; see also Marcin, 895 F.Supp.2d at 114.
The Court also reiterated its previous finding that
defendants' reliance on the opinions of Dr. Dean and Dr.
Shipko, medical consultants who conducted a paper review of
plaintiff's records, was not unreasonable, arbitrary and
capricious, or evidence of bias. Order (Feb. 24, 2015) at
4-5; see also Marcin, 895 F.Supp.2d at 120
n.7. The Court refrained, however, from determining whether
defendants' reliance on the new vocational report was
reasonable. Order (Feb. 24, 2015) at 5. In addition, the
Court did not rule on the ultimate question in this case:
whether Reliance's denial of benefits to plaintiff was
Court held a hearing on the remainder of defendants'
motion on March 20, 2015. At the hearing, plaintiff's
counsel submitted supplemental exhibits containing legal
authority that had not been cited in plaintiff's previous
pleadings. See Pl.'s Ex. Submission [Dkt. # 40].
In particular, plaintiff argued that it was unreasonable for
Reliance to refuse to consider the finding of the Social
Security Administration that she had been disabled since
August 20, 2007. Id. at 2-4. In light of this
belated submission, the Court permitted defendants to file a
supplemental submission of their own to address " the
question of whether -- assuming the Social Security decision
was part of the record before the insurer -- it would have
been unreasonable for the insurer to fail to consider
it." Min. Order (Mar. 27, 2015). Defendants filed a
supplemental pleading on March 31, 2015, arguing that it was
not unreasonable for Reliance to " refuse" to
consider the Social Security decision. Defs.'
Supplemental Submission in Resp. to March 27, 2015 Order
[Dkt. # 41] (" Defs.' Supp." ) at 3-4.
April 14, 2015, the Court denied defendants' motion for
summary judgment and remanded the case to Reliance once
again. Mem. Op. & Order at 16. It found first that it was
unreasonable for Reliance to refuse to consider the Social
Security Administration's determination in connection
with its review of plaintiff's claim. Id. at
10-14. Second, the Court found that it was not clear from the
decision letter whether Reliance had " focused on the
time period that the Court identified as critical in this
case," namely the time period between November 2007,
when plaintiff returned to work, and March 1, 2008, when
plaintiff's plan coverage terminated. Id. at 14,
16. Accordingly, the Court exercised its discretion to remand
the case to Reliance once more with the following
Reliance is directed to reconsider its denial of benefits in
light of all of the materials before it, including, in
particular, the Social Security Administration's
determination and the vocational report plaintiff submitted
in response to the report of Kate M. Hulsey, relied upon in
the January 2013 decision. The decision on remand should also
state clearly whether plaintiff was disabled under the terms
of the policy at any time after November 6, 2007,
and before March 1, 2008. No new information may be added to
the record by the parties, and plaintiff is not entitled to
an administrative appeal of Reliance's decision after
this remand. Reliance shall notify plaintiff and the Court of
its final decision on plaintiff's application for
disability benefits on or before May 29, 2015.
Id. at 16.
29, 2015, Reliance notified the Court that it had reached a
final decision to deny plaintiff's claim for benefits.
Notice [Dkt. # 44]. That same day, the Court issued a Minute
Order permitting plaintiff to " submit a pleading not to
exceed 15 pages that sets forth her position on whether
defendants' decision can withstand the deferential
standard of review that applies in this case, and if not, why
not." Min. Order (May 29, 2015). The Court further
specified that plaintiff was not to " rely upon or
submit any new evidence that is not already in the
record," or to " revisit any of the issues the
Court has already resolved, including which materials are in
the record, the date on which plaintiff's coverage under
the Mitre policy ended, the propriety of defendants'
reliance on the opinions of Dr. Dean and Dr. Shipko, and the
applicable standard of review." Id.
29, 2015, plaintiff filed a memorandum in response to
Reliance's Final Decision. Pl.'s Suppl. Mem. [Dkt. #
45] (" Pl.'s Supp. Mem." ). Defendants
responded on July 7, 2015. Defs.' Resp. to Pl.'s
Supp. Mem. [Dkt. # 46] (" Defs.' Resp." ).
matter is before the Court after a second remand, and the
Court must now determine whether the insurer's decision
should be upheld under the applicable standard. ERISA
provides that a participant in, or beneficiary of, a covered
plan may sue " to recover benefits due to him under the
terms of [the] plan, to enforce his rights under the terms of
the plan, or to clarify his rights to future benefits under
the terms of the plan." 29 U.S.C. § 1132(a)(1)(B).
The Supreme Court has held that courts should apply a de
novo standard -- instead of the more deferential
arbitrary and capricious standard -- to a benefits
determination under ERISA " unless the plan provides to
the contrary." Metro. Life Ins. Co. v. Glenn,
554 U.S. 105, 111, 128 S.Ct. 2343, 171 L.Ed.2d 299 (2008),
citing Firestone Tire & Rubber Co. v. Bruch, 489
U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). A plan
" provides to the contrary" when it grants its
" administrator or fiduciary discretionary authority to
determine eligibility for benefits." Id.,
quoting Firestone, 489 U.S. at 115. Under those
circumstances, " ...