EDWARD M. CHEN, District Judge.
Thomas Heng worked at Decision View, Inc. (Decision View) from August 31, 2011 until June 30, 2012 and was co-employed by TriNet Group, Inc. (TriNet), which provided Decision View with payroll and benefits services. Heng ceased to be a TriNet employee after June 30, 2012, when Decision View terminated its contract with TriNet, effective July 1, 2012. On July 25, 2012, Heng died in a hiking accident.
Decedent Thomas Heng is survived by his wife, Plaintiff Petra Heng. Plaintiff submitted a claim for basic life benefits, basic accidental death and dismemberment (AD&D) benefits, and Voluntary AD&D benefits. Defendant Metropolitan Life Insurance Co. (MetLife) paid Plaintiff basic life benefits but denied AD&D claims. Plaintiff filed this lawsuit against Defendant MetLife, seeking the AD&D benefits. Docket No. 1.
Pending before the Court is Defendant MetLife's motion for summary judgment. Docket No. 27. The Court grants the motion.
Plaintiff was married to Thomas Heng, a system administrator for Decision View. Docket
No. 27 at 1. Decision View had contracted with TriNet, an entity that contracts with other business to manage their payroll and benefits services. Id. Pursuant to an agreement between TriNet and Decision View, TriNet was Decedent's co-employer, beginning in August 31, 2011. Id. at 6. Heng participated in TriNet's Employee Benefit Insurance Plan (the Plan), which is an employee welfare benefit plan governed by the Employee Retirement Income Security Act of 1974, as amended (ERISA), 29 U.S.C. § 1001, et seq. Id. at 1. He elected to supplement the basic plan of term life insurance and AD&D insurance in the flat amount of $20,000 by adding voluntary AD&D coverage of $750,000 at a cost to him of $7.50 per each day period. Docket No. 29 at 2. This premium payment was deducted from Decedent's semi-monthly paycheck, and he made his first premium payment on September 15, 2011. Id. Heng designated his wife Petra as his sole beneficiary. Id.
Decision View terminated its agreement with TriNet, effective July 1, 2012. AR
Around July 22, 2012, Heng died while hiking. AR 195. As Decedent's beneficiary, Plaintiff submitted a claim for basic life, basic AD&D, and Voluntary AD&D benefits dated August 6, 2012, along with a death certificate indicating that death was the result of a mountain hiking accident. AR 177-79. Defendant MetLife, the Plan's claim administrator, paid the basic life claim on the basis that Decedent died within the conversion period, but determined that Plaintiff did not qualify for either basic or voluntary AD&A benefits because coverage had terminated on June 30, 2012 and did not convert. AR 186, 206-08. On February 11, 2013, Plaintiff appealed the denial of her claim. AR 237-42. MetLife affirmed its denial on October 1, 2013, which Plaintiff appealed on February 10, 2014. AR 538-41, 565-67. On October 23, 2014, MetLife responded to Plaintiff's appeal by upholding the denial of the claim. AR 578-82.
On July 22, 2016, Plaintiff filed this suit. Docket No. 1.
MetLife issued Group Insurance Policy No. 1164937-1-G (the Policy) to TriNet to fund the life and AD&D benefits under the Plan. AR 1-137. TriNet served as the Plan's administrator and sponsor. AR 48, 134. MetLife served as the Plan's claim administrator. Docket No. 27 at 2. The Plan provides basic life and AD&D coverages, AR 1-47, and supplemental life, dependent life, and voluntary AD&D coverages, AR 52-133. While co-employed by TriNet, Decedent was covered under the plan for certain benefits, including basic life insurance in the amount of $20,000, basic AD&D coverage in the amount of $20,000, and Voluntary AD&D coverage in the amount of $750,000. AR 164, 185.
The Plan pays Basic Life benefits in the amount of $20,000, AR 23, and Basic AD&D benefits, in its full amount, "equal to [the participant's] Life Insurance," AR 24.
The Plan's Basic Life and Basic AD&D section entitled "
AR 28-29 (emphasis in original). The Plan further advises the participant to "refer to the section entitled LIFE INSURANCE: CONVERSION OPTION FOR YOU for information concerning the option to convert to an individual policy of life insurance if Your Life Insurance ends." AR 29.
The section entitled "
AR 35-36 (emphasis in original).
The Plan's section for Supplemental Life, Dependent Life, and Voluntary AD&D benefits provides one of six options for life insurance. Decedent did not choose any. The Plan also provides six options for Voluntary AD&D benefits, of which Decedent chose Option 6 that increases the benefit to $750,000. AR 78, 80, 185.
Coverage under this section takes effect as follows:
AR 92 (emphasis in original). Participants become eligible on the date they enter the class of TriNet's full-time employees. AR 91.
The Plan's Supplemental Life, Dependent Life, and Voluntary AD&D section entitled "
The Plan's section on Supplemental Life, Dependent Life, and Voluntary benefits has a conversion provision identical to the one in the Basic Life and Basic AD&D. AR 113-14.
The MetLife Group Life Booklet provides that "Conversion is available on all Group Life insurance coverages. Conversion is
The 2011-2012 TriNet Benefits Guidebook and Summary Plan Description (SPD) at Chapter 16, Section 16.3 explains two types of TriNet life insurance and AD&D coverage as follows:
AR 499.
Section 16.5 provides under "
The only documents TriNet provided to Heng when his employment with TriNet ended are the TriNet COBRA Guide and COBRA Notice. AR 528; Docket No. 33 at 2.
The TriNet COBRA Guide states that while "Continuation of TriNet life insurance coverage is not available through federal COBRA, . . . you (the employee) can purchase an individual plan from MetLife if MetLife receives a completed conversion application from for [sic] you within 31 days after the date your TriNet insurance ends." Docket No. 29-1 Exhibit B to the Declaration of Wesley M. Lowe. The TriNet COBRA Guide is silent about whether the AD&D coverage can be converted to an individual policy when the insurance under the MetLife Group Policy ends.
The Notice of Group Life Insurance Conversion Privilege is silent about whether AD&D coverage can be continued or converted to an individual policy when the insurance under the MetLife Group Police terminates. Docket No. 29-1 Exhibit D to the Declaration of Wesley M. Lowe.
A principal purpose of the summary judgment procedure is to identify and dispose of factually unsupported claims. Celotex Corp. v. Cattrett, 477 U.S. 317, 323-24 (1986). Summary judgment is proper when the "pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to judgment as a matter of law." Fed. R. Civ. P. 56(c).
A party moving for summary judgment, who does not have the ultimate burden of persuasion at trial, must produce evidence which either negates an essential element of the non-moving party's claims or show that the non-moving party does not have enough evidence of an essential element to carry its ultimate burden of persuasion at trial. Nissan Fire & Marine Ins. Co. v. Fritz Cos., 210 F.3d 1099, 1102 (9th Cir. 2000).
Once the moving party meets his or her initial burden, the non-moving party must go beyond the pleadings and by its own evidence "set forth specific facts showing that there is a genuine issue for trial." Fed. R. Civ. P. 56(e). In order to make this showing, the non-moving party must "identify with reasonable particularity the evidence that precludes summary judgment." Keenan v. Allan, 91 F.3d 1275, 1279 (9th Cir. 1996). It is not the Court's task to "scour the record in search of a genuine issue of triable fact." Id. (quoting Richards v. Combined Ins. Co., 55 F.3d 247, 251 (7th Cir.1995)). If the non-moving party fails to make this showing, the moving party is entitled to judgment as a matter of law. Celotex, 477 U.S. at 323.
An issue of fact is "genuine" only if there is sufficient evidence for a reasonable fact finder to find for the non-moving party. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248-49 (1986). A fact is "material" if it may affect the outcome of the case. Id. at 248. "In considering a motion for summary judgment, the court may not weigh the evidence or make credibility determinations, and is required to draw all inferences in a light most favorable to the nonmoving party." Freeman v. Arpaio, 125 F.3d 723, 735 (9th Cir. 1997).
ERISA allows a participant in an employee benefit scheme to bring a civil action to recover benefits due under the terms of a plan. 29 U.S.C. § 1132(a)(1)(B). Courts review a denial of benefits challenged under § 1132(a)(1)(B) "under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989).
Here, Parties have stipulated that the Court should review the denial of benefits de novo. Docket No. 27 at 8; Docket No. 29 at 7. Under the de novo standard, "in considering motions for summary judgment, the district court must decide whether there are genuine issues of material fact, not whether there was substantial or ample evidence to support the plan administrator's decision." Mongeluzo v. Baxter Travenol Disability Benefit Plan, 46 F.3d 938, 942 (9th Cir. 1995). Thus, Defendant's argument — that the Court's review is limited to the evidence that was before the claims administrator at the time of its determination and that Plaintiff maintains the burden of proving entitlement to benefits, Docket No. 27 at 8-9 — does not apply to the pending summary judgment motion.
Defendant argues that it correctly denied Plaintiff's claims for AD&D benefits under the clear and unambiguous terms of the Plan and the 2011-2012 TriNet Benefits Guidebook and Summary Plan Description (SPD). Docket No. 27 at 9-10, 13-14. Reading the Plan and SPD in the light most favorable to Plaintiff, the Court agrees with Defendant and finds no genuine issues of material fact.
The Plan's sections entitled "
AR 28-29, 94-95 (emphasis in original). The SPD provides: "Your participation in the TriNet Benefits Plan will terminate on the last day of the month in which any of these events occur a. The date you cease to be employed by TriNet. . . ." AR 469.
Decision View terminated its contract with TriNet effective July 1, 2012, and Decedent's last day of employment was June 30, 2012. Docket No. 29 at 2; Docket No. 33 at 2. Thus, under the terms of the Plan and the SPD, Decedent's coverage for Basic Life, AD&D, and Voluntary AD&D ended on June 30, 2012.
When Heng's employment ended, he had the option to convert his life insurance coverage to "an individual policy of life insurance" up to "the amount of life insurance" which ended under the Plan. AR 29, 95. However, the Plan explicitly excludes AD&D coverage from converted individual policies: it states "the new policy will be issued without an accidental death and dismemberment benefit." AR 35, 113.
Plaintiff's interpretation of the terms of the Plan to the contrary fails to raise a genuine issue of material fact, even when viewed in the light most favorable to her.
First, Plaintiff argues that "the MetLife Group Policy is fundamentally a group life insurance policy that includes accidental death and dismemberment insurance as an additional benefit" because "[t]he face page of MetLife's Certificate of Insurance for Thomas Heng, effective date 8/31/2011 (Exhibit A to the Lowe Dec) refers to the type of insurance being extended as `
Second, Plaintiff argues that the sections entitled "
Third, Plaintiff disputes that the Plan excludes AD&D coverage from Heng's converted insurance, although she concedes that the Plan states that "the new policy will be issued without an accidental death and dismember benefit." Docket No.29 at 10. Specifically, Plaintiff argues that this limitation in the Plan is "ambiguous and confusing given its placement and location and especially when viewed in the context of MetLife's attempt to provide notice of this limitation." Id. However, the limitation is plainly stated; it is not ambiguous or confusing because it is located under the section that discusses conversion option and is set apart by its own separate subsection titled "Option Conditions."
Plaintiff argues that premiums are prospective and that coverage existed in July 2012, when the death occurred, because Decedent paid his last premiums in June 2012. Docket No. 29 at 15-16. However, Defendant provided administrative record that Decedent's date of hire with TriNet was August 31, 2011, which is also the effective date under the terms of the Plan and the effective date listed on the employer's claim statement. AR 28, 92, 184-85.
Plaintiff argues that AD&D benefits should be extended into the conversion period because California Insurance Code § 10209 requires it. Docket No. 29 at 12.
Section 10209 provides:
Cal. Ins. Code § 10209 (West).
Section 10209 does not apply to Plaintiff's AD&D coverage. Section 10209 appears in the "Group Life Policies" chapter of the insurance code. Cal. Ins. Code § D. 2, Pt. 2, Ch. 2, Refs & Annos (West). The Ninth Circuit has held that section 10209 does not apply to accidental death policies in Henkin v. Northrop Corp., 921 F.2d 864 (9th Cir. 1990). In holding so, the Ninth Circuit relied on the California Supreme Court's dicta in Williams v. American Casualty Co., 491 P.2d 398 (Cal. 1971). Henkin, 921 F.2d at 867-68. Although the Williams court referred to the policy at issue therein as a disability policy, it was actually referring to an accidental death & dismemberment policy — the opinion states:
Williams, 491 P.2d at 400 (emphasis added); see Henkin v. Northrop Corp., 921 F.2d 864, 868 (9th Cir. 1990) ("The policy in Williams was an accidental death and dismemberment policy, 6 Cal.3d at 269, 491 P.2d 398, 98 Cal.Rptr. 814, and yet was referred to throughout the opinion as a disability policy."). Thus, Section 10209 does not apply to Plaintiff's AD&D coverage.
Both parties agree that ERISA preempts California estoppel law. Docket No. 27 at 19; Docket No. 29 at 14. At issue is whether federal common law estops Defendant from denying coverage.
Plaintiff argues that "[i]t can be reasonably inferred that Thomas Heng relied on a number [sic] representations about the insurance which were contained in the MetLife Group Policy and believed that these representations allowed him to convert the protection he had under the Group Policy into an individual policy." Docket No. 29 at 14. Although Plaintiff seems to suggest that there are a number of representations in the Plan about conversion of the AD&D benefits, Plaintiff fails to name any. Plaintiff only points to the certificate pages (AR 3, 54) and argues that "an employee would think that all of the insurance and protection he had under the Group Policy could be converted." Id.
The Ninth Circuit has established four federal common law elements of equitable estoppel that are applicable to an ERISA action:
Ellenburg v. Brockway, Inc., 763 F.2d 1091, 1095 (9th Cir. 1985). The Ninth Circuit has imposed two additional prerequisites on a plaintiff attempting to allege a claim of equitable estoppel in an ERISA action:
Pisciotta v. Teledyne Indus., Inc., 91 F.3d 1326, 1331 (9th Cir. 1996).
Plaintiff raised an argument applying the first four factors but failed to state the latter two factors. Docket No. 29 at 14-15. Even assuming that the terms of the Plan are ambiguous, Plaintiff never argued that Defendant made any representations involving oral interpretations of the Plan.
Plaintiff additionally argues that MetLife should be estopped from denying coverage because neither TriNet COBRA Guide and COBRA Notice (the only documents TriNet provided to Heng when his employment with TriNet ended, AR 528; Docket No. 33 at 2) provided any notice that Decedent stood to lose his accidental death and dismemberment coverage when his employment ended. Docket No. 33 at 2. This argument assumes that MetLife owes Heng a duty to notify that a third-party employer's termination of a plan participant triggered the termination of coverage under the terms of the Plan. However, Plaintiff failed to provide any authority for imposing such a duty. In fact, the Ninth Circuit has rejected analogous attempts to impose notice requirements on administrators for information already contained in the Plan documents and SPD. See, e.g., Scharff v. Raytheon Co. Short Term Disability Plan, 581 F.3d 899, 908 (9th Cir. 2009) (declining to requiring plan administrators to inform participants separately of time limits already contained in a summary plan description). As discussed above, Plaintiff and Decedent were already on notice of the termination by the clear terms of the Plan and SPD. AR 28-29, 94-95, 469.
Moreover, the cases cited in Plaintiff's supplemental briefing — Salterelli v. Bob Baker Group Medical Trust, 35 F.3d 382; Haynes v. Farmers Ins. Exchange, 32 Cal.4th 1198, 1212-1215 (2004); Bareno v. Employer's Life Ins. Co., 7 Cal.3d. 875 — fail to support her argument that the allegedly required notice is also subject to the reasonable expectations doctrine. Unlike in Salterelli and Haynes, Plaintiff does not and cannot argue that MetLife excluded coverage through an inconspicuous provision in the Plan. Moreover, unlike in Bareno, which held that ambiguities in certificate of insurance and notice of termination should be construed against the insurer, Plaintiff does not allege any ambiguities in the certificate page or notice but only silence as to AD&D conversion.
For the foregoing reasons, the Court
This order disposes of Docket No. 27.
AR 94-95 (emphasis in original).
AR 113-14 (emphasis in original).
Second, the Supplemental Life, Dependent Life, and Voluntary AD&D Insurance provides:
AR 92 (emphasis in original). Since Heng was not required to give evidence of his insurability for Voluntary AD&D benefits, under the clear terms of the Plan, coverage for these benefits took effect on the date Heng entered the class of TriNet's full-time employees.
Third, the life insurance claim form filled out by TriNet shows that "the effective date of amount of insurance being claimed" for Thomas Heng was August 31, 2011. AR 184. The claim form also shows that the effective dates for basic life, AD&D, and voluntary AD&D insurance are August 31, 2011 and that Heng was a TriNet employee as of August 31, 2011. AR 185.
