ROBERT M. DOW, JR., District Judge.
Plaintiff Ted Baxter seeks judicial review of the final decision of Defendant Sun Life Assurance Company of Canada to offset Plaintiff's long-term disability benefits with a malpractice settlement that Baxter received from Evanston Hospital. The question before the Court is whether Sun Life's decision to offset Plaintiff's long term disability ("LTD") benefits by a portion of his tort settlement was arbitrary and capricious. For the reasons set forth below, the Court finds that Sun Life's decision was not reasonable in light of the plain language of Plaintiff's long-term disability policy. Therefore, the Court denies Defendant's motion for judgment under Federal Rule of Civil Procedure 52[27] and enters judgment in favor of Plaintiff Ted Baxter.
Plaintiff's claim is governed by the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001, et seq., which was "enacted to promote the interests of employees and their beneficiaries in employee benefit plans, and to protect contractually defined benefits." Black & Decker Disability Plan v. Nord, 538 U.S. 822, 829, 123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003) (quoting Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 113, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989)). The statute permits a person who is denied benefits under an ERISA employee benefit plan to challenge that denial in federal court. Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 108, 128 S.Ct. 2343, 171 L.Ed.2d 299 (2008); see also 29 U.S.C. § 1132(a)(1)(B). Both parties ask the Court to determine the question of Plaintiff's eligibility for benefits based on the case file reviewed by the Administrator and the proffered Program documents, as well as the deposition of Otis Robert Goodall, the claim consultant employed by Sun Life who adjudicated Plaintiff's claim.
Generally, "[t]he standard of review of a Plan Administrator's decisions regarding benefits depends on whether the Plan Administrator was given the discretion to make those decisions." Vallone v. CNA Fin. Corp., 375 F.3d 623, 629 (7th Cir. 2004). The Supreme Court has held that "a denial of benefits challenged under § 1132(a)(1)(B) is to be reviewed 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, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). In ruling on Plaintiff's motion to compel, the Court concluded that the language included in Plaintiff's policy — indicating that Sun Life's decisions are "conclusive and binding" and that judicial review will be subject to an "arbitrary and capricious" standard — gave Baxter adequate notice that the plan administrator had discretionary authority to determine eligibility for benefits or to construe the terms of the plan. Thus, the Court determined that the appropriate standard for its review of Sun Life's benefits determination would be whether the plan administrator's decision was arbitrary and capricious.
On April 21, 2005, Plaintiff Ted Baxter, then a global controller at Citadel Investment Group, LLC ("Citadel"), became disabled as a result of brain damage following a cerebrovascular accident (a stroke). At the time that Plaintiff became disabled, he was insured under a group long term disability ("LTD") insurance policy provided by his employer and insured and underwritten by Defendant Sun Life Assurance Company of Canada. The policy promises to pay benefits based on an employee's past earnings minus any applicable offsets, so long as an employee remains disabled under the terms of the policy. Pursuant to the policy, total disability benefits are calculated by subtracting "Other Income Benefits" from the monthly benefit amount. The pertinent part of the policy regarding "Other Income Benefits" states:
Initially, Sun Life paid Plaintiff a next monthly benefit of $15,000.00. Then, on December 4, 2005, Plaintiff was awarded Social Security Disability Income Benefits ("SSDIB"), which dated back to April 21, 2005. Sun Life subsequently offset Plaintiff's monthly LTD benefit amount by the amount of his SSDIB, which was approximately $2,133.00, reducing Sun Life's monthly payout to $12,867.00.
Then, in November 2006, Plaintiff brought suit against Evanston Hospital for medical malpractice relating to the treatment Plaintiff received for the stroke he suffered. The Baxters alleged that as a result of the hospital's negligent treatment of Plaintiff after his April 2005 stroke, Plaintiff suffered "injuries of a personal and pecuniary nature." In March 2007, Plaintiff and Evanston Hospital settled for approximately $19,500,000.00. The settlement agreement did not enumerate a payment for loss of wages, but rather stated only the gross amount of the settlement. Sun Life obtained a copy of Baxter's malpractice complaint, as well as the settlement agreement, answers to interrogatories, Mrs. Baxter's deposition, and the mediation statement. The mediation statement listed Plaintiff's damages to include disability, loss of normal life, disfigurement, lost income, loss of society, physical pain, and
In a letter dated April 18, 2008, Robert Goodall notified Plaintiff that Sun Life had determined that the medical malpractice settlement would offset his monthly LTD benefit amount pursuant to the policy's definition of "Other Income Benefits" — specifically, the provision which allows an offset against monthly benefits payable for "any amount you receive due to income replacement or lost wages paid to you by compromise, settlement, or other method as a result of a claim for any Other Income Benefit." Mr. Goodall determined that "the vast majority of Mr. Baxter's claims relate to his lost wages" and applied one-third of the $19.5 million settlement in his calculation of the offset. More specifically, Mr. Goodall stated that:
Mr. Goodall recalculated the net benefit based on the offset created by the settlement. To determine the monthly amount of the offset, Mr. Goodall took one-third of the $19.5 million settlement and divided that amount by 283 months.
Plaintiff timely appealed, challenging Defendant's offset determination and seeking reinstatement of benefit payments at the full amount. In July 2008, Brian Sullivan, a Sun Life "appeal specialist," forwarded Plaintiff's claim file to David C. Jensen, a litigation attorney with a "special emphasis on professional liability and commercial litigation."
Mr. Jensen prepared a written opinion dated August 12, 2008. Mr. Jensen stated that he focused his review on the malpractice complaint, Plaintiff's discovery responses, the mediation statement (and its supporting exhibits), and medical records. In his August letter, Mr. Jensen opined that the amount of the settlement "was significantly influenced by [Plaintiff's] high earning capacity." According to Mr. Jensen:
Mr. Jensen observed that at the time of Plaintiff's stroke, he was making $1.3 million per year and had an established earning history at two previous jobs. Mr. Jensen observed that Dr. Skurski's Economic Loss Report showed Plaintiff's net past loss of income of $997,342 and future lost income ranging from $28,943,212 to $63,248,192, depending on whether Plaintiff remained in the job he had at the time of his stroke or received promotions. In rendering his opinion, Mr. Jensen reviewed recent settlements and verdicts from Cook County "to help assess the role lost earnings likely played in this matter." Mr. Jensen noted that Plaintiff received a settlement that was $2 million more than a severely injured former model, and he concluded this greater amount was "based on his income loss." Mr. Sullivan faxed Mr. Jensen's August letter to Plaintiff's counsel on September 2, 2008.
On January 28, 2009, Baxter submitted additional documentation to Sun Life, including an expert witness report prepared by Neil Posner that challenged Sun Life's position concerning the application of the malpractice settlement proceeds to offset the LTD benefit. The report concluded that an uncategorized settlement of a suit for personal injuries alleging bodily injury does not constitute income replacement or payment of lost wages. Mr. Sullivan forwarded Mr. Posner's letter to Mr. Jensen for his review and asked whether Mr. Posner's letter changed Mr. Jensen's opinions. Mr. Jensen responded that his opinion remained unchanged, citing the Economic Loss Report that was part of the Baxters' Mediation Statement and stating that the evaluation "absolutely builds" on the impact that Plaintiff's stroke had on his ability "to maintain his high level of income." Mr. Jensen also stated that Plaintiff "is not the victim of a stroke the cause of which is likely to repeat itself" and that the "principle risk factor for recurrent stroke has been dramatically reduced, if not eliminated." Mr. Jensen stated that he could not comment on the tax issues raised in Mr. Posner's letter.
In June 2009, Mr. Sullivan asked James McElligott, Jr., an attorney that who handles employment, executive compensation,
Mr. Sullivan also asked George J. DiDonna, M.D. FACC (Board Certified in Cardiology) to review Mr. Jensen's August and May Letters and Plaintiff's medical records and provide his opinion concerning whether Mr. Jensen's opinion about Plaintiff's future medical expenses was reasonable. Dr. DiDonna agreed with the explanation and conclusions of Mr. Jensen regarding "the mechanism of the CVA [stroke]" in Plaintiff's case. Dr. DiDonna also stated that Plaintiff would not be "at high risk of repeated embolic CVA [stoke] as evidenced by his medical treatment * * *." On June 16, 2010, Sun Life faxed to Plaintiff's counsel Mr. Jensen's May Letter, Mr. McElligott's letter, and Dr. DiDonna's report. In response, Plaintiff filed the present lawsuit.
Sun Life denied Plaintiff's appeal by letter dated July 8, 2009. Mr. Sullivan stated that Sun Life was applying two "Other Income Benefits" offsets to Plaintiff's monthly long term disability benefit: Plaintiff's $2,049.00 monthly SSDI benefit and $22,965.90 per month for income replacement or lost wages received by settlement. Mr. Sullivan noted that Sun Life sought an additional review by Mr. Jensen, as well as reviews by Dr. DiDonna and Mr. McElligott. The letter concluded that:
The appeal denial letter stated that in light of the "Other Income Benefit" offsets, Plaintiff is due the Minimum Monthly Benefit payable under the Policy ($1,500.00), and because Plaintiff did not provide Sun Life with timely notice of "all Other Income Benefits Mr. Baxter receives," he was overpaid LTD benefits in the amount of $378,480.00. The appeal denial letter requested that Plaintiff reimburse the amount of the overpayment, and if he did not do so, Sun Life stated it would withhold future monthly benefits and "credit them against the overpayment until the overpayment is satisfied." Plaintiff has not reimbursed Sun Life.
As previously stated, the Court granted Plaintiff's motion to compel the deposition of Robert Goodall in order to allow the parties to conduct limited discovery into a conflict of interest on the part of Sun Life. During his August 2010 deposition, Goodall
When asked to explain why he chose one-third as the amount attributable to "lost wages," Goodall answered: "I can't recall specifically how one-third was determined other than to say that I felt it was a conservative estimate based on my review of the complaint documents that were provided." Goodall also did not recall why he did not subtract attorneys' fees and other expenses from the gross settlement amount of $19.5 million prior to applying a one-third offset to the malpractice settlement.
Review under the deferential standard — whether the administrator's decision was arbitrary and capricious — "is not a rubber stamp" (Holmstrom v. Metropolitan Life Ins. Co., 615 F.3d 758, 766 (7th Cir.2010)), and courts should not uphold a termination "when there is an absence of reasoning in the record to support it" (Hackett v. Xerox Corp. Long-Term Disability Income Plan, 315 F.3d 771, 774-75 (7th Cir.2003). The Seventh Circuit has advised lower courts to focus on "procedural regularity, substantive merit, and faithful execution of fiduciary duties" in considering whether an administrator decision was arbitrary and capricious. Holmstrom, 615 F.3d at 766. An administrator's conflict of interest is a "key" consideration under this deferential standard. Id. Courts are to remain "cognizant of the conflict of interest that exists when the administrator has both the discretionary authority to determine eligibility for benefits and the obligation to pay benefits when due." Jenkins v. Price Waterhouse Long Term Disability Plan, 564 F.3d 856, 861 (7th Cir.2009) (citing Glenn, 554 U.S. at 111, 128 S.Ct. 2343)). In such cases, like the present one, the conflict of interest is "weighed as a factor in determining whether there is an abuse of discretion."
The fundamental question before the Court is whether it was reasonable for Sun Life to conclude, under the terms of its policy, that the Baxters' malpractice settlement constituted an "Other Income Benefit." As pointed out by Sun Life, under the deferential standard of review, "an administrator's interpretation is given great deference and will not be disturbed if it is based on a reasonable interpretation of the plan's language." Wetzler v. Illinois
See Morton v. Smith, 91 F.3d 867, 871 (7th Cir.1996); see also Marrs v. Motorola, Inc. ("Thus, as we explained in Ross v. Indiana State Teacher's Ass'n Ins. Trust, 159 F.3d 1001, 1011 (7th Cir.1998), `although, generally, ambiguities in an insurance policy are construed in favor of an insured, in the ERISA context in which a plan administrator has been empowered to interpret the terms of the plan, this rule does not obtain.'"). Although interpretations that "controvert the plain meaning of a plan" may be overturned (see Green v. UPS Health and Welfare Package for Retired Employees, 595 F.3d 734, 738 (7th Cir. 2010)), district courts in this circuit do not employ the rule of contra proferentem when undertaking deferential review of a plan administrator's decision.
Sun Life maintains that it was "reasonable" to offset Plaintiff's disability benefits with a portion of the gross malpractice settlement (without considering the attorney's fees incurred by Plaintiff) because the malpractice settlement constituted an "Other Income Benefit" under Plaintiff's LTD policy. Sun Life relies on paragraphs 1 & 9 of the "Other Income Benefits" section of the Policy. First, Defendant contends that it was reasonable for Sun Life to offset Mr. Baxter's malpractice settlement against his LTD benefits because paragraph 1 of the "Other Income Benefits" section of the policy defines "Other Income Benefits" as "[t]he amount the Employee is eligible for under * * * [a]ny other act or law of like intent." According to Defendant, Plaintiff's malpractice recovery was obtained through "any other act or law of like intent" because all of the laws listed in paragraph 1 (i.e., (Workers' Compensation Law, Occupational Disease Law, Unemployment Compensation Law, Compulsory Benefit Act or Law, and an automobile no-fault insurance plan) compensate an injured person for lost income. Defendant further contends that the offset was appropriate under paragraph 9 of the "Other Income Benefits" section of the policy which allows for an offset of "[a]ny amount you receive due to income replacement or lost wages paid to you by compromise, settlement or other method as a result of a claim for any Other Income Benefit." Defendant maintains that Plaintiff's malpractice settlement was an amount he received "due to income replacement or lost wages paid * * * by settlement" as a result of a claim under a law of "like intent" when compared with the laws listed in paragraph 1.
Based on the language of the policy, unless Plaintiff's malpractice claim arose under one of the enumerated classifications of "Other Income Benefits," there is no basis to permit Sun Life to take an offset. Although tort claims are not specifically listed in paragraph 1, Defendant maintains that Plaintiff's malpractice settlement was designed to compensate Baxter for his lost income and thus is akin to
Defendant's position that insurance companies can include provisions requiring other lost wage recoveries to be offset against benefits payable under the LTD policy is sound. See, e.g., Hall v. Life Ins. Co. of N. America, 317 F.3d 773, 775 (7th Cir.2003) (discussing reasons for income offset provisions). These clauses "not only reduce the employer's outlay for disability coverage (and thus enable the employer to provide additional fringe benefits from a given budget) but also control the moral hazard of insurance — that is, the chance that the existence of insurance will increase the likelihood of the insured event." Id. But as Hall indicates, deductions generally are not "universal," and the policy documents must support the company's reading. Id. Here, the plain language of the policy does not support Defendant's view that a malpractice recovery that arose out of a tortious act is "like" state-mandated, no-fault recoveries that traditionally arise after a disability. Put another way, a malpractice recovery is not a typical "income benefit" which foreseeably results from a disabling stroke.
As noted above, the Seventh Circuit does not recognize the rule of contra proferentem during a deferential review. See Marrs v. Motorola, Inc., 577 F.3d 783, 786-87 (7th Cir.2009). But even if the rule were in play, there would be no need to invoke it in this instance, for applying an offset for a medical malpractice recovery is contrary to the plain meaning of the plan. Nothing in the plan language gives the employee any indication that tort recoveries will be considered an "Other Income Benefit." As the drafter, Sun Life had the ability to draft its policy to specifically
One of the primary statutory goals of ERISA is to insure that "every employee may, on examining the plan documents, determine exactly what his rights and obligations are under the plan." Young v. Verizon's Bell Atlantic Cash Balance Plan, 575 F.Supp.2d 892, 916 (N.D.Ill. 2008) (quoting Int'l Union of Electronic, Elec., Salaried, Machine and Furniture Workers, AFL-CIO v. Murata Erie North America, Inc., 980 F.2d 889, 907 (3d Cir. 1992)). If policy language is in fact ambiguous, then the subjective intent of the policy sponsor might, along with other evidence,
A final note regarding the structural conflict of interest mentioned above: As discussed above, a structural conflict of interest may come into play where the administrator has both the discretionary authority to determine eligibility for benefits and the obligation to pay those benefits. Glenn, 554 U.S. 105, 111, 128 S.Ct. 2343 (2008); Jenkins v. Price Waterhouse Long Term Disability Plan, 564 F.3d 856, 861 (7th Cir.2009). "A structural conflict is one factor among many that are relevant in the abuse-of-discretion analysis * * * and will `act as a tiebreaker when the other factors are closely balanced.'" Raybourne, 576 F.3d at 449 (quoting Glenn, 554 U.S. at 117, 128 S.Ct. 2343). A detailed analysis of any potential conflict of interest at work here is unnecessary, as the Court finds that the administrator's decision was not supported by the plain language of the policy. That being said, the Court briefly comments on some of the factors present in this case that suggest that a conflict of interest may have been at work. See, e.g., Holmstrom v. Metropolitan Life Ins. Co., 615 F.3d 758, 777 (7th Cir.2010).
First, Sun Life's decision not to use experts in making its initial determination, but only in defending its claim administrator's admittedly imprecise offset,
In sum, Sun Life's application of the offset under paragraph 1(f) of the "Other Income Benefits" section lacked a "reasoned basis," as tort law is not a law of "like intent" when compared with the laws listed under paragraph 1(a)-(e). See Call v. Ameritech Management Pension Plan, 475 F.3d 816, 821-22 (7th Cir.2007) (refusing to adopt plan administrator's self-serving plan interpretation, despite the deferential review, because the interpretation lacked a "reasoned basis."). Nor did the malpractice claim fall within the scope of any of the other provisions set forth in paragraphs 2 through 10, such as Social Security disability, pension, sick leave, salary continuation, or severance pay. Because Sun Life did not have a reasoned basis for concluding, under the terms of its own policy, that the Baxters' malpractice settlement constituted an "Other Income Benefit," the decision to offset Plaintiff's long term disability ("LTD") benefits by a portion of his tort settlement was arbitrary and capricious.
Because the Court finds that Sun Life's decision to offset Plaintiff's long term disability ("LTD") benefits by a portion of his tort settlement was arbitrary and capricious in light of the plain language of Plaintiff's long-term disability policy, the Court denies Defendant's motion for judgment under Rule 52[27] and enters judgment in favor of Plaintiff Ted Baxter and against Defendant Sun Life. The Court orders restoration of monthly benefit payments to the pre-offset amount ($12,951.00) retroactive to April 18, 2008. Plaintiff is not liable for the claimed overpayment in the amount of $375,480.00.
Plaintiff also seeks costs, attorney fees, and prejudgment interest on benefits due since April 2008. In a beneficiary's ERISA action, "the court in its discretion may allow a reasonable attorney's fee and costs of action to either party." 29 U.S.C. § 1132(g)(1). The Seventh Circuit reviews a district court's decision to award or deny attorney fees for abuse of discretion, and will not disturb the district court's finding "if it has a basis in reason." Bowerman v. Wal-Mart Stores, Inc., 226 F.3d 574, 592 (7th Cir.2000). Whether to award an ERISA claimant prejudgment interest is "a question of fairness, lying within the court's sound discretion, to be answered by balancing the equities." Fritcher v. Health Care Service Corp., 301 F.3d 811,