LILES C. BURKE, UNITED STATES DISTRICT JUDGE.
This matter comes before the Court on Defendant Lincoln National Life Insurance Co.'s ("Lincoln") and Plaintiff Alexander Harris's cross motions for Summary Judgment. (respectively Doc. 40, & 28), and Lincoln's former motion for summary judgment (Doc. 12) which has now been superseded. This action involves an employer provided insurance policy and is subject to the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§ 1001, et seq. ("ERISA").
Mr. Harris filed a two count Complaint against Lincoln including: (i) a claim for dismemberment benefits; and (ii) a claim asserting wrongful withholding of documents related to Lincoln's denial of the dismemberment claim. Both Lincoln and Mr. Harris have each separately moved for summary judgment on both claims. (respectively, Doc. 40, & 28.) Lincoln's recently filed reformatted motion (Doc. 40), replaces its previously filed motion (Doc. 12).
For the reasons stated below, Lincoln's Motion for Summary Judgment (Doc. 12) is due to be
On January 1, 2014, Lincoln issued two insurance policies to Mr. Harris's employer, QinetiQ North America, Inc. ("QinetiQ"). AR 000018, AR 000105.
The Basic Policy provides a dismemberment benefit for accidental injuries. AR 000065. The Basic Policy, however, excludes coverage of those losses that resulted from other contributing causes including disease. AR 000065. The Basic Policy provides in relevant part:
AR 000065 (underlined emphasis added).
Similarly, the Voluntary Policy provides a dismemberment benefit for accidental injuries. AR 000130. The Voluntary Policy also excludes coverage of those losses that resulted from other contributing causes including disease. AR 000137. The Voluntary Policy provides in relevant part:
(b) the accidental ingestion of a poisonous food substance; . . . .
AR 000130, AR 000137 (underlined emphasis added). The Basic Policy and the Voluntary Policy (collectively, the "Policies") both provided that an insured could recover "1/2 Principal Sum" for the "Loss of One Member" which included the loss of a foot. AR 000065; AR 000130.
The claim procedures for both Policies are included in the respective policy document. See AR 000062; AR 000143. Both Policies provide that: "Written notice of an . . . dismemberment claim must be given within 20 days after the loss occurs; or as soon as reasonably possible after that." AR 000062; AR 000143. Once a claim is received, Lincoln was obligated to send a claims form to the claimant so that he could submit the requisite proof of loss. Id. The claimant then submits to Lincoln proof of his claim including information that shall "state the nature, date and cause of the loss." Id. In addition to the returning the claim, the claimant is required to include other materials that Lincoln "may reasonably require in support of the claim." Id.
The Policies, in a section titled, "Company's Discretionary Authority," grant Lincoln the authority to determine a claimant's entitlement to benefit:
The Company's authority includes (but is not limited to) the right to:
AR 000064; AR 000145. The Polices require Lincoln to send the claimant written notice of its decision, and, in case of a denial, Lincoln is required to explain "the reason for the denial . . .;" "how the claimant may request a review of the Company's decision;" and "whether more information is needed to support the claim." AR 000063; AR 000144.
In the Summary Plan Descriptions for each plan, the Policies designate QinetiQ as the Plan Administrator. AR 000107; AR 000166.
On August 14, 2014, Mr. Harris had an accidental injury. (Doc. 42, p. 3, ¶ 4.) In his Dismemberment Claim Form (signed December
Three days after the surgery, Mr. Harris was ambulatory at the hospital and using a rolling walker. AR 004323. He had fever and pneumonia-like symptoms, nevertheless, he was discharged on November 26, 2014, "with symptoms of fatigue, a low-grade fever and drainage from a prior flap site." Id. Mr. Harris had persistent fevers and general feeling of illness; thus, he went to a hospital emergency room. AR 002621; AR 004323. On December 8, 2014, he was then transferred from that hospital to Vanderbilt University Medical Center. AR 002625; AR 004323.
Upon admission to Vanderbilt, Mr. Harris also met with Dr. Holt. AR 002625. Dr. Holt discussed with him that if he had an infection Dr. Holt would proceed with an amputation. Id. Dr. Holt reported that a test revealed that his leg was infected with MRSA. Id. On December 10, 2014, Dr. Holt met with Mr. Harris to discuss with him the need to amputate his leg and Mr. Harris consented. That day, Dr. Holt performed a below knee amputation on Mr. Harris's leg. Id.
On December 23, 2014, Mr. Harris signed a Dismemberment Claim Form in which he claimed $57,500 under the Basic Policy and $ 280,000 under the Voluntary Policy. AR 004544. He wrote that on August 16, 2014: "I was walking in my yard and when I put my foot down my left tibia broke in several pieces. Attempts to repair it were unsuccessful and resulted in amputation of my left leg below the knee." AR 004544. Attached to the form was an Attending
On February 17, 2015, a Lincoln employee contacted Mr. Harris and requested additional medical records, because Dr. Holt indicted that his amputation was not due to an accident. AR 002578. That same day, Lincoln sent Mr. Harris a letter requesting additional information including: medical records, hospital records, CT scan results, MRI results, and office visit notes. AR 004530.
On March 17, 2015, Lincoln sent Mr. Harris a letter again requesting the same additional information. AR 004528. The letter requested that the information be provided within 15 days, and stated that the claim file would otherwise be closed. Id. On March 30, 2015, Lincoln sent Mr. Harris a letter stating that his "file is being closed due to insufficient information." AR 004524. Lincoln wrote that if the documentation was later provided, then Lincoln would continue its review. AR 004524.
On April 29, 2015, Mr. Artrip, on behalf of Mr. Harris, sent Lincoln a letter stating, "We are in the process of obtaining all relevant medical records and will provide them to you when received. Please provide a copy of the policy including any and all endorsements and exclusions." AR 004523. On August 18, 2015, Mr. Artrip sent Lincoln a letter including medical records. AR 004321. Mr. Artrip acknowledged that 15 years previously Mr. Harris had been diagnosed with malignant fibrous histiocytoma in his left leg. Id. Mr. Artrip stated that Mr. Harris "was functional and disease free" at the time of his injury. Id. In his letter, Mr. Artrip described the accident as Mr. Harris "running across an overgrown vacant lot" and that "[h]e stepped in a hole covered by long grass and broke his leg." AR 004322. On May 7, 2015, Lincoln sent Mr. Artrip copies of the Policies. AR 004521.
Lincoln asked its employee,
On September 9, 2015, Lincoln sent Mr. Artrip a letter denying Mr. Harris's claim. AR 002712. Lincoln reasoned that the Mr. Harris's "loss was a result of complicated chronic medical conditions from malignant fibrous histiocytoma resection, radiation osteonecrosis and infection." AR 002713. Lincoln also noted that the denied claim could be reviewed. Id.
On November 6, 2015, Mr. Harris's attorney, Glen Connor, sent Lincoln a letter requesting "documents relevant to [Mr. Harris's] claim, including a copy of your entire claim file...." AR 002709. That same day, Mr. Connor, sent Lincoln a separate letter (characterized as a "second level appeal") appealing Lincoln's initial determination. AR 002683. Mr. Connor sent Lincoln a declaration by Mr. Harris, AR 002686-87, and other medical documents. AR 002688-707.
In his November 6, 2015, declaration, Mr. Harris stated that his injury occurred on August 16, 2014, because while he was jogging his foot was suddenly stopped by something on the ground and it caused him to fall. AR 000266. He described the events in relevant part as follows:
AR 000266-67.
On November 12, 2015, Lincoln responded to Mr. Connor stating that it had received his letter requesting an appeal. AR 002599-600. Lincoln acknowledged that he had sent additional information, and asked him to contact Lincoln immediately if he would be submitting any more additional information. Id. Lincoln did not reference Mr. Connor's request that documentation be sent to him. Id.
That same day Carla Larimore, an Appeals Senior Claims Examiner for Lincoln, asked Bryan Gall to assign the review of Mr. Harris's claim to a nurse staff member. AR 002601. On December 16, 2016, Nurse Lynn Sucha, whose title is "Disability Nurse Consultant," emailed Ms. Larimore a report. AR 002595, AR 002597. In the report, Nurse Sucha stated that she had received: (i) Dr. Maples August 19, 2014, report, Dr. Holt's August 26, 2014, report, and Dr. Welkert's report. AR 002597. She wrote that:
AR 002597. That same day, Ms. Larimore emailed Nurse Sucha, stating, "On this one, I'm trying to determine if the initial injury in 2014 was a direct cause for the amputation, or if the injury in 2015 was the direct cause." AR 002595. Nurse Sucha responded:
AR 002594.
On December 30, 2015, Lincoln sent Mr. Connor a letter in which it stated that it was denying benefits and that Mr. Connor could request an appeal of the decision. AR 002590-92. Lincoln explained that:
AR 002592 (emphasis added).
On February 2, 2016, Mr. Connor sent Lincoln a letter requesting "a copy of the report from the health care consultant upon which you rely to deny benefits." AR 002588. On February 19, 2016, Lincoln's employees "processed" Mr. Connor's request, but Mr. Connor never received the file. AR 000222.
On February 26, 2016, Mr. Connor sent Lincoln another letter requesting an appeal of Lincoln's prior benefits decision. AR 002422. In his letter, Mr. Connor stated that he had sent Lincoln letters on both
In her letter, dated February 26, 2016, Dr. Holt discounted the sarcoma and radiation as contributing to his infection and amputation concluding that they may have been caused by other factors. AR 002378-79. Her letter states in relevant part:
AR 002378-79 (emphasis added).
On March 3, 2016, Jarod Ashley, Lincoln's "Senior Claims Examiner, Appeals," called Mr. Connor asking to verify whether Mr. Connor had received the complete file he requested, and whether Mr. Connor would be sending any additional information. AR 000195. On March 9, 2016, Mr. Ashley sent Mr. Connor an email asking for verification of the same information. Id. Over two weeks later, on March 25, 2016, Mr. Connor responded stating that he had not received the claim file and that without it Mr. Harris would not know what "additional information would be necessary or appropriate to prove his claim." Id.
On March 29, 2016, Mr. Jarrod responded that due to the size of the file he could not email the entire file, but he requested a copy be sent to Mr. Connor and attached 200 pages of medical records to his email. AR 000194.
On April 15, 2016, Mr. Connor responded that he had not received the file and also asked for "the summary plan description and the policy." AR 000194. On April 21, 2016, Mr. Ashley sent an email to Mr. Connor stating that a copy of the complete file would be sent out that day or the following day, and he also stated that he needed a time extension since the deadline for deciding the appeal was approaching. AR 000193. That day, Mr. Connor acknowledged receipt of the email writing "Received. Thank you." Id.
"On June 14, 2016, Mr. Ashley sent Mr. Connor an email stating that Lincoln was proceeding with the second appeal and if any additional information was sent to Lincoln, then Lincoln would review that information as well." AR 000191. On June 15, 2016, Mr. Ashley sent an email to Mr. Gall asking that Mr. Harris's claim be review be assigned to one of Lincoln's employee nurses for review. AR 000197.
On June 15, 2016, Mr. Gall referred the claim review to Nurse Tina Vrbka. AR 000177. In her review, Nurse Vrbka, next to the reference "Documents reviewed," listed "Dr. Ginger Holt/orthopedics 08/26/14-02/26/16." AR 000170. She did not list Mr. Harris's declaration. See id. Nurse Vrbka produced a review in which she concluded:
AR 000170. Under the section described as "Rationale with medical findings", Nurse Vrbka wrote, "Claimant was walking in his yard when put his left foot down and broke his left tibia in several places on 08/16/14." Id. She also wrote "Dr. Holt: Letter dated 08/26/14: Consult for claimant, who was chasing dog and felt a snap in is [sic] leg, immediate pain, and fell." Id.
On August 4, 2016, Lincoln sent Mr. Connor a letter stating that Lincoln's review was complete and Lincoln was denying Mr. Harris's claim. AR 000173. Lincoln explained:
AR 000175.
On September 13, 2016, Mr. Harris filed his two count Complaint asserting: (i) a claim for dismemberment benefits; and (ii)
On November 17, 2017, Lincoln filed its Motion for Summary Judgment (Doc. 12), on December 18, 2017, Mr. Harris filed a Response in Opposition to the motion (Doc. 19), and, on January 25, 2018, Lincoln filed a Reply brief (Doc. 22). On March 5, 2018, Mr. Harris filed his own Motion for Summary Judgment (Doc. 28), and, on March 26, 2018, Lincoln filed a response (Doc. 34).
On December 4, 2018, this Court ordered that the parties resubmit their briefs reformatted in a manner consistent with the undersigned judge's Amended Initial Order. (Doc. 37.) On December 19, 2018, Lincoln filed its Reformatted Motion for Summary Judgment (Doc. 40), and, the next day, Mr. Harris filed his reformatted brief (Doc. 42) in support of his motion. On January 7, 2019, Lincoln and Mr. Harris filed their responses (respectively Docs. 50 & 51), and, on January 14, 2019, they filed their replies (Doc. 54 (Lincoln's reply), Doc. 55 (Mr. Harris's reply)).
ERISA does not set out a standard for courts reviewing the benefits of plan administrators or fiduciaries. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). Consequently, the United States Court of Appeals for the Eleventh Circuit developed a test to review an administrator's decision to deny benefits. Blankenship v. Metropolitan Life Ins. Co., 644 F.3d 1350, 1355 (11th Cir. 2011).
Blankenship, 644 F.3d at 1355 (emphasis in original).
The Court now analyzes the parties' motions as they related to Mr. Harris's claims: (i) a claim for dismemberment benefits; and (ii) a claim asserting wrongful withholding of documents related to Lincoln's denial of the dismemberment claim.
Lincoln argues that examining its decision to deny dismemberment benefits under the first step, the decision was de novo correct. (Doc. 40, p. 34, 36-43.) Mr. Harris argues that Lincoln's decision was wrong, because:
(i) the decision failed to consider his declaration in which he stated how he was injured (Doc. 51, p. 20; Doc. 42, p. 10);
(ii) the medical records "corroborate[ ]" that his fall was the cause of his break (Doc. 51, p. 20 (citing AR 003636));
(iii) two nurse reviewers "were either never informed of Mr. Harris [sic] testimony or ignored it[,]" (Doc. 51, p. 20; see Doc. 42, p. 10);
(iv) Dr. Holt "never closely questioned him about exactly how the break occurred[,]" and Mr. Harris was "never offered the opportunity to correct any errors which might exist in the medical records as to the sequence of events the [sic] led to or caused the accident[,]" (Doc. 51, p. 20-21);
(v) Dr. Holt "confirmed" that "the leg was amputated due to the break and not prior treatment ..." (Doc. 42, p. 10); and
(vi) "Lincoln is wrong as a matter of law regarding the interpretation of the policy." (Doc. 51, p. 25; see Doc. 42, p 10-11.)
The Court shall first discuss how it shall interpret the preexisting condition exclusion included in the Policies prior to analyzing the parties' arguments directed towards the six-part Blankenship test reviewing Lincoln's decision.
The Eleventh Circuit in Dixon v. Life Ins. Co. of N. Am., 389 F.3d 1179, 1183-84 (11th Cir. 2004), explained how courts should interpret language in a policy that precludes recovery for an accidental injury where a preexisting condition was a contributing factor. The Dixon Court adopted the "substantially contributed" test and required that preexisting conditions "substantially contributed" to an injury or loss to preclude recovery. Id. at 1184.
In Dixon, the defendant insurance company had issued an insurance policy that provided accidental death benefits to the plaintiff's husband who died of heart failure during an auto accident. Id. at 1180-81. The policy included exclusionary language that precluded coverage resulting from "sickness, disease, or bodily infirmity[,]" and the insurance company denied the plaintiff's claim for benefits stating that the decedent's death "was not `caused by an accident' but resulted from `other
The Eleventh Circuit, examining the issue of whether "language in an ERISA policy may preclude recovery for accidental injury where some preexisting condition was a contributing factor[,]" explained:
Id. at 1184. The Dixon Court adopted the "substantially contributed" test, but found that plaintiff's husband's pre-existing condition "substantially contributed" to his death and affirmed the district court judgment. Id. at 1184-85.
The Eleventh Circuit, in Bradshaw v. Reliance Standard Life Ins. Co., 707 Fed.Appx. 599, 600 & 610 (11th Cir. 2017), applying the substantially contributed test, found that an insurance company unreasonably denied long-term disability benefits in claiming that the insured's healthy pregnancy qualified as a pre-existing condition that "contributed to" the insured's stroke. In Bradshaw, the plaintiff was a few weeks pregnant when she bought a long-term disability insurance policy from the defendant insurance company. Id. at 601. The insurance policy excluded coverage where a disability was caused by a pre-existing condition, defined to include "Sickness" which in turn was defined to include pregnancy. Id. at 602. Prior to giving birth, the plaintiff was diagnosed with "mild preeclampsia," and after giving birth, she had a stroke; as a result, she filed an application for disability benefits. Id. at 601. The defendant denied the plaintiff's claim asserting that her disability from the stroke resulted from a "pre-existing condition" from which she received treatment, namely, the pregnancy. Id. at 602.
The district court granted summary judgment in favor of the insurance company. Id. at 603. The Bradshaw Court observed the Dixon Court adopted the "substantially contributed" test. Id. at 608. The Bradshaw Court stated that drawing a connection between the plaintiff's healthy pregnancy and the disabling condition required one to create four links (the (1) pregnancy led to (2) high blood pressure, which in turn led to (3) preeclampsia, which in turn led to a (4) stroke) which was too attenuated. Id. at 610. Thus, the Bradshaw Court held that the defendant's use of the pre-existing condition exclusion to deny benefits was unreasonable. Id.
The policies at issue in the case before the Court contain pre-existing condition exclusions, see AR 000065, AR 000130, AR 000137, similar to those in the policies in the Dixon and Bradshaw cases. Thus, in light of Dixon, the Court shall apply the substantially contributed test in interpreting the policies.
In reviewing the administrator's denial of dismemberment benefits, the Court must first determine whether the administrator's denial is "wrong." Blankenship, 644 F.3d at 1355. The Eleventh Circuit further explained that:
Glazer v. Reliance Standard Life Ins. Co., 524 F.3d 1241, 1246 (11th Cir. 2008) (emphasis in original). This Court has observed that "Courts have found that an administrator is `wrong' where it `disregarded the unanimous medical opinions' of treating physicians." Pickert v. Reliance Standard Life Ins. Co., No. 5:13-cv-2222-TMP, 2015 WL 12697726, at *8 (N.D. Ala. Jun. 9, 2015) (Putnam, M.J.) (quoting Gharagozloo v. Aetna Life Ins. Co., No. 08-23349-CIV, 2009 WL 3753589, *15 (S.D. Fla. Nov. 5, 2009)).
The Eleventh Circuit explained, albeit in an unpublished decision, that a court conducting the de novo review "applies the terms of the policy." Ruple v. Hartford Life and Acc. In. Co., 340 Fed.Appx. 604, 611 (11th Cir. 2009). This Court also stated that in determining whether an administrator is correct in denying benefits, "this court begins with a review of the [p]olicy itself, since an ERISA plan administrator must discharge its duties `in accordance with the documents and instruments governing the plan insofar as such documents and instruments are consistent with the provisions of [ERISA]'." Hillyer v. Hartford Life and Acc. Ins. Co., No. 2:09-cv-00843-JHH, 2011 WL 925027, at *13 (N.D. Ala. Jan. 31, 2011) (Hancock, J.) (quoting 29 U.S.C. § 1104(a)(1)) (second bracket in original).
Lincoln's Policies limit its coverage for dismemberment claims to situations where the insured's loss is caused by an accident, and there are no other factors that contribute to causing the loss. See AR 000065; AR 000130; AR 000137. In light of Dixon, 389 F.3d at 1184, the Court construes this provision as precluding recovery where factors, other than the accident, "substantially contribute" to the loss. In other words, if a disease substantially contributed to the Mr. Harris's loss, then Lincoln would be correct in denying Mr. Harris's claim under the Policies.
The Court now turns to the administrative record to examine Mr. Harris's treating physician's opinions. This Court has previously observed:
Pickert, 2015 WL 12697726, at *8.
According to Mr. Harris, his leg broke while he was running outside; specifically, his "foot was suddenly stopped and caused a fall." AR 003636. Mr. Harris's description of his accident describes the circumstances of how he fell and broke his leg. The Eleventh Circuit has found that an insurer's preference for medical opinions
If the fracture of Mr. Harris's leg, which occurred when he fell, was not substantially affected by disease, then Mr. Harris should be able to recover dismemberment benefits. The Court turns to the Administrative Record and, in particular, the opinions of Mr. Harris's treating physicians.
Viewing the record as a whole, the Court lacks a basis to conclude that on this evidence Lincoln was wrong when it denied Mr. Harris's dismemberment claim, because his pre-existing radiation necrosis was, according to his treating physicians, a substantial cause of his loss.
Mr. Harris argues that the Lincoln's decision was wrong, because Lincoln's nurse reviewers "were either never informed of Mr. Harris [sic] testimony or ignored it." (Doc. 51, p. 20.) Mr. Harris asserts that Lincoln did not provide Mr. Harris's "testimony" to its employee reviewer, because (1) the manner in which Nurse Sucha and Nurse Vrbka described
The Court in performing a de novo review of the medical evidence did not provide any weight to the opinions of Lincoln's employee reviewers. Thus, their lack of review of that declaration has no impact on the Court's de novo review of Mr. Harris's medical record with respect to the first step of the Blankenship test.
Mr. Harris argues that Lincoln's decision was wrong, because Dr. Holt "never closely questioned him about exactly how the break occurred[,]" and he was "never offered the opportunity to correct any errors which might exist in the medical records as to the sequence of events the [sic] led to or caused the accident." (Doc. 51, p. 20-21.) Assuming this is true, Mr. Harris's argument fails to identify how Lincoln's denial of benefits was "wrong" in light of Dr. Holt's alleged failure to question him about the circumstances of his break or her alleged failure to permit him to correct errors in medical records. To the extent that Mr. Harris believes that Dr. Holt failed to adequately diagnosis him, Mr. Harris was certainly free to retain other medical providers and submit that evidence to Lincoln in support of his claim. Moreover, the record shows that Mr. Harris informed his medical providers as to the circumstances of his accident. AR 000266-67 ("I have consistently told my physicians that this is what happened."). Given that he informed his physicians as to the circumstances of his accident, it is reasonable that Dr. Holt would not need to question Mr. Harris as to how his accident occurred. Furthermore, Mr. Harris provides no legal basis for his argument that his medical providers should have permitted him to correct medical records regarding the causation of his loss. Mr. Harris does not contend to be a medical provider and appears to have no professional training which would give him a basis upon which he would be professionally justified to correct the medical opinions of his treating physicians. Finally, Mr. Harris does not explain how the particular circumstances of Mr. Harris's leg fracture, whether it was from putting his foot down or having it stop suddenly, would alter his treating physicians' findings that the leg fracture was caused by radiation necrosis.
Mr. Harris also argues that "Lincoln is wrong as a matter of law because it relies upon the underlying suggestion that the injury must be the `sole cause' of the injury for benefits to be paid." (Doc. 51, p. 25-27; see Doc. 42, p 10 (citing Bradshaw, 707 Fed.Appx. at 606-07; Dixon, 389 F.3d at 1183).) As discussed above, Bradshaw and Dixon stand for the proposition that the
Assuming arguendo, that Lincoln's denial of dismemberment benefits was wrong, summary judgment is still due to be granted to Lincoln and denied to Mr. Harris, because Lincoln's decision was reasonable. The Court proceeds to analyze the parties' arguments under the second and third steps of the Blankenship test.
If the Court finds that the administrator's decision is de novo wrong in denying benefits for a claimant, then the Court is required to review that denial for "reasonableness" under an arbitrary and capricious standard if the administrator was vested with discretion in reviewing claims. Blankenship, 644 F.3d at 1355. The Policies expressly grant Lincoln discretion in reviewing a claimant's claim for benefits. See AR 000064; AR 000145; see Garrison, 294 F.Supp.3d at 1284 & 1296 (finding that similar language granted insurance company discretion in reviewing claims for benefits and applying "arbitrary and capricious standard"). Therefore, assuming, for sake of argument, that Lincoln's denial of benefits to Mr. Harris was wrong, the Court examines whether that denial was reasonable.
Under the third step, the Court determines "whether `reasonable' grounds supported [Lincoln's decision] (hence, review [the] decision under the more deferential arbitrary and capricious standard)." Blankenship, 644 F.3d at 1355. This Court has described the arbitrary and capricious standard of review:
Hillyer, 2011 WL 925027, at *18 (brackets in original).
Lincoln argues the decision was supported with "reasonable" grounds (Doc. 40, p. 43-47).
In light of the analysis above, the Court finds that Lincoln was not unreasonable in giving more credence to the opinions of Dr. Reddy, Dr. Welkert, and Dr. Grantham, than it did to Dr. Maples or to Dr. Holt's inconclusive letter. Lincoln's reliance on the opinions of these physicians does not constitute a failure on Lincoln's part to consider how the injury occurred or a demonstration of disregard to Mr. Harris's declaration of his other physicians. Mr. Harris fails to demonstrate why Lincoln's reliance on these opinions over the opinion of Dr. Maples and the indecisive opinion of Dr. Holt is at all "unreasonable" as either a practical matter or as a matter of law.
Mr. Harris argues that Lincoln's failed to provide its employee reviewers with his declaration or Dr. Maples's opinion. (Doc. 51, p. 21-22.) Mr. Harris's argument relies upon an unproven factual assumption that Lincoln did not provide its reviewers with his declaration or Dr. Maples's opinion. The failure of Lincoln's employees to recite the facts of how Mr. Harris broke his leg, consistent with the manner he provided in his declaration, see supra n. 16; AR 002597; AR 000170, did, however, demonstrate a lack of diligence on the part of Lincoln and its employees to review that declaration. Yet, his declaration could not be construed to demonstrate persuasive evidence of medical causation worthy of the same weight afforded to that of a medical professional. Lincoln's employees' reliance on the opinions of Mr. Harris's medical providers over his own declaration statement was reasonable. Thus, Mr. Harris's contention, with regards to his own declaration, has little bearing on whether Lincoln had reasonable grounds to support its decision.
Thus, even if the de novo review of Lincoln's decision demonstrated that Lincoln's decision was wrong, other reasonable grounds supported Lincoln's decision. Nevertheless, the Court finds that Lincoln's determination of benefits was not
The Court analyzes Mr. Harris's second claim that Lincoln wrongfully withheld documents related to the Lincoln's denial of the dismemberment claim. This claim requires a different standard of review (than the Blankenship test); it is the classic Federal Rule of Civil Procedure 56 standard, that the Court sets forth below.
"The 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(a). To demonstrate that there is a genuine dispute as to a material fact, a party must cite "to particular parts of materials in the record, including depositions, documents, electronically stored information, affidavits or declarations, stipulations (including those made for purposes of the motion only), admissions, interrogatory answers, or other materials." Fed. R. Civ. P. 56(c)(1)(A). When considering a motion for summary judgment, the Court must view the evidence in the record in the light most favorable to the non-moving party and draw reasonable inferences in favor of the non-moving party. White v. Beltram Edge Tool Supply, Inc., 789 F.3d 1188, 1191 (11th Cir. 2015).
The filing of cross motions for summary judgment does not alter the Rule 56 standard. See United States v. Oakley, 744 F.2d 1553, 1555-56 (11th Cir. 1984) ("Cross motions for summary judgment will not, in themselves, warrant the court in granting summary judgment unless one of the parties is entitled to judgment as a matter of law on facts that are not genuinely disputed.").
Lincoln argues that summary judgment should be granted in its favor on Mr. Harris's second claim, because: the claim applies only to plan administrators, and Lincoln is not the plan administrator; (ii) the claim does not apply to the types of documents at issue here; and (iii) even if the claim was applicable to Lincoln and the types of documents at issue, Lincoln acted diligently and in good faith, and its actions should not be penalized. (Doc. 40, p. 49.)
Mr. Harris, however, argues that: "(1) Lincoln is designated under the plan as an administrator with sole authority `to establish and enforce procedures to administer the Policy and claims under it' and (2) alternatively, Lincoln is clearly a de facto administrator under the Eleventh Circuit." (Doc. 51, p. 30.)
The relevant statute governing Mr. Harris's claim provides:
29 U.S.C. § 1132(c). An "administrator" is:
29 U.S.C. § 1002(16)(A)(1).
The Eleventh Circuit has adopted the de facto plan administrator doctrine. Rosen v. TRW, Inc., 979 F.2d 191, 194-94 (11th Cir. 1992). In Rosen, the Eleventh Circuit held that: "if a company is administrating the plan, then it can be held liable for ERISA violations, regardless of the provisions of the plan document." Id. at 193-194. The Eleventh Circuit, however, declined to apply the doctrine to third-party claims administrators. Oliver v. Coca-Cola Co., 497 F.3d 1181 (11th Cir. 2007), vacated in part on other grounds, 506 F.3d 1316 (11th Cir. 2007), aff'd in part and remanded in part, 546 F.3d 1353 (11th Cir. 2008). In Oliver, the Eleventh Circuit stated that it had rejected application of the doctrine to third-party administrative services providers, as opposed to employers. Id. at 1194; see also Smiley v. Hartford Life & Accident Ins. Co., 610 Fed.App'x 8, 8-9 (11th Cir. 2015) ("We have consistently rejected the use of the de facto plan administrator doctrine `where a plaintiff has sought to hold a third-party administrative services provider liable, rather than the employer. . . .'" (quoting Oliver, 497 F.3d at 1194)).
The Polices designate QinetiQ as the plan administrator. AR 000107; AR 000166. Accordingly, QinetiQ is the "the person specifically so designated by the terms of the instrument under which the plan is operated[,]"29 U.S.C. §§ 1002(16)(A)(1)(i), and is the Plan Administrator.
Mr. Harris argues that the statute applies to Lincoln, because the Policies, in the sections titled "Company's Discretionary Authority," grants "authority to administer the plan" to Lincoln. (Doc. 51, p. 32.) Mr. Harris's assertion is a mischaracterization of the Policies. The Policies grant Lincoln authority to administer "claims." Thus, his argument, premised on a misrepresenting the Policies' terms, lacks merit.
Mr. Harris argues that Lincoln is the Plan Administrator, because "[o]nly Lincoln has the authority to establish and enforce procedures for administering the policies. . . ." (Doc. 51, p. 32.) Mr. Harris fails to prove or even attempt to demonstrate the argument's underlying assumption that "only" Lincoln has this authority. The Court need not search the record to find evidence to support Mr. Harris's claim for him. Given that the argument is premised on an unproven assumption, Mr. Harris's argument lacks persuasive force. Regardless, even if Mr. Harris had proven this assumption, Section 1002(16)(A)(1) does not define an "administrator" as someone with sole authority over establishing and enforcing policy administration procedures.
Mr. Harris argues that the Summary Plan Description information is inapplicable because: "The policies are the instruments that govern the operation of the Plans the [Summary Plan Descriptions]'s expressly state so." (Doc. 51, p. 32 (citing AR 000107; AR 000166).) The Summary Plan Descriptions state: "This Summary Plan Description is only intended to provide an outline of the Plan's benefits. The Plan Document will govern if there is any discrepancy between the information contained in this Description and the Plan."
Mr. Harris also argues that the Summary Plans Descriptions "create an issue as to whether more than one person has been designated as an administrator. . . ." (Doc. 51, p. 32-33.) He relies on language in the Summary Plan Descriptions that state: "The Lincoln National Life Insurance Company has the sole discretionary authority to determine eligibility and to administer claims in accord with its interpretation of the policy provisions on the Plan Administrator's behalf." (Id. (citing AR 000107; AR 000166).) Mr. Harris has not cited any authority for the proposition that Lincoln's determination and eligibility and administration of claims makes Lincoln the Plan Administrator especially in this context where the Plan Administrator has been designated as QinetiQ. In essence, Mr. Harris is arguing that this policy language makes Lincoln a de facto plan administrator. But, that argument fails because Lincoln is not Mr. Harris's employer and the de facto plan administrator doctrine only applies to employers. See Oliver, 497 F.3d at 1194.
Mr. Harris makes another variation of the de facto plan administrator argument stating that: "Lincoln's exclusive control over the policies and the payment of benefits when coupled with its financial responsibility clearly support the finding that Lincoln is a de facto administrator." (Doc. 51, p. 34-36; see also Doc. 51, p. 37 (arguing that QinetiQ is a "nominal administrator").) This argument also fails for the same reason that the de facto plan administrator doctrine only applies to employers. See Oliver, 497 F.3d at 1194.
Mr. Harris also claims that Oliver supports its position that Lincoln could be found to be a Plan Administrator in this context. (Doc. 51, p. 36-37.) Mr. Harris describes the significance of Oliver as follows:
(Doc. 51, p. 37.) Mr. Harris presents the Court with an incorrect proposition of law and fails to address subsequent applicable legal authority that described this case's holding as contrary to the one that Mr. Harris presents. See Smiley, 610 Fed. App'x at 8-9 ("We have consistently rejected the use of the de facto plan administrator doctrine `where a plaintiff has sought to hold a third-party administrative services provider liable, rather than the employer. . . .'" (quoting Oliver, 497 F.3d at 1194)). Oliver does not stand for the proposition that a third-party claims administrator with a certain threshold of control over a plan is deemed a de facto administrator. See Oliver, 497 F.3d at 1195.
The Court finds that with respect to Mr. Harris's claim pursuant to 29 U.S.C. § 1132, summary judgment is due to be granted in favor of Lincoln and denied with respect to Mr. Harris, because the claim should be directed to the Plan Administrator and Lincoln is not the Plan Administrator or a de facto plan administrator.
For the reasons stated above, Lincoln's Motion for Summary Judgment (Doc. 12) is
Carol DerSarkissian (reviewer), Understanding Bone Fractures — the Basics, WebMD (Oct. 29, 2017), https://www.webmd.com/a-to-z-guides/understanding-fractures-basic-information.
Garrison v. Lincoln National Life Ins. Co., 294 F.Supp.3d 1281, 1293 n.10 (N.D. Ala. 2018) (Coogler, J.) (brackets in original).
Lincoln acknowledges that these nurses were Lincoln employees, but also argues that they were independent. (Doc. 54, p. 15.) Lincoln provided a declaration of Thomas Vargo, Lincoln's Director of Risk. (Doc. 46-1.) In his declaration, Mr. Vargo asserts that: "Lincoln maintains its life claims department and appeals unit as separate and independent entities[;]" "Each decision-maker in Lincoln's appeals unit is charged with making an independent assessment of the adverse benefits determination based on the relevant provisions in the governing policy and upon all of the information submitted, considered, and generated during the claims process[;]" Lincoln "does not compensate claims and appeals department employees based on the outcome of claims, in order to reduce potential bias, promote accuracy and ensure a full and fair review of life/AD & D claims[;]" "Lincoln does not provide financial or other incentives to its employees to deny or close claims[;]" "Employees in Lincoln's claims and appeals units are paid fixed salaries and they may be eligible for an annual bonus[;]" "Annual bonuses are based on the overall financial performance of Lincoln and its related entities for all areas of Lincoln's business[;]" "The consulting nurses are not given any authority to make claims decisions." (Doc. 46-1, p. 2-3.)
Lincoln, however, provides no authority that such working conditions make a Lincoln employee independent of Lincoln. (See Doc. 54, p. 15.) To the contrary, these consulting nurses are admittedly Lincoln employees and their compensation is structured in such a way to encourage them to recommend the denial of claims. Given that their bonuses are based on the overall financial performance of the company, they have an incentive to deny benefits that the company would pay out so that Lincoln will have a better financial performance.
Oliver, 497 F.3d at 1195 (first bracket added, other brackets in original).
