WILEY Y. DANIEL, Senior District Judge.
THIS MATTER is before the Court on plaintiff, Randall C. Mustain-Wood's, review of defendant, Northwestern Mutual Life Insurance Company's ("Northwestern") denial of disability benefits to Mustain-Wood. For the reasons stated below, I REVERSE Northwestern's decision to deny Mustain-Wood's long-term disability claim ("LTD claim") and REMAND the case to Northwestern for the sole and limited purpose of determining the exact amount of benefits owed to Mustain-Wood pursuant to the terms and conditions of his disability insurance policy.
On January 13, 2011, Mustain-Wood filed an Amended Complaint [ECF No. 15] against Northwestern, alleging that it violated the Employee Retirement Income Security Act of 1974 ("ERISA"), as
Mustain-Wood is a 65 year-old family law attorney. Mustain-Wood's law firm, Mustain-Wood, Walker & Schumacher, LLC, purchased a group long term disability insurance policy ("the policy") [ECF No. 26-2, pp. 192-219] from Northwestern which became effective on March 1, 1995. On March 1, 2009, Mustain-Wood's law firm renewed the policy with Northwestern.
On October 7, 2009, Mustain-Wood experienced "congestive heart failure with marked pulmonary hypertension due to chronic valvular heart disease and aortic stenosis." ECF No. 33, p. 2, ¶ 2. On October 8, 2009, Mustain-Wood was admitted to a hospital. On October 13, 2009, Dr. Thomas L. Matthew, performed aortic valve replacement surgery and thoracic aortic aneurysm repair on Mustain-Wood. On November 13, 2009, Dr. John A. McNeil, Mustain-Wood's emergency room cardiologist, prescribed Mustain-Wood 36 sessions of cardiac rehabilitation. Mustain-Wood commenced cardiac rehabilitation on January 20, 2010.
In November of 2009, Mustain-Wood submitted his LTD claim to Northwestern stating that he became disabled, by way of congestive heart failure, on October 8, 2009. Northwestern denied Mustain-Wood's LTD claim on January 20, 2010, stating that Mustain-Wood did not qualify for long term disability benefits because he was not disabled for the requisite 90 day period under the policy. ECF No. 26-2, p. 97. Mustain-Wood appealed the denial of his LTD claim on July 27, 2010. On October 21, 2010, Northwestern's Administrative Review Unit ("ARU") upheld the denial of his LTD claim.
On December 6, 2010, Mustain-Wood filed his Original Complaint [ECF No. 1] against Northwestern, alleging that Northwestern's denial of his LTD claim violates ERISA. On January 13, 2011, Mustain-Wood filed an Amended Complaint [ECF no. 15] alleging that Northwestern's denial of his LTD claim violates ERISA and COLO.REV.STAT. §§ 10-3-1115 and 10-3-1116. On October 14, 2011, Northwestern filed its Opening Brief [ECF No. 32], arguing that: (1) the applicable standard of review in this case is abuse of discretion; (2) based on the administrative record, the denial of Mustain-Wood's LTD claim does not constitute an abuse of discretion; and, (3) Mustain-Wood's second claim for relief under and COLO.REV.STAT. §§ 10-3-1115 and 10-3-1116 fails because ERISA pre-empts any claim under those statutes. That same day, Mustain-Wood filed his Opening Brief [ECF No. 33] arguing that: (1) the applicable standard of review is de novo; (2) he is disabled under the policy's terms; and, (3) he should have received partial disability benefits under the policy. On February 14, 2013, I held a Motions Hearing in which the parties presented their arguments in open court.
The issue of whether COLO.REV. STAT. § 10-3-1116 applies in this action is important because: (1) Northwestern argues that ERISA preempts Mustain-Wood's claims under the statute; and, (2) Mustain-Wood argues that under the statute, the appropriate standard of review is de novo. Pursuant to COLO.REV.STAT. § 10-3-1116:
COLO.REV.STAT. § 10-3-1116 became effective August 6, 2008. Mustain-Wood's policy became effective March 1, 1995. Thus, in order to apply to Mustain-Wood's policy, the statute would have to apply retroactively. The United States Court of Appeals for the Tenth Circuit has held that COLO.REV.STAT. § 10-3-1116 does not apply retroactively. McClenahan v. Metropolitan Life Ins. Co., 416 Fed.Appx. 693, 698 (10th Cir.2011) (internal quotations and citations omitted) ("While an express declaration of retroactivity isn't required, there is no indication that the statute before us [COLO.REV.STAT. § 10-3-1116] was ever intended to apply to prior conduct ... So it is clear under Colorado Supreme Court precedent, the statute here can't be applied to MetLife's claim determination, and the district court properly reviewed MetLife's decision in this case for abuse of discretion"). I agree with the Tenth Circuit on this issue and have stated so on at least two prior occasions. Morrison v. United of Omaha Life Ins. Co., 2011 WL 2621365, *6-7, 2011 U.S. Dist. LEXIS 71867, *17-18 (D.Colo. July 7, 2011) (citing McClenahan, 416 Fed.Appx. at 698) ("[T]he Tenth Circuit has conclusively held that the Colorado Statute [COLO.REV.STAT. § 10-3-1116] does not apply retroactively"); Bray v. Sun Life & Health Ins. Co., 2011 WL 3349815, *2, 2011 U.S. Dist. LEXIS 85121, *4-5 (D.Colo. Aug. 3, 2011) (citing McClenahan, 416 Fed.Appx. at 698) ("I agree with the Defendants that C.R.S. § 10-3-1116 is inapplicable because the Tenth Circuit has conclusively held that the Colorado statute does not apply retroactively"). Mustain-Wood concedes this point, yet argues that because his law firm renewed the policy while COLO.REV.STAT. § 10-3-1116 was in effect, the renewed policy is subject to the terms and conditions of the statute. I disagree.
Mustain-Wood does not offer any binding precedent on this issue and I am not
"ERISA was enacted to promote the interests of employees and their beneficiaries in employee benefit plans, and to protect contractually defined benefits." Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 113, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). Under ERISA, a plan beneficiary has a right to seek review of an administrator's denial of benefits in federal district court. 29 U.S.C. § 1132(a). Though ERISA grants such a right, it does "not establish the standard of review for such decisions." Chambers v. Family Health Corp., 100 F.3d 818, 824-25 (10th Cir.1996).
In Firestone, the United States Supreme Court established the basic framework for determining the standard of review in ERISA cases that challenge the denial or termination of benefits. The Supreme Court stated 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." 489 U.S. at 115, 109 S.Ct. 948. If the plan "gives the administrator discretionary powers, the district court reviews the administrator's decisions under an arbitrary and capricious standard."
ECF No. 26-2, p. 216. This provision's plain language "gives the administrator or fiduciary [Northwestern] discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Firestone, 489 U.S. at 115, 109 S.Ct. 948. Thus, under Firestone, I am required to review Northwestern's denial of Mustain-Wood's LTD claim under an abuse of discretion standard.
Under an abuse of discretion standard, "the federal courts are limited to the `administrative record' — the materials compiled by the administrator in the course of making [the] decision." Hall v. UNUM Life Ins. Co. of Am., 300 F.3d 1197, 1201 (10th Cir.2002). "[W]e uphold an administrator's decision `so long as it is predicated on a reasoned basis.'" Loughray, 366 Fed.Appx. at 923 (quoting Adamson v. Unum Life Ins. Co. of Am., 455 F.3d 1209, 1212 (10th Cir.2006)). "[T]here is no requirement that the basis relied upon be the only logical one or even the superlative one." Id. "Thus, we only ask whether the administrator's decision resides somewhere on a continuum of reasonableness—even if on the low end." Id. (quotations and citations omitted).
The policy provides that the insured shall receive disability benefits, if disabled, on the "91st day of Disability in the first 120 days after the date [the insured] become[s] Disabled." ECF No. 26-2, p. 199. According to the policy, an insured may qualify as disabled in one of three ways: (1) under the policy's "Own Occupation Definition of Disability"; (2) under the policy's "Any Occupation Definition of Disability"; or, (3) under the policy's "Partial Disability Definition". ECF No. 26-2, p. 187. The definition that bears on this matter is the policy's definition of "Own Occupation Definition of Disability." With respect to "Own Occupation:"
ECF No. 26-2, pp. 187-88.
Northwestern based its decision to deny Mustain-Wood's LTD claim on a "Group
On January 20, 2010, Northwestern sent Mustain-Wood a letter regarding his LTD claim. ECF No. 26-2, pp. 97-98. Northwestern stated that "the issue upon which we must focus is whether or not the medical documentation currently available to us provides satisfactory written proof that you were disabled from your own occupation due to your medical condition." Id. at 98. Based on Dr. McNeil's report, Northwestern stated that it had "no option but to deny liability on [Mustain-Wood's claim] at this time." ECF No. 26-2, p. 97.
On July 27, 2010, Mustain-Wood appealed the decision to Northwestern's ARU. On October 21, 2010, Northwestern sent a letter [ECF No. 26-2, pp. 7-21] to Cameron W. Tyler, Mustain-Wood's counsel, stating that the ARU upheld the initial decision to deny Mustain-Wood's LTD claim. The letter states, in pertinent part:
ECF No. 26-2, p. 13, ¶¶ 5, 7-8 (emphasis added). Thus, the ARU analyzed whether Mustain-Wood was disabled based on the general duties of a lawyer and did not take into account his specific duties as a family law practitioner. The ARU concluded that Mustain-Wood was not disabled during the requisite 90 day period under the policy and therefore denial of his LTD claim was proper.
I agree with the ARU that the policy's terms and conditions confine the analysis of Mustain-Wood's LTD claim to the general duties of a lawyer, not Mustain-Wood's specific duties as a family law practitioner. That said, I disagree with the ARU's conclusion for several reasons.
First, the practice of law, whether civil or criminal, requires: (1) a high degree of cognitive ability and function; (2) precise analytical skills; (3) the ability to clearly and succinctly communicate arguments and ideas orally and in writing; and, (4) the ability to effectively handle multiple tasks simultaneously. Most importantly, an attorney must have the ability to cope with rising levels of stress and anxiety that vary on an hourly basis. An attorney, regardless of what he or she practices, who suffers congestive heart failure is not likely to be able to resume the full gamut of his or her duties within 90 days of congestive heart failure. The duties and stressors of an attorney require him or her to operate at optimum levels of efficiency. Save the rare the occasion, this is not possible within 90 days of congestive heart failure.
Second, Mustain-Wood attempted to return to work, in a limited capacity, and the effects of congestive heart failure prevented him from working. Dr. Jamie Doucet of the Colorado Cardiovascular Center, who rendered a second opinion, issued a report on July 21, 2010, regarding Mustain-Wood's heart condition. Dr. Doucet stated, "[Mustain-Wood] has tried to return to work in a relatively low stress position as a mediator at his practice on Tuesdays and Fridays, but even with those interactions, he has experienced undue chest discomfort, tightness and some anxiety." ECF No. 26-1, p. 43. Dr. Doucet also stated that, "[o]n my review of his records and today's history and physical, it does not appear to me that Randy's heart has reverted to normal." Id. (emphasis added). Dr. Doucet further stated that "[w]e know that Randy's heart is still structurally abnormal...". Id. (emphasis added).
Third, Dr. McNeil wrote a letter [ECF No. 26-1, p. 118] on March 17, 2010, stating that Mustain-Wood was unable to return to work. Specifically, the letter states, "Randy Mustain-Wood is currently enrolled and taking part in a cardiac rehabilitation program. Due to his commitment to his recovery he is unable to work during his treatment period. Mr. Mustain-Wood is due to complete his program June 13, 2010." Id. This letter contradicts Dr. McNeil's statements in the Group Disability Claim Attending Physician Statement [ECF No. 26-1, pp. 132-33] in which he states that Mustain-Wood can return to work full-time or part time at any time. The ARU discounted this letter because it contradicts Dr. McNeil's earlier statements and because there was no evidence that Mustain-Wood sought treatment from Dr. McNeil subsequent to the Northwestern's initial denial of his LTD claim. Though Dr. McNeil's most recent statement contradicts with his previous statement, it coincides with Dr. Doucet's opinion that Mustain-Wood is not able to return to work. Thus, two doctors state that Mustain-Wood is not able to return to work.
Fourth, at the February 14, 2013, Motions Hearing, Northwestern's counsel proposed that Mustain-Wood
Based on my analysis above, I find that starting on October 8, 2009, Mustain-Wood had a physical injury and/or disease that impaired his ability to perform the material duties of an attorney as it is usually performed in the general economy. I also find that Mustain-Wood was disabled for the requisite 90 day period under the policy: from October 8, 2009, to January 6, 2010. Therefore, Mustain-Wood qualifies as disabled under the terms and conditions of the policy. I find that Northwestern's decision to uphold its original denial of Mustain-Wood's LTD claim was an abuse of discretion and such decision does not lie anywhere on the "continuum of reasonableness." Loughray, 366 Fed. Appx. at 923.
Under the policy's terms and conditions, the insured's maximum benefit period is determined by the insured's age when his disability begins. ECF No. 26-2, p. 199. Mustain-Wood was born on January 23, 1948. Thus, on October 8, 2009, the date his disability began, Mustain-Wood was 61 years old. The policy states that if the insured is 61 years old or younger when the disability begins, he is entitled to benefits "to age 65,
ORDERED that Northwestern Mutual Life Insurance Company's denial of Randall Mustain-Wood's disability claim is
FURTHER ORDERED that this action is
FURTHER ORDERED that Northwestern Mutual Life Insurance Company shall determine the benefits owed to Mustain-Wood pursuant to the terms and conditions of the policy
FURTHER ORDERED that Northwestern Mutual Life Insurance Company
FURTHER ORDERED that the parties shall file a Joint Status Report