CARL J. BARBIER, District Court.
This matter is before the Court on the parties' cross-motions for judgment on the administrative record
This civil action is a claim for additional disability benefits under an employee benefit plan governed by the Employee Retirement Income Security Act ("ERISA"). Plaintiff Kathleen O'Brien worked as a traveling nurse for American Nursing Services, Inc., and is a participant in and a beneficiary of a Group Short-Term Disability, Long-Term Disability, Supplemental Dependant Life, and Supplemental Term Life Plan ("the Plan") created and sponsored by her former employer.
Under the terms of Hartford's policy, short-term and longterm disability benefits are payable only if the insured becomes "Disabled from a covered injury, Sickness, or pregnancy."
The term "Pre-disability Earnings" is defined under the policy's short-term disability benefits section as "[the insured's] regular weekly rate of pay, not counting bonuses, commissions, tips and tokens, overtime pay or any other fringe benefits or extra compensation in effect on the date" the insured was actively at work before becoming disabled.
Plaintiff filed a claim for disability benefits with Hartford after experiencing severe headaches that precluded her from continuing to work as a full-time registered nurse. After reviewing her claim, Hartford determined that Plaintiff was disabled under the terms of the policy and began paying her short-term disability benefits, based upon Plaintiff's $20/hour wage, for a total weekly rate of pay of $800.
Subsequently, during a periodic review of benefits, Hartford requested and reviewed Plaintiff's 2009 tax returns, at which point it reportedly discovered that Plaintiff's weekly taxable rate of pay was $770.38, and not $1,682.
Plaintiff promptly challenged Hartford's decision through an administrative appeal, arguing that her "Pre-disability Earnings" included a weekly per diem payment of $882, which included $280 per week for meals and other incidentals and $602 per week for housing.
Having exhausted her administrative appeals, Plaintiff initiated this action in federal court, seeking payment of benefits under the policy, along with prejudgment interest, attorney's fees, and costs.
In her motion, Plaintiff argues that her $882 per diem allowance was part of her regular monthly rate of pay, rather than a "fringe benefit" or form of "extra compensation," contrary to Hartford's determination. She reports that this payment was regularly made with each pay check she received from her employer, and not as an additional or irregular form of compensation. She also points out that this payment was made regardless of whether she actually incurred any expenses for lodging, meals, or any other incidental costs, and in exchange she waived her right to seek reimbursement for any other business expenses incurred in connection with her employment with American Nursing Services. She further notes that Hartford was operating under a structural conflict of interest, because it both evaluates and pays claims. In sum, because the administrative record shows that her per diem was a component of her regular rate of pay, Plaintiff submits that Hartford's determination that it was a "fringe benefit" or "extra compensation" was arbitrary and capricious.
Finally, Plaintiff argues that Hartford is estopped from reducing the disability benefits due under the policy pursuant to the "ERISA estoppel doctrine" adopted by the Fifth Circuit in Mello v. Sara Lee Corp., 431 F.3d 440 (5th Cir.2005). Under Mello, a party seeking to apply the ERISA estoppel doctrine must establish (1) a material misrepresentation; (2) reasonable and detrimental reliance upon the misrepresentation; and (3) extraordinary circumstances. See id. at 444. Here, Plaintiff points out that Hartford regularly accepted premiums based upon a regular rate of pay that included the amount of the per diem payment without ever advising her that this calculation may be incorrect. Plaintiff avers that she reasonably relied upon this representation to her detriment by failing to obtain additional disability insurance, and that this constitutes an extraordinary circumstance. Accordingly, Plaintiff submits that Hartford is estopped from now asserting that the fixed per diem payments should be excluded in computing her regular rate of pay. Based on the foregoing, Plaintiff requests that the Court grant judgment in her favor and against Hartford, awarding her increased benefits of $4,737.64 per month retroactive to August 11, 2009, as well as attorney's fees, costs, and prejudgment interest.
In opposition to Plaintiff's motion, and in support of its own motion, Hartford argues that Plaintiff has not shown that its determination that her per diem allowance is not properly included in her Pre-disability Earnings was arbitrary and capricious. To the contrary, Hartford argues that its determination was both reasonable and based upon a rational connection to the evidence contained in the administrative record. In considering whether Plaintiff's per diem payments were included as Pre-disability Earnings, Hartford acknowledges that it relied on the IRS's Taxable Fringe Benefit Guide, and despite Plaintiff's contentions to the contrary, it maintains that it was within its discretion to consult this guide in reaching its determination. The IRS defines the term "fringe benefit" as a "form of pay (including property, services, cash, or cash equivalent) in addition to the stated pay for the performance of services."
Next, addressing Plaintiff's alternative argument, Hartford argues that Plaintiff has provided insufficient evidentiary support to make out an ERISA estoppel claim, arguing that she has failed to prove even one of the three essential elements cited above. Hartford submits that Plaintiff has not set forth what material misrepresentation it is alleged to have made, any facts showing that she reasonably or detrimentally relied on such misrepresentation, or any extraordinary circumstances that would justify applying the doctrine in the instant case. As such, it urges the Court to decline to apply the ERISA estoppel doctrine. In conclusion, Hartford requests that the Court deny Plaintiff's motion and instead grant judgment in its favor on its counterclaim for $40,313.36 in overpaid long-term benefits and $13,680.74 in overpaid short-term benefits.
In reply, Plaintiff responds that she has proved every essential element of her ERISA estoppel claim. She argues that the administrative record conclusively shows that Hartford made a material misrepresentation when it accepted her stated regular rate of pay that included the per diem allowance without ever notifying her that this calculation was incorrect, and that she reasonably relied on this representation to her detriment in failing to obtain alternative or additional disability insurance. She submits that this must constitute an "extraordinary circumstance" unless it is Hartford's regular practice to inaccurately determine premiums. As such, even if Hartford's determination was not arbitrary and capricious, Plaintiff maintains that the ERISA estoppel doctrine should be applied under the facts presented.
ERISA provides federal courts with jurisdiction to review determinations made under employee benefit plans. See 29 U.S.C. § 1132(a)(1)(B). It is undisputed that the policy at issue in the instant case is governed by ERISA. The Fifth Circuit has recognized that the administrator of an ERISA employee benefit plan must generally make two types of determinations in deciding whether a claimant is entitled to benefits under the plan. See Schadler v. Anthem Life Ins. Co., 147 F.3d 388, 394 (5th Cir.1998) (citing Pierre v. Conn. Gen. Life Ins. Co., 932 F.2d 1552, 1557 (5th Cir.1991)). First, it must determine the facts underlying the claim. Id. (citing Pierre, 932 F.2d at 1562). Second, the administrator must decide whether the facts determined give rise to a valid claim under the terms of the plan. Id.
Generally, an administrator's determination regarding a claimant's eligibility for benefits or plan terms is subject to de novo review by a federal district court. Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). However, where the plan grants the administrator discretionary authority to determine eligibility for benefits or to construe the terms of the plan, as the policy does here,
In Ellis v. Liberty Life Assurance Co. of Boston, 394 F.3d 262, 269-70 (5th Cir.2004), the Fifth Circuit outlined a two-step process for reviewing an administrator's interpretation and application of an ERISA plan for abuse of discretion. First, a court should determine whether the administrator's determination was legally correct. If it was, then no abuse of discretion is possible, and the inquiry ends. Id. at 270. If the administrator's determination was not legally correct, however, then the court must review whether the decision was an abuse of discretion. Id. However, a court is not ultimately required to confine itself to this two-step analysis. The first step may be bypassed if the Court can more readily determine whether the administrator has abused its discretion. See Holland, 576 F.3d at 246 n. 2. Here, because resolution of the present case is more easily reached under the abuse of discretion standard, the Court's analysis will proceed directly to the second step of this inquiry.
Under the abuse of discretion standard, a court must decide whether the administrator's determination was arbitrary and capricious. Anderson v. Cytec Indus., Inc., 619 F.3d 505, 512 (5th Cir. 2010). A decision is arbitrary only if made without a rational connection between the known facts and the decision or between the found facts and the evidence. Holland, 576 F.3d at 246; see also Lain v. UNUM Life Ins. Co., 279 F.3d 337, 342 (5th Cir.2002) ("A plan administrator abuses its discretion where the decision is not based on evidence, even if disputable, that clearly supports the basis for its denial.").
Additionally, the plan administrator's decision to deny benefits must be supported by substantial evidence. Ellis, 394 F.3d at 273. Substantial evidence "is more than a scintilla, less than a preponderance, and is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Corry v. Liberty Life Assurance Co. of Boston, 499 F.3d 389, 398 (5th Cir.2007). Ultimately, the court's "review of the administrator's decision need not be particularly complex or technical; it need only assure that the administrator's decision fall somewhere on a continuum of reasonableness-even if on the low end." Id. (quoting Vega v. Nat'l Life Ins. Servs., Inc., 188 F.3d 287, 297 (5th Cir.1999)).
Finally, when the same entity that maintains discretionary control over disability determinations is also the entity that must pay any disability benefits, a court must account for this structural conflict of interest. In such circumstances, courts employ a "sliding scale" standard of review, under which less deference is given to the administrator's determination in proportion to the evidence of conflict. Ellis, 394 F.3d at 269-70. In short, the standard of review remains abuse of discretion, but the existence of a conflict of interest is a factor that should be considered in determining whether the administrator abused its discretion. Here, the parties do not dispute that a structural conflict of interest exists, as Hartford admittedly acts as both insurer and administrator of the Plan at issue. However, because Plaintiff has introduced no additional
As previously noted, disability benefits are paid as a percentage of "Pre-disability Earnings," which is defined as the insured's "regular weekly rate of pay" for short-term disability benefits and "regular monthly rate of pay" for long-term disability benefits.
It is undisputed that the terms "pay," "fringe benefit," and "extra compensation" are not defined in the policy. Accordingly, these terms should be interpreted in accordance with their "ordinary and popular" meanings. Crowell v. Shell Oil Co., 541 F.3d 295, 314 (5th Cir.2008) (citations omitted). Here, the administrative record shows that Hartford consulted the IRS's Taxable Fringe Benefit Guide in interpreting the term "fringe benefit."
Plaintiff responds by arguing that the "tax treatment" of her per diem allowance "is neither material nor relevant" in determining how it should be classified under the terms of the policy, noting that the policy references neither federal tax regulations nor IRS definitions.
Here, the evidence in the administrative record clearly supports Hartford's conclusion that Plaintiff's per diem allowance was a "fringe benefit" rather than an element of her "regular rate of pay," in accordance with the common meaning of these terms.
A number of the cases Plaintiff cites in her memorandum are inapplicable to the case at hand, in that they involve interpretation of the terms "wages" and "fringe benefits" as those terms are used in the Longshore and Harbor Workers' Compensation Act, rather than in an employee benefit plan governed by ERISA. See, e.g., James J. Flanagan Stevedores, Inc. v. Gallagher, 219 F.3d 426, 432 (5th Cir. 2000); Universal Mar. Serv. Corp. v. Wright, 155 F.3d 311, 320 (4th Cir.1998); B & D Contracting v. Pearley, 548 F.3d 338, 342 (5th Cir.2008); Custom Ship Interiors v. Roberts, 300 F.3d 510 (4th Cir. 2002). Of the cases that are at least topically relevant, none undermines the Court's conclusion regarding the reasonableness of Hartford's determination. See Abraham v. Exxon Corp., 85 F.3d 1126, 1131 (5th Cir.1996) (holding that Treasury regulations do not authorize a district court to rewrite the terms of an ERISA plan to include "leased employees" as plan participants, where employer had designed the plan to exclude them); Keszenheimer v. Reliance Standard Life Ins. Co., 402 F.3d 504, 508-10 (5th Cir.2005) (holding that district court erred in concluding that employee's per diem and automobile allowance were part of his "monthly salary" rather than "overtime pay, bonuses or any other special compensation," even though these payments were "expected," "usual," and "guaranteed"); Wegner, 129 F.3d at 818 (holding that employee's $300 per day salary was not "overtime" under the terms of the policy simply because he worked more than eight hours per day, and further finding that his salary did not constitute "other extra compensation" because the salary was a fixed, non-variable amount of compensation, and thus was not "extra" in any way).
In sum, having considered the administrative record, the Court cannot hold that
Plaintiff alternatively contends that Hartford is estopped from denying her benefits under the policy under the doctrine of equitable estoppel. The Fifth Circuit has held that the doctrine of equitable estoppel applies in the context of ERISA claims. See Mello, 431 F.3d at 444-45. In order to establish an ERISA estoppel claim, Plaintiff must have introduced evidence showing: (1) a material misrepresentation, (2) reasonable and detrimental reliance upon that representation, and (3) extraordinary circumstances. Id.
A plaintiff's reliance on the alleged misrepresentation must be both reasonable and detrimental. Id. at 445. The Fifth Circuit has explained that a judicial finding that the terms of the plan are unambiguous is sufficient to defeat the reasonableness of a plaintiff's reliance on a misinterpretation of those terms. See id. at 447 ("Because our decisions require that any detrimental reliance on plan language also be `reasonable,' our finding that the [terms of the Plan] are unambiguous undercuts the reasonableness of any detrimental reliance ...."), (quoting In re Unisys Corp. Retiree Med. Benefit ERISA Litig., 58 F.3d 896, 908 (3d Cir.1995); see also Sprague v. GMC, 133 F.3d 388, 404 (6th Cir.1998) (noting that a "party's reliance can seldom, if ever, be reasonable or justifiable if it is inconsistent with the clear and unambiguous terms of plan documents available to or furnished to the party")).
Here, as explained above, the Court finds that Hartford's policy unambiguously excludes "fringe benefits" such as the per diem allowance that Plaintiff received, from the calculation of an insured's Pre-disability Earnings. Accordingly, any reliance Plaintiff may have placed on the inclusion of this benefit in the calculation of her disability benefits is not reasonable.
Furthermore, even if the terms were ambiguous, Plaintiff has not otherwise shown the existence of "extraordinary circumstances" sufficient to invoke estoppel, as required by the third Mello element. Although the Fifth Circuit has yet to elaborate on the contours of what circumstances are "extraordinary" for estoppel purposes, it has cited with approval the Third Circuit's approach to the issue. See E-Systems, 459 F.3d at 580 n. 3 (5th Cir. 2006) (citing Curcio v. John Hancock Mut. Life Ins. Co., 33 F.3d 226 (3d Cir.1994)). Under the Third Circuit's approach, extraordinary circumstances "generally ... involve acts of bad faith on the part of the employer, attempts to actively conceal a significant change in the plan, or commission of fraud." See Burnstein v. Ret. Account Plan for Emps. of Allegheny Health Educ. & Research Found., 334 F.3d 365, 383 (3d Cir.2003).
Here, Plaintiff has introduced no evidence suggesting any bad faith or fraudulent conduct on behalf of Hartford. In the instant case, at most, Plaintiff has shown only that Hartford initially mis-calculated the amount of disability benefits for which she was eligible based on Plaintiff's representations regarding her earnings, and accepted premiums based on this miscalculation.
Finally, the Court turns to Hartford's counterclaim, through which it seeks to recover $40,313.36 in overpaid long-term benefits and $13,680.74 in overpaid short-term benefits. The policy provides Hartford the right to recover from a plan participant any amount that it determines to be an "overpayment."
Here, as explained above, Hartford determined that an overpayment occurred when it mistakenly calculated Plaintiff's "Pre-disability Earnings" to include her per diem allowance, which constituted a "fringe benefit" or "extra compensation" under the terms of the policy. Accordingly, because Hartford is entitled to recover the $40,313.36 in overpaid long-term benefits and $13,680.74 in overpaid short-term benefits pursuant to the terms of the policy,
Accordingly, for all the reasons expressed above,