JOSEPH F. BIANCO, District Judge:
Plaintiff Jonel Barbu ("plaintiff") brings this action under the Employee Retirement Income Security Act of 1974 ("ERISA"), challenging the denial of his
It is well settled that the standard of review is de novo, unless the disability plan grants greater discretion to the insurer. In the present motion, plaintiff argues that LINA did not receive such discretion in the insurance policy governing the disability plan, and that de novo review is, therefore, required. Defendant does not dispute that the insurance policy itself grants no discretion, but identifies discretionary language in a separate document — namely, the "Employee Welfare Benefit Plan Appointment of Claim Fiduciary" (the "ACF") — and contends that this document triggers the application of arbitrary and capricious review. In a recent decision, CIGNA Corp. v. Amara, the Supreme Court made clear that a summary document about a plan — in that case, a Summary Plan Description or "SPD" — does not, simply by its existence and reference to the policy and plan, constitute the terms of the plan itself. ___ U.S. ___, 131 S.Ct. 1866, 179 L.Ed.2d 843 (2011). As other courts (such as the Tenth Circuit) have made clear since Amara, an insurer can still make a summary document part of the plan by, for example, explicitly doing so in the policy or on the face of the summary document itself. This Court concludes that the Amara holding applies with equal force to the ACF and, thus, defendant has the burden of demonstrating that the policy itself or another document (such as the ACF itself) made clear that the language of the ACF was integrated into the plan and contained terms of the plan. Ultimately, in this particular case, defendant fails to meet that burden because it has not shown clear language that any document besides the insurance policy contains enforceable plan terms. On the contrary, the insurance policy contains an integration clause defining the "entire contract," which does not include the ACF. Moreover, neither the ACF itself, nor any other document, identifies the ACF as part of the plan. At the very least, the conflict among the documents in this case creates an ambiguity to be construed in plaintiff's favor. Thus, it is clear that the de novo standard of review must be applied.
The following facts are not disputed by the parties. Plaintiff was an employee of Underwriter Laboratories and was covered by its Long Term Disability Plan ("the Plan"), which is a benefit plan under ERISA. (Def. Br. at 1.) Defendant determined eligibility for Plan benefits in its capacity as Claim Administrator. (Id.)
Plaintiff's recent medical history includes back and neck problems, carpal tunnel syndrome, ulcerative colitis and inflammatory bowel disease, among other ailments. (Ans. ¶¶ 35, 55.) In 2010, defendant approved several of plaintiff's claims for disability benefits. (Id. ¶¶ 29, 34, 40.) In 2011, defendant adjusted plaintiff's benefits because plaintiff also began receiving Social Security Disability benefits. (Id. ¶ 67.) In June 2011, defendant determined that plaintiff was no longer entitled to disability benefits under the Plan. (Def. Br. at 1.)
As noted, there is no dispute that the Plan falls under ERISA, but the question of what constitutes the Plan is at the center
There is no document before the Court that, on its face, defines the term "plan documents." The Policy does state, however, that it "describes the terms and conditions of coverage." (Ex. A to Delott Aff. at LINA 1222.) It also contains the following integration clause, under the heading "Entire Contract":
(Id. at LINA 1242.) Plaintiff argues that these two provisions provide a textual basis for the conclusion that documents besides the Policy and the applications are extrinsic, and do not contain enforceable Plan terms.
Defendant's argument rests on a document not named in the Policy's integration clause. That document is called the "Employee Welfare Benefit Plan Appointment of Claim Fiduciary" (hereinafter "ACF"), and it was executed the same day as the Policy, on January 1, 2004. In short, the ACF appears to contain a grant of discretion from the Plan administrator (the Compensation Committee of Underwriter Laboratories) to defendant as "Claim Fiduciary," enabling defendant to make final benefit eligibility determinations under the Plan. Courts interpreting similar documents have considered this language sufficient to trigger arbitrary and capricious review. See, e.g., Raybourne v. Cigna Life Ins. Co. of N.Y., 576 F.3d 444, 448-49 (7th Cir.2009).
The ACF does not state that it is part of the Plan — in fact, it refers to "the Plan" as if it is something separate — but the ACF does require that its terms be made known to Plan participants through the Plan's summary descriptions. Summary plan descriptions (SPDs) are ERISA-required documents meant to convey the contents of the Plan "in a manner calculated to be understood by the average plan participant." 29 U.S.C. § 1022(a). Whether SPDs are themselves legally enforceable plan documents has been the subject of some debate, with the Supreme Court recently holding that they generally are not, see CIGNA Corp. v. Amara, ___ U.S. ___, 131 S.Ct. 1866, 1877-78, 179 L.Ed.2d 843 (2011), although SPDs may still be incorporated into a plan explicitly. See, e.g., Eugene S. v. Horizon Blue Cross Blue Shield of N.J., 663 F.3d 1124, 1131 (10th Cir.2011) ("[A]n insurer is not entitled to deferential review merely because it claims the SPD is integrated into the Plan. Rather, the insurer must demonstrate that the SPD is part of the Plan, for example, by the SPD clearly stating on its face that it is part of the Plan.").
Here, a "Group Insurance Certificate" ("Certificate") served as the SPD. The Certificate is a document delivered to individual
In sum, there are three documents relevant to the present motion: the Policy, the ACF, and to a lesser extent, the Certificate, which echoes the ACF and serves as the SPD. The question is which of these three documents states enforceable Plan terms.
After exhausting administrative remedies, plaintiff initiated this suit under Section 502(a) of ERISA "to recover benefits due him under the terms of his plan [and] to enforce his rights under the terms of the plan." 29 U.S.C. § 1132(a)(1)(B). Plaintiff filed his complaint on April 3, 2012, and defendant answered on May 21, 2012. The parties proceeded to engage in discovery, and in October 2012, plaintiff received the ACF from defendant for the first time. Previously, plaintiff made multiple requests for his entire claim file, but he had not received the ACF before.
On May 30, 2013, plaintiff filed the present motion for a declaratory judgment. In particular, plaintiff seeks an order declaring that a de novo standard of review applies based on the language in the Policy. On June 14, 2013, defendant responded in opposition to the motion. Defendant does not oppose the consideration of this motion, but argues that the ACF is sufficient to trigger arbitrary and capricious review. Plaintiff replied on June 23, 2013, and oral argument was held on December 17, 2013.
Because plaintiff seeks a declaratory judgment, the discussion turns first to the standard for considering a declaratory judgment action, and second to the standard for reviewing the denial of plaintiff's benefits.
Jurisdiction to consider a declaratory judgment action exists only if there is an "actual controversy," 28 U.S.C. § 2201(a), defined as one that is "real and substantial ... admitting of specific relief through a decree of a conclusive character, as distinguished from an opinion advising what the law would be upon a hypothetical state of facts." E.R. Squibb & Sons, Inc. v. Lloyd's & Cos., 241 F.3d 154, 177 (2d Cir.2001) (internal citation and quotation marks omitted).
There is nothing hypothetical about the facts underlying this motion: plaintiff has been denied benefits and the resolution of his case likely depends on the standard of review applied. Accordingly, neither party contests this Court's entertainment of a declaratory judgment action. "The decision to grant declaratory relief rests in the sound discretion of the district court." Lijoi v. Continental Cas. Co., 414 F.Supp.2d 228, 247 (E.D.N.Y.2006). That discretion is informed by two primary considerations: (1) whether the judgment will serve a useful purpose in clarifying or settling the legal issues involved; and (2) whether it would finalize the controversy and offer relief from uncertainty. See Broadview Chem. Corp. v. Loctite Corp., 417 F.2d 998, 1001 (2d Cir.1969). The lack of any dispute about these factors indicates that the present motion is useful and will offer relief to the parties.
District courts may also consider: "(1) whether the proposed remedy is being
"ERISA does not set out the applicable standard of review for actions challenging benefit eligibility determinations." Zuckerbrod v. Phoenix Mut. Life Ins. Co., 78 F.3d 46, 49 (2d Cir.1996). In Firestone Tire & Rubber Co. v. Bruch, the Supreme Court held that the standard of review is de novo until it is shown that the benefit plan grants broader discretion to an administrator or fiduciary. 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). If the plan does grant discretion, an arbitrary and capricious standard of review applies. Zuckerbrod, 78 F.3d at 49. Defendant carries the burden of proving that the arbitrary and capricious standard of review applies, and any ambiguities are resolved in plaintiff's favor. Krauss v. Oxford Health Plans, Inc., 517 F.3d 614, 622 (2d Cir.2008); see also Kinstler, 181 F.3d at 249.
Here, it is undisputed that the language of the Policy itself does not trigger arbitrary and capricious review. The Policy requires a beneficiary to submit "satisfactory proof of disability (Ex. A to Delott Aff. at LINA 1233), which is the same language that the Second Circuit has held requires de novo review. Kinstler, 181 F.3d at 251.
With no support in the text of the Policy, defendant turns to the ACF. It contains a grant of some form of discretion,
That point brings the Court to the critical factual distinction between this case and Raybourne. There, the defendant could at least point to a clause in the SPD stating that the ACF contained plan terms. Here, the SPD (which is the Certificate) does not contain a similar provision, and defendant has relied on its text only to argue that it provided notice of the ACF's terms, not to argue that it supports the ACF's incorporation into the Plan. In short, defendant has identified no text in any document that incorporates the ACF into the Plan to any extent. Moreover, not only does this case lack equivalent text noting the incorporation of the ACF into the Plan, it is distinguished from Raybourne in another material way: there is actually text to support the opposite conclusion. Here, the integration clause does not include the ACF among the three items ("the Policy, the application of the Employer ... and the applications ... of the Insureds,") making up the "entire contract." (Ex. A. to Delott Aff. at LINA 1242.) There was no integration clause discussed in Raybourne.
It is worth noting that the integration clause refers to the Policy, not to the Plan, and on its face it defines the "entire contract," not the "entire set of plan documents." Courts in this and other circuits, however, have relied on very similar integration clauses when declining to enforce documents extrinsic to the insurance policy. See Hamill v. Prudential Ins. Co. of Am., No. 11-CV-1464, 2013 WL 27548, at *2 (E.D.N.Y. Jan. 2, 2013) (noting importance of SPD's omission from policy's integration clause referring to "[t]he entire Group Contract"); Francis v. Anacomp, Inc. Accidental Death & Dismemberment Plan, No. 10-CV-467, 2011 WL 4102143, at *4-5 (S.D.Cal. Sept. 14, 2011) (rejecting argument that ACF was an enforceable plan document where policy purported to be fully integrated); Jobe v. Med. Life. Ins. Co., 598 F.3d 478, 486 (8th Cir.2010) (reviewing multiple "plan documents" and concluding that fully-integrated policy "controls over the inconsistent grant of discretion to the administrator in the summary plan description"); Grosz-Salomon v. Paul Revere Life Ins. Co., 237 F.3d 1154, 1161 (9th Cir.2001) (holding SPD unenforceable where policy's integration clause limited entire contract to policy and applications).
This Court likewise concludes that the ACF's grant of discretion is unenforceable because it is not part of the "entire contract" described in the Policy. To the
To be clear, the Court certainly does not disagree with defendant that there may be multiple enforceable plan documents. That general point has long been recognized. See, e.g., Myron v. Trust Co. Bank Long Term Disability Benefit Plan, 522 F.Supp. 511, 519 (N.D.Ga.1981) ("[T]he Court has found no authority that states this written instrument must be one all-inclusive document. Indeed the legislative history indicates that Congress contemplated the possibility of more than one writing constituting an ERISA plan.").
Of the many documents available in an ERISA case, however, it is not always obvious which ones contain plan terms. As part of its burden to justify more deferential review, the insurer must show that the document containing a grant of discretion is incorporated into the broader plan. See Wenger v. Prudential Ins. Co. of Am., No. 12-CV-1896, 2013 WL 5441760, at *6 (S.D.N.Y. Sept. 26, 2013) ("Like the courts in Durham, Hamill, and Sullivan ... this Court finds that Defendant has failed to meet its burden of showing that the [SPD] was incorporated into the LTD Plan." (citing Durham v. Prudential Ins. Co. of Am., 890 F.Supp.2d 390, 395 (S.D.N.Y.2012); Hamill, 2013 WL 27548, at *6; Sullivan v. Prudential Ins. Co. of Am., No. 12-C1173, 2013 WL 1281861, at *1 (E.D.Cal. Mar. 25, 2013))).
The burden to show incorporation of a particular document flows naturally from Amara's focus on which documents actually contain plan terms. Wenger and the cases it cites are all post-Amara cases. Although each of them dealt with SPDs, the same logic applies to an ACF, particularly when the policy contains an integration clause. A policy's integration clause could distinguish which of multiple "plan documents" contained enforceable plan terms even before Amara. See, e.g., Palmiotti v. Metro. Life Ins. Co., 423 F.Supp.2d 288, 298-99 (S.D.N.Y.2006).
In essence, the question presented here is decided by the defendant's burden to
Defendant has thus failed to meet its burden to prove that arbitrary and capricious review applies because it has not shown that clear language incorporates the ACF into the Plan. On the contrary, the Policy's integration clause defines the "entire contract," which does not include the ACF. In any event, at the very least, the conflict between the Policy and the ACF creates an ambiguity to be construed in plaintiff's favor, and mandates application of the de novo standard of review.
For the reasons set forth above, plaintiff's Rule 57 motion is granted, and the Court will apply the de novo standard of review to the denial of plaintiff's claim for long-term disability benefits.
SO ORDERED.