Horton v. United of Omaha Life Insurance Co.
MEMORANDUM OPINION. Signed by Magistrate Judge John E Ott on 3/24/2017. (KAM, )
2017 Mar-24 AM 11:07
U.S. DISTRICT COURT
N.D. OF ALABAMA
UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
UNITED OF OMAHA LIFE
Case No.: 1:15-cv-0933-JEO
In this action, Plaintiff Joey Horton (“Horton”) brings a claim pursuant to the
Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et
seq., challenging Defendant United of Omaha Life Insurance Company’s (“United
of Omaha”) denial of his long-term disability and continuation of life insurance
benefits claims. (Doc. 1, ¶ 2 (“Complaint or “Compl.”)).1 United of Omaha
contends that Horton did not timely exhaust his administrative remedies as to its
“final determination that he was no longer disabled under the terms of the applicable
long-term disability policy” prior to filing this case. (Doc. 31 at 1; See also Doc.
References to “Doc. ___” are to the electronic numbers assigned by the Clerk of the Court. Page
references will be to the electronic page numbers at the top of the document unless noted otherwise.
32).2 On that basis, United of Omaha asks the court to enter judgment in its favor
on its motion for summary judgment. (Doc. 32). For the reasons set forth below,
the court finds the defendant’s motion for summary judgment is due to be granted.
FACTUAL BACKGROUD 3
For ten years, Horton, a 55-year old man, worked as a quality engineer at
American Furuwaka, Inc. (Doc. 1, ¶ 6). He installed and repaired machinery and
equipment for the company. (Id.). Horton suffers from “coronary artery disease,
congestive heart failure, high cholesterol, dyslipidemia, hypertension, diabetes
mellitus type II, peripheral neuropathy, joint pain, degenerative disc disease, chronic
back pain, and depression.” (Doc. 36-1, ¶ 3). According to Horton, he “take[s]
medications that affect [his] everyday living and [his] ability to function.” (Id., ¶ 4).
Horton claims that his “disabilities force[d] him to stop working” at the company as
of March 25, 2011. (Doc. 1, ¶ 6). And since that time, Horton maintains that he has
been “critically ill,” “hospitalized numerous times.” (Doc. 36-1, ¶¶ 5–6).
Horton argues that his “claim for benefits under the life insurance policy is properly before the
Court.” (Doc. 35, pp. 25–26). United of Omaha did not specifically address this contention in its
reply. (See Doc. 37). The court raised this issue with counsel in a telephone conference call.
Counsel for United of Omaha agreed that this aspect of the case is properly before the court for
substantive review. This opinion concerns only Horton’s long-term disability benefits claim, not
his life insurance claim.
Consistent with the summary judgment standard, the court presents the facts in the light most
favorable to Horton.
A. The Plan
As an American Furuwaka employee, Horton participated in the company’s
employee welfare benefit plan (the “Plan”). (Doc. 30-4, pp. 173-74). United of
Omaha administered the Plan. (Doc. 1, ¶ 2; Doc. 32, ¶ 1).4 The Plan provided
Horton with short-term disability (“STD”); long-term disability (“LTD”); life and
accidental death and dismemberment insurance (“LADD”); and voluntary term life
insurance (“VTLP”). (Docs. 30-2; 30-7; 30-16 & 17; 30-19; 40-1).5 Each policy of
the Plan sets forth its coverage terms, as well as procedures for appealing adverse
benefit determinations. (Docs. 30-2; 30-7; 30-16 & 17; 30-19; 40-1). 6 For instance,
under the STD and LTD policies, an insured must “appeal within 180 days following
[the] receipt of notification of an Adverse Benefit Determination.” (Doc. 30-2, p.
24; Doc. 30-7, p. 32). According to United of Omaha, if an insured does not appeal
an adverse benefits determination within United of Omaha’s allotted timeframe,
barring special circumstances, that decision is final and binding. (Doc. 30-9, p. 3).
B. Termination of STD and LTD Benefits
Not long after Horton stopped working at American Fukuwara, United of
Omaha approved Horton’s application for STD benefits. (Doc. 30-4, pp. 173–176).
It is undisputed that ERISA governs the Plan. (Docs. 1, 30).
The court refers collectively to Horton’s LADD and VTLP policies as the “Life Policies.”
An “adverse benefit determination” means “a denial, reduction, or termination of, or failure to
provide or make payment (in whole or in part) for a benefit . . . .” (Doc. 30-2, p. 23).
From April 2, 2011 to September 30, 2011, United of Omaha paid Horton $600.93
per week in STD benefits. (Doc. 30-4, pp. 3–5, 7). But pursuant to the Plan, after
United of Omaha pays an insured STD benefits for 26 weeks, an STD claim converts
into an LTD claim. (Doc. 30-2, pp. 4, 11; Doc. 30-4, pp. 3–5). On October 1, 2011,
Horton’s STD claim converted into an LTD claim. (Doc. 30-4, pp. 3–5; Doc. 3012, pp. 1–2; Doc. 30-11, p. 74). United of Omaha assigned Horton LTD claim
number “111020007802.” (Doc. 1-2, p. 2; Doc. 12, pp. 1-2; Doc. 30-9, p. 26).
After paying monthly LTD benefits to an insured for two years, under the
LTD policy, United of Omaha will continue extending LTD benefits only if the
insured is “disabled.” (Doc. 30-7, p. 39). That is, an insured must be “unable to
perform all the [m]aterial [d]uties of any [g]ainful [o]ccupation.” (Doc. 30-7, p. 39).
On November 15, 2013, after disbursing $833.01 per month in LTD benefits for two
years to Horton, United of Omaha notified Horton by letter that it was terminating
his LTD benefits. (Doc. 1-2; Doc. 30-9, pp. 26–31). In that letter, United of Omaha
provided the LTD policy number and Horton’s LTD claim number. (Doc. 1-2; Doc.
30-9, p. 26). Based on Horton’s more recent medical records, United of Omaha
determined that Horton was not disabled, as defined by the LTD policy. (Doc. 309, pp. 26–31). United of Omaha advised Horton not only of his right to appeal, but
also the steps to do so. (Doc. 30-9, p. 30). In particular, United of Omaha’s
November 15, 2013 letter warned Horton that if it did not “receive [Horton’s] appeal
within 180 days from the date [he] received t[he] [November 15, 2013] letter,” the
termination of his LTD benefits would be final. (Doc. 30-9, p. 31).
C. Life Insurance Benefits
While United of Omaha reviewed Horton’s LTD claim, it considered
simultaneously Horton’s life waiver of premium benefits (“LWOP” or “life
insurance benefits”) claim under the Life Policies. (Doc. 30-21, p. 30). At first,
United of Omaha determined that Horton qualified for a LWOP. (Doc. 32, ¶ 15).
But in a March 19, 2013 letter, United of Omaha reversed that determination,
concluding that Horton “no longer qualified for waiver of premium coverage based
on the any occupation provisions of the policy.” (Doc. 30-21, pp. 42–45). In other
words, because Horton could “perform the physical and mental demands of a
sedentary occupation” and was not “totally disabled,” pursuant to the Life Policies,
Horton was no longer eligible to receive life insurance benefits. (Id., p. 42). As with
the November 15, 2013 LTD benefits termination letter, the March 19, 2013 LWOP
termination letter informed Horton how to appeal United of Omaha’s decision. (Id.
pp. 43–44). The letter also listed in the subject line the Life Policies and Horton’s
LWOP claim number. (Id., p. 42).
On April 22, 2013, Horton appealed United of Omaha’s adverse LWOP
determination, citing to the Life Policies’ numbers. (Doc. 30-21, p. 36). The subject
line says, “Appeal the Denial of Life Insurance,” and the first line of Horton’s appeal
states, “Please accept this as my appeal to the life insurance denial from Mutual of
Omaha Life Insurance Company!”
(Doc. 30-21, p. 36).
On May 3, 2013,
referencing the Life Policies and Horton’s LWOP claim number, United of Omaha
acknowledged receipt of Horton’s LWOP appeal.
(Doc. 30-21, p. 65).
December 10, 2013, Omaha upheld its denial of his LWOP claim. (Doc. 1-3, pp. 2–
4). The letter references Horton’s LWOP claim number; and the first line of the
letter states that it concerns Horton’s “appeal for continuation of life insurance
benefits.” (Id., p. 2). The letter concluded that the medical evidence in Horton’s
claim file did not support disability under the Life Policies and that the denial of
LWOP benefits determination was final. (Id., p. 4). The letter informed Horton that
he had exhausted his administrative remedies with regard to his LWOP benefits and
that Horton had “the right to bring a civil action suit.” (Id.).
Horton contends that when he received United of Omaha’s December 10,
2013 final decision letter relating to the Life Policies, he believed “that [the letter]
related to all his claims with Omaha,” including his STD and LTD claims. (Doc. 35,
p. 6). Horton states that he was “critically ill” and “frequently” hospitalized in 2013
and 2014, and that he was taking medication that affected his cognitive abilities as
well as his memory, which, Horton alleges, affected his ability to appeal and
impaired his reading comprehension. (Doc. 36-1, ¶¶ 4–6).
Horton alleges that he retained legal counsel to pursue his LTD benefits
shortly after being released from the hospital. (Doc. 35, pp. 6, 22–23). On August
22, 2014, Horton, through counsel, wrote to United of Omaha. (Doc. 30-21, pp. 7–
9). In the subject line of that letter, it is undisputed that counsel for Horton
referenced the Life Policies and Horton’s LWOP claim number. (Doc. 1-4, p. 2;
Doc. 30-21, p. 7). Counsel wrote that her firm had “been retained to represent Mr.
Horton in his claim for disability benefits.” (Doc. 1-4, p. 2). Horton sought “a copy
of any Plan document that govern[s] [his] claim and all other documents that
[Horton] must be furnished pursuant to a request under 29 U.S.C. § 1024(b)(4).”7
(Doc. 1-4, p. 2). In addition, Horton’s August 22, 2014 inquiry requested that United
of Omaha confirm whether Horton “has exhausted all administrative rights to
appeal.” (Id., p. 2). Furthermore, in the accompanying privacy release to the August
22, 2014 letter, although Horton cited to the Life Policies and his LWOP claim
number, Horton wrote that he was “seeking a reassessment of my claim for Long
Term Disability benefits.” (Doc. 1-4, p. 4; Doc. 30-21, p. 9).
On September 15, 2014, United of Omaha responded to Horton’s August 22,
2014 letter, “providing information only for [Horton’s] waiver of premium claims.”
29 U.S.C. § 1024(b)(4) requires a claims administrator to “upon written request of any participant
or beneficiary, furnish a copy of the latest updated summary, plan description, and the latest annual
report, any terminal report, the bargaining agreement, trust agreement, contract, or other
instruments under which the plan is established or operated.” Id.
(Doc. 1-5; Doc. 35, pp. 6–7; Doc. 30-21, pp. 4–6). That letter also confirmed that
Horton had exhausted his appeal rights with respect to the Life Policies. (Doc. 32,
pp. 10–11; Doc. 35, pp. 6–7; Doc. 30-21, pp. 4–6). But as with the subject line of
Horton’s August 22, 2014 letter, the reference line in Omaha’s September 15, 2014
response letter dealt only with Horton’s Life Policies and Horton’s LWOP claim
number. (Doc. 1-5; Doc. 30-21, pp. 4–6). The September 15, 2014 letter did not
discuss Horton’s STD or LTD policies. (Doc. 1-5; Doc. 30-21, pp. 4–6).
D. Appeal of LTD Benefits
On March 10, 2015, Horton appealed United of Omaha’s termination of his
LTD benefits. (Doc. 1-6; Doc. 30-9, pp. 9–10). In the subject line of Horton’s letter,
he referenced the LTD disability policy as well as his LTD policy number. (Doc. 16; Doc. 30-9, p. 9). Horton stated that, on December 10, 2013, while he received
information related to the Life Policies, he did not receive information pertaining to
his LTD claim. (Doc. 1-6; Doc. 30-9, p. 9). Horton also said that he had “previously
requested that Mutual of Omaha clarify [Horton’s] appeal rights on his disability
claim.” (Doc. 1-6; Doc. 30-9, p. 9). “[G]iven the apparent confusion,” Horton
requested copies of his disability claim file.
(Doc. 1-6; Doc. 30-9, pp. 9–10).
Horton also inquired about whether he had exhausted his administrative appeals with
respect to his LTD benefits. (Doc. 1-6; Doc. 30-9, pp. 9–10).
On March 20, 2015, United of Omaha upheld the denial of Horton’s LTD
claim for benefits. (Doc. 1-7; Doc. 30-9, pp. 1–5). The beginning of the letter
referenced the LTD policy and Horton’s LTD claim number. (Doc. 1-7; Doc. 30-9,
pp. 1–5). United of Omaha stated:
The adverse benefit decision was sent to Mr. Horton on November 15,
2013. As noted above, Mr. Horton had a period of 180 days from
receipt of this letter to file an appeal. We have no record of an appeal
being filed prior to or around May 14, 2014, 180 days after the adverse
We are in receipt of your August 22, 2014, letter. This letter asked
about [the Life Policies].
The appeal for the [LTD] disability claim is dated March 10, 2015.
Both the August 22, 2014, and March 10, 2015, letters were submitted
well after the 180 days that Mr. Horton had to file an appeal for
disability benefits. We are not able to accept and evaluate an appeal
submitted after May 14, 2014.
(Doc. 1-7, p. 4; Doc. 30-9, pp. 3–4). Because Horton did not submit a timely LTD
benefits appeal, United of Omaha wrote that it was “unable to accept and evaluate”
Horton’s late appeal. (Doc. 1-7; Doc. 30-9, pp. 3–4). United of Omaha advised
Horton that he had “exhausted all administrative rights to appeal” and that the
adverse LTD benefits decision was final. (Doc. 1-7, p. 5; Doc. 30-9, pp. 3–4). The
letter informed Horton of his “right to bring a civil action . . . once all administrative
rights to review have been exhausted.” (Doc. 1-7, p. 5; Doc. 30-9, pp. 3–4).
On June 3, 2015, Horton filed this action against United of Omaha, contending
that he was entitled to LTD benefits. (Doc. 1). Horton testified that—“[t]o the best
of [his] knowledge”—he thought that he had complied with the steps that United of
Omaha “told [him] to take to appeal the denial of [his] [LTD] disability benefits.”
(Doc. 36-1, ¶¶ 7–14).
SUMMARY JUDGMENT STANDARD
Pursuant to Rule 56 of the Federal Rules of Civil Procedure, a party is
authorized to move for summary judgment on a claim or defense asserted by or
against the movant. Under that rule, 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). “Disposition of a
summary judgment motion in a declaratory judgment action is governed by the same
basic principles that generally rule the grant or denial of such a motion.” Bingham,
Ltd. v. United States, 724 F.2d 921, 924 (11th Cir. 1984).
The party moving for summary judgment “always bears the initial
responsibility of informing the district court of the basis for its motion,” relying on
submissions “which it believes demonstrate the absence of a genuine issue of
material fact.” Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986); see also Clark v.
Coats & Clark, Inc., 929 F.2d 604, 608 (11th Cir. 1991); Adickes v. S.H. Kress &
Co., 398 U.S. 144 (1970). Where the movant will not bear the burden of proof on a
claim or issue at trial, the movant can satisfy that burden by pointing to specific
portions of the materials on file that either negate an essential element of the nonmovant’s claim or that affirmatively indicate “that the party bearing the burden of
proof at trial will not be able to meet that burden.” Clark, 929 F.2d at 608; see also
United States v. Four Parcels of Real Prop. in Greene & Tuscaloosa Ctys. in State
of Ala., 941 F.2d 1428, 1438 n. 19 (11th Cir. 1991). By contrast, when the moving
party has the burden of proof at trial, it must support its motion with credible
evidence that would entitle it to a directed verdict if not controverted at trial. See
Four Parcels, 941 F.2d at 1438. “In other words, the moving party must show that,
on all the essential elements of its case on which it bears the burden of proof at trial,
no reasonable jury could find for the nonmoving party.” Id.
Once the moving party has met its initial burden, the nonmoving party must
“go beyond the pleadings” and refer the court to evidence demonstrating that there
is a genuine issue for trial. Celotex Corp., 477 U.S. at 324. In its review of the
evidence, a court must credit the evidence of the non-movant and draw all justifiable
inferences in the non-movant’s favor. See Stewart v. Booker T. Washington Ins.,
232 F.3d 844, 848 (11th Cir. 2000). At summary judgment, “the judge’s function is
not himself to weigh the evidence and determine the truth of the matter but to
determine whether there is a genuine issue for trial.” Anderson v. Liberty Lobby,
Inc., 477 U.S. 242, 249 (1986).
ERISA authorizes a civil action by a participant “to recover benefits due to
him under the terms of his plan.” 29 U.S.C. § 1132(a)(1)(B). But in this circuit,
even though the text of ERISA itself does not mandate exhaustion, the “law is wellsettled that plaintiffs in ERISA actions must exhaust available administrative
remedies before suing in federal court.” Lanfear v. Home Depot, Inc., 536 F.3d
1217, 1223 (11th Cir. 2008); see also Watts v. BellSouth Telecomms., Inc., 316 F.3d
1203, 1207 (11th Cir. 2003).
This court-imposed requirement is based on
Congressional intent and statutory interpretation. See Watts, 316 F.3d at 1207. In
Mason v. Continental Group, Inc., the Eleventh Circuit explained:
Compelling considerations exist for plaintiffs to exhaust administrative
remedies prior to instituting a lawsuit. Administrative claim-resolution
procedures reduce the number of frivolous lawsuits under ERISA,
minimize the cost of dispute resolution, enhance the plan’s trustees’
ability to carry out their fiduciary duties expertly and efficiently by
preventing premature judicial intervention in the decision making
process, and allow prior fully considered actions by pension plan
trustees to assist courts if the dispute is eventually litigated.
763 F.2d 1219, 1227 (11th Cir. 1985). Therefore, when a plaintiff fails to exhaust
his administrative remedies by not filing a timely appeal, based on the Eleventh
Circuit precedent, that claim is barred and the claims administrator’s decision is
final. See Counts v. Am. Gen. Life & Acc. Ins. Co., 111 F.3d 105, 108 (11th Cir.
In this case, Horton argues that he “exhausted his ERISA administrative
remedies and is entitled to have his case heard before this court.” (Doc. 35, p. 12).
The court disagrees. On November 12, 2013, United of Omaha informed Horton
that he was no longer eligible for LTD benefits. (Doc. 1-2; Doc. 30-9, pp. 26–31).
The Plan required Horton to appeal the denial of his LTD within 180 days of
receiving his termination letter. (Doc. 30-7, p. 32). Horton should have appealed
the adverse LTD benefits decision by May 14, 2014. (Doc. 1-7; Doc. 30-9, pp. 1–5;
Doc. 30-7, p. 32). Horton, however, did not do so. He did not appeal the unfavorable
LTD benefits determination until March 10, 2015. (Doc. 1-6; Doc. 30-9, pp. 9–10).
That is fatal. Because Horton submitted an untimely LTD benefits appeal, pursuant
to Eleventh Circuit precedent, he failed to exhaust his remedies. See Counts, 111
F.3d at 108. Accordingly, Horton is barred from suing United of Omaha for LTD
benefits in federal court, and United of Omaha’s LTD benefits decision is final and
A. Equitable Estoppel
Horton contends that United of Omaha should be estopped from asserting as
a defense his failure to exhaust because, in United of Omaha’s March 20, 2015 LTD
final denial letter, United of Omaha informed Horton that he had exhausted his
administrative remedies with regard to his LTD benefits and had a right to sue. (Doc.
35, pp. 17–19). This argument is not persuasive. To succeed under the Eleventh
Circuit’s “very narrow common law doctrine under ERISA for equitable estoppel,”
Horton must “show that (1) the relevant provisions of the plan at issue are
ambiguous, and (2) the plan provider or administrator has made representations to
Horton that constitute an informal interpretation of the ambiguity.” Jones v. Am.
Gen. Life & Acc. Ins. Co., 370 F.3d 1065, 1069 (11th Cir. 2004); Glass v. United of
Omaha Life Ins. Co., 33 F.3d 1341, 1347 (11th Cir. 1994) (citation omitted); see
also Braden v. Aetna Life Ins. Co., 597 F. App’x 562, 567 (11th Cir. 2014).8
Estoppel does not apply “either for oral modifications (as opposed to interpretations)
or when the written plan is unambiguous.” Glass, 33 F.3d at 1347 (citations
To begin, Horton’s argument overlooks a crucial point of this circuit’s
collateral estoppel doctrine:
that, as a prerequisite, there must be ambiguous
provisions in the Plan on which United of Omaha relied to deny Horton’s benefit
claim. See Kane v. Aetna Life Ins., 893 F.2d 1283, 1285 (11th Cir. 1990); see also
Braden, 597 F. App’x at 567. Not only that, but Horton does not argue that any
section of the Plan or its summary is ambiguous. This is a non-starter. The LTD
policy required Horton to appeal the denial of his LTD within 180 days of receiving
his termination letter. (Doc. 30-7). The LTD policy does not express that a claimant
Unpublished opinions of the Eleventh Circuit Court of Appeals are not considered binding
precedent; however, they may be cited as persuasive authority. 11th Cir. R. 36-2.
who files an untimely appeal for an adverse benefits determination has the right to
sue in federal court to challenge that benefits decision.9 Permitting estoppel here—
to override the clear terms of the Plan documents—would be inconsistent with this
circuit’s application of ERISA principles. See Jones, 370 F.3d at 1069.
But even if United of Omaha’s pro forma “right to sue” text equates to a
misstatement of Eleventh Circuit precedent, because Horton had long missed the
deadline for filing an appeal when he received the letter, that misstatement was not
material. (Doc. 1-7). Put another way, the “right to sue” language did not to prevent
Horton from timely filing an appeal. Accordingly, because Horton neglected to
timely appeal his adverse LTD benefits determination despite an unambiguous LTD
policy, the Eleventh Circuit’s “very narrow common law doctrine under ERISA for
equitable estoppel” does not apply in this matter. See Glass, 33 F.3d at 1347.
B. Exceptions to Exhaustion Requirement
Horton also posits that “the exhaustion requirement is due to be excused due
to exceptional circumstances” because United of Omaha’s “denial letters contained
insufficient language to inform Mr. Horton of his appeal rights and adverse
Even assuming Horton relied on United of Omaha’s March 20, 2015 letter, he has failed to cite
any authority holding that the inclusion of boilerplate “right to sue” language within a defendant
claim administrator’s final denial letter, standing alone, later bars that defendant from raising a
plaintiff’s failure to exhaust as a defense where, pursuant to this circuit’s law, Horton failed to
exhaust his administrative remedies. See, e.g., Katz v. Comprehensive Plan of Group Ins., 197
F.3d 1084, 1090 (11th Cir. 1999) (finding that representations that contradict unambiguous
provision do not give rise to estoppel, even if relied upon to an insured’s detriment).
consequences of failure to exhaust.” (Doc. 35, p. 17). In addition, Horton argues
that his hospitalization should excuse the exhaustion requirement. (Doc. 35, pp. 22–
25; Doc. 36-1). The court is not convinced by either argument.
While, as a general rule, the Eleventh Circuit strictly mandates that ERISA
plaintiffs exhaust available administrative remedies before filing suit in court, there
are two exceptions: when “resort to administrative remedies would be futile or the
remedy inadequate, or where a claimant is denied meaningful access to the
administrative review scheme in place.” Perrino v. Southern Bell Tel. & Tel. Co.,
209 F.3d 1309, 1315–16 (11th Cir. 2000). “The decision of a district court to apply
or not apply the exhaustion of administrative remedies requirement for ERISA
claims is a highly discretionary decision which [is] review[ed] only for a clear abuse
of discretion.” Id; see also Bickley v. Caremark RX, Inc., 461 F.3d 1325, 1328 (11th
Aside from being “unwell during a large portion of the LTD appeal period,”
Horton asserts that two United of Omaha’s written communications to him were
misleading and prevented him from filing a timely claim: (1) the November 15,
2013 letter, which terminated Horton’s LTD benefits; and (2) the December 10, 2013
letter, which informed Horton that he had exhausted all administrative rights with
respect to the Life Policies benefits. (Doc. 35, pp. 17, 20–25; Doc. 36-1). This
argument is without merit.
As a preliminary matter, the court is faced with two versions of the November
15, 2013 and December 10, 2013 letters. (Doc. 1-2, pp. 2–7; Doc. 30-9, pp. 26–31;
Doc. 1-3; Doc. 30-21, p. 16–18). While United of Omaha’s versions of the letters
bear reference lines identifying policies and policy numbers, Horton’s versions of
the November and December letters do not. (Doc. 1-2, pp. 2–7; Doc. 30-9, pp. 26–
31; Doc. 1-3; Doc. 30-21, p. 16–18). Nevertheless, both versions are otherwise the
same, and in particular, both contain the claim numbers. (Doc. 1-2, pp. 2–7; Doc.
30-9, pp. 26–31; Doc. 1-3; Doc. 30-21, p. 16–18). The parties resolved this dispute
via a joint stipulation that the letters in the administrative record 10 are true and
accurate copies of the letters sent to Horton during the review process. (See Doc.
43). Therefore, for determining whether either letter is ambiguous, that Horton’s
version is silent with respect to policy numbers is of no moment.
Even without the LTD policy number, the November 15, 2013 letter refers
clearly to Horton’s LTD benefits. (Doc. 1-2, pp. 2–7; Doc. 30-9, pp. 26–31). The
letter throughout references the LTD policy six times. (Doc. 1-2, pp. 2–7; Doc. 309, pp. 26–31). The letter provides Horton’s LTD claim number. (Doc. 1-2, p. 2;
Doc. 30-9, p. 26). The first sentence states that United of Omaha has completed its
“review of [Horton’s] claim for ongoing Long Term Disability benefits under policy
The stipulation of the parties references these letters as documents “United 000308” and
“United 001012.” They are Document 30-9, p. 26 and Document 30-21, p. 16, respectively.
GLTD 850F.” (Doc. 1-2, p. 2; Doc. 30-9, p. 26). The letter advises Horton that he
has “180 days of the date” that he “receive[s] this notice of denial” to appeal United
of Omaha’s adverse LTD benefits determination. (Doc. 1-2, p. 6; Doc. 30-9, p. 30).
Both variants of the November letters make clear that if United of Omaha does not
receive Horton’s “appeal within 180 days from the date” he received the letter, the
“claim determination will be final.” (Doc. 1-2, p. 7; Doc. 30-9, p. 31). The letter
does not discuss Horton’s other policy benefits, much less mention any other policy
or claim. (Doc. 1-2, pp. 2–7; Doc. 30-9, pp. 26–31).
Likewise, the December 10, 2013 letter deals unambiguously with the LWOP;
that letter upholds United of Omaha’s denial of Horton’s appeal for life insurance
benefits. (Doc. 1-3; Doc. 30-21, p. 16–18). The letter references Horton’s LWOP
claim number, and the first line indicates that the letter relates to Horton’s “appeal
for continuation of life insurance benefits.” (Doc. 1-3, p. 2; Doc. 30-21, p. 16). Even
it is assumed that Horton was confused about the December 10, 2013 letter, because
the only appeal that Horton had filed when he received the December letter was for
his LWOP benefits, practically speaking, that letter could have referred only to
Horton’s LWOP claim. (Doc. 30-21, p. 18). Indeed, in his LWOP appeal notice,
Horton cited explicitly to both of the Life Policies and their numbers; the subject
line says, “Appeal the Denial of Life Insurance;” and the first line asserts, “Please
accept this as my appeal to the life insurance denial from Mutual of Omaha Life
Insurance Company!” (Doc. 30-21, p. 66). In Horton’s appeal, his delineation of
his life insurance benefits and the absence of any other reference to other benefits
belies his excusal argument.
Even assuming that both the November 15, 2013 and December 10, 2013
letters technically violated ERISA, Eleventh Circuit precedent “makes clear that the
exhaustion requirement for ERISA claims should not be excused for technical
violations of ERISA regulations that do not deny plaintiffs meaningful access to an
administrative remedy procedure through which they may receive an adequate
remedy.” Perrino, 209 F.3d at 1317. There is no evidence demonstrating that
United of Omaha’s conduct militated against Horton’s ability to purse a timely
appeal to challenge the discontinuance of his LTD benefits. Rather, by singling out
portions of United of Omaha’s letters and characterizing them as ambiguous, Horton
attempts to manufacture a factual dispute where there is no such dispute. The letters,
when read in context, are clear. Allegations based on Horton’s misreading of United
of Omaha’s letters are not sufficient to trigger an exception to ERISA’s exhaustion
requirement. Nor do they establish factual issues to be resolved by a jury. Therefore,
as it relates to United of Omaha’s November 15, 2013 and December 10, 2013
letters, the court cannot excuse Horton from ERISA’s exhaustion requirement.
Alternatively, Horton argues that his hospitalization interfered with his ability
to timely appeal United of Omaha’s denial of his LTD benefits because “during the
entire appeal period he was under the care of physicians and taking medication that
affected his cognitive abilities as well as his memory.” (Doc. 35, p. 23; Doc. 36-1).
On this basis, Horton argues that “such failure is certainly excusable.” (Doc. 35, pp.
22–23). This argument stands on no better footing. For starters, Horton has not
cited, nor has the court found, any Eleventh Circuit case law acknowledging a
hospitalization exception to the ERISA exhaustion requirements. Because the
Eleventh Circuit has not announced such an exception, this court is not in a position
to do so here. Perrino, 209 F.3d at 1318. While the court sympathizes with Horton’s
health complications, the court must decline Horton’s invitation to forge an
uncharted path in his favor. See also Springer v. Wal–Mart Assocs.’ Group Health
Plan, 908 F.2d 897, 900 n. 1 (11th Cir. 1990) (declaring that “the district court is
bound by controlling Eleventh Circuit precedent”). 11
For the foregoing reasons, the court finds Horton’s challenge to the denial of
his long-term disability benefits claim is final and binding, and his claim is barred
Even if Horton’s hospitalization theory constituted a recognized exception to the ERISA
exhaustion rule in the Eleventh Circuit, Horton has adduced scant evidence that he would qualify
for such an exception. Horton alleges that he was hospitalized for “one week in May 2014” and
“almost half of July 2014.” (Doc. 35, p. 22). The deadline for Horton’s LTD claim was May 14,
2014. (Doc. 1-7; Doc. 30-9, pp. 1–5). Thus, based on Horton’s factual allegations, the court would
find little reason to consider Horton’s hospitalization sufficient for excusing the ERISA exhaustion
requirement, even if such an exception was recognized.
from further review. United of Omaha’s motion for summary judgment (doc. 32) is
due to be GRANTED. An appropriate order will be entered separately.
DONE, this the 24th day of March, 2017.
JOHN E. OTT
Chief United States Magistrate Judge
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