George A. Hinshaw v. UNUM Life Insurance Company of America et al

Filing 39

ORDER GRANTING DEFENDANT UNUM LIFE INSURANCE COMPANY OF AMERICAS MOTION FOR SUMMARY JUDGMENT 30 AND DENYING PLAINTIFF GEORGE A. HINSHAWS MOTION FOR SUMMARY JUDGMENT 22 by Judge Dean D. Pregerson . (lc). Modified on 5/6/2015 (lc).

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UNITED STATES DISTRICT COURT

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CENTRAL DISTRICT OF CALIFORNIA

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GEORGE A. HINSHAW,

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Plaintiff,

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v.
UNUM LIFE INSURANCE COMPANY
OF AMERICA,

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Defendant.
___________________________

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Case No. CV 14-06157 DDP (PLAx)
ORDER GRANTING DEFENDANT UNUM
LIFE INSURANCE COMPANY OF
AMERICA’S MOTION FOR SUMMARY
JUDGMENT AND DENYING PLAINTIFF
GEORGE A. HINSHAW’S MOTION FOR
SUMMARY JUDGMENT
[Dkt. Nos. 22, 30]

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This is an action for long-term disability benefits pursuant

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to the Employee Retirement Income Security Act of 1974 (“ERISA”),

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29 U.S.C. § 1001 et seq.

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proceeding pro se, contests the termination of his long-term

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disability benefits by Defendant Unum Provident Life Insurance

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Company of America (“Unum”).

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Hinshaw and Unum’s cross-motions for summary judgment.

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Nos. 22, 30.)

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oral argument, the Court GRANTS Defendant Unum’s motion, DENIES

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Plaintiff Hinshaw’s motion, and adopts the following order.

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Plaintiff George A. Hinshaw (“Hinshaw”),

Presently before the Court are
(See Dkt.

Having considered the parties’ submissions and heard

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I.

BACKGROUND
Hinshaw was working as a cable television installer in 2005,

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when he was involved in a car accident while on the job.

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(Administrative Record (“AR”) 79, 85.)

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accident, he had bad back pain and persistent lumbar/spine issues,

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and he submitted a claim for long-term disability (“LTD”) benefits

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to Unum in December 2005. (AR 79-85.)

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investigation that included review of Hinshaw’s medical records and

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evaluation by a doctor, Unum decided that Hinshaw qualified for LTD

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As a result of the

In August 2006, After

benefits and started monthly payments.

(AR 203.)

Under the terms of Unum’s LTD Plan, the first two years of

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payments are automatic once the employee has been deemed

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“disabled.”

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insured remains disabled and thus eligible for continued LTD

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benefits.

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that by reason of his disability, he “cannot perform each of the

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material duties of his regular occupation and, after 24 months, the

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insured cannot perform each of the material duties of any gainful

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occupation for which he is reasonably fitted by training, education

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or experience.”

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(AR 1806.)

(Id.)

After this, Unum must determine if the

To qualify as disabled, the insured must show

(Id.)

The initial 24 month period would have ended for Hinshaw in

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December 2007.

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indicated that it did not anticipate a change in his disability or

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medical status and therefore extended its approval of his benefits

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through the year 2024.

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approval was subject to verification from time to time, whereupon

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Unum would ask Hinshaw to provide Unum with updated medical

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information or other documentation.

In a June 11, 2007 letter to Hinshaw, Unum

(AR 924-26.)

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The letter stated that this

(Id.)

Unum also required that

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Hinshaw provide Unum with notice should Hinshaw be able to return

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to work in any capacity.

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of Unum’s LTD Plan, which required that for monthly payments to

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continue, the insured should provide proof, upon request, of

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continued disability and regular attendance of a physician.

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1810.)

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(Id.)

This was consistent with the terms

(AR

Unum periodically requested more documentation from Hinshaw

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after 2007, which Hinshaw provided.

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Hinshaw informed Unum that he had been “tutoring and mentoring” at

(AR 966-1206.)

In June 2009,

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MLB Academy on a part-time basis, but Unum apparently decided to

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continue Hinshaw’s LTD benefits.

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what appears to be a regular review of Hinshaw’s file, Unum ran a

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comprehensive online data search and found that Hinshaw had been

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working as a baseball coach at Los Angeles City College, a fact

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Hinshaw had never disclosed to Unum.

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also obtained a Bachelor’s degree (2006) and a Master’s degree in

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Education (2008) from the University of Phoenix.

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Hinshaw a request for his 2012 tax returns and supporting

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documentation.

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doctor for more updated medical records, and Hinshaw’s doctor

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informed Unum that Hinshaw’s last visit had been in May 2011.

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1454-1458.)

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requested Hinshaw’s tax returns for 2008-2012 as well as updated

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medical documentation of Hinshaw’s disability.

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1482.)

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2012 taxes, but either could not find or did not file his 2011

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taxes.

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orthopedic specialist - as of May 2011, but it appears that Hinshaw

(AR 1423-25.)

(AR 997, 1160.)

In 2013, during

(AR 1310-1420.)

Hinshaw had

(Id.)

Unum sent

Unum also sent requests to Hinshaw’s

(AR

Based on the new information, in April 2013, Unum

(AR 1470-72, 1477-

Hinshaw submitted proof of a request for extension on his

(AR 1506.)

Hinshaw had been to see a doctor - his

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did not see a doctor after this date.

Unum then requested to

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schedule an in-person visit with Hinshaw, which Hinshaw cancelled

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or postponed before it could be held.

(AR 1474-75, 1513.)

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After several months of trying to obtain information from

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Hinshaw and his doctors, Unum arranged for an internal medical

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review to determine whether the information they had could support

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a finding that Hinshaw still qualified for benefits.

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Internal medical staff determined that, based on the information

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they have, Hinshaw could perform work that was sedentary to medium

(AR 1526-27.)

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in activity, and suggested three alternate occupations for Hinshaw:

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eligibility worker, order clerk, and student adviser.

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1537-1549.)

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Hinshaw was not entitled to further LTD benefits and sent a letter

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to Hinshaw informing him that his benefits would be terminated

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effective August 23, 2013.

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(AR 1533,

Based on its own internal review, Unum concluded

(1561-66.)

In December 2013, Hinshaw appealed the termination decision to

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UNUM’s appeals unit, but did not appear to provide much new

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information regarding his medical condition other than a detailed

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medical examination report from 2010 and related deposition

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testimony of a doctor who had performed the 2010 examination.

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1578-1663.)

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information for his appeal, Hinshaw stated that he believed the

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information that he had provided was sufficient.

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assigned to the appeal upheld the decision to terminate.

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88.)

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court.

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(AR

When asked if he was going to provide additional

The specialist
(AR 1781-

Hinshaw has now appealed the termination of benefits to this

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II.

LEGAL STANDARD
Summary judgment is proper where a movant “shows that there is

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no genuine dispute as to any material fact and the movant is

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entitled to judgment as a matter of law.”

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In other words, summary judgment should be entered against a party

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“who fails to make a showing sufficient to establish the existence

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of an element essential to that party’s case, and on which that

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party will bear the burden of proof at trial.”

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Valley Hosp. Med. Ctr., 630 F.3d 794, 798-99 (9th Cir. 2010).

Fed. R. Civ. P. 56(a).

Parth v. Pomona

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To satisfy its burden at summary judgment, a moving party

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without the burden of persuasion “must either produce evidence

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negating an essential element of the nonmoving party’s claim or

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defense or show that the nonmoving party does not have enough

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evidence of an essential element to carry its ultimate burden of

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persuasion at trial.”

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Cos., Inc., 210 F.3d 1099, 1102 (9th Cir. 2000).

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moving party with the burden of persuasion, “to prevail on summary

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judgment it must show that the evidence is so powerful that no

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reasonable jury would be free to disbelieve it.”

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Schriro, 514 F.3d 878, 890 (9th Cir. 2008) (internal quotation

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marks omitted).

Nissan Fire & Marine Ins. Co., Ltd. v. Fritz
With respect to a

Shakur v.

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“If the party moving for summary judgment meets its initial

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burden,” the nonmoving party must, “by affidavit or as otherwise

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provided in Rule 56,” affirmatively identify “specific facts

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showing that there is a genuine issue for trial.”

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Serv., Inc., v. Pac. Elec. Contractors Ass’n, 809 F.2d 626, 630

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(9th Cir. 1987) (internal citations and quotation marks omitted).

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Establishing a genuine issue for trial means doing “more than
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T.W. Elec.

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simply show[ing] that there is some metaphysical doubt as to the

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material facts.”

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Corp., 475 U.S. 574, 586 (1986).

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whole could not lead a rational trier of fact to find for the non-

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moving party, there is no ‘genuine issue for trial.’” Id. at 587.

Matsushita Elec. Indus. Co., Ltd. v. Zenith Radio
“Where the record taken as a

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With that said, courts do not weigh conflicting evidence or

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adjudge credibility at the summary judgment stage, and must view

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all evidence and draw all inferences in the light most favorable to

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the non-moving party.

See T.W. Elec. Serv., 809 F.2d at 630-31

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(citing Matsushita Elec. Indus. Co., 475 U.S. at 587); Hrdlicka v.

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Reniff, 631 F.3d 1044 (9th Cir. 2011); Motley v. Parks, 432 F.3d

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1072, 1075 & n.1 (9th Cir. 2005).

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III.

ANALYSIS

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A.

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The initial issue in this case is what standard of review the

Unum’s Termination of Plaintiff’s Benefits

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Court should apply.

Unum argues in its motion that the abuse of

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discretion applies.

Although Hinshaw mostly seems to accept an

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abuse of discretion standard in sections of his motion, he also

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appears to argue that the Court should apply a more rigorous

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standard of review.

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The denial of benefits under an ERISA plan is reviewed de novo

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by the district court, unless the terms of the plan “unambiguously”

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grant the plan administrator or fiduciary discretionary authority

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to determine eligibility for benefits.

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Pension Plan, 484 F.3d 1211, 1216 (9th Cir. 2007); Firestone Tire &

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Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989).

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denial of benefits is reviewed for abuse of discretion.

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Wells Fargo & Co. Long Term Disability Plan, 511 F.3d 1206, 1209
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Opeta v. Northwest Airlines

In that event, the
Saffon v.

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(9th Cir. 2008).

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“examine whether the terms of the ERISA plan unambiguously grant

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discretion to the administrator.”

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Tech., Inc., 463 F.3d 880, 883 (9th Cir. 2006)(internal quotation

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omitted).

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Accordingly, the “essential first step” is to

Feibusch v. Integrated Device

Discretionary authority consists of the “power to construe the

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terms of the plan,” as opposed to where the plan merely

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“identif[ies] the plan administrator’s tasks, but bestow[s] no

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power to interpret the plan.”

Opeta, 484 F.3d at 1216 (internal

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quotation omitted); see also Abatie v. Alta Health & Life Ins. Co.,

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458 F.3d 955, 962-65 (9th Cir. 2006)(holding that discretion is

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unambiguously conferred on the administrator when a plan grants

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“the power to interpret plan terms and to make final benefits

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determinations,” and particularly where exclusive authority for

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final benefits determinations rests with the plan administrator).

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However, if the plan administrator is also an insurer, then

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there is a conflict of interest, and that conflict of interest

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“must be weighed as a factor in determining whether there is an

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abuse of discretion.”

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970, 976 (1999).

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still for abuse of discretion, it is less deferential to the

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administrator.

Tremain v. Bell Industries, Inc., 196 F. 3d

In such a circumstance, although the review is

Id.

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If a plaintiff can present evidence that the conflict of

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interest arises to the level of a breach of a fiduciary duty to the

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plan participant, however, then the district court should review

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the plan administrator’s decision de novo.

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program participant presents “material, probative evidence, beyond

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the mere fact of the apparent conflict, tending to show that the
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If, however, the

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fiduciary’s self interest caused a breach of the administrator’s

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fiduciary obligations to the beneficiary,” a rebuttable presumption

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arises in favor of the participant.

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Plan of Sponsor Applied Remote Technology, Inc., 125 F.3d 794, 798

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(9th Cir. 1997).

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presumption by producing evidence to show that the conflict of

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interest did not affect its decision to deny or terminate

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benefits.”

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rebutting the presumption, the court will review the

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Id.

Lang v. Long–Term Disability

The plan then “bears the burden of rebutting the

If the administrator fails to carry this burden of

administrator’s decision de novo.
Here, the terms of the LTD Plan explicitly give Unum

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“discretionary authority both to determine an employee’s

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eligibility for benefits and to construe the terms of this policy.”

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AR at 1800.

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However, at a minimum, a heightened standard of review should

This grant of discretionary authority is unambiguous.

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apply because Unum is both the plan administrator and the insurer,

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a factor which must be taken into account as a potential cause of a

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conflict of interest.

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Unum contends that under the abuse of discretion standard, its

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termination of Hinshaw’s benefits was clearly reasonable and

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justified.

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minimum, he argues that the LTD Plan’s terms were unclear, and that

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Unum’s communications to him were misleading and in bad faith -

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possibly in violation of Unum’s fiduciary duty towards Hinshaw.

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Hinshaw further argues that Unum’s termination of his benefits fail

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the abuse of discretion standard.

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there is sufficient evidence before the Court to show that Unum’s

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self-interest cause a breach of fiduciary duty to Hinshaw, the

Hinshaw’s arguments are difficult to decipher, but at a

Although it is unclear whether

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Court need not resolve this issue, as it finds that either under a

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de novo or abuse of discretion standard, Unum’s termination of

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Hinshaw’s benefits was sufficiently supported by the evidence on

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the record.

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When reviewing a decision under either a de novo or abuse of

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discretion standard, the Court generally should only consider the

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record that was in front of the plan administrator at the time of

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the decision.

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1090 (9th Cir. 1999); Winters v. Costco Wholesale Corp., 49 F.3d

See Kearney v. Standard Ins. Co., 175 F.3d 1084,

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550, 553 (9th Cir. 1995).

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full administrative record, which the Court has reviewed in making

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its determination.

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consider any material outside of the administrative record.

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Unum has provided the Court with the

Hinshaw has not argued for the Court to

Hinshaw primarily argues that Unum only conducted a “paper

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review” of his eligibility for benefits, which was insufficient for

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Unum to determine whether he was still disabled as defined by the

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terms of the LTD Plan.

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that Unum gave Hinshaw notice that it was reviewing his eligibility

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and requested prior tax returns as well as medical documentation

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from him.

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notice that Unum was aware of his employment during the time when

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he was disabled and required documentation of his continued

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disability.

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documentation of his injury and continued lack of ability to return

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to work.

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Hinshaw, which Hinshaw himself cancelled.

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his last visit to a doctor had been in 2011, two years prior.

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However, the administrative record shows

At least from April 2013, if not earlier, Hinshaw was on

Unum gave Hinshaw several months to provide additional

It also attempted to schedule an in-person visit with
Hinshaw confirmed that

Given evidence of Hinshaw’s coaching and tutoring jobs in
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2008-2009 and his lack of post-2011 medical visits, added to

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Hinshaw’s lack of responsiveness to Unum’s request for further

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documentation and proof of disability, Unum reasonably concluded

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that Hinshaw no longer qualified for benefits under the LTD Plan.

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Although Unum’s own internal review conducted by medical personnel

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was only a “paper” review, Unum’s conclusion that Hinshaw could be

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employed in a more sedentary position was reasonably supported by

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the evidence.

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report would qualify as “any gainful occupation for which [the

The suggested types of employment in Unum’s internal

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insured] is reasonably fitted by training, education or

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experience.”

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(AR 1806.)

The Court cannot find evidence of egregious mishandling of

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Hinshaw’s case – either under abuse of discretion standard or under

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de novo review.

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investigation of Hinshaw’s disability, Unum gave Hinshaw multiple

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opportunities to provide updated medical documentation of his

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disability, both during its 2013 review of Hinshaw’s eligibility

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and during Hinshaw’s appeal.

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visit from a representative, which Hinshaw cancelled.

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clear to Hinshaw in its letters and in the terms of the LTD Plan

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that he would be asked to provide documentation such as doctor’s

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exams in order to support his continued claim.

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seen his doctor since 2011 and did not see his doctor even after

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receiving Unum’s letters requesting medical documentation, it was

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reasonable and within the terms of the LTD Plan for Unum to decide

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to terminate Hinshaw’s benefits.

Although Unum might have conducted a more thorough

Unum also requested an in-person
Unum made

As Hinshaw had not

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B.

Safe Harbor

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Hinshaw also argues that ERISA is not applicable to this case,
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because the “safe harbor” provision applies.

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provides the exclusive remedies for claims for benefits under a

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plan governed by ERISA, and completely preempts application of

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state law to an action based upon an insurer’s alleged failure to

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pay benefits under the terms of an ERISA plan.

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1144(a).

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employer, however, fall under a “safe harbor” provision, and

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are exempt from ERISA coverage.

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Typically, ERISA

29 U.S.C. §

Plans which are not maintained or established by an

29 C.F.R. § 2510.3-1(j).

The “safe harbor” provision does not apply here, as the

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evidence undisputably shows that the LTD Plan .

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specifically states that it falls under ERISA, and further that the

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employer and employee both pay into the plan.

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Since the LTD Plan at issue is an employer-sponsored plan, it does

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fall under ERISA and the “safe harbor” provision does not apply.

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IV.

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The LTD Plan

(AR 1796, 1800.)

CONCLUSION
For the reasons stated above, the Court GRANTS Unum’s motion

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for summary judgment and DENIES Hinshaw’s motion for summary

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judgment.

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IT IS SO ORDERED.

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Dated: May 6, 2015
DEAN D. PREGERSON
United States District Judge

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