Robison v. Life Insurance Company of North America
Filing
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ORDER GRANTING MOTION FOR SUMMARY JUDGMENT by Judge Jon S. Tigar granting 24 Motion for Summary Judgment. (wsn, COURT STAFF) (Filed on 5/3/2016)
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UNITED STATES DISTRICT COURT
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NORTHERN DISTRICT OF CALIFORNIA
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RODNEY ROBISON,
Case No. 15-cv-01331-JST
Plaintiff,
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v.
ORDER GRANTING MOTION FOR
SUMMARY JUDGMENT
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LIFE INSURANCE COMPANY OF
NORTH AMERICA,
Defendant.
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United States District Court
Northern District of California
Re: ECF No. 24
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Before the Court is Defendant Life Insurance Company of North America’s (“LINA”)
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Motion for Summary Judgment. ECF No. 24. The Court will grant the motion.
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I.
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BACKGROUND
Plaintiff Rodney Robison brought this action under the Employee Retirement Income
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Security Act (“ERISA”), 29 U.S.C. § 1001 et seq., seeking to recover accidental death and
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dismemberment benefits allegedly due to him resulting from the death of his stepson, Cody
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Brown, who was killed in an automobile accident on October 27, 2014. ECF No. 16. Mr. Brown
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was born on June 19, 1994. ECF No. 25-1 at 1. He was 20 years and four months old at the date
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of his death.
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At the time of Mr. Brown’s death, Plaintiff was enrolled in an accidental death and
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dismemberment insurance policy (“the Policy”) offered by LINA with a benefit limit of $10,000
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for dependents. ECF No. 25-7 (the Policy); ECF No. 25-8 (enrollment summary). The Policy
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covers “a sudden, unforeseeable, external event that results, directly and independently of all other
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causes, in a Covered Injury or Covered Loss and” occurred “while the Covered Person is insured
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under this Policy.” ECF No. 25-7 at 9. A “Covered Person” is defined as “[a]n eligible person . . .
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for whom an enrollment form has been accepted by [LINA] and required premium has been paid
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when due and for whom coverage under this Policy remains in force. The term Covered Person
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shall include, where th[e] Policy provides coverage, an eligible Spouse and eligible Dependent
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Children.” Id. It is undisputed that Plaintiff submitted an enrollment form for Mr. Brown at least
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as of 2012, ECF No. 25-8, and that all required premiums had been paid when due as of the time
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of the accident on October 27, 2014.
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United States District Court
Northern District of California
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The Policy goes on to define “Dependent Children” as follows:
An Employee’s unmarried child who meets the following
requirements:
1. A child from live birth to 19 years old;
2. A child who is 19 or more years old but less than 23 years old,
enrolled in a school as a full-time student and primarily supported
by the Employee;
3. A child who is 19 or more years old, primarily supported by the
Employee and incapable of self-sustaining employment by reason of
mental or physical handicap. Proof of the child’s condition and
dependence must be submitted to Us within 31 days after the date
the child ceases to qualify as a Dependent Child for the reasons
listed above. During the next two years, We may, from time to time,
require proof of the continuation of such condition and dependence.
After that, We may require proof no more than once a year.
ECF No. 25-7 at 10.
According to the Policy, “[i]nsurance becomes effective for an Employee’s eligible
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dependents if the Employee applies and agrees to make required contributions within 31 days of
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the date his dependents become eligible . . . .” Id. at 10. The Policy provides that “[t]he insurance
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on a Covered Person will end on the earliest date below: . . . 2. the next premium due date after the
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date the Covered Person is no longer in a Covered Class or satisfies eligibility requirements under
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this Policy; . . . 4. the next premium due date after the Covered Person attains the maximum Age
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for insurance under this Policy . . . .” Id. at 13.
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The parties do not dispute that Mr. Brown worked for Certified Tire & Service Center
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(“Certified Tire”) in Livermore, CA from July 9, 2014 to August 5, 2014. ECF No. 24 at 7; ECF
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No. 28 at 6. Nor do the parties dispute that Mr. Brown stopped working at Certified Tire in
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August 2014 due to a work-related back injury. Id. The parties do, however, dispute the extent of
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Mr. Brown’s injuries and the degree to which these injuries rendered Mr. Brown unable to work.1
Plaintiff submitted his claim to LINA on October 31, 2014. ECF No. 25-9 at 1. Plaintiff
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submitted a revised claim form later that same day. Id. at 2–4. LINA wrote Plaintiff several
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letters between November 2014 and December 2015 seeking additional documentation regarding
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Plaintiff’s claim. See, e.g., ECF No. 27-9 at 43; ECF No. 27-2 at 27. On January 12, 2016, LINA
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wrote to Plaintiff, informing him that it had determined that the benefit was not payable. ECF No.
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27-2 at 13–18. The letter included the definition of “Dependent Child” quoted above and
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explained that “Cody Brown was not enrolled in a school as a full-time student at the time of his
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death, nor was he incapable of self-sustaining employment by reason of mental or physical
handicap. He does not meet the definitions of Dependent Child as defined under the
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United States District Court
Northern District of California
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policies . . . .” Id. at 16. The letter also stated that “[t]he available medical records were reviewed
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by staff Medical Director Norton Hall, MD who opined that the ‘clinical notes of Mr. Brown’s
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attending physician, Dr. Ng, of 10/6/16, 9/9/14 and 8/12/14’ were ‘devoid of any documented,
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significant, quantified, positive, neuromusculovasculoskelatal or clinical finding, physical
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impairment or functional loss.” Id.
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II.
JURISDICTION
Plaintiff’s cause of action arises under ERISA, a federal statute. The Court therefore has
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federal question jurisdiction over this matter pursuant to 28 U.S.C. § 1331.
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III.
LEGAL STANDARD
“ERISA was enacted ‘to promote the interests of employees and their beneficiaries in
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employee benefit plans,’ and ‘to protect contractually defined benefits.’” Firestone Tire & Rubber
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Co. v. Bruch, 489 U.S. 101, 113 (1989) (internal citations omitted). ERISA “permits a person
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denied benefits under an employee benefit plan to challenge that denial in federal court.”
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Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 108 (2008). “ERISA’s civil-enforcement
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provision . . . allows a claimant ‘to recover benefits due to him under the terms of his plan [and] to
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Because the Court’s ruling does not turn on the extent of Mr. Brown’s work-related injuries, the
Court will not further analyze the parties’ disputed positions related to Mr. Brown’s work-related
injuries at this juncture.
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enforce his rights under the terms of the plan.’” Muniz v. Amec Const. Mgmt., Inc., 623 F.3d
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1290, 1294 (9th Cir. 2010) (quoting 29 U.S.C. § 1132(a)(1)(B)).
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“[A] denial of benefits challenged under § 1132(a)(1)(B) is to be reviewed under a de novo
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standard unless the benefit plan gives the administrator or fiduciary discretionary authority to
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determine eligibility for benefits or to construe the terms of the plan.” Firestone, 489 U.S. at 115.
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In this case, the parties agree that de novo review is appropriate. See ECF No. 24 at 13; ECF No.
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28 at 5. Under de novo review, “the court simply proceeds to evaluate whether the plan
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administrator correctly or incorrectly denied benefits with no deference given to the
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administrator’s decision.” Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 963 (9th Cir.
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United States District Court
Northern District of California
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2006) (en banc).
ERISA’s “statutory scheme . . . ‘is built around reliance on the face of written plan
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documents.’” U.S. Airways, Inc. v. McCutchen, 133 S. Ct. 1537, 1548 (2013) (quoting Curtiss-
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Wright Corp. v. Schoonejongen, 514 U.S. 73, 83 (1995)). “Courts construe ERISA plans, as they
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do other contracts,” with reference to “ordinary principles of contract interpretation.” U.S.
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Airways, 133 S.Ct. at 1548–49 (2013). Ambiguities are construed against the drafter and in favor
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of the insured. Kearney v. Standard Ins. Co., 175 F.3d 1084, 1090 (9th Cir. 1999). “[W]hen the
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court reviews a plan administrator’s decision under the de novo standard of review, the burden of
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proof is placed on the claimant.” Muniz, 623 F.3d at 1294.
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Summary judgment is proper when a “movant shows that there is no genuine dispute as to
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any material fact and the movant is entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a).
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“A party asserting that a fact cannot be or is genuinely disputed must support the assertion by”
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citing to depositions, documents, affidavits, or other materials. Fed. R. Civ. P. 56(c)(1)(A). A
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party also may show that such materials “do not establish the absence or presence of a genuine
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dispute, or that an adverse party cannot produce admissible evidence to support the fact.” Fed. R.
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Civ. P. 56(c)(1)(B). An issue is “genuine” only if there is sufficient evidence for a reasonable
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fact-finder to find for the non-moving party. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248–
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49 (1986). A fact is “material” if the fact may affect the outcome of the case. Id. at 248. “In
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considering a motion for summary judgment, the court may not weigh the evidence or make
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credibility determinations, and is required to draw all inferences in a light most favorable to the
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non-moving party.” Freeman v. Arpaio, 125 F.3d 732, 735 (9th Cir. 1997).
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Where the party moving for summary judgment would not bear the burden of proof at trial,
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that party bears the initial burden of either producing evidence that negates an essential element of
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the non-moving party’s claim, or showing that the non-moving party does not have enough
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evidence of an essential element to carry its ultimate burden of persuasion at trial. If the moving
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party satisfies its initial burden of production, then the non-moving party must produce admissible
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evidence to show that a genuine issue of material fact exists. See Nissan Fire & Marine Ins. Co. v.
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Fritz Cos., 210 F.3d 1099, 1102–03 (9th Cir. 2000). The non-moving party must “identify with
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United States District Court
Northern District of California
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reasonable particularity the evidence that precludes summary judgment.” Keenan v. Allan, 91
F.3d 1275, 1279 (9th Cir. 1996). Indeed, it is not the duty of the district court to “to scour the
record in search of a genuine issue of triable fact.” Id. “A mere scintilla of evidence will not be
sufficient to defeat a properly supported motion for summary judgment; rather, the nonmoving
party must introduce some significant probative evidence tending to support the complaint.”
Summers v. Teichert & Son, Inc., 127 F.3d 1150, 1152 (9th Cir. 1997) (citation and internal
quotation marks omitted). If the non-moving party fails to make this showing, the moving party is
entitled to summary judgment. Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986).
IV.
Defendant argues that Plaintiff cannot recover under the Policy because “the undisputed
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DISCUSSION
evidence proves that Mr. Brown was not insured under the [] Policy at the time of his death on
October 27, 2014.” ECF No. 24 at 18. According to Defendant, Mr. Brown was covered as a
“Dependent Child” until he turned nineteen, but “coverage terminated shortly after he turned
nineteen years old on June 19, 2013 ‒ which was more than a year and four months before his
accident.” Id.
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The Group Policy defines a “Covered Person” to include “an eligible Spouse and eligible
Dependent Children.” ECF No. 25-7 at 9. “Dependent Children,” in turn, are defined as:
An Employee’s unmarried child who meets the following
requirements:
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1. A child from live birth to 19 years old;
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2. A child who is 19 or more years old but less than 23 years old,
enrolled in a school as a full-time student and primarily supported
by the Employee;
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3. A child who is 19 or more years old, primarily supported by the
Employee and incapable of self-sustaining employment by reason of
mental or physical handicap. Proof of the child’s condition and
dependence must be submitted to Us within 31 days after the date
the child ceases to qualify as a Dependent Child for the reasons
listed above. During the next two years, We may, from time to time,
require proof of the continuation of such condition and dependence.
After that, We may require proof no more than once a year.
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United States District Court
Northern District of California
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Id. at 10.
The parties do not dispute that Mr. Brown turned nineteen on June 19, 2013. ECF No. 24
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at 19; ECF No. 28. Likewise, the parties do not dispute that Mr. Brown was not “enrolled in a
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school as a full-time student” at the time of his death. ECF No. 24 at 19; ECF No. 28 at 4.
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Accordingly, Mr. Brown was not covered as a “Dependent Child” under the first or second prongs
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of the Group Policy’s definition of “Dependent Children.” The parties do, however, dispute
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whether Mr. Brown was covered under the third prong, as a “child who is 19 or more years old,
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primarily supported by the Employee and incapable of self-sustaining employment by reason of
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mental or physical handicap.” ECF No. 25-7 at 10.
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While the Court doubts whether Mr. Brown’s inability to work temporarily due to his
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work-related injuries rendered him “incapable of self-sustaining employment by reason of mental
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or physical handicap,” the Court need not decide this issue because Plaintiff never submitted
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“[p]roof of [Mr. Brown’s purported] condition and dependence . . . within 31 days after the date
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[Mr. Brown] cease[d] to qualify as a Dependent Child” by reason of his turning nineteen, as is
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required by the third prong of the Policy’s definition of “Dependent Children.” Id. As Defendant
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argues, “[n]either Plaintiff nor anyone else submitted any information to LINA within 31 days of
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Mr. Brown’s 19th birthday proving that Mr. Brown was ‘incapable of self-sustaining employment
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by reason of mental or physical handicap.’” ECF No. 24 at 20. Defendant’s argument is
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supported by a letter sent to Plaintiff by an “accident specialist” at Cigna (of which LINA is a
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subsidiary) on September 15, 2015, stating: “[o]ur records indicate that proof of Cody Brown’s
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condition and dependence was not submitted to us after Cody Brown turned age 19 or at any time
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prior to his death.” ECF No. 27-2 at 35.
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Plaintiff does not contend that he submitted proof to LINA of any “mental of physical
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handicap” which Mr. Brown may have had, which could have rendered him “incapable of self-
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sustaining employment” within 31 days after the date Mr. Brown turned nineteen. ECF No. 28 at
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7–8. Rather, Plaintiff argues that the requirement that proof be submitted to LINA within 31 days
“is contrary to the [Group Policy’s separate] provision that ‘insurance becomes effective for an
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United States District Court
Northern District of California
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Employee’s eligible dependents if the Employee applies and agrees to make required contributions
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within 31 days of the date his dependents become eligible . . . .” ECF No. 28 at 7 (quoting ECF
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No. 25-7 at 12). While the Court agrees with Plaintiff that “[t]here is nothing in this [latter]
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provision that requires providing notice of disability,” nothing in the latter provision negates the
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requirement under the third prong of “Dependent Child” definition requiring that “proof of the
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child’s condition and dependence must be submitted to [LINA] within 31 days after the date the
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child ceases to qualify as a Dependent Child” once he turns nineteen.
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Plaintiff also argues that “any requirement for having to [re-enroll a child] into the plan
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[after the child turns nineteen] would not meet the reasonable expectations of the insured.” Id. at
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7. Plaintiff cites no authority on point, except for Peterson v. Am. Life & Health Ins. Co., for the
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general proposition that “[u]nder the ‘reasonable expectations’ doctrine, as a matter of federal
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common law governing ERISA contracts, even an unambiguous exclusion may be unenforceable
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unless it is sufficiently ‘clear, plain, and conspicuous’ to overcome a layperson’s reasonable
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expectations.” 48 F.3d 404, 411 (9th Cir. 1995). However, as Peterson makes clear, the
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reasonable expectations doctrine only applies when “a provision in an insurance policy is . . . not
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sufficiently conspicuous.” Id. Here, the requirement that proof be submitted of a child’s
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condition and dependence within 31 days after the child turns nineteen appears in the sentence
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directly following (and in the same paragraph as) the sentence defining “Dependent Children” to
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include “[a] child who is 19 or more years old, primarily supported by the Employee and
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incapable of self-sustaining employment by reason of mental or physical handicap.” ECF No. 25-
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7 at 10. Accordingly, the Court concludes that the proof requirement is sufficiently conspicuous
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that the reasonable expectations doctrine does not apply.
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Given that Plaintiff bears the burden of proof to show that benefits were due to him under
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the Policy, Muniz, 623 F.3d at 1294, the Court concludes that Plaintiff’s claim fails because he has
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not presented the Court with any evidence that he submitted proof of Mr. Brown’s “condition and
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dependence” within 31 days of his nineteenth birthday as required by the Policy. See Staats v.
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Goodyear Tire & Rubber Co., No. 05-cv-1386, 2006 WL 2707969, at *4 (N.D. Cal. Sept. 19,
2006) (granting defendant’s motion for summary judgment in ERISA case based on the fact that
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United States District Court
Northern District of California
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“even if the plaintiff’s daughter’s condition had sufficiently changed by the summer of 2002, and
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the change was properly documented, so that she was eligible based on the disabling condition for
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continued medical coverage, the plaintiff failed to provide the defendant with the required notice
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of her changed status within 31 days of its occurrence.”). Because no genuine issue of material
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fact exists regarding Mr. Brown’s not being covered by the Policy as a “Dependent Child,” the
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Court grants Defendant’s motion for summary judgment.
CONCLUSION
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Defendant’s motion for summary judgment is granted.
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IT IS SO ORDERED.
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Dated: May 3, 2016
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JON S. TIGAR
United States District Judge
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