Basham v. Prudential Insurance Company of America

Filing 87

MEMORANDUM OPINION AND ORDER by Senior Judge Charles R. Simpson, III on 2/21/2014 - Bashams 72 Motion for Judgment as a Matter of Law is DENIED, matter shall be REMANDED to Prudential for a full and fair review of Bashams LTD claim. As a result, the following motions are hereby DISMISSED AS MOOT: 73 Bashams Motion for Hearing regarding her Motion for Judgment as a Matter of Law; 76 Prudentials Motion to Exclude Evidence from Outside the Administrative Record; 80 Bashams Motion for Lea ve to File a Sur-Reply to Prudentials Reply in Support of its Motion to Exclude Evidence from Outside the Administrative Record; 81 Prudentials Motion for Leave to File a Sur-Reply to Bashams Reply in Support of her Motion for Judgment as a Matter of Law.cc:counsel (DAK)

UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF KENTUCKY
AT LOUISVILLE
DENISE R. BASHAM

PLAINTIFF

v.

CIVIL ACTION NO. 3:11-CV-00464-CRS

PRUDENTIAL INSURANCE
COMPANY OF AMERICA

DEFENDANT

MEMORANDUM OPINION AND ORDER
This matter is before the Court on the following motions:
1) Plaintiff Denise R. Basham’s (“Basham”) Motion for Judgment as a Matter of
Law (DN 72);
2) Basham’s Motion for Hearing regarding her Motion for Judgment as a Matter
of Law (DN 73);
3) Defendant Prudential Insurance Company of America’s (“Prudential”) Motion
to Exclude Evidence from Outside the Administrative Record (DN 76);
4) Basham’s Motion for Leave to File a Sur-Reply to Prudential’s Reply in
Support of its Motion to Exclude Evidence from Outside the Administrative
Record (DN 80);
5) Prudential’s Motion for Leave to File a Sur-Reply to Basham’s Reply in
Support of her Motion for Judgment as a Matter of Law (DN 81).
For the reasons set forth in this opinion, the Court will deny the motion for judgment as a
matter of law, and will instead remand to Prudential for a full and fair review of Basham’s LongTerm Disability claim. As explained below, this disposition will moot the remaining motions
submitted for the Court’s decision.

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BACKGROUND
Unless otherwise indicated, the following facts are undisputed. Basham is a former
employee of Harrah’s Operating Company, Inc. (“HOC”), where she worked as a retail
supervisor. As part of its employee benefits program, HOC sponsored Short-Term Disability
(“STD”) as well as Long-Term Disability (“LTD”) benefits. While Prudential both administers
and insures HOC’s LTD benefits, HOC self-insures its STD benefits, for which Prudential
merely acts as administrator.
On April 6, 2010, Basham was forced to stop working due to a variety of medical issues,
including depression, anxiety, migraines, irritable bowel syndrome, muscle pain, and an inability
to concentrate. In accordance with Prudential’s instructions, Basham shortly thereafter filed a
claim for STD benefits by submitting an Attending Physician’s Statement (“APS”), an
Employee’s Statement, and an Employer’s Statement.1 After reviewing Basham’s application,
Prudential informed her by letter dated April 16, 2010, that her STD benefits had been approved
beginning April 21, 2010, and continuing through May 18, 2010. On May 10, 2010, Basham’s
Attending Physician Dr. Ellen Knox (“Dr. Knox”) submitted a second APS listing Basham’s
expected return-to-work date as July 1, 2010. Based on the second APS, Prudential informed
Basham by letter dated May 14, 2010, that her STD benefits had been extended until June 30,
2010, at which point they would expire. Also included in the letter was information regarding
Basham’s right to appeal Prudential’s determination as well as an explanation of the procedures
necessary for doing so.
On June 8, 2010, Basham attempted to apply for LTD benefits by faxing Prudential
another APS prepared by Dr. Knox which changed her expected return-to-work date to “unable

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The record is unclear regarding the order in which Basham submitted these items, or whether Prudential actually
obtained some of these items on Basham’s behalf. However, it is undisputed that Prudential received all forms
necessary to properly file Basham’s claim for STD benefits.

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[to determine] at this time.” (D107–09). On June 9, 2010, Basham called Prudential to confirm
that it had received her fax. After a Prudential representative confirmed that Prudential had
received the APS, Basham asked to speak to Prudential’s Disability Claims Manager Russell
Lashua (“DCM Lashua”) about her claim for LTD benefits, at which point the representative
transferred Basham to DCM Lashua’s voicemail.
Having not heard back from DCM Lashua, on June 10, 2010, Basham emailed Prudential
to once again inquire about the status of her LTD claim. In her e-mail, Basham specifically stated
that “I have sent in an application to apply for Long Term Disability faxed from Dr. Ellen Knox
on June 8, 2010.” (D170). That same day, Prudential Representative Eileen Valentino responded
to Basham’s e-mail stating that “the information you provided for claim number 113243642 was
forwarded to the claims manager for review.” (D170–71).
On June 24, 2010, DCM Lashua left a message on Basham’s voicemail acknowledging
receipt of the APS on June 8, 2010, but requesting additional medical documentation to support
Basham’s claim that she would remain disabled beyond June 30, 2010. That same day,
Prudential sent Basham a letter informing her that additional medical support would be required
within 15 days in order to re-open her STD claim. At no point in either the voicemail or the letter
did DCM Lashua inform Basham that additional medical evidence would be required in order for
her to proceed with her LTD claim.
On July 6, 2010, DCM Lashua sent Basham an identical letter once again instructing her
to provide additional medical documentation in support of her STD claim. Like the letter dated
June 24, 2010, this letter made no mention of Basham’s LTD claim and did not inform her that
additional medical evidence would be required in order for her to proceed with her LTD claim.
On August 9, 2010, DCM Lashua sent a final letter to Basham informing her of Prudential’s

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This is the claim number for Basham’s STD claim.

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denial of her claim for STD benefits and providing information related to the procedures for
filing an appeal. Once again, this letter made no mention of Basham’s LTD claim.
PROCEDURAL HISTORY
On August 16, 2011, Basham filed the present action against Prudential seeking recovery
of past-due STD and LTD benefit payments, as well as attorneys’ fees, costs, and pre- and postjudgment interest, based on the following legal theories: 1) breach of contract under 29 U.S.C. §
1132(a)(1)(B); (2) breach of fiduciary duty under 29 U.S.C. § 1132(a)(3); and 3) entitlement to
attorneys’ fees and costs under 29 U.S.C. § 1132(g). (DN 1).
On December 6, 2011, Prudential filed a motion for judgment on the pleadings arguing
that: 1)  Basham’s STD benefits are self-funded by HOC, meaning that Prudential is not
responsible for payment thereof and thus cannot be liable for STD benefit payments allegedly
owed to Basham; and (2) that Basham’s breach of fiduciary duty claim is not viable under 29
U.S.C. § 1132(a)(3) because the remedy for failure to pay benefits due under an ERISAgoverned plan requires a claim under 29 U.S.C. § 1132(a)(1)(B). (DN 14).
On January 13, 2012, prior to the resolution of Prudential’s Motion for Judgment on the
Pleadings, Basham filed a motion to amend complaint wherein she voluntarily abandoned her
breach of contract claim with respect to STD benefit payments as well as her claim for breach of
fiduciary duty under 29 U.S.C. § 1132(a)(3). (DN 23). In lieu thereof, Basham’s Amended
Complaint asserted state common law claims for breach of duty of good faith and fair dealing
and tortious interference with contract. As a result, Basham’s only remaining claims were her
claim for LTD benefits, her claim for attorneys’ fees and cost under 29 U.S.C. § 1132(g), and the
substituted state-law claims.

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On February 20, 2012, Basham filed a motion to remand for a full and fair review of her
LTD claim. (DN 27). In response, Prudential filed a motion for summary judgment arguing that
Basham failed to exhaust her administrative remedies with respect to her LTD claim. (DN 32).
After extensive discovery, on November 20, 2012, the Court addressed the abovementioned motions in a Memorandum Opinion. (DN 61). While granting Basham’s Motion to
Amend Complaint to the extent it withdrew her claim for STD benefits and her breach of
fiduciary duty claim under 29 U.S.C. § 1132(a)(3), we held that Basham’s substituted state-law
claims were preempted by ERISA. Concluding that they were mooted by this disposition, we
refused to consider Basham’s Motion to Remand for Full and Fair Review as well as Prudential’s
Motion for Summary Judgment.
On May 31, 2013, Basham filed a motion for judgment as a matter of law (DN 72), as
well as a motion for a hearing thereon (DN 73), arguing that there was no genuine dispute of
material fact regarding her entitlement to LTD benefits. In support of her motion, Basham
attached several documents which were not included in the Administrative Record. In response,
Prudential filed a motion to exclude evidence from outside the administrative record arguing that
the Court’s decision on Basham’s Motion for Judgment as a Matter of Law must be based
exclusively on materials contained in the Administrative Record. (DN 76). After extensive
briefing on these motions, Basham filed a motion for leave to file a sur-reply (DN 80) with
respect to Prudential’s Motion to Exclude Evidence from Outside the Administrative Record,
and Prudential filed a motion for leave to file a sur-reply (DN 81) with respect to Basham’s
Motion for Judgment as a Matter of Law.
Having considered the parties’ briefs and being otherwise sufficiently advised, the Court
will now address the motions submitted for decision.

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STANDARD
The Secretary of Labor has defined the minimum requirements for employee-benefits
claims procedures as including reasonable procedures for the filing of claims, notification of
decisions, and appeals. 29 C.F.R. § 2560.503-1(a)–(b). Reasonable claim procedures are
procedures that “do not contain any provision, and are not administered in any way, that unduly
inhibits or hampers the initiation or processing of claims for benefits.” 29 C.F.R. § 2560.5031(b)(3). Importantly, ERISA regulations require the claims administrator to notify a claimant of
an adverse benefit determination within forty-five (45) days of receiving a claim for disability
benefits. 29 C.F.R. § 2560.503–1(f)(3).
Furthermore, pursuant to 29 C.F.R. § 25 60.503–1(h)(1), every employee benefits plan
must have a procedure under which the participant can appeal an adverse benefit determination
and have the opportunity for a full and fair review of the decision. “[T]he claims procedures of a
plan will not be deemed to provide a claimant with reasonable opportunity for a full and fair
review of a claim and adverse benefits determination unless the claim procedures” provide the
following:
(1) 180 days to appeal the determination;
(2) an opportunity for the claimant to “submit written comments, documents, records, and
other information relating to the claim for benefits;”
(3) access, upon request by the claimant, to all information relevant to his or her claim;
(4) a “review that takes into account all comments, documents, records, and other
information submitted by the claimant relating to the claim, without regard to whether
such information was submitted or considered in the initial benefit determination”;
(5) a review that does not afford deference to the initial adverse benefit determination;
(6) identification of medical experts consulted; and
(7) consultation by a medical consultant who was not consulted in connection with the
adverse benefit determination.
See 29 C.F.R. § 2560.503–1(h)(2) & (3).
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DISCUSSION
Three considerations have persuaded the Court that remand to Prudential for a full and
fair review of Basham’s LTD claim is both necessary and appropriate. First, contrary to
Prudential’s repeated objections, Basham properly filed her LTD claim for Prudential’s review.
Second, despite the fact that it was properly filed, and in direct violation of ERISA regulations,
Prudential never rendered a decision on Basham’s LTD claim. Finally, as a result of the
foregoing, the administrative record contains little information related to Basham’s LTD claim,
making remand to Prudential for further development thereof particularly appropriate.
i. Basham properly filed her LTD claim
Perhaps the most vigorously contested issue in this case has been whether Basham
properly filed her LTD claim by complying with Prudential’s requirements for doing so.
According to Prudential, Basham did not properly file her LTD claim because she failed to
successfully appeal its denial of her STD claim. While conceding that she did not successfully
appeal Prudential’s denial of her STD claim, Basham argues that she nevertheless complied with
Prudential’s requirements for filing an LTD claim by submitting an APS, Employee’s Statement,
and Employer’s Statement specifically directed to her LTD claim. In response, Prudential argues
that, even were this the proper method for filing an LTD claim, Basham failed to submit an
Employer’s Statement and therefore did not properly file her LTD claim.
Despite Prudential’s arguments to the contrary, the Administrative Record supports
Basham’s argument that she properly filed her LTD claim. Although not itself part of the
Administrative Record, a document entitled “Disability Claim Instructions” clearly establishes
that the only requirement for filing an LTD claim is the proper filing of an STD claim.
Specifically, the document states in pertinent part that:

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If you have Short-Term Disability (STD) coverage with Prudential, your
claim for STD benefits will be considered filed, when you meet both of these
two criteria: 1) We receive the Employee’s Statement, the Employer’s
Statement, and the Attending Physician’s Statement; 2) Your STD elimination
period has started.
If you have Long-Term Disability (LTD) coverage with Prudential, your
claim for LTD benefits will be considered filed, when you meet both of these
two criteria: 1) We receive the Employee’s Statement, the Employer’s
Statement, and the Attending Physician’s Statement; 2) The date is 45 days
before the end of your LTD elimination period.
If you have both STD and LTD coverages with Prudential, and you have filed
a claim for STD, there is no need to resubmit the statements noted above for
the LTD portion of your claim. Your claim for LTD benefits, in this case, will
be considered filed, when you meet both of these two criteria: 1) We receive
the Employee’s Statement, the Employer’s Statement, and the Attending
Physician’s Statement; 2) The date is 45 days before the end of your LTD
elimination period.
(Disability Claim Instructions, DN 72-10, at 1) (emphasis added) (edited for clarity). While not
disputing that it created this document, Prudential argues that the Court should refuse to consider
it in determining whether Basham properly filed her LTD claim because it is not contained in the
Administrative Record and therefore not properly considerable to the extent the Court’s review
must be restricted to the four corners of the Administrative Record.
Although Prudential is correct that the document itself is not contained in the
Administrative Record, the Court nevertheless concludes that it is properly considerable in
determining whether Basham properly filed her LTD claim. In its letter dated May 14, 2010,
Prudential referred Basham to its website http://www.prudential.com/mybenefits for information
related to her claim for disability benefits. Notably, this same website address appears not only in
this letter, but also in the header of every single letter Prudential sent to Basham regarding her
disability benefits, as well as the header of the critical “Disability Claim Instructions” document.
Although neither Basham nor Prudential so suggest, the Court can only presume that Basham
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obtained the “Disability Claims Instructions” document from this website. The document is
clearly intended to provide information for disability claimants, and thus would most likely be
located on a website specifically designed for use by disability claimants. Furthermore, it is
common practice for web developers to include the web address from which a document is
obtained in either the header of footer of the document as a means of identifying the document’s
source. Based on these considerations, as well as the fact that Prudential’s logo and copyright
information appears throughout the document, the Court concludes that Prudential referred
Basham to the document and therefore must abide by its terms. Because the document is highly
relevant, Prudential cannot now expect the Court to ignore it in determining whether she
properly filed her LTD claim.
Based on the plain language of the “Disability Claims Instructions” document, the Court
concludes that Basham properly filed her LTD claim. As clearly stated therein:
If you have both STD and LTD coverages with Prudential, and you have filed a
claim for STD, there is no need to resubmit the statements noted above for the
LTD portion of your claim. Your claim for LTD benefits, in this case, will be
considered filed, when you meet both of these two criteria: 1) We receive the
Employee’s Statement, the Employer’s Statement, and the Attending Physician’s
Statement; 2) The date is 45 days before the end of your LTD elimination period.
Because it is undisputed that Basham properly filed her STD claim by submitting an APS,
Employee’s Statement, and Employer’s Statement, her LTD claim should have been “considered
filed” along with STD claim.3 Therefore, Prudential’s argument that Basham failed to properly
file her LTD claim is unavailing.

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As Prudential has pointed out several times in its briefs, this Court previously determined that “we do not see any
proof that [Basham] ever filed a LTD benefits claim.” (Memorandum Opinion, DN 61, at 4–5). Importantly,
however, this statement was made before Plaintiff had provided the critical “Disability Claims Instructions”
document clearly outlining the requirements for filing an LTD claim. Without this document, the Court could not
have possibly divined that there was an alternative method for filing an LTD claim other than successfully appealing
the denial of STD benefits. Accordingly, the Court will not bind itself to this prior determination.

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ii. Prudential violated applicable ERISA regulations by failing to render a decision on her
LTD claim
Having properly filed her LTD claim, Basham was entitled to a decision thereon pursuant
to 29 C.F.R. § 2560.503–1(f)(3)’s provision that “[i]n the case of a claim for disability benefits,
the plan administrator shall notify the claimant… of the plan's adverse benefit determination
within a reasonable period of time, but not later than 45 days after receipt of the claim by the
plan.” Furthermore, 29 C.F.R. § 2560.503–1(g) requires that “[t]he notification shall set forth, in
a manner calculated to be understood by the claimant:
(i) The specific reason or reasons for the adverse determination;
(ii) Reference to the specific plan provisions on which the determination is based;
(iii) A description of any additional material or information necessary for the claimant to
perfect the claim and an explanation of why such material or information is necessary;
(iv) A description of the plan's review procedures and the time limits applicable to such
procedures, including a statement of the claimant's right to bring a civil action under
section 502(a) of the Act following an adverse benefit determination on review…
Although Prudential fully complied with these provisions in rendering its decision on Basham’s
STD claim, it wholly failed to do so with respect to her LTD claim. Thus, Basham never
received notice of Prudential’s adverse determination on her LTD claim, the reasons therefor, or
a request for additional material information necessary to perfect her claim. Because this failure
clearly violated applicable ERISA regulations, the only remaining question is the appropriate
remedy.
iii. The proper remedy for Prudential’s violation of 29 C.F.R. § 2560.503–1(f)(3) is remand
to Prudential for a full and fair review of Basham’s LTD claim
Having determined that Basham properly filed her LTD claim and that Prudential violated
29 C.F.R. § 2560.503–1(f)(3) by failing to render a decision thereon, the question now becomes
how to remedy the resulting stalemate between the parties. There are two possible alternatives:

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we could either remand to Prudential for a full and fair review of Basham’s LTD claim or render
a de novo determination regarding Basham’s entitlement to LTD benefits. For reasons similar to
those set forth in Hackney v. Lincoln Nat. Life Ins. Co., No. 3:11-CV-268-TBR, 2012 WL 13343
(W.D. Ky. Jan. 4, 2012), the Court will remand to Prudential for a full and fair review of
Basham’s LTD claim.
In Hackney, the plaintiff filed suit against the claims administrator following its failure to
render a decision on his claim for LTD benefits. See id. at *2. Because the administrator’s failure
to render a decision amounted to a clear violation of 29 C.F.R. § 2560.503–1(f)(3), the only
question was the appropriate remedy. While the plaintiff argued that the court should make a de
novo determination regarding his eligibility for LTD benefits, the claims administrator argued
that the court should remand the case for a decision on the plaintiff’s LTD claim in the first
instance. In concluding that remand was appropriate, the court relied heavily on Elliot v. Metro.
Life Ins. Co., 473 F.3d 613 (6th Cir. 2006), and Shelby Cnty. Healthcare Corp. v. Majestic Star
Casino, LLC Group Health Benefit Plan, 581 F.3d 355 (6th Cir. 2009).
“Elliott… stands for the proposition that remand [to the claims administrator] is the
appropriate remedy where a claimant is denied LTD benefits because of a problem ‘with the
integrity of [the plan's] decision-making process....’” Hackney, 2012 WL 13343 at *4 (quoting
Elliot, 473 F.3d at 622). In Elliott, the plaintiff sued her claims administrator following its denial
of her claim for LTD benefits as well as her subsequent appeal. After reviewing the
administrator’s decisionmaking process, the Sixth Circuit held that its denial of the plaintiff’s
LTD benefits was arbitrary and capricious insofar as it “was neither deliberate nor based on
reasoning.” Elliot, 473 F.3d at 621. Having so held, the court next addressed whether it should
either “award benefits to the claimant or remand to the plan administrator.” Id. Ultimately, the

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court chose to remand to the administrator, explaining that “where the problem is with the
integrity of the plan's decision-making process, rather than that a claimant was denied benefits to
which he was clearly entitled, the appropriate remedy generally is remand to the plan
administrator.” Id. at 622 (internal quotation marks and alterations omitted) (emphasis added). In
Hackney, the court cited Elliot for the proposition that “[w]here an insurance company's
decision-making process was plagued by procedural errors, the claim should be remanded for a
more complete review.” Hackney, 2012 WL 13343 at *4. Accordingly, the court concluded that
the administrator’s failure to render a decision on the plaintiff’s LTD benefits warranted remand
for a full and fair review. See id. at 4–5.
In addition to Elliott, Hackney also relied heavily on the Sixth Circuit’s decision in
Shelby Cnty. Healthcare Corp. v. Majestic Star Casino, LLC Group Health Benefit Plan, 581
F.3d 355 (6th Cir. 2009). In Majestic Star, the court followed Elliott in holding that “[r]emand ...
is appropriate in a variety of circumstances, particularly where the plan administrator's decision
suffers from a procedural defect or the administrative record is factually incomplete.” Id. at 373.
Specifically, the court enumerated three circumstances in which remand is appropriate:
First, a claim should be remanded where “the plan administrator fails to comply
with ERISA's appeal-notice requirements in adjudicating a participant's claim ...
‘so that a full and fair review can be accomplish.’” Second, a claim should be
remanded where “the plan administrator merely ‘fail[ed] ... to explain adequately
the grounds of [its] decision.’” Finally, outside of “procedural irregularities, an
incomplete factual record provides a basis to remand the case to the plan
administrator.”
Hackney, 2012 WL 13343 at *5 (quoting Majestic Star) (citations omitted).
In Hackney, the court concluded that “[a]ll three remand-warranting situations outlined in
Majestic Star are present in this case.” Hackney, 2012 WL 13343 at *5. First, the court noted
that, “although this is a not a case where a plan administrator violated ERISA's appeal-notice

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requirements, it is a situation in which the plan administrator violated ERISA's initial notice
requirement contained in 29 C.F.R. § 2560.503–1(f)(3).” Reasoning that there was no
justification for treating such a violation differently from procedural violations related to an
administrative appeal, the court concluded this factor weighed in favor of remand. Id. Second, to
the extent “[the] plan administrator never rendered a benefits determination,” the court
concluded that the claims administrator had failed to adequately explain the grounds therefor. Id.
Finally, the court explained that “this case is in a nascent stage with only a partial administrative
record,” meaning that “[a]ny de novo decision… would necessarily involve evidentiary matters
that would best be resolved by the administrative process conducted by the claims
administrator.” Id. Based on these considerations, the court explained that “remand to the claims
administrator for a full review consistent with the terms of the policy is the best remedy for a
violation of the ERISA regulations resulting from an employee's procedural error.” Hackney,
2012 WL 13343 at *4. Accordingly, the court remanded to the claims administrator for a full and
fair review of the plaintiff’s LTD claim.  
Like Hackney, all three remand-warranting situations outlined in Majestic Star
weigh in favor of remanding Basham’s LTD claim to Prudential for a full and fair review.
First, Prudential clearly failed to comply with ERISA’s initial-notice requirement insofar
as it never notified her regarding its “decision” on her LTD claim. Although it is true that
Majestic Star only referenced an administrator’s failure to comply with ERISA’s appealnotice requirement, the Court agrees with Hackney that there is no significant distinction
between the two that might justify treating them differently. Second, by failing to render
a decision in the first place, Prudential certainly did not “explain adequately the grounds
of [its] decision.” Finally, although the record is replete with information related to

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Basham’s STD claim, there is considerably less information concerning her LTD claim.
Indeed, beyond Basham’s initial application materials, there is nothing in the record
related to Basham’s LTD claim. Without a more developed factual record, remand is
particularly appropriate because the Court lacks both the information and expertise
necessary to make a decision on Basham’s LTD claim in the first instance.
Accordingly, IT IS HEREBY ORDERED that Basham’s Motion for Judgment as a
Matter of Law is DENIED, and that this matter shall be REMANDED to Prudential for a full
and fair review of Basham’s LTD claim consistent with the terms of the policy. As a result, the
following motions submitted for the Court’s decision are hereby DISMISSED AS MOOT:
1) Basham’s Motion for Hearing regarding her Motion for Judgment as a Matter of Law
(DN 73);
2) Prudential’s Motion to Exclude Evidence from Outside the Administrative Record
(DN 76);
3) Basham’s Motion for Leave to File a Sur-Reply to Prudential’s Reply in Support of
its Motion to Exclude Evidence from Outside the Administrative Record (DN 80);
4) Prudential’s Motion for Leave to File a Sur-Reply to Basham’s Reply in Support of
her Motion for Judgment as a Matter of Law (DN 81).

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February 21, 2014

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