Krysztofiak v. Boston Mutual Life Insurance Co.

Filing 55

MEMORANDUM OPINION (c/m to Plaintiff 9/16/22 sat). Signed by Judge Deborah K. Chasanow on 9/16/2022. (sat, Chambers)

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 1 of 21

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF MARYLAND
:

DANA KRYSZTOFIAK

:

v.

:

Civil Action No.

DKC 19-879

:

BOSTON MUTUAL LIFE INSURANCE
COMPANY

:

MEMORANDUM OPINION
Pending

in

this

case

brought

pursuant

to

the

Employee

Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001,
et seq., challenging denial of disability benefits, are the motion
for summary judgment filed by Plaintiff Dana Krysztofiak, (ECF No.
44), and the cross motion for summary judgment filed by Defendant
Boston Mutual Life Insurance Company, (ECF No. 52).
have

been

necessary.

briefed.

The

court

Local Rule 105.6.

now

rules,

no

The issues

hearing

being

For the following reasons, the

motion for summary judgment filed by Ms. Krysztofiak will be denied
and the cross motion for summary judgment filed by Boston Mutual
will be granted in part.

Once Plaintiff’s counsel situation is

resolved, the case will be remanded to the claim administrator.
I.

Background
Unless otherwise noted, the following facts are undisputed.

This case involves Ms. Krysztofiak’s attempts to obtain disability
benefit payments from Defendant Boston Mutual.

The facts of this

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 2 of 21

litigation

are

recited

opinions.

(See ECF Nos. 20; 28; 39).

from fibromyalgia.

in

more

detail

in

the

court’s

prior

Ms. Krysztofiak suffers

She first claimed disability benefits as of

December 29, 2016, under a group long term disability insurance
policy issued by Defendant Boston Mutual Life Insurance Company to
Homecare Maryland, LLC [Policy No. 0054697-00001] (“the Policy”).
Boston Mutual initially awarded her disability benefits.
one year, however, the benefits were terminated.

After

She subsequently

filed this case.
There are two types of disability benefits at issue.
is

no

question

occupation”

about

definition

the
of

first,

benefits

disability.

under

The

the

court

There

“regular

previously

determined Ms. Krysztofiak was entitled to benefits under that
definition.

(ECF Nos. 20 and 21).

Those benefits were available

to Ms. Krysztofiak for up to twenty-four months and have now been
paid.

The

second

type,

benefits

under

the

definition of disability, remain in dispute.
potentially

available

to

Ms.

Krysztofiak

“any

occupation”

Those benefits are
after

the

initial,

“regular occupation” benefits have been exhausted. 1
In their papers, the parties cite to the Policy. Or what
they say is the Policy.
When reciting the definitions of
disability, Plaintiff cites to Administrative Record (“AR”) 7140,
which is located at ECF No. 50-5, at 213. (ECF No 44-1, at 2 n.2).
When citing to the “pre-remand Policy,” Plaintiff cites the preremand administrative record at AR1508-63, which is located at ECF
No. 11-15, at 55-110. (ECF No. 53, at 1-2). The last three pages
of that second citation appear to be part of a different document,
1

2

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 3 of 21

In June 2020, the case was remanded to Disability Reinsurance
Management

Services,

Inc.

(“DRMS”),

Boston

Mutual’s

claim

administrator, for a full and fair review to determine whether Ms.
Krysztofiak was disabled within the meaning of the “any occupation”
definition of disability.

(ECF No. 33, at 2).

DRMS denied Ms. Krysztofiak’s application for benefits under
the “any occupation” definition of disability on September 26,
2020.

(ECF No. 50-1, at 110-14) (Administrative Record (“AR”)

5321-25).

Ms. Krysztofiak appealed the denial, (ECF No. 50-1, at

85) (AR5296).
appeal.

DRMS, however, never decided the administrative

After DRMS took longer than it was permitted to decide

the appeal, (see e.g., ECF No. 39, at 2-3), Ms. Krysztofiak filed
a motion to reopen the case, (ECF No. 34), which was granted, (ECF
Nos. 39 and 40).
Ms. Krysztofiak filed a motion for summary judgment, (ECF No.
44), and Boston Mutual filed a cross motion for summary judgment,
(ECF No. 52).

The parties respectively opposed each other’s

but the remainder of the citation appears to be what Plaintiff
intended to cite. Similarly, Defendant cites to AR5406 for the
definitions of disability, which is located at ECF No. 50-1, at
195. (ECF No. 52-1, at 5). These references are, in part, to
provisions of the Certificate of Coverage for Disability
Insurance, not the actual Policy.
On remand, the claim
administrator must be careful to interpret the terms of the Policy.
Should this case once more be subject to judicial review, the
parties should be careful to cite to the Policy.
3

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 4 of 21

motions and replied in support of their own.

(ECF Nos. 52; 53;

54).
In its cross motion for summary judgment, Boston Mutual
asserts that the Policy contains a “Special Conditions Limitation
Rider”

(“the

Rider”)

which

limits

disability

benefits

for

fibromyalgia to twenty-four months, which Ms. Krysztofiak has
already received. 2

(ECF No. 52-1, at 4).

As Ms. Krysztofiak

explains, this Rider was not present in the Policy when this case
was remanded in June 2020.

(ECF No. 53, at 1).

Policy was amended in 2020 to add the Rider.
was

supposed

beginning,

to

but

have

was

been

omitted

included
due

to

in
an

Instead, the

Apparently, the Rider
the

Policy

unknown

or

from

the

unexplained

mistake.
In August 2018, DRMS realized that the Policy issued to Ms.
Krysztofiak’s employer was priced to include the twenty-four-month
Special Conditions Limitation, but that the Policy did not include
that provision.

(ECF No. 50-1, at 228) (AR5439).

It does not

appear that any action was taken at that time to remedy the missing

This appears to be the first time that Boston Mutual has
formally raised the Rider as a ground for denying Ms. Krysztofiak’s
claim either on administrative or judicial review. Boston Mutual
did reference the Rider and its potential impact on Ms.
Krysztofiak’s claim in its opposition to Ms. Krysztofiak’s motion
to reopen, (ECF No. 37, at 4), but it did so as part of its
recitation
of
the
communications
between
DRMS
and
Ms.
Krysztofiak’s
counsel
during
the
ultimately
unresolved
administrative appeal.
2

4

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 5 of 21

Special Conditions provision.

Two years later, in August 2020, a

senior claims manager for DRMS was reviewing Ms. Krysztofiak’s
eligibility for continued coverage under the Policy.

The senior

claims manager confirmed that there was no Special Conditions
provision in the Boston Mutual policy, although there had been
such a provision in the “prior carrier’s plan.”
314) (AR5525).

(ECF No. 50-1, at

The senior claims manager recommended notifying

“Plan Services” and asking them to “correct the UW coding to
reflect no special conditions limitation.”
Instead,

by

the

next

day,

the

Plan

(Id.).
had

apparently

“corrected” to include the Special Conditions provision.

been

A lead

policy administrator for DRMS informed another DRMS employee that
Ms. Krysztofiak’s employer “was quoted and issued with 24 mo
lifetime benefit for the Spec Cond.”
(AR5388).

(ECF No. 50-1, at 177)

The lead policy administrator attached a copy of the

“corrected cert with the benefit included” and an email from a
Boston Mutual employee confirming that the employee was having the
“cert corrected to include 24 mo Spec Cond.”

(Id.).

The Special Conditions Limitation Rider states:
All other provisions under this policy apply
to this Rider unless modified in this Rider.
SPECIAL CONDITIONS WILL HAVE A MAXIMUM PERIOD
OF PAYMENT.
If you are disabled and meet the eligibility
requirements of this contract, the lifetime
5

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 6 of 21

maximum period of payment for all disabilities
due to special conditions is 24 months.
Only 24 months of benefits will be paid for
any combination of such disabilities even if
the disabilities:
1. are not continuous; and/or
2. are not related.
We will continue to send you payments beyond
the 24 month period if you meet one or both of
these conditions:
1. If you are
health facility
of the 24 month
to send you
confinement.

confined to a hospital,
or institution at the end
period, we will continue
payment(s) during your

If you are still disabled when you are
discharged, we will send you payment(s)
for a recovery period of up to 90 days.
If you become reconfined at any time
during the recovery period and remain
confined for at least 14 days in a row,
we will send payment(s) during that
additional
confinement
and
for
one
additional recovery period up to 90 more
days.
2. In addition to item 1, if you continue
to be disabled after the 24 month period,
and subsequently become confined to a
hospital,
health
facility,
or
institution for at least 14 days in a
row, we will send payment(s) during the
length of the reconfinement.
We will not make payments beyond the limited
pay period as indicated above, or the maximum
period of payment, whichever comes first.
DEFINITIONS
. . .
6

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 7 of 21

Special Conditions means:
. . .
3.

Fibromyalgia

(ECF No. 50-1, at 222-23) (AR5433-34)(emphasis in original).
The first page of the pre-remand Policy states “[t]his policy
may be changed in whole or in part.”
(AR1508

(pre-remand

Disability

AR)). 3

Insurance

The

similarly

(ECF No. 11-15, at 55)

Certificate
states

of

“[i]f

Coverage

the

terms

for
and

provisions of the certificate of coverage issued to you differ
from the policy issued to the Policyholder, the policy will govern.
Your coverage may be canceled or changed in whole or in part under
the terms and provisions of the policy.”

(ECF No. 11-15, at 65)

(AR1518) (emphasis added).
DRMS did not reference the Rider in its September 26, 2020,
denial of Ms. Krysztofiak’s claim for Long Term Disability benefits
under the “any occupation” definition of disability.
1, at 110-14) (AR 5321-25).
the

Rider’s

existence

after

(ECF No. 50-

DRMS did notify Ms. Krysztofiak of
she

initiated

her

administrative

appeal, (ECF No. 37-1, at 6), but it never issued a decision on
Ms. Krysztofiak’s appeal.

The bates numbers are different between the administrative
record filed in 2019 and the updated administrative record filed
in 2022.
3

7

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 8 of 21

II.

Remand
Usually merits issues would be resolved before determining

whether remand is appropriate.

The unusual procedural nature of

this case requires a different approach.

Typically, a court

reviews the decision of the defendant or its claim administrator
after one of them issues a decision on an administrative appeal.
Here, however, there is no administrative appeal decision for the
court to review.

Moreover, Boston Mutual has raised a basis for

denying Ms. Krysztofiak’s claim which was not a basis for DRMS’s
denial of Ms. Krysztofiak’s claim in 2020.

That basis is the

Special Conditions Limitation Rider which, if found applicable to
Ms.

Krysztofiak’s

dispute.

claim,

would

seem

to

resolve

the

parties’

The court, for the reasons below, will remand this case

for a full and fair review of the Special Conditions Limitation
Rider. Before remanding, the court will resolve the legal disputes
between the parties regarding amendments to an ERISA governed
welfare benefits plan.
It is left to the court’s discretion whether to remand the
case to the plan administrator.

See Champion v. Black & Decker

(U.S.) Inc., 550 F.3d 353, 363 (4th Cir. 2008).

Remand, however,

“should be used sparingly,” id. at 362, especially where evidence
shows that a plan administrator abused its discretion, Helton v.
AT & T, Inc., 709 F.3d 343, 360 (4th Cir. 2013).

Ms. Krysztofiak

asserts that another remand would be inappropriate.
8

(ECF No. 53,

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 9 of 21

at 10).

She asserts that Boston Mutual is a “serial abuser” which

has abused its discretion by denying her claim on remand, failing
to comply with ERISA regulatory guidelines applicable to her
administrative appeal, and by purporting to “correct” the Plan’s
omission of the Special Conditions Limitation.

(Id. at 10-11).

On the other hand, Boston Mutual concedes that “[i]f the [c]ourt
concludes that by not including [the Rider as a] basis for denying
the claim Plaintiff did not receive a full and fair review, then
remand is appropriate under [Gagliano v. Reliance Standard Life
Ins. Co., 547 F.3d 230 (4th Cir. 2008)].” 4

(ECF No. 52-1, at 6).

In Gagliano, the defendant insurer terminated plaintiff’s
benefits and gave her notice of her administrative appeal rights.
547 F.3d at 232.

Gagliano filed an administrative appeal, as well

as a civil action.

The district court stayed the civil action

pending the administrative review.
then

issued

different
policy.
did

not

a

second

reason—a

denying

pre-existing

Id. at 233.
include

denial,

The defendant-administrator
Gagliano’s

conditions

claim

limitation

for
in

a

the

The second denial purported to be final and

notice

to

the

plaintiff

that

she

could

administratively appeal the decision. Id. Ultimately the district
Boston Mutual also asserts that it does not believe remand
is necessary, because “the evidence overwhelmingly points to
fibromyalgia as the basis for Plaintiff’s claim.”
(Id.).
The
wiser course of action is to remand for the claim administrator to
conduct a full and fair review that includes interpreting the terms
of the Policy.
4

9

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 10 of 21

court entered judgment for the plaintiff and ordered the defendant
to pay benefits to the plaintiff.
part and reversed in part.

The Fourth Circuit affirmed in

It explained how the ERISA appeals

process works and why it is important:
ERISA requires that every employee benefit
plan “provide adequate notice in writing to
any participant or beneficiary whose claim for
benefits . . . has been denied, setting forth
the specific reasons for such denial.”
29
U.S.C. § 1133 (2008). The Plan must further
“afford a reasonable opportunity to any
participant whose claim for benefits has been
denied a full and fair review by the
appropriate named fiduciary of the decision
denying the claim.”
Id.
The regulations
implementing these statutory requirements
provide that a “full and fair review” includes
the opportunity for the claimant to appeal the
adverse benefits determination and to submit
written comments or records.
The claimant
must also be given reasonable access to
documents relevant to her claim, and the
resulting review must take into account all
relevant
information
submitted
by
the
claimant.
29 C.F.R. § 2560.503–1(h)(1–2)
(2008).
The purpose of the ERISA mandated appeal
process is an important one.
That process
enables a claimant who is denied benefits to
have an impartial administrative review, but
also make an administrative record for a court
review if that later occurs. Ellis v. Metro.
Life Ins. Co., 126 F.3d 228, 236–37 (4th Cir.
1997).
Without this opportunity to make a
meaningful
administrative
record,
courts
could not properly perform the task of
reviewing such claims, a specific function
entrusted to the courts by ERISA. Moreover,
plan participants would be denied their
statutory rights. Id. Procedural guidelines
are at the foundation of ERISA and “full and
fair review must be construed . . . to protect
10

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 11 of 21

a
plan
participant
from
arbitrary
or
unprincipled decision-making.”
Weaver v.
Phoenix Home Life Mut. Ins. Co., 990 F.2d 154,
157 (4th Cir.1993) (quoting Grossmuller v. UAW
Local 813, 715 F.2d 853, 857 (3d Cir.1983)).
Gagliano, 547 F.3d at 235 (emphasis added).

The Fourth Circuit

then held that the district court did not err in determining that
the insurer failed to comply with the notice requirements of ERISA.
Id. at 237.

The Fourth Circuit, however, also held that the

district court erred by ordering the defendant to pay benefits to
the plaintiff. Because the failure to give notice was a procedural
violation of ERISA, the “proper remedy was to remand to the plan
administrator for the ‘full and fair review’ to which Gagliano is
entitled regarding the denial of benefits on the basis of the PreExisting Conditions Limitation in the Second Termination Letter.”
Id. at 241.
In this case, Boston Mutual has similarly failed to comply
with ERISA procedure by seeking to prevail on a basis which has
never been subjected to a full and fair review.
intended

to

rely

on

the

Rider

in

its

Perhaps DRMS

administrative

appeal

decision, as suggested by the fact that it made Ms. Krysztofiak’s
attorney aware of the Rider’s existence during the administrative
appeal.

This can only be speculated about because DRMS never

issued such a decision.

Moreover, changing the basis for denial

may have resulted in the same procedural violation as in Gagliano,
necessitating another administrative appeal.
11

In any event, DRMS

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 12 of 21

never issued a decision interpreting whether the Policy permitted
amendment, vested Ms. Krysztofiak’s interest in the disability
benefits,

or

whether

the

Rider

was

applicable

to

her

claim.

Because of that, the court exercises its discretion and determines
that remand is appropriate here. 5

Cf. Smith v. Continental Cas.

Co., 369 F.3d 412, 421 (4th Cir. 2004) (holding that defendant
apparently ignored provision of plan that entitled plaintiff to
some benefits and stating that “[i]f the district court concludes
that Continental Casualty failed to consider this Plan language,
it

can

remand

the

case

to

Continental

Casualty

for

further

administrative review.”).
III. Analysis
The parties present two disputes: (1) can Ms. Krysztofiak’s
claim be denied because the Special Conditions Limitation Rider
terminates her eligibility for further disability benefits; and
(2) whether the denial of Ms. Krysztofiak’s claim for disability
benefits under the “any occupation” definition of disability was
reasonable.

Only the first dispute is addressed at this time.

The first dispute raises several sub-questions.

Whether

ERISA governed welfare benefits plans may be amended, and what

Ms. Krysztofiak’s frustration is understandable, but as
explained below, she is incorrect as a matter of law on the issue
of an interest in disability benefits vesting. Given that, it is
most appropriate to remand for the claim administrator to conduct
a full and fair review of the Policy and to determine if a provision
of the Policy vested her interest in disability benefits.
5

12

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 13 of 21

limitations as a matter of law are on that power to amend, are
questions

of

law.

Other

questions

raised

by

the

parties’

arguments, such as whether (1) the Policy in this case gave Boston
Mutual the power to amend the Policy in the way that it did; (2)
Boston Mutual did amend the policy permissibly; (3) a provision of
the Policy vested Ms. Krysztofiak’s interest in the disability
benefits; and (4) the sole basis of Ms. Krysztofiak’s claim is
fibromyalgia, are all questions of either interpreting the Policy
or

fact,

which

administrator.
be amended.

should

be

answered

initially

by

the

claim

As explained below, an ERISA governed policy may
The initial resolution of the remaining questions

relating to the Rider will be for the claim administrator on
remand.
Regarding the questions of law, Boston Mutual asserts that it
has the power to amend the Policy to add the Rider, pursuant to
the terms of the Policy, and that it may rely on the Rider to deny
Ms. Krysztofiak’s claim.

Ms. Krysztofiak argues that her interest

in the disability benefits vested when she became disabled as of
December 29, 2016, and thus a subsequent amendment to the Policy
cannot be relied upon to deny her claim.

(ECF No. 53, at 3).

Ms.

Krysztofiak has not contradicted Boston Mutual’s reading of the
Rider, nor identified language in the Policy that would vest her
rights to the disability benefits.

Instead, she argues that (1)

her

vested

right

to

disability

benefits
13

on

the

date

of

her

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 14 of 21

disability; (2) Boston Mutual is trying to reform the contract
equitably, but that it cannot do so; and (3) the “plan document
rule” requires the Plan to be “enforce[d] in accordance with the
terms then in existence when she became disabled.”

(ECF No. 53,

at 3-5).
A. Amending Welfare Benefits Policies and the Vesting of
Interests in Welfare Benefits
The answer to the threshold question of whether a welfare
benefits policy may be amended is yes, although there are some
restrictions.

“Indeed, a welfare benefit may be terminated at any

time so long as the termination is consistent with the terms of
the plan.”

Price v. Bd. of Trustees of Indiana Laborer’s Pension

Fund, 707 F.3d 647, 651 (6th Cir. 2013) (citations omitted).
The Supreme Court of the United States has explained:
Although ERISA imposes elaborate minimum
funding and vesting standards for pension
plans,
§§
1053,
1082,
1083,
1084,
it
explicitly exempts welfare benefits plans from
those rules, §§ 1051(1), 1081(a)(1). Welfare
benefits plans must be “established and
maintained pursuant to a written instrument,”
§ 1102(a)(1), but “[e]mployers or other plan
sponsors are generally free under ERISA, for
any reason at any time, to adopt, modify, or
terminate
welfare
plans,” Curtiss–Wright
Corp. v. Schoonejongen, 514 U.S. 73, 78, 115
S.Ct. 1223, 131 L.Ed.2d 94 (1995). As we have
previously
recognized:
“[E]mployers
have
large leeway to design disability and other
welfare plans as they see fit.” Black & Decker
Disability Plan v. Nord, 538 U.S. 822, 833,
123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003). And,
we have observed, the rule that contractual
“provisions ordinarily should be enforced as
14

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 15 of 21

written
is
especially
appropriate
when
enforcing an ERISA [welfare benefits] plan.”
Heimeshoff v. Hartford Life & Accident Ins.
Co., 571 U.S. 99, 108, 134 S.Ct. 604, 611–612,
187 L.Ed.2d 529 (2013). That is because the
“focus on the written terms of the plan is the
linchpin of a system that is not so complex
that administrative costs, or litigation
expenses, unduly discourage employers from
offering [welfare benefits] plans in the first
place.”
Ibid. (internal quotation marks,
brackets, and citation omitted).
M & G Polymers USA, LLC v. Tackett, 574 U.S. 427, 434–35 (2015)
(emphasis added).
Welfare benefits may not be amended, however, if the interest
in the welfare benefits has vested.

See Blackshear v. Reliance

Standard Life Ins. Co., 509 F.3d 634, 640 (4th Cir. 2007) (abrogated
on other grounds) (“An employer sponsoring the plan may therefore
unilaterally terminate or modify previously offered benefits that
are not vested.”) (cleaned up).
Because welfare benefits under ERISA governed plans do not
automatically vest, an employee’s right to welfare benefits must
vest in at least one of two other ways.

First, “the terms of a

plan may create vested rights in welfare benefits even though the
employer is under no obligation to do so.”
at 640.

Blackshear, 509 F.3d

“Once an employer or plan sponsor grants vested rights

under a welfare benefit plan, however, it may not retroactively
amend the plan to deprive a beneficiary of a vested benefit.
See Wheeler, 62 F.3d at 638, 640.”
15

Id.

Ms. Krysztofiak did not

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 16 of 21

assert that a term of the Policy vested her interest in the
disability benefits.

Nonetheless, the question of whether such a

term exists is first a question for the claim administrator, to
whom

the

Policy

gives

the

discretion

to

interpret

Policy

provisions.
Second, for certain types of welfare benefits, the occurrence
of a “triggering event” will vest an employee’s right to the
welfare benefits.

In Blackshear, the Fourth Circuit recognized

two types of welfare benefits for which rights vest as the result
of

a

triggering

event:

insurance benefits.

medical

insurance

benefits

and

life

Medical insurance benefits vest at the time

that the “covered loss occurs.”

Id. at 641 (citing Wheeler v.

Dynamic Eng’g, Inc., 62 F.3d 634, 638 (4th Cir. 1995)).
insurance benefits vest at the moment the insured dies.

Life
Id.

Blackshear does not address disability benefits.
Ms. Krysztofiak argues that disability benefits should be
treated like medical insurance and life insurance benefits, and
vest upon the occurrence of a disability.

(ECF No. 53, at 3-4).

She argues that “[u]nder general principles of insurance contract
law,

when

a

covered

loss

occurs,

the

contract

is

no

longer

executory and must be performed in accordance with the terms then
in

existence.”

(Id.

at

3)

Blackshear, 509 F.3d at 641).

(emphasis

in

original)

(citing

She concludes from that proposition

that her right to disability benefits vested when she became
16

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 17 of 21

disabled as of December 29, 2016.

(Id. at 4).

Blackshear,

however, does not address whether rights to disability benefits
vest upon an insured becoming disabled.

As other courts have

recognized, those two types of welfare benefits are different from
disability benefits.
America,

the

court

In Dejoe v. Unum Life Insurance Company of
rejected

the

plaintiff’s

citation

to

Blackshear:
That is the initial critical distinction
between these cases and the one at hand. An
insured life can only end once; the event
giving rise to a specific benefit occurs only
once. While the condition of death continues,
the entitlement to benefits under the life
insurance policy does not. A single payment
becomes due at the time of death. To use the
plaintiff’s words, that is when the insurer’s
performance “became due.” See Members Servs.,
130 F.3d at 957.
Similarly, the medical
expenses for which payment is due occur once
and do not continue indefinitely.
By contrast, a disabled individual could
recover sufficiently to return to work. The
disability policy entitles a beneficiary to
periodic payments that, by its terms, may be
adjusted at various times.
No. 07-109-P-S, 2008 WL 2945576 at *7 (D.Me. July 28, 2008) report
and recommendation adopted by No. 2008 WL 3929581 (D.Me. Aug. 27,
2008).
The Sixth Circuit reached the same conclusion when resolving
a petition for rehearing in Price v. Bd. of Trustees of Indiana
Laborer’s Pension Fund, 531 Fed.Appx. 535 (6th Cir. 2013).

In its

prior opinion, the Sixth Circuit had held that, under abuse of
17

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 18 of 21

discretion review, it was reasonable for the defendant to interpret
a plan to permit an amendment which had the effect of terminating
disability benefits.

Price, 707 F.3d at 651-52.

The policy had

permitted amendments, but also prohibited amendments that had the
effect of reducing benefits for plan participants whose rights had
vested under the provisions of the plan.

Id. at 651.

In his

petition for rehearing, plaintiff argued that the Sixth Circuit
had created a circuit split regarding the vesting of welfare
benefits and cited, among other cases, Blackshear.

Price, 531

Fed.Appx. at 535. The Sixth Circuit rejected this argument, saying
“[t]hese cases have two things in common: We do not disagree with
any of them, and they do not help resolve this distinct dispute.”
Id. at 535.
The Fourth Circuit does not appear to have addressed the
vesting of disability benefits upon a triggering event theory.

It

has, however, recognized that differences in types of injuries and
benefits can affect whether an interest in benefits vests.

In

Wheeler v. Dynamic Eng’g, Inc., 62 F.3d 634 (4th Cir. 1995), the
plaintiff sought a declaratory judgment that she was entitled to
coverage for breast cancer.
breast

cancer,

chose

a

completed the first step.

The plaintiff was diagnosed with

multi-step
Id. at 637.

treatment

procedure,

and

Around the same time, the

plaintiff’s employer adopted a new health care plan.

The old plan

covered plaintiff’s course of treatment, the new plan did not.
18

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 19 of 21

Id.

The Fourth Circuit concluded that the plaintiff’s coverage

for the procedure and its expenses vested under the old plan
because she had incurred the expenses for the treatment and began
it while the old plan was still effective. Id. at 640. In reaching
that conclusion, the Fourth Circuit distinguished cases cited by
the defendant involving claims by plaintiffs diagnosed with AIDS.
In those cases, the defendant-insurers had amended their health
plans to eliminate coverage for AIDS-related claims.

Id.

The

Fourth Circuit explained:
Essentially, the employees argued that the
right to benefits for any potential future
treatment
for
AIDS
they
might
undergo
throughout their lifetimes vested at the
moment they were diagnosed with the disease.
In contrast, Wheeler seeks coverage for a
particular medical procedure whose scope is
relatively short and well defined. We believe
a meaningful distinction may be made between
[Wheeler’s
breast
cancer
treatment],
a
specific procedure terminating after several
months,
and
treatment
for
AIDS,
which
continues throughout an employee’s lifetime
and
may
well
involve
a
variety
of
unforeseeable future procedures. See Butler,
617 F.Supp. at 729 (noting that comparison of
the long-term disease, diabetes, to a ninemonth pregnancy for coverage purposes would be
“a comparison of apples and oranges”).
Id.

Wheeler, Dejoe, and cases like them draw their distinctions

based on the differences between injuries and benefits of an
indeterminate nature and duration and injuries and benefits of a
determinate nature and duration.

19

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 20 of 21

Disability benefits are not the same as medical insurance
benefits or life insurance benefits.

Disability benefits are not

contingent upon a singular event, but upon the continued existence
of a disability.
her disability,

If a claimant fortunately recovers from his or
then

disability benefits.
disability

benefits

the

claimant

is

no

longer

eligible

for

Thus, as a matter of law, an interest in
does

not

vest

upon

the

occurrence

of

a

disability. 6
This opinion should not be read to address whether an
interest in disability benefits vests after an insurer begins
paying out the benefits to an insured. Boston Mutual has never
awarded Ms. Krysztofiak disability benefits under the “any
occupation” definition of disability. Nor is Boston Mutual seeking
to claw back benefits already paid. Other courts have addressed
that issue, such as the Sixth Circuit in Price, where it held that
a policy could be amended to terminate disability benefits which
had been paid out for over a decade. Judge Jonker, dissenting in
Price, articulated the danger of such an outcome:
6

If a plan may unilaterally terminate alreadyawarded benefits while the participant remains
disabled, the plan provides no meaningful
protection.
Everyone agrees that death
benefits already awarded cannot be undone in
this fashion under the Plan. The same logic
should apply to disability benefits under the
same Plan. There is no functional distinction
between a disability benefit package payable
under the Plan terms in effect at the time of
disability, and a death benefit package,
whether paid out in a lump sum or over a fixed
period of time under the same Plan. In both
cases, once the person is actually dead or
disabled, there is no way to cover the risk
through the purchase of alternative coverage.
This leaves the participant without the
promised plan benefit and without the ability
to cover the risk in some other way.
20

Case 1:19-cv-00879-DKC Document 55 Filed 09/16/22 Page 21 of 21

B. Ms. Krysztofiak’s Alternative Arguments
Ms. Krysztofiak’s other arguments regarding the doctrine of
equitable reformation and the plan documents rule are not resolved
at this time because they are not related to the legal questions
resolved above.
C. Plaintiff’s Counsel
The court learned recently that Plaintiff’s Counsel, James
Koch, unfortunately passed away suddenly on September 6, 2022.

In

order to give Plaintiff time to resolve whether she wishes to
secure new counsel or represent herself, the court will defer
entering an order remanding this case for a brief period.

Once

she notifies the court as to her plans, a telephone conference
will be convened to discuss the proper scope of the remand.
Plaintiff is requested to provide a status report within 30 days.
IV.

Conclusion
For

the

foregoing

reasons,

Ms.

Krysztofiak’s

motion

for

summary judgment is denied and Boston Mutual’s motion for summary
judgment is granted in part.

A separate order will follow in due

course.
/s/
DEBORAH K. CHASANOW
United States District Judge

Price, 707 F.3d at 653 (Jonker, J., dissenting).
however, is not present here.
21

That scenario,