Sepulveda-Rodriguez v. Metropolitan Life Insurance Company et al

Filing 74

AMENDED MEMORANDUM AND ORDER - The motions for summary judgment filed by Defendants Metropolitan and Ford (Filing Nos. 56 and 58 ) are denied. The motion for summary judgment filed by plaintiff (Filing No. 65 ) is granted. MetLife Group, Inc. is dismissed as a party defendant. Plaintiff shall file a motion for attorney fees within fourteen (14) days of the date of this order. After the attorney fee issue is resolved, judgment will be entered in favor of the plaintiff and against defendant Ford in the amount of $2,090.00 on the plaintiff's failure to provide plan documents claim; Judgment will be entered in favor of the plaintiff and against defendant Metropolitan in the amount of $92,694.00 on the plaintiff's claim for denial of benefits; Judgment will be entered in favor of the plaintiff and against defendants Metropolitan and Ford on the plaintiff's equitable claims. Ordered by Senior Judge Joseph F. Bataillon. (ADB)

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF NEBRASKA

SILVIA SEPULVEDA-RODRIGUEZ,
Plaintiff,

8:16CV507

v.

AMENDED
MEMORANDUM AND ORDER

METLIFE GROUP, INC., a New York
Corporation; METROPOLITAN LIFE
INSURANCE COMPANY, a New York
Corporation; and FORD MOTOR
COMPANY, a Delaware Corporation;
Defendants.

This matter is before the court on the parties’ cross motions for summary
judgment, Filing Nos. 56, 58 and 65.1 Although styled as cross-motions for summary
judgement this is an action for judicial review of an administrative determination denying
benefits under the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. §
1001 et seq.

The plaintiff alleges defendants wrongfully denied her claim for life

insurance benefits under a policy provided by late husband’s employer. She seeks a
reversal of that determination.

The defendants move for a judgment affirming the

decision.
The plaintiff alleges five claims. She first seeks the statutory penalty for failure to
provide plan documents, specifically, the Summary Plan Description (“SPD”) under 29

1

The defendants seek dismissal of all claims against defendant MetLife Group, Inc. (“MetLife”), a
corporate affiliate of defendant Metropolitan Life Insurance Company (“Metropolitan”). They contend that
MetLife is an improper and unnecessary party and was not involved in the employee benefit plan at issue.
See Filing No. 60, Brief at 3 n.1. The plaintiff has not responded to or objected to that contention. The
record shows Ford and Metropolitan are the plan fiduciaries and are proper defendants. Accordingly, the
plaintiff's claims against MetLife will be dismissed.

U.S.C. § 1132(c) from defendant Ford Motor Company.2 Filing No. 32, First Amended
Complaint at 5.

She next seeks an award of benefits pursuant to 29 U.S.C.

§1132(a)(1)(B) from defendants MetLife Group, Inc. and Metropolitan Life Insurance
Company (“Metropolitan”).3 The plaintiff also asserts three claims for equitable relief
under 29 U.S.C. § 1132(a)(3) against both Ford and Metropolitan and seeks relief in the
nature of surcharge, reformation and equitable estoppel.
In its motion, Met Life seeks dismissal of the plaintiff’s claims. It asks the court to
affirm Metropolitan’s determination. Metropolitan argues its claim determination was not
an abuse of discretion. It also contends that the plaintiff’s breach of fiduciary duty
claims are improper under ERISA and are barred by the decedent's allegedly
inequitable acts.
Defendant Ford seeks dismissal of the plaintiff’s penalty claim as well as her
claims for breach of fiduciary duty. Ford argues it substantially complied with ERISA
requirements to provide the SPD and contends that because the plaintiff has a remedy
for the benefits she seeks under Section (a)(b)(1), there is no need for a duplicative
equitable claim.
The plaintiff seeks a summary judgment against defendant Ford for damages in
the amount of the statutory penalty for failure to timely provide plan documents.
Further, she asserts she is entitled to judgment in her favor on her claims for benefits
and breaches of fiduciary duty under 29 U.S.C. §§ 1132 (a)(1)(B) and (a)(3). She urges

2

By stipulation of the parties the court dismissed Claim I as to defendants MetLife and
Metropolitan. Filing No. 43. The parties agreed that it is Ford’s duty, as the plan administrator, to provide
the SPD.
3

Similarly, by stipulation of the parties, the court dismissed this claim against defendant Ford. Id.

2

the court to reverse the decision denying the plaintiff’s claim for optional life insurance
benefits.
I.

FACTS

A.

Background

The facts are gleaned in part from the parties' statements of undisputed facts, the
administrative record and affidavits submitted in connection with the motions.

See

Filing No. 53-1, Administrative Record (Restricted) (“Admin. R.”); Filing No. 57, Ford’s
Brief at 5, 7-14; Filing No. 60, Metropolitan Brief at 2-8; Filing No. 67, Plaintiff’s Brief at
1-5; Filing No. 68, Ford Reply Brief at 3-4; Filing No. 69, Metropolitan Reply Brief at 3-4;
Filing No. 70, Plaintiff’s Reply Brief at 1-4.

The administrative record filed by

Metropolitan includes a copy of the Ford Motor Co. Life and Accidental Death and
Disability Policy (“the Plan”) and screenshots of the online version of the Summary Plan
Document (“SPD”) for the Plan. See Filing No. 53-1, Adm. R. at 120-141. In addition to
the Plan documents, the record contains 27 pages of Metropolitan internal records,
numerous medical records authorization forms, the decedent’s medical records dating
back to 2008, and correspondence to and from the plaintiff’s counsel.4 Id. 142-169.
It is undisputed that Ford Motor Company is the Plan Sponsor and Plan
Administrator of the Plan. Metropolitan is the insurer and claim administrator under the

4

The internal claim records are somewhat cryptic and include various acronyms and insurance
jargon. The internal documents include emails, various computer screen shots, "inquiry snapshots" that
apparently document telephone calls and refer to correspondence and emails, and a digital “comments
list,” which apparently documents intra-company communications and work-flow. The record also
contains computer printouts, in the nature of spreadsheets, of digital records that ostensibly show
responses to medical history questions, but there is no explanation of the meaning of the coded
responses or any way to correlate the answers to questions. See e.g., id. at 244-45. Some documents in
the record are highlighted and redacted but there is no record of who highlighted or redacted them.

3

Plan.5

The parties agree Metropolitan issued Group Insurance Policy Nos. 113729-1-

G, 113729-G and 113729-16-G to Ford Motor Company. Ford’s SPD states that: “The
Plan Administrator and Metropolitan have discretionary authority to construe, interpret,
apply and administer the Plan. Decisions of the Plan Administrator and Metropolitan are
final and conclusive, and are only subject to the arbitrary and capricious standard of
judicial review.”

Filing No. 53-1, Admin. R. 138 & 139.

Ford provided Basic Life

Insurance to employees at no cost to them, but employees had to pay the cost of any
Optional Life Insurance they elected. Id. at 123.
The plaintiff is the widow of Jose Monarrez (“the decedent”), who died on June 4,
2015, of "hypertensive and atherosclerotic heart disease." Filing No. 53-1, Admin. R. at
188.

The decedent was employed by Ford as a customer service representative

beginning on October 1, 2013. Monarrez enrolled in the Plan when he first became
eligible, and benefits were effective on or after November 1, 2013. He requested both
basic life insurance coverage in the amount of one and a half times his base annual
earnings of $37,077.60 (or $55,616.00) and optional employee life insurance coverage
in the amount of two and a half times his base annual earnings, which amounted to
$92,694.

Id. at 186-87, 504.

After he submitted his application for Optional Life

Insurance, premiums were withheld thereafter by Ford and forwarded to Metropolitan.
Id. at 123-24.

5

The difference between a claims administrator and a plan administrator is that “whereas a plan
administrator makes ‘plan-level decisions about covering employees (e.g., whether employee x will be
covered at all—for anything—under the policy),’ a claims administrator makes ‘claim-level decisions about
paying benefits (e.g., to what extent employee x's visit to doctor y on date z is covered).’” Pearson v.
Wellmark, Inc., No. 4:15-CV-3164, 2017 WL 2371142, at *5 (D. Neb. May 31, 2017)(quoting Werb v.
ReliaStar Life Ins. Co., 847 F. Supp. 2d 1140, 1146 (D. Minn. 2012). “Presumably, then, the claims
administrator's duties are more limited and circumscribed than the plan administrator's.” Id.

4

After Monarrez's death, Metropolitan paid the basic life benefit of $55,616 to the
plaintiff, his widow. Id. at 144. Metropolitan denied the plaintiff’s claim for optional life
insurance benefits. Id. at 153, 414-15.
With respect to optional life insurance, the Plan provides:
If You complete the enrollment process when first eligible for Optional Life
Insurance and Optional Accident Insurance under the Flexible Benefits
Plan, such insurance will take effect as follows:
•

for any amount which You are not required to give evidence of
Your insurability, such insurance will take effect on the later of the
date You become eligible for such insurance and the first day of the
calendar month following the date You complete the Enrollment
Process, if You are Actively at Work on that date. You are not
required to give evidence of Your insurability for Optional Accident
Insurance.

•

for any amount for which You are required to give evidence of
Your insurability and We determine that You are insurable, such
insurance will take effect on the first day of the calendar month
following the date We approve Your evidence of insurability, if You
are Actively at Work on that date.

Id. at 57 (emphasis in original). The Plan defines Proof as follows:
Proof means Written evidence satisfactory to Us that a person has
satisfied the conditions and requirements for any benefit described in this
certificate. When a claim is made for any benefit described in this
certificate,
Proof must establish: the nature and extent of the loss or condition; Our
obligation to pay the claim; and the claimant’s right to receive payment.
Proof must be provided at the claimant's expense.
Id. at 54.
The SPD provides that employees are eligible to enroll in optional life insurance
on the date of hire or rehire and “Coverage is effective the first of the month following
enrollment date or the first of the month following approval of Statement of Health,
5

whichever is later.” Id. at 123. The coverage effective date the first of the month
following approval of a Statement of Health form (if required). Id. Proof of good health
for optional life insurance is described as follows:
Proof of Good Health - Optional Life Insurance
If you elect coverage or increase your coverage when first eligible, during
annual enrollment or due to a Qualified Event, you must provide proof of
your good health before the election or increase will be effective.
The process of providing proof of good health involves answering five
questions about your health status. Depending on your answers to these
questions, you may also need to complete a more detailed questionnaire
(i.e., a Statement of Health form). In addition to a Statement of Health,
medical records or a physical examination may be required at your
expense. Any life insurance elections that require proof of good health will
not go into effect until evidence of insurability is received and approved by
MetLife. MetLife makes all decisions regarding approvals.
Id. at 125. Neither insurability, good health, nor statement of health are defined in the
Plan documents.
The plaintiff filed a claim under the policy on September 21, 2015. Id. at 189-90.
Metropolitan responded with a letter stating an investigation was necessary with respect
to the claim for optional benefits. Id. at 195, 207. MetropoIitan also contacted Ford’s
third-party administrator for confirmation of the decedent’s enrollment in the Plan. Id. at
193-98. The response indicated that the optional life coverage was elected during the
2013 new hire enrollment. Id. at 193. The record contains several screenshots of
computer images with typed notations showing that Monarrez was a “new-hire_rehire
eff 10-1-13,” and had Optional Life coverage effective on November 1, 2013. Id. at 200.
Another screenshot indicates an annual enrollment effective January1, 2015. Id. at 199.

6

Thereafter, internal records show the following task was assigned to Metropolitan
employee Edward Sullivan, who is identified in the record as a Senior Client Services
Consultant:
Insured enrolled in Optional Life coverage as new hire on 11/1/2013 for
2.5 of base annual earnings ($92,694.00). Per Plan Master under [Medical
Evidence of Insurability or] MEOI: New hire participants who enroll initially
eligible are subject to MEOI. All amounts require medical questions. Can
you please provide me with his questionnaire or confirm that he answered
No to all medical questions.
Id. at 506. The reason for the request is shown as “MEOI Provisions Need assistance
Obtaining enrollment History from Employer.” Id. On October 8, 2015, Sullivan emailed
the following to Terrence Davis and Robert Skulnik:
We suddenly seem to have more frequent inquiries from our group life
claims office. This one is regarding JOSE L MONARREZ, SSN [redacted],
who died on June 4, 2015. The claim amount we need more information
on is $92,694.00 of Optional Life Insurance that was effective November
1, 2013.
Can one of you provide me with a screen print of the enrollment history
and the answers to the five medical questions? With this being within the
two-year contestability period, we'll need his responses to the five medical
questions he should have answered at the time of his enrollment. If you
provide this in the format of an Excel file, please include the questions,
answers, the employee's name, and the date/time of the web transaction.
We need all of this information included for the purpose of documenting
the claim file.
Id. at 239 (redaction added). Rob Skulnik, Client Service Manager, HR Outsourcing
Solutions, Xerox HR Services, LLC, responded that “This [participant] made this
election as a new hire back in 2013. He was not required to answer the questions. Do
you want a screen shot of that election?” Id. at 205. The following day, Sullivan again
emailed Skulnik, asking him to double check the new hire enrollment for the medical
questions.

Id. at 204.

After several more requests for the information, Skulnik
7

responded “We have no record of this [participant answering the EOI questions.” Id. at
203. On October 19, 2015, Sullivan again emailed Skulnik asking for information. Id. at
202. Skulnik replied “Ed, we are still researching into further but this appears to be an
isolated case and our research so far shows the questions were asked but not recorded
in our system.” Id.
Internal records also contain screenshots headed “MetLife Life Claim Request
Entered” and additional notations indicating “WebMaker – Application” and a web
address. Id. at 500-507. Those records and computer generated notices of comments
to workflow show a Claim Inquiry was completed on October 15, 2015 as follows: “The
[Third Party Administrator or] TPA responded via email that the medical questions were
not asked when this person enrolled as a new hire. The GLIF plan is correct - MEOI is
required for new hire enrollments and the questions should have been asked. Please
see attached[,]” apparently referring to the screenshots set out above. Id. at 198, 507.
Notes created on October 21, 2015 by Edward Sullivan state:
The employer's TPA [third party administrator] has indicated they are still
researching the case further but this appears to be an isolated case and
their research so far shows the questions were asked but not recorded in
their system. In order for the coverage to go into effect, the TPA states
their programming requires "no" responses to all questions; otherwise,
coverage would have been pended for MetLife approval of a SOH. Please
see the attached email exchange.
Id. at 505. Notes created by Tamara Wurz, identified as a Life Claim Examiner, to
Edward Sullivan dated November 30, 2015, state:
Would you please check to see if they are able to provide us with
evidence of the data that they do have—is there something showing that
the 5 medical questions had been asked but the answers not recorded?
also, can they show us an example of an enrollment where the answers to
the medical questions were recorded so that we could compare?”
8

Id. at 503.

An email dated December 1, 2015, from Terrence Davis at Xerox HR

Solutions to Edward Sullivan later states “I was able to find some more info on this. The
election was processed through a CSR via IVR enrollment.

In the attached, I've

highlighted the recorded questions and answers for optional life as of 11/5/2013.” Id. at
234. The record contains no explanation of the meaning of those terms. Following that
email, the administrative record contains a spreadsheet, a listing of questions—some
incomplete, a sheet of computer data sets in columns and 27 separately listed date and
time stamps each indicating “11/5/2013 7:17:59.” Id. at 242-44.6
On 12/07/2015, Sullivan states:
Upon further review, the TPA found the medical questions and answers
had been recorded after all. I was informed that the person who handled
the initial inquiry may not have been accessing the correct table to obtain
the data. Please see the attached email. The Excel file provided has the
questions in rows 20 -28 and the responses in column Q. The employee
answered no to all questions according to the data.
Id. at 503. The life claim inquiry was reviewed and closed on December 29, 2015. Id.
at 502.
A senior referral form authored by Tammi Wurz and dated January 22, 2016
states:
Received claim with [Optional Life Insurance or] OLI coverage. The OLI
effective date is 11/01/2013 and Insureds [date of death or] dod
06/04/2015 —previous examiner requested 2 yrs. of medical history per lcl
response In comments, the firm assures that the medical questions are
asked and prior to coverage becoming effective all medical answers must
be answered "no" —they are unable to provide this information but state if
they had not been asked and answered no then this individual would have
been flagged on their end of SOH/Metlife approval. Letters had been sent

6

Metropolitan contends that these cryptic documents show the Monarrez completed an electronic
questionnaire on November 5, 2013 in which he answered “no” to all of the questions asked. The court
finds the documents do not establish that proposition.

9

to numerous doctors/hospitals and received 1st response back requesting
additional authorization prior to releasing Information. Insureds death due
to hypertensive and artherosclerotic (sic) heart disease. **medical records
received— records from Alegent Health Clinic show treatment for HTN
from pg 145-191 which includes date ranges all prior to the time the
Insured would have answered medical questions.
Id. at 402. Wurz suggested that the senior reviewer “advise if should be sent to SOH at
this time to see if insured would’ve been approved.” Id. at 403. The Senior Reviewer,
Charles Rose, responded on January 22, 2016:
Agree please refer to SOH with a PDF of all medical records, should the
insured have marked off yes to one or more of the medical record
questions. Specifically, should he have marked 'Yes'' to the question
about chest pains. 2. If a SOH would have been triggered, based on the
medical records, would the SOH had been declined. If so, on what basis?
Once we receive a response from SOH, please re-refer to Srs.
Id. at 403. On Jan 26, 2016, Tamara Wurz wrote, via email, to Senior Statement of
Health Specialist Wes Vivyan. The record indicates Wurz asked:
Please see medical records provided and advise:
1. Based on the medical records, should the insured had marked off "Yes"
to one or more of the medical question. Specifically, should he have
marked "Yes" to the question about chest pains.
2. If a SOH would have been triggered, based on the medical records,
would the SOH had been declined. If so, on what basis?
Id. at 405.

In response, email correspondence from Kelly Zawada, apparently a

Metropolitan underwriter, dated Jan 26, 2016, states:
Based on the medical records received if the insured had submitted a
Statement of Health to us and had indicated the conditions listed in his
medical records (Hypertension, hyperlipidemia, chest pains) he would
have had to have checked off the box indicating cardiovascular and
indicated chest pains in the comment section. The high blood pressure is
a seperate (sic) question and is self explanatory on the SOH. We
normally would not work up hypertension or hyperlipidemia based on a
Statement of Health unless the applicant was being treated specifically by
a cardiologist or had multiple medications noted that could indicate a
10

condition other than what was reported. Had the applicant indicated chest
pains on the SOH we would have worked this up.
Review of the medical records the applicant appeared to have been
treating with a [primary care provider] and had referrals on several
occasions to cardiology for further work up or chest pain. However after
investigating into the notes a little more closely it appears that there was a
history and ongoing use of cocaine and alcohol and MD advised the
patient to cease cocaine use on multiple occasions. This could have been
a factor in the chest pains. There was some sort of cardiac work up,
records submitted however nothing significant or abnormal that would
contribute to chest pains. MD advised for the patient to continue to take
medications for hypertension and hyperlipidemia which again in the notes
the MD indicates the patient was a not compliant at all times, stating "he
ran out of meds" or "I stopped taking the meds because I felt better."
Had the chest pains been worked up and medical that came in that
indicated it was not cardiac in nature but due to drug and alcohol abuse
that was current he may have been declined based on our guidelines.
However the records were dated back to 2004-2009 with the exception of
an operative report from 2014 as well as an office note form March 2015
which did not indicate any drug/alcohol abuse or non-compliance at that
time.
Id. at 404. On January 28, 2016 the file was returned to the claims examiner with this
notation:
RETURNED TO TAMMI: It's unclear what the definitive answer is. Also,
not sure what is meant by "work up". Please reach back out and ask them
to kindly answer yes or no: 1. Based on the medical records we have on
file, should the insured have answered yes for being diagnosed with chest
pains? 2. If he answered yes, would that have triggered a full SOH? 3. If
yes, based on the medical submitted, would the insured have been
declined for the increase in insurance coverage? 4. If we do not have
enough information, can you at least confirm, based on the medical we
received, that the insured should have checked yes to one or more of the
medical questions, which would have triggered a full SOH?
Id. at 154. Senior Reviewer Charles Rose wrote the following on February 2,
2016:
TO TAMMI TO [DRAFT] DENIAL BASED ON MEDICAL QUESTIONS
NOT ANSWERED CORRECTLY AND SOH CONFIRMING A SOH
11

WOULD HAVE BEEN TRIGGERED AND A FULL WORK UP WOULD
HAVE BEEN REQUIRED
Id. at 154.
The record shows that the plaintiff called Metropolitan inquiring about the claim in
early February 2016. Id. at 153. In her affidavit, the plaintiff states that in a phone call
on February 9, 2016, Kelly Zawada informed her that Metropolitan was prepared to pay
$92,691, but was awaiting some sort of additional approval “from Ford Credit.” Filing
No. 66-1, Index of Evidence, Ex. 1, Affidavit of Silvia Sepulveda-Rodriguez (“SepulvedaRodriguez Aff.” at 3.
Metropolitan denied the Optional Life Insurance benefits in a letter dated
February 15, 2016. Id. at 153, 414-15. Metropolitan quoted language that appears in
the Plan under the heading “Changing Your Elections,” and stated:
According to our records, the decedent first elected Optional Life
Insurance during his 2013 new hire enrollment. The Plan states that when
a request to enroll in Optional Life Insurance coverage is made part of the
process of providing proof of good health involves answering five
questions about your health status. Mr. Monarrez answered "no" to all of
these medical questions. Based on the medical records we have obtained
and reviewed, Mr. Monarrez should have answered "yes" to one or more
of the medical questions. If these questions had been answered
accurately a full Statement of Health would have been required. Per the
Plan any life insurance election that required proof of good health would
not have gone into effect until evidence of insurability had been received
and approved.
We do not have any record of a completed Statement of Health
form being submitted. Since a Statement of Health form as evidence of
insurability was never received and therefore, not approved, there was no
Optional Life Insurance in effect at the time of his death.
Therefore, based on the record before MetLife, we must deny your
claim for Optional Life Insurance.
Id. at 415.
12

Metropolitan continued to receive Monarrez’s medical records from February to
May 2016.

Id. at 150-51.

Under the heading “Activity,” comments entered on a

document entitled “Claim Comments List” dated April 20, 2016 indicate that an appeal
had been received.

Id. at 150.

In her appeal, the plaintiff requested documents,

including the policy, the SPD, and the decedent’s answers to the questionnaire
referenced in the denial letter. Id. at 435. She based her appeal on the contention that
Metropolitan could not have relied on any such representations because her late
husband had undergone two physical examinations for the purpose of life insurance and
she produced records of those examinations. Id. Tamara Wurz again referred the
appeal to a senior claims representative for review.

Id. at 150.

An informational

comment authored by David Indolfi dated April 29, 2016 states:
draft uphold of the denial for the [Optional Life Insurance or] OLI based
upon the misrepresentation on the short form medical questions.
Specifically answering no for high blood pressure when the medical
provided show a past medical history of hypertension as well as that was
the cause of death. In uphold be specific to the questions asked that he
misrepresented and the information in our claim file that reflects he was
aware of the high blood pressure prior to completing the questions. Also
prepare a copy of the claim file for the claimant.
Id. A denial letter was sent to the plaintiff on May 18, 2016. Id. at 149. In its letter
denying the plaintiff’s appeal, Metropolitan stated:
You have filed an appeal based on your disagreement that Mr. Monarrez's
answers on the questionnaire could have been false. Based upon the
review of Mr. Monarrez's medical records received from his various
physicians' it has been determined that Mr. Monarrez's answers were a
misrepresentation. Specifically his "no" answer to question regarding high
blood pressure when past medical history shows hypertension which
happens to also be the cause of his death.

13

Id. at 451. Internal records show mail was received on June 28, 2016, and the following
was noted “6/27 - rcvd letter from attny for Silvia advising did not receive response to
appeal and did not receive requested documents to team to review and respond to
attny.” Id. at 149. The file was again referred to Senior Review in July 2016. Id. On
August 23, 2016, notes indicate an appeal had been received. Id. at 148.
On September 8, 2016, comments by Senior reviewer Kay Fleming show that the
file was returned to Claim Examiner calling for further review:
[State of Health or] SOH said that they would not request additional
documentation unless the [employee] had hypertension and hyperlipedia
and was being treated by a cardiologist and being medicated. They also
say that based upon the medical records, the [employee] should have
stated they had chest pains. The questionnaire (pg 74) does not appear
to ask about chest pains; however, the question for Have you even been
diagnosed or treated by a phsycial [sic] or other healthcare provider for--does not show the drop downs, only the next question which is diagnosed,
treated, or given medical advice by a phyician [sic] or other healthcare
provider for. . . . 1) Is there more to this form where the first question is? 2)
Planmaster states we ask about chest pains; however, this form doesn’t
show that question. 3) Planmaster does not state that we has about
hypertension but their questionnaire does. Complete an mpm and ask if
they have an agmt at signing of what questions we are supposed to be
asking.
Id. at 148, 463. Following a senior referral form containing the above-quoted language
under the heading “Course of Action” is a single page document that lists nine healthrelated questions, with space for entry of “yes” or “no” answers. Id. at 464.
On 9/12/2016, Tamara Wurz followed up as follows:
we previously denied the optional life portion of this claim due to the
required medical questions not being answered accurately and if they had
a statement of health would have been required. they have filed an
appeal and we need additional information upon our further review. Is
there an agreement at signing of what questions we are suppose (sic) to
be asking? Their questionnaire does not appear to ask about chest pains
but plan master states that we do? Plan master does not state that we
14

ask about hypertension however their questionnaire does. Please review
discrepancies and advise.
Id. at 501, 148. On 09/26/2016, Wurz indicates in the claim Comments List that a
response was received.

Id. at 147.

Senior Claims Examiner Edward Sullivan

responded:
Tamara, I attached the full text of the medical questions that Ford asks at
the time of enrollment. The documentation of this employee's answers
had some of the text of the questions cut off. Please note these are the
standard MetLife questions for life only enrollments when it is done on
paper. The paper version questions are used even though it is an online
enrollment because it is not on MetLife's website. Please note that GLIF
does not have the option select the exact wording of these questions so
the closest ones are chosen in the applicable plans.
Id. Wurz then suggested the file again be referred for Senior Review of information
preciously submitted. Id. The summary of the referral refers to a prior senior response
indicating
Discussed with UL Pati, we will deny the additional [optional life
insurance]. Please draft denial In the denial letter quote the language from
the Changing Elections section and the from Plan regarding Proof of Good
Health-Optional Life Insurance and also quote the section. Also quote the
section about coverage not being eff[ective] until after a SOH Is
completed. We will deny based on the medical records on lie, the Insured
should've answered yes to one or more of the medical questions—
specifically regarding chest pains. If he had answered yes that would
have triggered a full SOH and based on the medical records presented if
he had answered the SOH questions correctly, we would have required a
full medical work-up prior to the coverage being effective. This is quoted
in the Statement of Health section. A SOH was required but because the
medical questions were not answered correctly, we never requested one.
As an approved SOH was required and one was never approved, the
coverage Is not valid.
Id. at 490. The file was referred and reviewed by Andrew Borelli, who concluded
on October 11, 2016:

15

The claim was re-reviewed and discussed with management. The claim
file has previously been supplied to the claimant and to her attorney. The
claimant's appeal has already been reviewed and our decision to deny
was upheld. We have notified the attorney how to obtain the SPD, as it is
the benefit administrator's responsibility to provide it. Decision to deny
remains unchanged. Will notify attorney in writing that decision to deny
remains unchanged, and send copies of the medical question answers
again.
Id. at 147, 490.
In her appeal of the denial, the plaintiff submitted records of physical
examinations Monarrez and his wife underwent on or about March 23, 2015, believing
them necessary to maintain his life insurance.
Sepulveda-Rodriguez Aff. at 2-3.

Id., 409, 437-44; Filing No. 66-1,

Medical records submitted to Metropolitan also

showed that Monarrez had undergone sinus surgery in May of 2014 and records show
no cardiac problems. Filing No. 53-1, Admin. R. at 248-306.
The plaintiff has submitted evidence that, because they believed Monarrez to be
covered by the Optional Life Insurance, neither Mr. Monarrez nor his widow obtained
additional life insurance for him. Filing No. 66-1, Sepulveda-Rodriguez Aff. at 1. The
defendants have submitted an affidavit stating that the medical examinations that the
plaintiff and her decedent underwent in March 2015 had no relationship to the optional
life insurance benefit. Filing No. 59-1, Second Affidavit of Jennifer Konarske (“Konarske
Aff. 2”). She states the records of the decedent’s wellness examination were provided
only to the third-party vendor that administered the Ford’s wellness benefit, not to either
Ford or to Metropolitan. Id. at 2. To the contrary, the record shows records of the
wellness examination were provided to and considered by Metropolitan in making its
determination. Filing No. 53-1, Admin. R. at 404, 409-10, 437-42.

16

The plaintiff requested the relevant summary plan description (SPD) from
defendant Metropolitan on April 15, 2016; June 23, 2016; August 19, 2016; and
September 1, 2016. Id. at 434, 453, 458, 472. The record shows Metropolitan provided
copies of the claim file to the plaintiff’s attorney in July 2016, but did not inform the
plaintiff that she would have to obtain the SPD from the employer.

Id. at 149-50.

Metropolitan Life eventually responded in a letter dated August 26, 2016, without
providing the SPD, and directed the plaintiff to submit an inquiry to Ford National
Employee Services Center ("Ford NESC”). Id. at 461.
The plaintiff did so on September 1, 2016 and again on October 4, 2016. Id. at
465, 472. The record shows the Ford NESC handles plan administration for the policy
at issue. Filing No. 57, Ford Brief at 13-14, Affidavit of Jennifer Konarske (“Konarske
Aff.”) at 1-2. Ford NESC's records show that plaintiff’s attorney's letter of September 1,
2016, requesting a copy of the SPD was received by Ford NESC on September 7,
2016. Id. at 2. Ford NESC mailed the SPD to the attorney on October 28, 2016. Id.
Ford admits it inadvertently failed to mail the SPD to Mr. Skalka within 30 days of
September 7, 2016, but contends it did not act in bad faith or intend to cause harm to
the plaintiff.

Id.

Plaintiff’s former attorney received the SPD from Ford NESC on

November 3, 2016. Filing No. 66-1, Sepulveda-Rodriguez Aff. at 4.
In addition, Ford has shown the SPD is available online at all times to all Ford
employees at www.myfordbenefits.com. Filing No. 57, Konarske Aff. at 2. The SPD is
available to any employee who is a plan participant and to any employee's spouse who
is a beneficiary and has the employee's user name and password. Id. The plaintiff

17

stated she did not know the document was online and did not know her deceased
husband’s username or password. Filing No. 66-1, Sepulveda-Rodriguez Aff. at 4.
II.

LAW
A.

Summary Judgment Standards

Summary judgment is appropriate when the pleadings, the discovery and
disclosure materials on file, and any affidavits show that there is no genuine issue as to
any material fact and that the movant is entitled to judgment as a matter of law. Fed.
R.Civ. P. 56(c). "The inquiry performed is the threshold inquiry of determining whether
there is the need for a trial—whether, in other words, there are any genuine factual
issues that properly can be resolved only by a finder of fact because they may
reasonably be resolved in favor of either party." Anderson v. Liberty Lobby, Inc., 477
U.S. 242, 250 (1986). A "genuine" issue of material fact exists when there is sufficient
evidence favoring the party opposing the motion for a jury to return a verdict for that
party. Id. at 251-52. "Where the unresolved issues are primarily legal rather than
factual, summary judgment is particularly appropriate." Koehn v. Indian Hills Cmty.
Coll., 371 F.3d 394, 396 (8th Cir. 2004.)
B.

Scope of review

Under ERISA, when a denial of benefits is challenged through judicial review,
“the record that was before the administrator furnishes the primary basis for review.”
Trustees of Electricians' Salary Deferral Plan v. Wright, 688 F.3d 922, 925 (8th Cir.
2012); see also Brown v. Seitz Foods, Inc., Disability Benefits Plan, 140 F.3d 1198,
1200 (8th Cir. 1998) (suggesting a district court should ordinarily limit its review to the
evidence contained in the administrative record). When reviewing the denial of benefits
18

under an ERISA plan, “the general rule is that review is limited to evidence that was
before the administrator.” Atkins v. Prudential Ins. Co., 404 Fed. App'x 82, 84 (8th Cir.
2010) (internal quotation marks omitted). The review of a benefits decision is generally
confined to the information available at the time of the claim decision.

Farley v.

Arkansas Blue Cross & Blue Shield, 147 F.3d 774, 777 (8th Cir. 1998). However, new
evidence may be considered under certain circumstances in order to enable the full
exercise of informed and independent judgment. Kostecki v. Prudential Ins. Co. of Am.,
No. 4:14-CV-695, 2014 WL 5094004, *1 (E.D. Mo. Oct. 10, 2014).
Although discovery of information outside of the administrative record is generally
not allowed, the limitation "does not apply to claims involving ERISA plans when the
claims are for equitable relief under § 1132(a)(3) or for equitable estoppel." Id.; see
e.g., Jensen v. Solvay Chems., Inc., 520 F. Supp. 2d 1349, 1355 (D. Wyo. 2007) (“Case
law does not constrain discovery under ERISA § [1132](a)(3) actions.”); Vogel v.
Anheuser Busch Companies, Inc., 2014 WL 3894497, at *1 (E.D. Mo. Aug. 8, 2014)
(holding the claimant was "entitled to limited discovery regarding his claims for civil
penalties and equitable estoppel”). “This is so because these types of actions ‘do not
benefit from the administrative process.’” Kostecki, 2014 WL 5094004 at *1 (quoting
Jensen, 520 F. Supp. 2d at 1355).
C.

ERISA Claim for Benefits

The underlying purpose of ERISA is to protect the interests of participants in
employee benefit plans and their beneficiaries. See Firestone Tire & Rubber Co. v.
Bruch, 489 U.S. 101, 113 (1989); 29 U.S.C. § 1001(b).

Under ERISA, a plan

“participant or beneficiary” may bring a “civil action” to “recover benefits due to him
19

under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify
his rights to future benefits under the terms of the plan.” 29 U.S.C. § 1132(a)(1)(B).
Claims administrators may be sued as defendants under 29 U.S.C. § 1132(a)(1)(B) and
(3). See Brown v. J.B. Hunt Transp. Servs., Inc., 586 F.3d 1079, 1081, 1088 (8th Cir.
2009); accord Harris Trust & Savings Bank v. Salomon Smith Barney Inc., 530 U.S.
238, 246 (2000) (holding that non-plan defendants may be sued under those
provisions). The proper party defendant in a claim for benefits under section (a)(1)(B) is
the party required by the plan to pay the benefits. Brown, 586 F.3d at 1088.
“In general, a claim administrator's denial of benefits is subject to de novo review
by the district court.” Cooper v. Metro. Life Ins. Co., 862 F.3d 654, 660 (8th Cir. 2017);
see Bruch, 489 U.S. at 115.

Where the plan grants the administrator or fiduciary

“discretionary authority” to determine eligibility for benefits, however, the standard of
review is relaxed, and abuse of discretion becomes the appropriate benchmark.
Cooper, 862 F.3d at 660; see also Donaldson v. Nat'l Union Fire Ins. Co. of Pittsburgh,
863 F.3d 1036, 1039 (8th Cir. 2017); Yafei Huang v. Life Ins. Co. of N. Am., 801 F.3d
892, 898 (8th Cir. 2015).
Where “‘a plan administrator holds the dual role of evaluating and paying benefits
claims,’ this conflict of interest should be considered ‘as a factor in determining whether
the plan administrator has abused its discretion.’”

Donaldson, 863 F.3d at 1039

(quoting Manning v. Am. Republic Ins. Co., 604 F.3d 1030, 1038 (8th Cir. 2010)); see
also Huang, 801 F.3d at 898. The simple fact a conflict exists, however, does not
eliminate the administrator's discretion or change the court’s review of the
administrator's decision to de novo review. Id.; see Brake v. Hutchinson Tech. Inc. Grp.
20

Disability Income Ins. Plan, 774 F.3d 1193, 1196 (8th Cir. 2014) (stating the court takes
“this inherent financial conflict of interest into account in deciding whether an abuse of
discretion has occurred.”). “While a conflict of interest must be ‘weighed as a factor,’
the weight afforded to it will depend on the facts presented to the court.” Cooper, 862
F.3d at 661 (quoting Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 115 (2008)
(citation and quotation omitted)).
The factors courts “have identified in the past as tending to demonstrate a
consequential conflict of interest include evidence that the insurer's claims review
process was tainted by bias; that the medical professionals who reviewed the claim for
benefits were employed by the insurer, or that their compensation was tied to their
findings; and that the insurer acted as little more than a rubberstamp for favorable
medical opinions.” Id.; see Whitley v. Standard Ins. Co., 815 F.3d 1134, 1140 (8th Cir.
2016); Carrow v. Standard Ins. Co., 664 F.3d 1254, 1259 (8th Cir. 2012). “Where an
insurer has a history of biased claims administration, the conflict may be given
substantial weight, but where the insurer has taken steps to reduce the risk that the
conflict will affect eligibility determinations, the conflict should be given much less
weight.”

Darvell v. Life Ins. Co. of North America, 597 F.3d 929, 934 (8th Cir.

2010)(noting that when the record contains little evidence of the insurer's efforts to
ensure that the conflict did not affect eligibility determinations, a court properly gives the
conflict some weight, but it is not determinative). Also, procedural irregularities may
trigger heightened review. Carr v. Anheuser-Busch Companies, Inc., 495 F. App'x 757,
763 (8th Cir. 2012).

21

When reviewed for an abuse of discretion, "an administrator's decision is upheld
if it is reasonable, that is, supported by substantial evidence . . . [which] means 'more
than a scintilla but less than a preponderance.'" Silva v. Metro. Life Ins. Co., 762 F.3d
711, 717 (8th Cir. 2014)(quoting Darvell, 597 F.3d at 934 (citations omitted)); see also
Cooper, 862 F.3d at 660. To determine if a plan administrator's interpretation of policy
terms is reasonable, the court examines: (1) whether their interpretation is consistent
with the goals of the plan, (2) whether their interpretation renders any language of the
plan meaningless or internally inconsistent, (3) whether their interpretation conflicts with
the substantive or procedural requirements of the ERISA statute, (4) whether they have
interpreted the words at issue consistently, and (5) whether their interpretation is
contrary to the clear language of the plan. Donaldson, 863 F.3d at 1039; see King v.
Hartford Life & Accident Ins. Co., 414 F.3d 994, 999 (8th Cir. 2005) (en banc).
D.

ERISA—Equitable Relief

Plan participants may also recover "other appropriate equitable relief" under 29
U.S.C. § 1132(a)(3). CIGNA Corp. v. Amara, 563 U.S. 421, 443, (2011) (recognizing
that an equitable claim for surcharge, reformation, or estoppel may be permitted in
some situations based upon an ERISA fiduciary's breach of a duty towards a covered
employee); see Silva, 762 F.3d at 722 (recognizing the Supreme Court's decision in
Amara changed the legal landscape by clearly spelling out the possibility of an equitable
remedy under ERISA for breaches of fiduciary obligations by plan administrators).
Equitable relief under § 1132(a)(3)(B) “is limited to those categories of relief that were
typically available in equity during the days of the divided bench (meaning, the period
before 1938 when courts of law and equity were separate).”
22

Montanile v. Bd. of

Trustees of Nat'l. Elevator Indus. Health Benefit Plan, ––– U.S. ––––, 136 S. Ct. 651,
657 (2016) (internal quotation marks omitted). Courts look to “cases and secondary
legal materials to determine if the relief would have been equitable in the days of the
divided bench.” Sereboff v. Mid Atl. Med. Servs., Inc., 547 U.S. 356, 362 (2006) (internal
quotation marks omitted).
ERISA does not provide a standard for establishing harm from breaches by
ERISA fiduciaries. Amara, 563 U.S. at 443. Such harm, however, includes detrimental
reliance and the loss of a right protected by ERISA. Id. at 444. A restitutionary claim for
premiums paid under § 1132(a)(3)(B) is potentially available to a beneficiary if there is a
plan violation. Ibson v. United Healthcare Servs., Inc., No. 16-3260, 2017 WL 6030647,
at *4 (8th Cir. Dec. 6, 2017). The surcharge remedy extends to a breach of trust
committed by a fiduciary encompassing any violation of a duty imposed upon that
fiduciary. Amara, 563 U.S. at 442. To obtain relief under the surcharge theory, a plan
participant is required to show harm resulting from the plan administrator's breach of a
fiduciary duty. See id. at 443-44 (stating a plan participant or beneficiary must show
that the violation injured him or her, but need only show actual harm and causation);
see Silva, 762 F.3d at 722 (involving allegations that employer breached its fiduciary
duty to act in the interest of plan participants when it failed to provide participant with
necessary information regarding enrolling in the Plan).
A reformation remedy may be available to reform contracts based on mutual
mistake or fraud. See Silva, 762 F.3d at 722-23 (addressing the argument that an
insurer breaches its fiduciary duty by collecting insurance policy premiums, reasonably
inducing an employee to believe that his application for a supplemental life insurance
23

policy was approved and that no further action was needed, and then, after participant’s
death, denying that he had a valid policy). The concept of equitable estoppel can also
be invoked in circumstances where “‘proof of words or deeds (or sometimes omissions
to speak or act) [ ] create a misleading impression upon which a reasonable person
would rely.’” Id. at 724 (stating that evidence of wrongful retention of premiums from
employees who lacked approved policies, and foregoing other insurance, can show
reliance).
A Plan Sponsor breaches its fiduciary duty to act in the interest of plan
participants when it fails to provide a participant with necessary information regarding
the Plan. Silva, 762 F.3d at 721. The Supreme Court has stressed “[t]he relevant
regulations . . . establish extensive requirements to ensure full and fair review of benefit
denials.” Aetna Health Inc. v. Davila, 542 U.S. 200, 220 (2004) (citing 29 C.F.R. §
2560.503–1). The regulations set forth “minimum requirements for employee benefit
plan procedures pertaining to claims for benefits.’” Midgett v. Washington Grp. Int'l
Long Term Disability Plan, 561 F.3d 887, 893 (8th Cir. 2009) (quoting 29 C.F.R. §
2560.503–1(a)).
As long as a claim for denial of benefits and a claim for breach of fiduciary duty
assert different theories of liability, plan beneficiaries may assert both. Jones v. Aetna
Life Ins. Co., 856 F.3d 541, 547 (8th Cir. 2017); see also Silva, 762 F.3d at 728 & n.12.
Eighth Circuit caselaw “prohibit[s] duplicate recoveries when a more specific section of
the statute, such as § 1132(a)(1)(B), provides a remedy similar to what the plaintiff
seeks under the equitable catchall provision, § 1132(a)(3).” Silva, 762 F.3d at 726. “At
summary judgment, a court is better equipped to assess the likelihood for duplicate
24

recovery, analyze the overlap between claims, and determine whether one claim alone
will provide the plaintiff with ‘adequate relief.’” Silva, 762 F.3d at 727 (8th Cir. 2014).
E.

Failure to provide SPD

Under 29 U.S.C. § 1024(b)(4), a plan administrator must furnish a SPD or other
instruments under which the plan is established or operated to participants and
beneficiaries upon written request. "[T]he summary plan description's objective is to
provide 'clear, simple communication' that states the terms and conditions of the Plan."
Silva, 762 F.3d at 721 (quoting Amara, 563 U.S. at 437).

"ERISA's disclosure

provisions were enacted to 'ensur[e] that the individual participant knows exactly where
he stands with respect to the plan,' and the regulations promulgated under ERISA are
designed to achieve that goal." Leyda v. AlliedSignal, Inc., 322 F.3d 199, 208 (2d Cir.
2003) (quoting Bruch, 489 U.S. at 118) (internal quotation marks omitted). ERISA's
disclosure provisions were designed to ensure that an individual participant knows
exactly where he or she stands with respect to the plan. Bruch, 489 U.S. at 118. This
requires ready access to information on how to apply for benefits and how to determine
eligibility for benefits. Mondry v. American Family Mut. Ins. Co., 557 F.3d 781, 793 (7th
Cir. 2009).
The ERISA statute and regulations describe the publication and disclosure
requirements that apply to SPDs. See 29 U.S.C. § 1024(b); 29 C.F.R. § 2520. The
statute requires the summary plan description to be "'written in a manner calculated to
be understood by the average plan participant,' and it must contain, among other
requirements, 'circumstances which may result in disqualification, ineligibility, or denial
or loss of benefits.'" Silva, 762 F.3d at 721 (citations omitted) (quoting 29 U.S.C. §
25

1022(a) and (b)).

The summary plan description must be "furnished" by the plan

administrator to the plan participants by a method or methods of delivery likely to result
in full distribution, and the administrator is required to use measures reasonably
calculated to ensure actual receipt of the material by plan participants. Id. at 721. With
respect to electronic distribution, the administrator must take appropriate and necessary
measures that are reasonably calculated to ensure that the system for furnishing
documents results in actual receipt of transmitted information (e.g., using return-receipt
or notice of undelivered electronic mail features, conducting periodic reviews or surveys
to confirm receipt of the transmitted information). 29 C.F.R. § 2520.104b–1(c)(1)(i) &
(i)(A).
Penalties under § 1132(c) are designed to provide plan administrators with an
incentive to comply with ERISA's disclosure requirements and to punish noncompliance.
Starr v. Metro Systems, Inc., 461 F.3d 1036, 1040 (8th Cir. 2006). Section 1132(c) sets
the maximum penalty at $100 a day, but this has been increased by regulation to $110
per day. See 29 C.F.R. § 2575.502c–3. Whether to assess a penalty, and the amount,
are committed solely to the Court's discretion. 29 U.S.C. § 1132(c). In exercising this
discretion, courts primarily consider any prejudice caused to the plaintiff and the nature
of the plan administrator's conduct. Starr, 461 F.3d at 1040. Prejudice in this context is
not limited to a loss of benefits, but includes the lost time, effort, and money spent
gaining access to information to which one was legally entitled. See Brown v. Aventis
Pharms., Inc., 341 F.3d 822, 825 (8th Cir. 2003). ERISA's requirements for furnishing
SPDs to plan participants are quite demanding. Brown v. Owens Corning Inv. Review
Comm., 622 F.3d 564, 578 (6th Cir. 2010). Penalties begin to accrue 31 days after a
26

plan sponsor receives a participant or beneficiary’s request and continue to accrue until
the day before the Plan Sponsor furnishes the documents.

Boyadjian v. CIGNA

Companies, 973 F. Supp. 500, 507 (D.N.J. 1997); see also Daniels v. Thomas & Betts
Corp., 263 F.3d 66, 80 (3d Cir. 2001).
III.

DISCUSSION
As a threshold matter, the court determines that its review in connection with the

plaintiff’s denial of benefits claim is limited to the administrative record in this case. The
affidavits submitted in connection with the motions will be considered only with respect
to the claim for failure to timely furnish the SPD and the equitable claims.
The court reviews Metropolitan’s denial of the plaintiff’s optional life insurance
benefits claim for an abuse of discretion since the SPD affords discretionary authority to
determine eligibility to both the claims administrator and the plan administrator. The
court will also consider as relevant the fact that the claims administrator is the paying
entity in this case. The record does not contain evidence of any efforts by Metropolitan
to ensure the conflict did not affect it eligibility determinations, so the court will give the
conflict some weight.
Applying that standard, the court finds Metropolitan’s decision to deny coverage
is not supported by sufficient evidence and is therefore not a reasonable interpretation
of the terms of the Plan.

Metropolitan’s characterization of the facts is simply

unsupported. The Plan requires proof of good health before optional life insurance is
effective. The SPD describes a process of answering five questions. The record before
the court does not establish what questions Monarrez was asked, nor does it establish
that he answered those questions and what his answers to the questions were. The
27

record shows widespread confusion between the employer, its third-party human
resources administrator, and its insurer with respect to the requirements for obtaining
optional life insurance coverage. First, a representative of the employer stated that the
newly hired employee was not asked health related questions. Then a representative
stated that the questions were asked but not recorded. Finally, the employer stated,
without further explanation, that “the election was processed through a CSR via IVR
enrollment.”

That statement is meaningless in the context of the record.

The

attachments apparently highlighting the supposed questions and purported answers—
digital records, spreadsheets, data sets and time stamps—do not establish what the
questions were, what the answers were, or who provided the answers. The documents
lack foundation or authentication and provide no evidence of what happened at the time
the decedent was hired by Ford and enrolled for benefits.

There is no paper or

electronic record of the plaintiff’s decedent’s application for optional life insurance
benefits. Based on the record presented to the court, Metropolitan has not proved that
Monarrez answered health-related questions untruthfully.
The record shows Metropolitan also had difficulty discerning what information
had been provided by Monarrez, which is shown by its inconsistent reasons for the
claim denial—first failure to report chest pain and then failure to report high blood
pressure. Metropolitan has not shown that the decedent answered “no” to either of
those questions.

Internal communications indicate Metropolitan employees were

befuddled about differences in paper as opposed to electronic questionnaires, exact
wording, and differences in questions asked over time.

The record shows no one

reviewing the claim file knew whether the five questions referred to in the SPD were
28

posed to the enrollee. The record contains one unidentified document that lists nine
questions. Even the computer evidence that Metropolitan relies on contain only partial
questions.

When it became clear to Metropolitan that there was no record that

Monarrez had been asked a question about chest pains, the focus turned to the high
blood pressure inquiry. Even if the court were to consider and fully credit the computer
records, nothing establishes any link between the questions and answers and Jose
Monarrez.

The evidence just as likely shows that the computerized records were

generated by human resources personnel or by a third-party administrator or bureaucrat
than by the decedent.

This is especially true in light of the evidence that Ford’s

representatives did not even know that the health questions were required.

The

evidence of record does not establish that Monarrez was untruthful in his application for
optional life insurance benefits.

Metropolitan’s internal communications even show

some level of unease in relying on the documents, in that the claim was repeatedly
referred for senior review.
Moreover, even assuming Metropolitan had shown that Monarrez had answered
“no” to the questions at issue, Metropolitan has not shown that it would have denied
coverage to Monarrez had Monarrez truthfully answered “yes” to the queries about
chest pains or high blood pressure. Metropolitan’s investigation and examination of the
decedent’s medical records did not result in any conclusive determination that coverage
would have been denied, even if Monarrez had submitted a full “Statement of Health.”
The underwriter’s communication seems to indicate that it was at best questionable
whether coverage would have been denied. She further noted that the medical records
used by Metropolitan to deny coverage were “old and even the most recent information
29

gave no indication of chest pains” by Mr. Monarrez.

The record shows continuing

uncertainty with respect to what Monarrez had reported on his application and a lack of
consensus as to whether or not he would have been denied benefits.
In spite of that uncertainty, Metropolitan denied the plaintiff’s optional benefits. It
paid lip service to policy language that was arguably not applicable, relied on vague
statements in the SPD and ignored the plaintiff’s requests for information. It made
coverage decisions before it had obtained all the medical records and did not address
the decedent’s recent examinations and surgeries, instead relying on dated information
that its own employees had questioned.
The court also finds the provisions of the plan that purportedly require proof of
good health or evidence of insurability are vague and inconsistent. The provisions of
the policy and SPD do not give a participant adequate notice or information about what
is required to obtain “approval.” There are also inconsistencies in the plan documents
concerning the requirement for initially enrolling for benefits as opposed to those
necessary to increase coverage under the plan. The plan documents state that the
insurance is effective on different dates depending on whether the participant is
required to give evidence of insurability, but is silent on the amount of insurance that
would trigger evidence of insurability.
The court finds Metropolitan’s decision to deny the claim is not consistent with
the goals of the Plan which are to provide life insurance to Ford employees at the
employees’ own expense. The denial renders the language in the Plan involving proof
of health, statements of health, and approval meaningless and internally inconsistent.
The claims administrator’s conduct also conflicts with the substantive or procedural
30

requirements of the ERISA statute, in that the plan documents do not reasonably
convey the necessary information to participants. Further, the record shows the various
decision-makers

interpreted

the

policy

requirements

interpretation is contrary to the language of the Plan.

inconsistently

and

their

Accordingly, the court finds

Metropolitan’s denial of the plaintiff’s claim for optional life insurance benefits was an
abuse of discretion. The plaintiff has shown it is entitled to a summary judgment against
Metropolitan.
Even if it were not an abuse of discretion for Metropolitan to deny optional life
insurance benefits to the plaintiff, the plaintiff would nonetheless be entitled to summary
judgment against Metropolitan for breach of fiduciary duty. Both Ford and Metropolitan
are proper defendants with respect to the equitable claims. As discussed below, Ford’s
failure to timely furnish the SPD is one breach of its fiduciary duty. The evidence also
establishes that both Ford and Metropolitan should be equitably estopped from denying
coverage on Monarrez. The record establishes that Ford withheld premiums from the
decedent’s paychecks and processed the payments by forwarding them to Metropolitan.
Metropolitan accepted the premiums.

The decedent and the plaintiff relied on the

withholding and processing of the premiums as a basis for the reasonable belief that
they were covered by optional life insurance. The plaintiff has shown that she and her
late husband relied on that belief of coverage to their detriment, foregoing other
insurance coverage. The evidence shows Ford breached its fiduciary duty to properly
administer the group life insurance policy in the sole interest of its insured employees
and their beneficiaries. Ford allowed Monarrez to enroll in the plan effective November
1, 2013, allowed him to renew optional life insurance coverage in January 2014 and
31

January 2015 respectively, and withdrew premiums for the entire period of time.
Further, it failed to provide the participants and beneficiaries with information sufficient
to cause them to be adequately informed in decisions to pursue benefits.
Monarrez, assuming he had read the entire policy and SPD, would have been
reasonable in a belief that no additional medical information, in the form of a statement
of health, was required.

The policy is silent on information needed during initial

enrollment, silent on the meaning of a statement of health or proof of insurability, and
silent as to the form or timing of any required approval. Neither the Plan (the certificate
of insurance) nor the SPD provided a definition or conveyed any clear understanding of
the requirements for a statement of health. Further, it did not concisely convey what the
“approval” process ordained.
Under the circumstances, Monarrez would have been justified in any belief that
Ford and Metropolitan either had sufficient evidence of his good health and insurability
or had waived any proof of good health requirement for optional coverage on initial
enrollment. It is not clear to the court what a reasonable person in Monarrez’s position
could have done differently to prevent this situation.

In light of the payment of

premiums, annual re-enrollments, and required physical examinations under the
wellness program that was part of Ford’s benefits plan, Monarrez was reasonable in
believing he had optional life insurance coverage and Ford is estopped from denying
coverage. See, e.g., Van Loo v. Cajun Operating Co., No. 16-1980, 2017 WL 3034275
(6th Cir. July 18, 2017); Silva, 762 F.3d at 723-24. Accordingly, both defendants are

32

liable to the plaintiff for breach of fiduciary duty and the plaintiff is entitled to summary
judgment against Ford and Metropolitan on her equitable claims.7
With respect to the failure to provide an SPD claim, Ford admits that it timely
failed to provide the plaintiff with a copy of the SPD. Nothing in the record substantiates
its claim of “substantial compliance.” Ford has propounded no reasons for the delay
other than inadvertence. The plaintiff has been prejudiced by the delay in that she has
now waited for years to collect life insurance rightly due her and has had to expend
money in pursuit of her claims. In view of the fact that the information necessary to
process the claim was likely in Ford’s, or its agent third-party administrator’s
possession, its failure to timely furnish the SPD to its beneficiary is not excusable. The
court thus finds a penalty is warranted.
Thirty days elapsed on October 7, 2016, and the penalties began to run from the
31st day, October 8, 2016. Ford furnished the documents on October 28, 2016. The
penalties run until the day before Ford furnished the documents. October 27, 2016.
This comes to a total of 19 days.
The court sees no reason to exercise its discretion to reduce the amount of
Ford’s liability from the statutory maximum. Accordingly the court will impose a penalty
on defendant Ford for its failure to produce Plan documents in the amount of $2,090.
IT IS ORDERED:

7

A duplicative recovery is not allowed, however. Although a plaintiff can pursue an equitable
action in the nature of a surcharge for the sums allegedly withheld from her by the denial of benefits, the
remedy for that denial, award of a sum sufficient to compensate her for the wrong, would duplicate the
relief awarded for the section (a)(1)(B) violation. The plaintiff has not requested equitable relief other than
the award of benefits. The significance of this holding relates only to Ford’s potential liability for attorney
fees.

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1.

The motions for summary judgment filed by Defendants Metropolitan and

Ford (Filing Nos. 56 and 58) are denied.
2.

The motion for summary judgment filed by plaintiff (Filing No. 65) is

granted.
3.

MetLife Group, Inc. is dismissed as a party defendant.

4.

Plaintiff shall file a motion for attorney fees within fourteen (14) days of the

date of this order.
5.

After the attorney fee issue is resolved, judgment will be entered in favor

of the plaintiff and against defendant Ford in the amount of $2,090.00 on the plaintiff’s
failure to provide plan documents claim;
6.

Judgment will be entered in favor of the plaintiff and against defendant

Metropolitan in the amount of $92,694.00 on the plaintiff’s claim for denial of benefits;
7.

Judgment will be entered in favor of the plaintiff and against defendants

Metropolitan and Ford on the plaintiff’s equitable claims.
Dated this 28th day of December, 2017.

BY THE COURT:
s/ Joseph F. Bataillon
Senior United States District Judge

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