Collins v. Unum Life Insurance Company of America
Filing
22
Opinion & Order signed by Judge James S. Gwin on 3/31/16. The Court, for the reasons set forth in this order, finds that the arbitrary and capricious standard applies to a limited review of the administrative record in this case and grants the defendant's motion to strike plaintiff's jury demand. The arbitrary and capricious briefing schedule set out at the case management conference will apply going forward. (Related Docs. 17 , 18 , and 19 ) (D,MA)
UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF OHIO
-----------------------------------------------------DANIEL COLLINS,
Plaintiff,
vs.
UNUM LIFE INSURANCE COMPANY
OF AMERICA,
Defendant.
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CASE NO. 15-CV-2229
OPINION & ORDER
[Resolving Docs. 17, 18, 19]
-----------------------------------------------------JAMES S. GWIN, UNITED STATES DISTRICT JUDGE:
Plaintiff Daniel Collins brings claims under 29 U.S.C. § 1132(a)(1)(B) against Defendant
Unum Life Insurance Company of America (“Unum”) for wrongful denial of ERISA plan
benefits. Plaintiff says that this Court should apply a de novo standard of review to his claim and
should authorize discovery into Unum’s denial process.1 Defendant Unum responds that this
Court should apply an arbitrary and capricious standard and responds that this Court should limit
its review to the administrative record at the time Unum denied Plaintiff’s claim for benefits.2
Defendant also moves to strike Plaintiff’s jury demand.3 For the following reasons, this Court
finds that the arbitrary and capricious standard applies to a limited review of the administrative
record in this case, and GRANTS Defendant’s motion to strike.
I. Background
Before January 6, 2012, Plaintiff Collins worked at Affymetrix. Affymetrix had an
employee’s insurance plan through Defendant Unum. The plan was governed by ERISA.4
1
Doc. 19. Defendant opposes. Doc. 20.
Doc. 17. Plaintiff opposes. Doc. 21.
3
Doc. 18.
4
29 U.S.C. § 1001 et seq.
2
Case No. 15-cv-2229
Gwin, J.
The policy covered accidental dismemberment. However, the policy had a coverage
exception for dismemberment “caused by, contributed to by, or resulting from . . . disease of the
body.”5 The policy also delegated discretion and authority to Defendant Unum to process claims
under the policy and to interpret the policy.6
On January 6, 2012, Plaintiff slipped and fell in the employee parking lot and got his leg
caught in a sewer grate.7 On February 8, 2013, Plaintiff underwent a foot amputation on the same
leg that had been caught in the sewer grate.8
Plaintiff applied for benefits under the Unum accidental dismemberment policy. On
November 21, 2013, Defendant Unum denied Plaintiff’s claim for benefits.9 Unum explained
that it denied Plaintiff’s claim because Unum believed that Plaintiff’s diabetes partly contributed
to the need to amputate Plaintiff’s foot. The amputation occurred more than one year from the
date of Plaintiff’s accident. On February 14, 2014, Plaintiff appealed the denial.10 Of February
24, 2014, Unum affirmed its benefits denial.11
On September 29, 2015, Plaintiff filed the complaint in this case.12 On October 20, 2015,
Defendants removed the case to federal court.13 On February 6, 2016, this Court held a case
management conference at which it instructed the parties to file briefs on the applicable standard
of review and scope of discovery in this case.14
5
Doc. 1-1 at 43.
Id. at 58.
7
Id. at 5.
8
Id.
9
Id. at 6.
10
Id.
11
Id.
12
Doc. 1-1.
13
Doc. 1.
14
Doc. 16.
6
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Gwin, J.
II. Legal Standard
Under ERISA, a denial of benefits is to be reviewed under a de novo standard
unless the benefit plan gives the administrator or fiduciary discretionary authority
to determine eligibility for benefits or to construe the terms of the plan. If the
administrator or fiduciary can show it has such discretionary authority, a benefits
denial is reviewed under the arbitrary and capricious standard. Although “magic
words” are not required, this Court has consistently required that a plan contain a
clear grant of discretion to the administrator or fiduciary before applying the
deferential arbitrary and capricious standard. A plan is not required to, but may
expressly provide for procedures for allocating fiduciary responsibilities.15
III. Discussion
Unum and Affymetrix’s accidental dismemberment and death insurance policy contains
the following provision:
The Plan, acting through the Plan Administrator, delegates to Unum and its
affiliate Unum Group discretionary authority to make benefit determinations
under the Plan. Unum and Unum Group may act directly or through their
employees and agents or further delegate their authority through contracts, letters
or other documentation or procedures to other affiliates, persons or entities.
Benefit determinations include determining eligibility for benefits and the amount
of any benefits, resolving factual disputes, and interpreting and enforcing the
provisions of the Plan.16
This Court finds that the provision above is a “clear grant of discretion to” Unum “to
determine eligibility for benefits or to construe the terms of the plan.”17 Therefore, this Court
uses the arbitrary and capricious standard to review Unum’s decision to deny Plaintiff’s claim for
benefits under this plan.
Under this standard, this Court is generally limited to reviewing the administrative record
at the time Unum denied Plaintiff’s claim for benefits.18 Plaintiff loses the argument that he is
15
Frazier v. Life Ins. Co. of N. Am., 725 F.3d 560, 566 (6th Cir. 2013) (internal citations and quotations omitted).
Doc. 1-1 at 58.
17
Frazier, 725 F.3d at 566 (internal citations and quotations omitted); see Moss v. Unum Life Ins. Co., 495 F. App’x
583, 590, n.2 (6th Cir. 2012) (finding that the same contractual provision in another Unum insurance policy “vests
the administrator with complete discretion in making eligibility determinations” and applying the arbitrary and
capricious standard).
18
McCartha v. Nat’l City Corp., 419 F.3d 437, 441 (6th Cir. 2005).
16
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Gwin, J.
nonetheless entitled to discovery on “the plan administrator, the claim, the claim process, appeals
process, intra-company communications, how Unum handles claims in which the ‘caused by,
contributed to by, or resulting from disease of the body’ exclusion is utilized to deny benefits,
and bonus/reward programs for Unum employees involved in Collins’s claim.”19 Plaintiff does
not make enough of a showing to justify this broader discovery.
Plaintiff correctly notes that Unum has a dual capacity as both the plan administrator and
payor. However, this structural conflict is not by itself sufficient evidence of Unum’s procedural
bias. Rather, this conflict is one factor for the Court to consider in deciding whether Defendant
Unum acted arbitrarily and capriciously in denying Plaintiff’s benefits claim.20
Plaintiff’s other arguments on this issue—for example, that there are “three inconsistent
physicians’ opinions in the administrative record”21—go more to the reasonableness of Unum’s
denial of benefits than to Unum’s procedural bias. At best, these are “mere allegation[s] of bias
[that are] not sufficient to permit discovery under Wilkins’ [150 F.3d 609, 616 (6th Cir. 1998)]
exception” to the general rule that courts are limited to reviewing the administrative record in
ERISA cases.22 Further discovery is therefore inappropriate.
Moreover, the Federal Rules of Civil Procedure do not support Plaintiff’s discovery
request. The scope and volume of the discovery Plaintiff requests are not proportional to the
discovery’s importance to Plaintiff’s claims.23 The requested discovery is even less important
because Defendant seems to admit that it is both the administrator and payor for claims under
19
Doc. 19 at 6–7.
Kalish v. Liberty Mut./Liberty Life Assur. Co. of Boston, 419 F.3d 501, 506 (6th Cir. 2005) (citing Firestone Tire
& Rubber Co. v. Bruch, 489 U.S. 101, 115, (1989)).
21
Doc. 21 at 3.
22
Johnson v. Connecticut Gen. Life Ins. Co., 324 F. App’x 459, 466 (6th Cir. 2009) (quoting Putney v. Med. Mut. of
Ohio, 111 F. App’x. 803, 807 (6th Cir. 2004)).
23
See Fed. R. Civ. P. 26(b)(1).
20
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Gwin, J.
this plan, including Plaintiff’s. Plaintiff does not show how any more discovery on this issue will
significantly aid Plaintiff’s claim that the dual capacity impacted Unum’s exercise of discretion.
Finally, this Court finds that Plaintiff is not entitled to a jury trial on his ERISA claim,
since it does not seek legal relief.24 Therefore, this Court GRANTS Defendant’s motion to strike
Plaintiff’s jury demand from the complaint.
IV. Conclusion
For the reasons above, this Court finds that the arbitrary and capricious standard applies
to Plaintiff’s claims and finds that discovery beyond the administrative record is inappropriate.
This Court GRANTS Defendant’s motion to strike Plaintiff’s jury demand. The arbitrary and
capricious briefing schedule set out at the case management conference will apply going
forward.25
IT IS SO ORDERED.
Dated: March 31, 2016
s/
James S. Gwin
JAMES S. GWIN
UNITED STATES DISTRICT JUDGE
24
Wilkins v. Baptist Healthcare Sys., Inc., 150 F.3d 609, 616 (6th Cir. 1998); Reese v. IBEW Local 82 Pension Plan,
2012 WL 832349, at *4 (S.D. Ohio Mar. 12, 2012) (citing Miner v. Comty. Mut. Ins. Co., 778 F. Supp. 402 (S.D.
Ohio 1991)).
25
Doc. 16 (“[T]he deadline for filing dispositive motions will be 5/23/16 . . . with responses due 6/23/16.”).
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