Dougharty v. Metropolitan Life Ins. Co. of America

Filing 25

MEMORANDUM OPINION AND ORDER: For the reasons explained above, plaintiff's Motion for Summary Judgment on the ERISA Record [Doc. 16] is DENIED, and defendant's Motion for Judgement on the Record [Doc. 18] is DENIED. See Memorandum Opinion and Order for details. Signed by District Judge Thomas A Varlan on 03/07/2025. (CAT)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF TENNESSEE
RANDY DOUGHARTY,
Plaintiff,
v.
METROPOLITAN LIFE INSURANCE
COMPANY OF AMERICA,
Defendant.

)
)
)
)
)
)
)
)
)
)

No.:

3:24-CV-83-TAV-DCP

MEMORANDUM OPINION AND ORDER
This matter is before the Court on the parties’ cross-motions for summary judgment
[Docs. 16, 18]. The parties have responded and replied to the respective motions [Docs.
19, 20, 22, 24]. Accordingly, this matter is ripe for review. See E.D. Tenn. L.R. 7.1(a).
For the reasons stated below, both plaintiff’s Motion for Summary Judgment on the ERISA
Record [Doc. 16] and defendant’s Motion for Judgement on the Record [Doc. 18] will be
DENIED.
I.

Background
This action arises from defendant’s alleged miscalculation of insurance benefits to

plaintiff under a long-term disability plan governed by the Employee Retirement Income
Security Act (“ERISA”).

Plaintiff seeks damages for unpaid benefits and an order

requiring defendant to pay recalculated benefits as long as he remains disabled, pursuant
to 29 U.S.C. § 1132(a)(1)(B) [Doc. 1].
In August 2020, plaintiff stopped work as a truck driver for TForce Holdings USA,
Inc. (“TForce”) due to lumbago from sciatica and idiopathic neuropathies [Doc. 15-20, pp.

76–79].1 Plaintiff’s employer, TForce, maintained a group long-term disability insurance
policy on behalf of its employees [Doc. 13-1, pp. 3–4]. A copy of this policy and
attachments, issued by defendant, are included in the ERISA record [Id. at pp. 5–65].2 The
policy states that it provides a monthly benefit equal to 60 percent of the first $16,667 of
the insured’s “Predisability Earnings” subject to certain conditions [Id. at 23]. The term
“Predisability Earnings” is later defined as “gross salary or wages You were earning from
the Policyholder in effect on the first of the year prior to the date Your Disability began.
We calculate this amount on a monthly basis” [Id. at 26]. In an “ERISA Information”
attachment to the policy, defendant specifies the following in regard to the determination
of disability benefits claims:
In carrying out their respective responsibilities under the Plan, the Plan
Administrator and other Plan fiduciaries shall have discretionary authority to
interpret the terms of the Plan and to determine eligibility for and entitlement
to Plan benefits in accordance with the terms of the Plan. Any interpretation
or determination made pursuant to such discretionary authority shall be given
full force and effect, unless it can be shown that the interpretation or
determination was arbitrary and capricious.
[Id. at 63].

As plaintiff notes, “both parties agree that [he] is disabled under the policy” [Doc. 17, p.
4]. Given that the parties’ dispute centers on the calculation of pre-disability earnings, the Court
does not recount detailed information regarding plaintiff’s medical diagnoses and treatment.
1

Although defendant submits that it “filed [the record] with the Court under seal,” the
Court notes that these documents are not presently sealed [Doc. 18-1, p. 2 n.1]. If either party
wishes to seal plaintiff’s sensitive medical records, the Court will entertain a motion to that effect.
2
2

In his disability claim filing3 on January 20, 2021, plaintiff indicated that he first
sought treatment for these conditions on August 3, 2020 [Id. at 86]. Defendant appears to
have contacted plaintiff’s employer regarding this claim, requesting, inter alia, “his salary
as of the first of the year prior to his date of disability” [Id. at 27]. A TForce representative
responded with “Annual Benefits Base Rate - $77,098.79” [Id.]. In response to defendant’s
initial denial of plaintiff’s claim, he sought additional information, including the monthly
benefit to which he would be entitled if he were to later receive a favorable coverage
determination [Doc. 15-15, pp. 78–80]. Defendant responded to this request, indicating
that plaintiff would be eligible for $3,854.94 per month if his claim was ultimately
approved [Id. at 76].
From November 2022 through early 2023, plaintiff’s counsel corresponded with
defendant, requesting additional information regarding its initial denial of plaintiff’s claim
[see, e.g., Doc. 13-10, pp. 93–95]. On May 8, 2023, plaintiff’s counsel requested a 30-day
extension to file his appeal from defendant’s benefit determination [Id. at 48]. On June 15,
2023, in response to defendant’s email indicating that no extension would be granted,
plaintiff stated his intention to appeal by a revised deadline of July 10, 2023, based upon
the United States Department of Labor’s (“Labor”) COVID-19 extension guidance [Id. at
43]. On July 10, 2023, plaintiff submitted a letter designated as his “written appeal,”

A “full and complete copy” of plaintiff’s claim history, which exceeds 500 pages, appears
to be included in the ERISA record pursuant to the Court’s Scheduling Order [Doc. 13-3, pp.
66–586; Doc. 10].
3
3

requesting that defendant “overturn the denial and make a favorable decision on [his] claim
for long-term disability benefits immediately” [Doc. 13-9, p. 39]. In this appeal, he stated:
First, this letter serves as Mr. Dougharty’s written appeal of the amount
($3,854.94) that MetLife has calculated as his monthly benefit. MetLife
appears to have calculated this amount based on a ‘benefits base pay’ of
$77,098.79. However, Mr. Dougharty’s predisability income was based on
a mileage rate, not a base pay. Under the policy, his benefit amount should
be calculated based on the amount that he was earning rather than the
‘benefits base rate’ that MetLife is using . . .
His average weekly earnings were $1,718.28. Based on this, his actual
monthly predisability earnings were $7,445.88. His monthly benefit should
be $4,467.53. After accounting for Mr. Dougharty’s receipt of Primary
Social Security benefits ($2,134), his net monthly benefit is $2,333.53 and
his claim has been underpaid $612.60 per month. The policy does not
contain a definition for wages or salary that would exclude Mr. Dougharty’s
mileage pay from his benefit calculations, and his paystubs show that this his
regular wages consisted of mileage pay.
[Id.]. Defendant acknowledged receipt on July 14, 2023, and stated that it would “notify
you of our decision in writing” “within 45 days” [Id. at 36].
On July 19, 2023, defendant requested additional information from plaintiff to
facilitative its review of his appeal, including office visit notes, MRI reports, and diagnostic
reports [Id. at 34]. Plaintiff responded to this request on July 28, 2023, indicating that he
was requesting certain MRI and diagnostic reports and would need an extension of 30 days
to submit this information [Id. at 32]. He also stated that “[w]e understand that MetLife
would need to toll the time that it takes us to submit this information” [Id.]. Defendant
granted this extension and stated its intention to decide on plaintiff’s appeal by October 8,
2023 [Doc. 13-4, p. 10]. On September 26, 2023, defendant reversed its previous denial
and determined that plaintiff was entitled to benefits [Doc. 13-1, p. 610]. On October 4,
4

2023, defendant again confirmed this decision [Id. at 599]. Apart from a request that
plaintiff complete an additional form on October 4, 2023, the ERISA record does not reflect
any additional responses to plaintiff’s appeal [see Doc. 13-1, pp. 575–84].4
II.

Standard of Review
The parties dispute the applicable standard of review. Plaintiff argues that because

defendant failed to render a decision as to the benefit calculation part of his appeal within
the applicable timeframe, the Court should apply a de novo standard of review [Doc. 17,
p. 5]. Specifically, he cites Labor regulations that require plan administrators to respond
to an appeal within 45 days [Id. at 5–6 (citing 29 C.F.R. § 2560.503-1(i)(3)(i))]. He submits
that the applicable deadline for defendant to respond to his appeal was August 24, 2023,
before which defendant did not respond to his benefit calculation appeal in writing [Id. at
6]. Under an amendment to ERISA regulations that took effect in 2017,5 plaintiff contends
that he is entitled to de novo review because defendant failed to strictly comply with §
2560.503-1(i)(3)(i) [Id. at 6–7 (citing id. § 2560.503-1(l)(2)(i))].

The Court notes that the final entries of defendant’s claim activity log contained in the
above-cited pages are redacted. No additional version of this log has been filed; so, it is impossible
for the Court to discern whether and to what extent defendant responded to plaintiff’s appeal after
the last visible entry on October 4, 2023.
4

5

The parties variously refer to this amendment by the years 2016 and 2018 [see Doc. 17,
p. 7; Doc. 20, p. 5]. For avoidance of doubt, the Court notes that Labor finalized the regulation in
question in late 2016, though it became effective as of January 18, 2017. 29 C.F.R. § 2560.503-1
(2017). However, the specific provision within that regulation at issue here was deemed applicable
only to claims for benefits filed after April 1, 2018. Id. § 2560.503-1(p)(3) (2017). Although the
regulation has been subsequently amended, the provision in question remains unchanged to the
present. Compare id. § 2560.503-1(l)(2)(i) (2017) with id. § 2560.503-1(l)(2)(i) (2020).
5

Defendant contends that an arbitrary and capricious standard of review applies
because the plan expressly assigns discretionary authority to the plan administrator and
plaintiff never requested information about the benefit calculation pursuant to the plan’s
“Routine Questions” guideline [Doc. 18-1, pp. 6–7 (citing Doc. 13-1, p. 60 (“If there is any
question about a claim payment, an explanation may be requested from the Employer who
is usually able to provide the necessary information.”))]. Defendant submits that beyond
requesting plaintiff’s earnings information from TForce, it did not make its own
determination of plaintiff’s “Predisability Earnings” [Id. at 7].

Even if §

2560.503-1(l)(2)(i) applies, defendant argues that Labor commentary clarifies that this
regulation is not intended to usurp district courts’ authority to apply appropriate standards
of review [Id.]. It contends that Sixth Circuit case law precludes such an application of the
regulation [Id. at 7–8 (citing Daniel v. Eaton Corp., 839 F.2d 263 (6th Cir. 1988))].
In their respective responses to the cross-motions for summary judgment, both
parties largely reiterate the same arguments originally raised in their memoranda in support
of summary judgment as to this issue [see Doc. 19, pp. 2–4; Doc. 20, pp. 2–5]. Plaintiff
notes that his appeal requested defendant “to consider both evidence of his continued
disability and evidence that its benefit calculation was incorrect” [Doc. 19, p. 2]. He also
argues that defendant’s citation to Daniel is outdated because that case predates the 2017
regulation that he cites in support of mandatory de novo review [Id. at 3]. Defendant, for
its part, asserts that plaintiff’s citation to out-of-circuit cases are unavailing with respect to
the continued applicability of Daniel [Doc. 20, pp. 4–5].
6

In a similar manner, the parties’ reply briefs retrace existing arguments [Doc. 22,
pp. 2–4; Doc. 24, pp. 2–4]. Of note, defendant further attempts to distinguish plaintiff’s
citation to Fessenden v. Reliance Standard Life Ins. Co., 927 F.3d 998 (7th Cir. 2019) by
arguing that the Sixth Circuit’s precedents are more broadly out of step with those of the
Seventh Circuit; therefore, it points once again to Labor’s commentary [Doc. 22, p. 3].
a. Strict Compliance with ERISA Regulations
When selecting the appropriate standard of review applicable to a plan
administrator’s decision under ERISA, courts first determine whether the plan, itself,
commits discretionary authority to its administrator. Clemons v. Norton Healthcare Inc.
Ret. Plan, 890 F.3d 254, 264 (6th Cir. 2018). If not, “a plan administrator’s denial-ofbenefits decision is reviewed de novo.” Id. (citing Firestone Tire & Rubber Co. v. Bruch,
489 U.S. 101, 115 (1989)).

“But if the plan ‘gives the administrator or fiduciary

discretionary authority to determine eligibility for benefits or to construe the terms of the
plan,’ we review such decisions under the arbitrary-and-capricious standard.” Id. (quoting
Firestone, 489 U.S. at 111, 115).
However, Labor has determined that even if a plan commits discretionary authority
to its administrator or fiduciary, arbitrary and capricious review may be forfeited as to
certain claims where the plan administrator fails to strictly comply with ERISA
requirements. See 29 C.F.R. § 2560.503-1(l)(2)(i). The regulation states:
In the case of a claim for disability benefits, if the plan fails to strictly adhere
to all the requirements of this section with respect to a claim, the claimant is
deemed to have exhausted the administrative remedies available under the
plan, except as provided in paragraph (l)(2)(ii) of this section. Accordingly,
7

the claimant is entitled to pursue any available remedies under section 502(a)
of the Act on the basis that the plan has failed to provide a reasonable claims
procedure that would yield a decision on the merits of the claim. If a claimant
chooses to pursue remedies under section 502(a) of the Act under such
circumstances, the claim or appeal is deemed denied on review without the
exercise of discretion by an appropriate fiduciary.
Id. (emphasis added).
Central to the parties’ dispute over the applicable standard of review is whether
plaintiff properly appealed his benefit calculation—not solely his eligibility for
coverage—and, if so, whether defendant responded to this facet of plaintiff’s appeal. The
Court finds that plaintiff appealed his benefit calculation in the first instance. His notice
of appeal dated July 10, 2023, states: “[f]irst, this letter serves as Mr. Dougharty’s written
appeal of the amount ($3,854.94) that MetLife has calculated as his monthly benefit” [Doc.
13-9, p. 39 (emphasis added)]. Defendant asserts that plaintiff’s request was improper
because he did not first ask his employer about the benefit calculation [Doc. 20, p. 3]. But
the provision to which defendant cites in the plan does not support its interpretation. As
an initial matter, the “Routine Questions” provision regarding “claim payment” arguably
encompasses a separate set of inquiries than where, as here, an insured seeks to challenge
defendant’s calculation of benefits—not its payment [See id.]. More importantly, the claim
and appeal process set forth in the subsequent paragraphs nowhere requires an insured to
‘exhaust’ his claim by first requesting information from his employer [Id. at 60–61].
Defendant appears to view plaintiff’s appeal of July 10, 2023, as solely contesting
benefit eligibility. But this consolidation of distinct grounds for appeal is not supported by
ERISA or defendant’s plan.

To the contrary, the procedures outlined for “Initial
8

Determination” and “Appealing the Initial Determination” expressly envision “den[ying]
your claim in whole or in part,” presumably confirming that an insured may challenge the
amount of benefits to which he is entitled in addition to his eligibility simpliciter [Id. at 60;
see also id. at 62 (“If you have a claim for benefits which is denied or ignored, in whole or
in part, you may file suit in a state or Federal court”) (emphasis added)]. And ERISA
regulations define “adverse benefit determination” to include, “[a] denial, reduction, or
termination of, or a failure to provide or make payment (in whole or in part) for, a
benefit[.]” 29 C.F.R. § 2560.503-1(m)(4)(i). Moreover, the United States Court of
Appeals for the Sixth Circuit has previously reversed a district court’s determination that
an insured has failed to exhaust his administrative remedies where he “endeavored
consistently both to inquire about and to challenge [insurer’s] methodology” and the
insurer “never demonstrated that it would alter or even consider altering its underlying
methodology.” Fallick v. Nationwide Mut. Ins. Co., 162 F.3d 410, 419 (6th Cir. 1998).
In sum, the Court finds that plaintiff appealed his benefit calculation on July 10,
2023. Accordingly, the Court also finds that defendant failed to respond in writing to this
aspect of plaintiff’s appeal. Although defendant cites to its internal comments in plaintiff’s
claim log noting that “should the attorney need to question that he would need to go through
the ER as there where we collected our information,” [Doc. 13-1, p. 503], the record does
not reflect, as plaintiff notes, that defendant “provided a written decision responding to his
appeal of the benefit calculation” [Doc. 24, p. 3]. Defendant’s written notices dated
September 26 and October 4, 2023, in which it reversed its previous denial of plaintiff’s
9

benefits, nowhere mention a determination or explanation as to his benefit calculation
[Doc. 13-1, pp. 599, 610]. February 20, 2024, the date on which plaintiff filed suit, is well
past the 45 day timeframe for defendant to respond pursuant to 29 C.F.R. §
2560.503-1(i)(3)(i). Having determined that § 2560.503-1(l)(2)(i) is activated, the Court
must determine what effect this relatively new provision may have.
b. Effect of the 2017 Amendment to § 2560.503-1(l)(2)(i)
Because defendant did not timely respond to plaintiff’s benefit calculation appeal,
the Court now proceeds to determine whether and to what extent 29 C.F.R. §
2560.503-1(l)(2)(i) dictates the applicable standard of review in this case.

Here,

defendant’s characterization of the law misses the mark. First, it cites Claims Procedure
for Plans Providing Disability Benefits, 81 FR 92316-01, at *92327 (Dec. 19, 2016) in
which Labor explained that, in promulgating § 2560.503-1(l)(2)(i), it “[did] not intend to
establish a general rule regarding the level of deference that a reviewing court may choose
to give a fiduciary’s decision interpreting benefit provisions in the plan’s governing
documents.” Contrary to defendant’s assertion that this regulation “merely creates a factual
scenario,” the commentary goes on to state that “[t]he legal effect of the definition may be
that a court would conclude that de novo review is appropriate because of the regulation
that determines as a matter of law that no fiduciary discretion was exercised in denying the
claim.” Id. at *92328. And Labor asserts that this regulation “relies on the regulatory
authority granted the Department in ERISA sections 503 and 505 and is intended to define
what constitutes a denial of a claim.” Id. at *92327. In sum, it appears that this regulation
10

was promulgated for the express purpose of altering a court’s calculus as to the applicable
standard of review in circumstances where “a plan fails to adhere to all the requirements in
the claims procedure regulation.” Id. at *92327.
Despite this regulatory context, defendant proceeds to cite case law that either
predates or does not address § 2560.503-1(l)(2)(i) as amended. First, it discusses Daniel
in which the Sixth Circuit held that “the standard of review is no different whether the
appeal is actually denied or is deemed denied.” 839 F.2d at 267. However, this 1988
opinion analyzed a prior version of the regulation. Critically, the provision analyzed in
Daniel lacked the phrase “without the exercise of discretion by an appropriate fiduciary,”
which Labor appears to have deliberately added to alter the standard of review. See id.; 81
FR 92316-01, at *92327–28. Next, it cites Martin v. Guardian Life Ins. Co. of Am., No.
5:20-CV-507, 2021 WL 2516083, at *3 (E.D. Ky. June 15, 2021) in support of the
proposition that Daniel’s holding remains operative. Yet, it conveniently elides the United
States District Court for the Eastern District of Kentucky’s statement therein that
“[plaintiff’s] claim is governed by the version of the regulation applicable to claims filed
after January 1, 2002, but before April 1, 2018” and the court therefore “declines to reach
a conclusion on whether the current version of the provision could require de novo
review[.]” Id. at *2, *3 n.2. Nor does defendant acknowledge more recent precedent from
the very same court, which holds to the contrary: “if subsection (l)(2)(i) applies, [plaintiff]
is entitled to de novo review,” provided that the claim at issue “[was] filed under a plan
after April 1, 2018.” Card v. Principal Life Ins. Co., No. 5:15-CV-139, 2023 WL 5706202,
11

at *8 (E.D. Ky. Sept. 5, 2023) (citing § 2560.503-1(p)(3)); see also Jordan v. Reliance
Standard Life Ins. Co., No. 22-5234, 2023 WL 5322417, at *2 n.1 (6th Cir. Aug. 18, 2023)
(recognizing the applicability of § 2560.503-1(l)(2)(i), though not discussing the “exercise
of discretion” portion). Finally, defendant’s citation to Rossiter v. Life Ins. Co. of N. Am.,
400 F. Supp. 3d 669, 672 (N.D. Ohio 2019) is similarly unavailing because the claim at
issue in that case was filed before April 1, 2018; therefore, the United States District Court
for the Northern District of Ohio did not have occasion to analyze the amended regulation.
In sum, defendant has not identified persuasive or controlling legal authority that
requires this Court to disregard 29 C.F.R. § 2560.503-1(i)(3)(i),6 which appears a priori to
have been promulgated through the appropriate administrative review process. Applying
this regulation, it appears that defendant has “fail[ed] to strictly adhere to all the
requirements of this section with respect to a claim” because it did not provide a written
response to plaintiff’s benefit calculation appeal within the prescribed timeframe. See §
2560.503-1(i)(3)(i).
Therefore, plaintiff’s “claim or appeal is deemed denied on review without the
exercise of discretion by an appropriate fiduciary.” § 2560.503-1(l)(2)(i). Because the
plan administrator has not exercised “discretionary authority” to determine plaintiff’s
benefit calculation appeal, we “review de novo the plan administrator’s denial of ERISA

6

Plaintiff notes that § 2560.503-1(i)(3)(ii) provides for an exception to §
2560.503-1(i)(3)(i) where certain conditions are met but argues that defendant is ineligible for this
exception [Doc. 17, p. 8]. Defendant did not advance any arguments that it qualifies for such an
exception [see Docs. 20, 22]. The Court agrees with plaintiff that defendant has not demonstrated
that it is eligible for this exception, in part because it has made no showing to this effect.
12

benefits.” Wilkins v. Baptist Healthcare Sys., Inc., 150 F.3d 609, 613 (6th Cir. 1998).
Specifically, this Court reviews de novo defendant’s benefit calculation. “This de novo
standard of review applies to the factual determinations as well as to the legal conclusions
of the plan administrator.” Id. (citing Rowan v. Unum Life Ins. Co., 119 F.3d 433, 435 (6th
Cir. 1997)).
As part of de novo review, general principles of summary judgment under Federal
Rule of Civil Procedure 56 apply. Summary judgment is proper only “if the movant shows
that there is no genuine dispute as to any material fact and the movant is entitled to
judgment as a matter of law.” Fed. R. Civ. P. 56(a). The moving party bears the initial
burden of establishing that no genuine issues of material fact exist. Celotex Corp. v.
Catrett, 477 U.S. 317, 330 n.2 (1986); Moore v. Philip Morris Cos., 8 F.3d 335, 339 (6th
Cir. 1993). Furthermore, all facts and inferences that the Court draws from the record
before it must be viewed in the light most favorable to the nonmoving party. Matsushita
Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 587 (1986); Burchett v. Kiefer, 301
F.3d 937, 942 (6th Cir. 2002). When assessing the parties’ cross-motions for summary
judgment “the court must evaluate each party’s motion on its own merits, taking care in
each instance to draw all reasonable inferences against the party whose motion is under
consideration.” McKay v. Federspiel, 823 F.3d 862, 866 (6th Cir. 2016) (quoting Taft
Broad. Co. v. United States, 929 F.2d 240, 248 (6th Cir. 1991)).
The court’s function at the point of summary judgment is limited to determining
whether sufficient evidence has been presented to make the issue of fact a proper question
13

for the factfinder. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 250 (1986). The court
does not weigh the evidence or determine the truth of the matter. Id. at 249. Nor does the
court search the record “to establish that it is bereft of a genuine issue of material fact.”
Street v. J.C. Bradford & Co., 886 F.2d 1472, 1479–80 (6th Cir. 1989). Thus, “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, 477 U.S. at 250.
III.

Analysis

Plaintiff argues that the relevant terms of the plan are unambiguous and require that
his predisability earnings be calculated “based on what he was earning at the first of the
year prior to his date of disability” [Doc. 17, p. 9]. In advancing this argument, he rejects
defendant’s deference to his employer’s “benefits base pay” rate as such a figure was not
specified in the plan, itself [Id. at 13]. Instead, he argues that his wages should be
calculated by multiplying his mileage pay rate of $0.24 per hour by the number of hours
he drove throughout January 2020 [Id. at 9–11]. Based on an average of 7,159 miles driven
per week in that timeframe, he ultimately arrives at a predisability earnings amount of
$7,445.88 and a monthly benefit of $4,467.53 [Id. at 11]. Alternatively, if the Court finds
that the terms are ambiguous, plaintiff argues that the doctrine of contra proferentum favors
construing the plan against the drafter [Id. at 12–13].

14

Defendant contends that it followed its standard procedure7 of requesting a
predisability earnings figure from plaintiff’s employer and adopting that figure [Doc. 18-1,
pp. 9–10]. Further, it argues that plaintiff’s preferred method of calculation is unsupported
by the plain language of the plan [Id. at 10–11]. Specifically, it asserts that the plan’s
phrase “ in effect on the first of the year” cannot reasonably refer to some period of days
after the start of the year [Id. at 11]. Additionally, defendant objects to plaintiff’s
calculation of an average of 7,159 miles driven per week in January 2020 on grounds that
he selectively chose two weeks in January and disregarded two other weeks [Id. at 11–12].
Finally, defendant argues that such a figure cannot reasonably form the basis of his benefit
calculation because it is unrepresentative of his average driving distances throughout the
remainder of the year [Id. at 12].
In response to defendant’s motion, plaintiff argues that his calculations are
consistent with the plan’s language because he derived an average of the miles he drove
during January 2020 and multiplied this average by his per mile wage rate [Doc. 19, pp.
5–6]. Additionally, he challenges defendant’s blind reliance on a prior year’s W-2 income
as there are numerous situations in which an employee’s income would not correlate to the

7

Defendant indicates in a footnote that it has subsequently received and/or provided
additional information about TForce’s underlying calculation after plaintiff filed his suit [Doc.
18-1, p. 10 n.3]. However, the Court may not consider this information for purposes of ruling on
the parties’ instant motions because ERISA suits are decided on the basis of the closed
administrative record at the time of filing suit. Moon v. Unum Provident Corp., 405 F.3d 373, 378
(6th Cir. 2005) (holding that ERISA review is appropriately confined to the administrative record
as it exists when the plan administrator issues its final decision).
15

prior year’s average [Id. at 6]. Plaintiff again notes that the plan, itself, does not refer to
the “benefits base pay” figure requested by defendant and provided by TForce [Id. at 7].
In response to plaintiff’s motion, defendant argues that the term “on” as used in the
phrase “in effect on the first of the year” can only reasonably refer to the first day of the
year; that is, January 1 [Doc. 20, p. 6]. It further contends that the second sentence of this
provision, stating that the amount will be calculated “on a monthly basis,” cannot be read
to convert the entire provision into a monthly calculation [Id. at 6–7]. Defendant also
rejects plaintiff’s calculation on grounds that he ignored the two weeks of January 12 and
26, 2020, in reaching his monthly average [Id. at 8]. It further notes that if plaintiff’s
preferred calculation is extrapolated to an annual rate of compensation, it totals $89,350,
well beyond the annual compensation plaintiff has previously reported [Id.].
In reply, plaintiff defends his calculation because he was allegedly paid for only the
two weeks he cited in January [Doc. 24, p. 4]. He further emphasizes that the terms of the
plan, and not defendant’s ordinary practices with respect to requesting employee
compensation figures, govern this dispute [Id. at 5].
Defendant replies by noting that even in view of plaintiff’s wage-based earnings,
the plan language cannot be reasonably read to refer to wages earned after the first of the
year as they would not be “in effect” at that time [Doc. 22, p. 5].
Courts tasked with interpreting ERISA plan provisions apply “general principles of
contract law” to determine meaning “in an ordinary and popular sense.” Farhner v. United
Transp. Union Discipline Income Prot. Program, 645 F.3d 338, 343 (6th Cir. 2011)
16

(quoting Williams v. Int’l Paper Co., 227 F.3d 706, 711 (6th Cir. 2000)). “In other words,
the Plan Administrator ‘must adhere to the plain meaning of [the Plan’s] language as it
would be construed by an ordinary person.’” Id. (quoting Kovach v. Zurich Am. Ins. Co.,
587 F.3d 323, 332 (6th Cir. 2009)). “A term or provision is ambiguous ‘if it is subject to
two reasonable interpretations.’” Wallace v. Oakwood Healthcare, Inc., 954 F.3d 879,
890–91 (6th Cir. 2020) (quoting Schachner v. Blue Cross & Blue Shield, 77 F.3d 889, 893
(6th Cir. 1996)). “Resolving ambiguities in the insured’s favor also accords with ERISA’s
goals ‘to promote the interests of employees and their beneficiaries in employee benefit
plans,’ and ‘to protect contractually defined benefits.’” Id. (quoting Firestone, 489 U.S. at
113) (citations omitted).
The Court finds that the “Predisability Earnings” provision is ambiguous. This
ambiguity arises from the provision’s interchangeable treatment of “salary” and “wages,”
despite the fact that these terms refer to distinct concepts. “Salary” has been defined as
“[f]ixed payment made periodically to a person as compensation for regular work.” Salary,
Oxford English Dictionary Online, https://doi.org/10.1093/OED/2376338795 (last visited
Mar. 7, 2025). “Wage,” by contrast, has been defined as “[a] payment to a person for
service

rendered.”

Wage,

Oxford

English

Dictionary

Online,

https://doi.org/10.1093/OED/2801008338 (last visited Mar. 7, 2025). In other words,
whereas a salary is a “fixed” number requiring no further data to compute, wages
necessarily require the multiplication of one’s rate of compensation by some measure of
work output. Given this distinction, the provision’s reference to “wages . . . in effect on
17

the first of the year prior to the date Your Disability began” is ambiguous on its face. If,
as defendant argues, this phrase pins the determination solely on January 1 of the relevant
year, how can a multiplication-based figure like wages be calculated when multiplied by
zero days or miles worked? The provision’s statement that “[w]e calculate this amount on
a monthly basis” would seemingly suggest that one month’s earning data, rather than a
single date, should inform the calculation, but defendant argues this statement means
something else entirely [See Doc. 20, pp. 6–7 (“‘[M]onthly basis,’ implying that the amount
resulting from the first sentence would need to be converted to a monthly rate, not that any
specific month’s worth of wages are used.”)]. In sum, the calculation of wages set forth in
the “Predisability Earnings” provision is susceptible to more than one reasonable
interpretation and is therefore ambiguous. See Wallace, 954 F.3d at 890–91.
Because this provision is ambiguous, the doctrine of contra proferentum applies and
the Court will construe the provision in plaintiff’s favor. “To the extent that the Plan’s
language is susceptible of more than one interpretation, we will apply the ‘rule of contra
proferentum’ and construe any ambiguities against [defendant] as the drafting part[y].”
Univ. Hosps. of Cleveland v. Emerson Elec. Co., 202 F.3d 839, 846–47 (6th Cir. 2000)
(quoting Perez v. Aetna Life Ins. Co., 150 F.3d, 550, 557 n.7 (6th Cir. 1998)); Trustees of
Iron Workers Defined Contribution Pension Fund v. Next Century Rebar, LLC, 115 F.4th
480, 493 (6th Cir. 2024) (noting that to the extent “base wage” is ambiguous, it should be
construed in favor of the insured). However, this construal does not necessarily dictate that
the Court agree with plaintiff’s actual calculated benefit amount.
18

After carefully reviewing plaintiff’s earning statements contained in the record, the
Court agrees with defendant that critical information is missing, and the present record is
therefore incomplete. The statements cover periods from December 22, 2019, to December
28, 2019; January 5, 2020, to January 11, 2020; and January 19, 2020, to January 25, 2020
[Doc. 13-9, pp. 27–27]. Thus, the record does not indicate plaintiff’s earnings or driving
miles between December 29, 2019, to January 4, 2020; January 12, 2020, to January 18,
2020; or January 26, 2020, to January 31, 2020 [See id]. If, as plaintiff claims, “the regular
wages he was earning as of the first of the year included these two weeks only,” he should
be able to adduce evidence that, for example, his earnings statements from the omitted
periods indicate a gross pay of $0 [Doc. 24, p. 4]. But closer inspection of the earning
statements only confirms the fact that plaintiff appears to have omitted non-zero
statements. The “Year to Date” column indicating the gross pay that plaintiff had earned
for each period jumps from $5,058.54 to $10,849.49 between the January 17 and January
31, 2020, statements [Doc. 13-9, pp. 26–27]. Given that the latter statement indicates an
additional $2,729.73 within that time frame, this leaves approximately $3,000 in
unaccounted, accrued compensation that plaintiff appears to have received in January 2020,
but that he has omitted from his calculation.
Synthesizing the foregoing analysis, while the Court may construe the plan in
plaintiff’s favor based upon the ambiguity in its “Predisability Earnings” provision, the
record lacks sufficient factual material for the Court to rule, as a matter of law, that plaintiff
is entitled to the exact sum he requests. As defendant argues, it is entirely possible that
19

even one additional week’s driving miles could impact the average such that plaintiff is
already receiving a greater benefit calculation than he is owed under the plan construed in
his favor [see Doc. 18-1, pp. 12–13]. So, the Court finds that a genuine dispute of material
fact remains as to plaintiff’s wages during the relevant period of time. Summary judgment
is therefore inappropriate. See Fed. R. Civ. P. 56(a); Anderson, 477 U.S. at 250.
Although relatively uncommon in an ERISA dispute,8 the Court therefore DENIES
plaintiff’s Motion for Summary Judgment on the ERISA Record [Doc. 16] and DENIES
defendant’s Motion for Judgement on the Record [Doc. 18]. Based on the foregoing
analysis, the Court does not conclude that defendant has shown that it is entitled to
summary judgment under its interpretation of the plan’s calculation method. The Court
also lacks sufficient evidence in the record to hold that plaintiff is entitled to his requested
benefit amount. “Such broad disagreement makes summary judgment in either party’s
favor inappropriate, as it would require the court to make credibility determinations and
weigh evidence.” Cent. States, Se. & Sw. Areas Pension Fund v. Transp. Serv. Co., No.
00-C-6181, 2009 WL 424145, at *13 (N.D. Ill. Feb. 17, 2009) (denying cross-motions for
summary judgment in ERISA dispute where certain factual issues remained contested).
However, this Memorandum Opinion and Order should narrow considerably the remaining

8

Although uncommon, this outcome is not unprecedented. See 2 Lee T. Polk, ERISA
Practice and Litigation § 11:72 (2025) (“Courts will normally decline to rule by summary
judgment where there are one or more key terms relating to material facts in a writing that are
ambiguous and require specific findings of fact.”)
20

issue(s) in dispute, given the Court’s findings regarding the “Predisability Earnings”
provision within the plan.
IV.

Conclusion
For the reasons explained above, plaintiff’s Motion for Summary Judgment on the

ERISA Record [Doc. 16] is DENIED, and defendant’s Motion for Judgement on the
Record [Doc. 18] is DENIED.
IT IS SO ORDERED.
s/ Thomas A. Varlan
UNITED STATES DISTRICT JUDGE

21