Sizemore v. Northwestern Mutual Life Insurance Company et al

Filing 27

MEMORANDUM OPINION AND ORDER granting Defendant's 21 Motion for Summary Judgment and denying Plaintiff's 19 Motion for Summary Judgment, as more fully set forth herein. Signed by Judge Thomas E. Johnston on 6/26/2019. (cc: counsel of record; any unrepresented party) (kew)

IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF WEST VIRGINIA
CHARLESTON DIVISION
VAUGHN T. SIZEMORE,
Plaintiff,
v.

CIVIL ACTION NO. 2:17-cv-00789

NORTHWESTERN MUTUAL LIFE
INSURANCE COMPANY, et al.,
Defendants.

MEMORANDUM OPINION AND ORDER
Before this Court are cross-motions for summary judgment filed by Plaintiff Vaughn T.
Sizemore (“Plaintiff”), (ECF No. 19), and Defendant Northwestern Mutual Life Insurance
Company (“Defendant”), (ECF No. 21). For the reasons explained more fully herein, Plaintiff’s
motion, (ECF No. 19), is DENIED. Defendant’s motion, (ECF No. 21), is GRANTED.
I.

BACKGROUND

Plaintiff brings this action pursuant to the Employee Retirement Income Security Act
(“ERISA”), 29 U.S.C. § 1001, et seq. (See ECF No. 1.) He alleges that Defendant improperly
discontinued his disability benefits, which he received under a group insurance plan he obtained
through his former employer. (See id.) Plaintiff is an attorney who, at the time he filed his claim
for disability benefits on February 17, 2012, was employed at a law firm that sponsors the plan at
issue in this case. (See ECF No. 20 at 5; ECF No. 22 at 5.) Plaintiff filed a claim for disability
benefits after his billable hours—and in turn, his overall compensation—decreased significantly.
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(ECF No. 20 at 6, 17–18; ECF No. 22 at 8.) His claim was approved on April 23, 2012, and he
continued to receive benefits until approximately June 22, 2015. (ECF No. 20 at 6, 9; ECF No.
22 at 9, 12.) In the interim, Plaintiff resigned from the law firm and on January 20, 2015, began
full-time employment as an attorney in state government. (ECF No. 22 at 11.)
Plaintiff submitted an internal appeal of Defendant’s decision to cease his disability
benefits on July 1, 2015. (ECF No. 20 at 9–10; ECF No. 22 at 12.) Defendant upheld its decision
on December 15, 2015, after informing him on October 13, 2015, that he did not qualify for
benefits under any of the plan’s definitions of disability. (ECF No. 20 at 15–16; ECF No. 22 at
14–15, 16.) On January 21, 2016, Plaintiff requested a review of the December 15, 2015 decision,
but Defendant denied his request. (ECF No. 20 at 18–19; ECF No. 22 at 17.) Plaintiff then
brought suit against Defendant on January 23, 2017. (ECF No. 1.)
Plaintiff filed his motion for summary judgment on January 14, 2019. (ECF No. 19.)
Defendant filed a timely response, (ECF No. 24), and Plaintiff filed a timely reply, (ECF No. 25).
Defendant filed its motion for summary judgment on January 14, 2019. (ECF No. 21.) Plaintiff
filed a timely response, (ECF No. 23), and Defendant filed a timely reply, (ECF No. 26). As such,
the motions for summary judgment are fully briefed and ripe for adjudication.
II.

LEGAL STANDARD

Summary judgment is appropriate when the moving party “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). “A fact is material when it ‘might affect the outcome of the suit under the governing
law.’” Strothers v. City of Laurel, 895 F.3d 317, 326 (4th Cir. 2018) (quoting Anderson v. Liberty
Lobby, Inc., 477 U.S. 242, 248 (1986)). “A genuine dispute arises when ‘the evidence is such
that a reasonable jury could return a verdict for the non-moving party.’” Id. (quoting Anderson,
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477 U.S. at 248). “Thus, at the summary judgment phase, the pertinent inquiry is whether 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.” Variety Stores, Inc. v. Wal-Mart Stores,
Inc., 888 F.3d 651, 659 (4th Cir. 2018) (alteration and internal quotation marks omitted).
“The burden is on the nonmoving party to show that there is a genuine issue of material
fact for trial . . . by offering ‘sufficient proof in the form of admissible evidence’ . . . .” Guessous
v. Fairview Prop. Invs., LLC, 828 F.3d 208, 216 (4th Cir. 2016). In ruling on a motion for
summary judgment, this Court “view[s] the facts and all justifiable inferences arising therefrom in
the light most favorable to the nonmoving party.” Jones v. Chandrasuwan, 820 F.3d 685, 691
(4th Cir. 2016) (quoting Libertarian Party of Va. v. Judd, 718 F.3d 308, 312 (4th Cir. 2013)).
III.

ANALYSIS

A. Applicable Standard of Review
As an initial matter, the parties disagree about the appropriate standard of review this Court
should apply to Defendant’s adverse benefit determination with respect to Plaintiff’s claim for
disability benefits under the plan. (Compare ECF No. 22 at 17–18, with ECF No. 25 at 6.) This
Court’s review “turns on whether the benefit plan at issue vests the administrator with
discretionary authority.” Helton v. AT&T Inc., 709 F.3d 343, 351 (4th Cir. 2013) (citing Firestone
Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989); Woods v. Prudential Ins. Co. of Am., 528
F.3d 320, 321–22 (4th Cir. 2008)). Specifically, this Court “reviews challenges . . . for denial of
benefits ‘under a de novo standard unless the benefit plan gives the administrator . . . discretionary
authority to determine eligibility for benefits or to construe the terms of the plan.’” Plotnick v.
Comput. Scis. Corp. Deferred Compensation Plan for Key Execs., 875 F.3d 160, 165 (4th Cir.
2017) (quoting Firestone, 489 U.S. at 115). If the plan vests such discretionary authority with the
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administrator, this Court “evaluates the plan administrator’s decision for abuse of discretion.”
Williams v. Metro. Life Ins. Co., 609 F.3d 622, 629–30 (4th Cir. 2010) (citing Champion v. Black
& Decker (U.S.) Inc., 550 F.3d 353, 359 (4th Cir. 2008); Ellis v. Metro. Life Ins. Co., 126 F.3d
228, 232 (4th Cir. 1997)). “[N]o specific words or phrases are required to confer discretion, but
. . . a grant of discretionary authority must be clear.” Cosey v. Prudential Ins. Co. of Am., 735
F.3d 161, 165 (4th Cir. 2013).
Defendant argues that the plan at issue grants it “broad discretionary powers.” (ECF No.
22 at 17–18.) Indeed, the plan provides that Defendant “has full and exclusive authority to control
and manage the [plan], to administer claims, and to interpret the [plan] and resolve all questions
arising in the administration, interpretation, and application of the [plan].” (ECF No. 18-1 at 33.)
This Court has previously held identical language sufficient to accord discretionary authority with
the plan administrator and to warrant abuse-of-discretion review. Caldwell v. Standard Ins. Co.,
No. 2:14-cv-25242, 2015 WL 5031485, at *2–*3 (S.D.W. Va. Aug. 25, 2015) (Copenhaver, J.)
(citing Hankins v. Standard Ins. Co., 677 F.3d 830, 835 (8th Cir. 2012); Fleisher v. Standard Ins.
Co., 679 F.3d 116, 122 (3d Cir. 2012); Black v. Long Term Disability Ins., 582 F.3d 738, 744 (7th
Cir. 2009)); see Dutkewych v. Standard Ins. Co., 781 F.3d 623, 633 (1st Cir. 2015); McKeehan v.
Cigna Life Ins. Co., 344 F.3d 789, 792 (8th Cir. 2003); McCready v. Standard Ins. Co., 417 F.
Supp. 2d 684, 696 (D. Md. 2006). The plan also gives Defendant “[t]he right to determine . . .
[claimants’] eligibility for insurance” and “entitlement to benefits.” (ECF No. 18-1 at 99.)
However, Plaintiff contends that Defendant’s failure to consider his appeal of the adverse
benefit determination made in December 2015 entitles him to de novo review. (ECF No. 25 at 6.
But see ECF No. 20 at 19 (“[T]he standard of review is abuse of discretion.”).) Whether
Defendant complied with its obligation to award Plaintiff “a full and fair review” of the denial of
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his claim for benefits, 29 U.S.C. § 1133(2), has no effect on the applicable standard of review
because Defendant “must comply with these procedural guidelines” “[u]nder either standard of
review.” Hall v. Metro. Life Ins. Co., 259 F. App’x 589, 593 (4th Cir. 2007). Accordingly,
because the plan under which Plaintiff seeks benefits confers discretionary authority on Defendant
to interpret the plan and determine eligibility for benefits, this Court applies the deferential abuseof-discretion standard of review.
In doing so, this Court does not “review the merits of the administrator’s decision, but
rather decide[s] only the contractual questions of whether the administrator exceeded its power or
abused its discretion because only those inquiries are relevant to whether the administrator’s
decision breached the contractual provision.” Griffin v. Hartford Life & Accident Ins. Co., 898
F.3d 371, 378 (4th Cir. 2018) (quoting Haley v. Paul Revere Life Ins. Co., 77 F.3d 84, 88 (4th Cir.
1996)).

“Under the abuse-of-discretion standard, [this Court] will not disturb a plan

administrator’s decision if the decision is reasonable, even if [this Court] would have come to a
contrary conclusion independently.” Williams, 609 F.3d at 630. “To be held reasonable, the
administrator’s decision must result from a ‘deliberate, principled reasoning process’ and be
supported by substantial evidence.” Id. In assessing reasonableness, this Court is guided by
“eight nonexclusive factors”: “(1) the language of the plan; (2) the purposes and goals of the plan;
(3) the adequacy of the materials considered to make the decision and the degree to which they
support it; (4) whether the fiduciary’s interpretation was consistent with other provisions in the
plan and with earlier interpretations of the plan; (5) whether the decisionmaking process was
reasoned and principled; (6) whether the decision was consistent with the procedural and
substantive requirements of ERISA; (7) any external standard relevant to the exercise of discretion;
and (8) the fiduciary’s motives and any conflict of interest it may have.” Id. (quoting Booth v.
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Wal-Mart Stores, Inc. Assocs. Health & Welfare Plan, 201 F.3d 335, 342–43 (4th Cir. 2000)); see
Griffin, 898 F.3d at 381.
B. Plaintiff’s Eligibility for Benefits
The principal issue for this Court to decide is whether Defendant reasonably concluded
that Plaintiff became ineligible for benefits under the terms of the plan upon returning to work fulltime in state government. By letter dated June 22, 2015, Defendant informed Plaintiff that it did
“not find support for any ongoing limitations and restrictions that would preclude [Plaintiff] from
returning to full time work in [his] Own Occupation as an attorney.” (ECF No. 18-5 at 270.) In
that letter, Defendant briefly detailed the available medical records from his treating physicians
and summarized the findings of a physician consultant who reviewed those records. (Id. at 271–
72.) Based on this information, Defendant concluded that Plaintiff’s “conditions have improved
and stabilized to a level which would allow [him] to return to work in a sedentary level occupation
working an eight hour[] day with a reasonably sustainable schedule.” (Id. at 274.) Defendant
therefore determined that Plaintiff no longer qualified for benefits. (Id.)
Plaintiff appealed Defendant’s decision on July 1, 2015, asserting that he satisfied the
plan’s definition of partial disability because he continued to earn less than 80% of his predisability
earnings following his change in employment. (ECF No. 18-6 at 9–11.) Plaintiff also took issue
with the physician consultant’s review of his medical records and argued that his decreased kidney
function and related issues made it difficult for him to concentrate and thus to perform “the
Material Duties of an Attorney.” (Id. at 6.)
Defendant upheld its earlier decision by letter dated December 15, 2015, noting that
Plaintiff previously received benefits because he satisfied the plan’s “own occupation” definition
of disability, not the “partial disability” definition. (Id. at 296–97.) In response to Plaintiff’s
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argument that he qualified under the partial disability definition, Defendant explained that while
receiving benefits, Plaintiff’s reduction in income was caused by a medical inability to work a
certain number of hours, but the reduction in income after his job change was not caused by any
medical condition.

(See id. at 297–98.)

Further, Defendant summarized the notes from

Plaintiff’s most recent appointments with his treating physicians, as well as a second physician
consultant’s review of his medical records, and emphasized that none described “work activity
limitations or restrictions” that would prohibit Plaintiff from full-time work. (Id. at 299–300.)
Plaintiff also appealed Defendant’s December 15, 2015 decision, arguing that he was
entitled to a second review because Defendant concluded for the first time that Plaintiff did not
qualify for partial disability benefits. (ECF No. 18-7 at 8.) By letter dated February 12, 2016,
Defendant declined to conduct an additional review because the previous review “exhausted the
administrative review procedures available . . . under the terms of the [plan]” and because
Plaintiff’s concerns had “already been reviewed and addressed.” (Id. at 56.)
1. Rejection of Appeal of December 15, 2015 Decision
Plaintiff asserts that Defendant’s refusal to reexamine its December 15, 2015 letter
unlawfully deprived him of a “full and fair review” of his claims. (ECF No. 25 at 6.) “ERISA
requires that plans provide claimants with a ‘reasonable opportunity . . . for a full and fair review
by the appropriate named fiduciary of the decision denying the claim.’” Harrison v. Wells Fargo
Bank, N.A., 773 F.3d 15, 21 (4th Cir. 2014) (quoting 29 U.S.C. § 1133(2)). This requirement is
intended “to protect a plan participant from arbitrary or unprincipled decision-making.” Gagliano
v. Reliance Standard Life Ins. Co., 547 F.3d 230, 235 (4th Cir. 2008) (quoting Weaver v. Phoenix
Home Life Mut. Ins. Co., 990 F.2d 154, 157 (4th Cir. 1993)). However, nothing in the statutory
or plan language mandates multiple reviews or appeals in order to satisfy the “full and fair”
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requirement. The plan language provides for a single review of the denial of a claim. (See ECF
No. 18-1 at 32–33; ECF No. 18-6 at 301.) ERISA’s regulations similarly require “a reasonable
opportunity to appeal an adverse benefit determination,” 29 C.F.R. § 2560.503–1(h)(1), a term the
regulations define in part as “[a] denial, reduction, or termination of . . . a benefit,” id. § 2560.503–
1(m)(4)(i). Thus, both the plan language and the regulations anticipate a single review of the
ultimate decision to terminate or deny benefits. Neither entitles Plaintiff to additional review
here. 1
2. Termination of Benefits
Plaintiff’s remaining argument is that Defendant unreasonably discontinued his disability
benefits after determining that he was no longer disabled under the terms of the plan. (See ECF
No. 20.) Plaintiff contends that in terminating his benefits, Defendant considered only whether
he qualified for benefits under the “own occupation” definition of disability. (Id. at 7.) He
asserts that he continues to qualify for benefits under the “partial disability” definition. (Id. at
20.)
The plan provides that a beneficiary is “Disabled if [he] meet[s]” any of the plan’s three
definitions of disability. (ECF No. 18-1 at 22–23.) As relevant here, a beneficiary satisfies the
“own occupation” definition “if, as a result of Sickness[ or] Injury . . . [he is] unable to perform
with reasonable continuity the Material Duties of [his] Own Occupation.” (Id. at 23.) He
satisfies the “partial disability” definition “if [he is] working in [his] Own Occupation but, as a
result of Sickness[ or] Injury . . . [he is] unable to earn more than the Own Occupation Income

This Court acknowledges that additional review may be required when the plan administrator’s response to the
claimant’s appeal “did not address the subject matter of [the claimant’s] administrative appeal but made a ‘final
decision’ to deny benefits on a wholly new ground.” Gagliano, 547 F.3d at 236. However, the December 15, 2015
letter’s discussion of the “partial disability” definition of disability was a response to the arguments Plaintiff made in
his appeal submission, not an entirely new basis for denying Plaintiff’s claim. Defendant thus had no obligation to
provide Plaintiff with a second appeal under the facts of Gagliano.

1

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Level,” which for the plan at issue is defined as “80% of [the claimant’s] Indexed Predisability
Earnings.” (Id. at 16, 23.) Plaintiff initially applied for benefits under the “partial disability”
definition, (ECF No. 18-3 at 208), but Defendant approved his claim based on the “own
occupation” definition, (ECF No. 18-4 at 3, 6).
Defendant reasonably concluded that Plaintiff no longer qualified as disabled under the
“own occupation” definition. It acted in accordance with its rights under the plan’s terms to
“investigate . . . claim[s] at any time” and “to determine . . . [claimants’] entitlement to benefits.”
(ECF No. 18-1 at 59, 67.) It obtained updated medical records from his treating physicians that
indicated lingering fatigue and exhaustion but overall clinical improvement. (See ECF No. 18-5
at 271–72.)

It also considered reports from a board-certified physician consultant and a

vocational consultant to conclude that Plaintiff’s medical conditions did not prohibit him from
working as an attorney on a consistent, full-time basis. (See id. at 272–74.) Indeed, Plaintiff was
working full-time as an attorney in state government when Defendant issued its decision. (See
ECF No. 18-6 at 118.) He agrees that he does not qualify for benefits under the “own occupation”
definition of disability. (See ECF No. 20 at 13 (“Plaintiff never claimed his medical conditions
prevented him from working as an attorney . . . .”; ECF No. 23 at 3 (“Plaintiff never claimed to be
disabled under the Own Occupation Definition of Disability.”).)
Defendant likewise reasonably concluded that Plaintiff failed to satisfy the “partial
disability” definition. Defendant explained that its previous determination that Plaintiff was
disabled was based not on Plaintiff’s inability “to perform particular, specific activities which had
formed the basis of [his] income” but on his inability “to work the number of hours [he] had
previously been capable of, which had caused [him] to have a reduction in income.” (ECF No.
18-6 at 297.) Defendant further explained that when Plaintiff “changed from a position where [he
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was] paid based on [his] specific production and guaranteed payments as a partner, to a full time
salaried position,” the resulting reduction in Plaintiff’s income was not “correlated with
[Plaintiff’s] ability or inability to work in [his] Own Occupation with reasonable continuity.” (Id.)
In other words, Defendant was unable to conclude that the reduction in Plaintiff’s earnings was
caused by a medically documented impairment. (See id. at 298.) This outcome is consistent with
the plan’s definition of “partial disability,” which requires that a claimant’s reduction in income
while “working in [his] Own Occupation” to be “a result of Sickness[ or] Injury.” (ECF No. 181 at 23.) The plan clarifies, “Own Occupation is not limited to your specific job with your
Employer or to your specific area of specialization, interest or expertise within the general
occupation.” (Id.) Defendant reasonably interpreted this language and applied it to Plaintiff in
light of the available medical evidence.
Specifically, Defendant had before it a host of medical records from Plaintiff’s treating
physicians, the most recent of which indicated that Plaintiff suffered from lingering fatigue and
exhaustion but saw clinical improvement and noted no functional limitations or restrictions. (See
ECF No. 18-5 at 271; ECF No. 18-6 at 299.) Defendant also considered reports from two
physician consultants, both of whom concluded after a review of Plaintiff’s claim file that his
diagnoses would not prevent him from engaging in consistent, full-time work as an attorney. (See
ECF No. 18-5 at 272–73; ECF No. 18-6 at 300.)

Defendant corresponded with Plaintiff

throughout 2015 and offered him opportunities to provide additional information in support of his
entitlement to benefits. (See ECF No. 18-6 at 297.) It conducted an in-person interview as part
of the review process. (See id. at 117–33.) There is no indication in the record that Defendant
accorded Plaintiff less than “a fair and thorough consideration of his claim.” Griffin, 898 F.3d at
381. Nothing more is required. See Williams, 609 F.3d at 630 (“To be held reasonable, the
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administrator’s decision must result from a ‘deliberate, principled reasoning process’ and be
supported by substantial evidence.”).
“Where an ERISA administrator rejects a claim to benefits on the strength of substantial
evidence, careful and coherent reasoning, faithful adherence to the letter of ERISA and the
language in the plan, and a fair and searching process, there can be no abuse of discretion . . . .”
Evans v. Eaton Corp. Long Term Disability Plan, 514 F.3d 315, 325–26 (4th Cir. 2008). In light
of that standard, this Court cannot conclude that Defendant abused its discretion in terminating
Plaintiff’s disability benefits because Plaintiff no longer qualified as disabled.
IV.

CONCLUSION

For the foregoing reasons, Plaintiff’s motion for summary judgment, (ECF No. 19), is
DENIED. Defendant’s motion for summary judgment, (ECF No. 21), is GRANTED.
IT IS SO ORDERED.
The Court DIRECTS the Clerk to send a copy of this Order to counsel of record and any
unrepresented party.
ENTER:

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June 26, 2019