Spies v. Life Ins. Co. of N. Am.
Spies v. Life Ins. Co. of N. Am.
Opinion of the Court
Defendant Life Insurance Company of North America's ("LINA") motion for summary judgment came on for hearing before this court on April 25, 2018. Plaintiff Brenda Spies appeared through her counsel, P. Randall Noah. Defendant appeared through its counsel, Anna Martin. Having read the papers filed by the parties and carefully considered their arguments and the relevant legal authority, and good cause appearing, the court hereby GRANTS defendant's motion, for the following reasons.
BACKGROUND
A. The Genesis of This Action
LINA contracted with Staples Inc. to provide short term and long term disability insurance ("STD" and "LTD," respectively). Staples employed Spies between September 3, 2013, and February 4, 2014. Dkt. 33-3, Maria Medina Decl. ¶¶ 11, 19. On February 5, 2014, Spies was hospitalized and diagnosed with ischemic colitis and lupus. Shortly thereafter, Spies submitted a claim for STD benefits. Medina Decl. ¶ 19.
On June 26, 2014, LINA approved plaintiff's STD claim through July 18, 2014. LINA later extended Spies' STD benefits through August 10, 2014, the 6-month maximum duration afforded by the STD plan. On August 21, 2014, LINA advised plaintiff that she was eligible for LTD benefits under the "regular occupation" definition of disability, with payments retroactively commencing on August 11, 2014. Though LINA reviewed medical records and physician opinions before making that determination, through an administrative mistake LINA failed to verify plaintiff's enrollment in and eligibility for benefits under the LTD plan. See Ex. G ("Eligibility Verification" form showing employee failed to verify existence of LTD "enrollment card"); Martin Decl. ¶ 3. As a result of this mistake, Spies received LTD benefits for nearly two years between August 2014 and June 2016.
In June 2016, because the definition of disability was set to change from "regular occupation" to "any occupation," LINA requested that plaintiff attend an independent medical examination. That examination concluded that plaintiff could work full time in a sedentary occupation. Accordingly, LINA determined that plaintiff was not entitled to further LTD benefits, notified her of that decision on July 28, 2016, and subsequently notified her that the decision had been upheld on appeal.
Plaintiff subsequently initiated this suit under
B. Staples' Benefits Plan and Spies' Benefits Elections
Staples offers a portfolio of health and welfare benefits for its full-time, non-exempt employees. Staples automatically enrolls its non-exempt employees in the following benefits: (1) basic life insurance; (2) accidental death & dismemberment insurance; and (3) short-term disability insurance. Medina Decl. ¶ 4.
Employees may also voluntarily elect other benefits.
Staples' open enrollment period occurs between May and June each year. See Medina Decl. ¶ 6. In conjunction with open enrollment, Staples distributes a corresponding "Benefits Guide" that describes the benefits available and the procedures for enrolling in or modifying coverage.
Eligible employees also have an opportunity to review and elect voluntary benefits when first hired. Medina Decl. ¶¶ 10, 13. Newly hired employees receive a worksheet that describes coverage options and the costs of those options.
When Staples hired Spies on September 3, 2013, Spies participated in the above process. Medina Decl. ¶ 13, 14. Plaintiff's initial employment paperwork included a personalized benefits worksheet, which included the option to elect LTD insurance.
Spies was on STD leave during Staples' 2014 open enrollment. Medina Decl. ¶ 17. Spies nevertheless received the 2014 Benefits Guide and, though she made no benefits changes, also received a subsequent Confirmation Statement. Medina Decl. ¶ 17; Ex. F. In any event, even if plaintiff had elected to enroll in LTD insurance at that time-and the evidence shows that she did not-that coverage would not have become effective because Spies never returned to Staples as a full-time employee. Ex. A. at 21 ("If an Employee is not in Active Service on the date insurance would otherwise be effective, it will be effective on the date he or she returns to any occupation for the employer on a full time basis."); see also Ex. A at 32 (defining "Active Service").
The best plaintiff musters in response to this evidence does not come close to creating a dispute of material fact about whether Spies enrolled in the LTD plan. Spies' declaration, the only evidence plaintiff submitted, merely states that Spies neither remembers being asked to opt in or out of LTD coverage nor remembers waiving that coverage. Dkt. 34-2, Spies Decl. ¶¶ 3-5.
DISCUSSION
A. Legal Standard
Summary judgment is proper "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 demonstrating the absence of a genuine issue of material fact. Celotex Corp. v. Catrett,
Once the moving party has met its burden, the burden shifts to the non-moving party to "set forth, by affidavit or as otherwise provided in Rule 56, 'specific facts showing that there is a genuine issue for trial.' " T.W. Elec. Service, Inc. v. Pacific Elec. Contractors Ass'n,
In deciding a summary judgment motion, the court must view the evidence in the light most favorable to the non-moving party and draw all justifiable inferences in its favor.
Summary judgment of an affirmative defense is proper in an ERISA case, particularly if the defense does not address the merits of an ERISA claim decision. See Gordon v. Deloitte & Touche, LLP Group Long Term Disability Plan,
B. Analysis
1. Whether Plaintiff Has Standing
Defendant first argues that plaintiff does not have standing to bring this action because she is not a participant in the LTD plan. Plaintiff disagrees, arguing that she has standing because this is an ERISA claim concerning a group employee benefit offered and paid to plaintiff, a group member. The court agrees with defendant.
As relevant here, under
[T]he term "participant" is naturally read to mean either employees in, or reasonably expected to be in, currently covered employment, or former employees who have ... a reasonable expectation of returning to covered employment or who have a colorable claim to vested benefits. In order to establish that he or she "may become eligible" for benefits, a claimant must have a colorable claim that (1) he or she will prevail in a suit for benefits, or that (2) eligibility requirements will be fulfilled in the future.... A former employee who has neither a reasonable expectation of returning to covered employment nor a colorable claim to vested benefits, however, simply does not fit within the [phrase] "may become eligible."
*812Firestone Tire & Rubber Co. v. Bruch,
"Whether a plaintiff is a plan participant is determined as of the time he files the lawsuit." Curtis v. Nevada Bonding Corp.,
The evidence shows that Spies never elected LTD coverage. Therefore, she never became a participant in that insurance plan. Plaintiff does not dispute that the LTD plan is distinct from the other benefit plans Staples provides. The record would also not support that assertion. See generally, Ex. A; Downey Decl. ¶ 2. And plaintiff submits no authority in support of her counterintuitive argument that she has standing because she participated in Staples' other group insurance plans.
Accordingly, the court GRANTS LINA's motion for summary judgment because plaintiff lacks standing to state a claim based on the LTD plan.
2. Whether Principles of Equitable Estoppel Apply
Assuming arguendo that plaintiff does have standing, defendant contends that it is also not obligated to continue paying Spies LTD benefits under an equitable estoppel theory. Though plaintiff disagrees, she does not attempt to meet the Ninth Circuit's test for equitable estoppel in an ERISA action. The court GRANTS defendant's motion for summary judgment on this alternative basis.
There is no dispute that under the right circumstances an ERISA insurer might be equitably estopped from withdrawing an ERISA plaintiff's benefits.
*813(1) the party to be estopped must know the facts; (2) he must intend that his conduct shall be acted on or must so act that the party asserting the estoppel has a right to believe it is so intended; (3) the latter must be ignorant of the true facts; and (4) he must rely on the former's conduct to his injury.
Gabriel v. Alaska Elec. Pension Fund,
(1) extraordinary circumstances; (2) that the provisions of the plan at issue were ambiguous such that reasonable persons could disagree as to their meaning or effect; and (3) that the representations made about the plan were an interpretation of the plan, not an amendment or modification of the plan.
First, plaintiff makes no attempt to meet the ERISA-specific requirements. That alone is sufficient to grant defendant's motion for summary judgment. Davis v. Pension Tr. Fund for Operating Engineers,
Further, plaintiff could not meet the second and third ERISA-specific requirements even if she had attempted to. The Ninth Circuit has "consistently held that a party cannot maintain a federal equitable estoppel claim in the ERISA context when recovery on the claim would contradict written plan provisions." Gabriel,
Second, regarding the traditional equitable estoppel requirements, Spies has not created a dispute of material fact about whether she was ignorant of the true facts. As described above, Staples informed plaintiff numerous times that she was required to affirmatively elect LTD coverage. See Medina Decl. ¶¶ 12, 17; Ex. B. After plaintiff elected certain voluntary benefits and declined LTD coverage during Staples' hiring process, Medina Decl. ¶ 14; Ex. C, Staples sent plaintiff a Confirmation Statement confirming that plaintiff had not elected LTD coverage. Medina Decl. ¶ 15; Ex. D. And between November 1, 2013 and February 4, 2014, plaintiff's paychecks reflected premium deductions for plaintiff's elected voluntary benefits and did not reflect deductions for LTD coverage. Ex. E. Plaintiff's vague attestations not only fail to create a dispute of material fact but fail to even contradict this showing. See generally, Spies Decl.
CONCLUSION
In short, though Spies never elected LTD insurance, Spies received an $11,000 *814windfall because LINA mistakenly approved and awarded Spies two-years' worth of LTD benefits. As plaintiff was not a participant in the LTD insurance plan, she lacks statutory standing to bring her claim against LINA for the reinstatement of LTD benefits. The court GRANTS defendant's motion for summary judgment on that basis. In the alternative, the court GRANTS defendant's motion because plaintiff has not created a material dispute of fact supporting equitable relief.
The Clerk shall close the file.
IT IS SO ORDERED.
The court's factual recitation reflects the parties' undisputed facts.
LINA does not seek reimbursement of the mistakenly paid benefits. Dkt. 33 at 9 n.9.
Spies also attests that her "understanding was that [she] had long term disability insurance as an employee benefit from staples, which is why [she] was paid long term disability insurance benefits for two years ..." Spies Decl. ¶ 6. Not only has plaintiff failed to show that her mistaken understanding is relevant, that understanding makes no chronological sense as Spies' mistaken belief needed to exist in September 2013, months before her hospitalization and a year before she began receiving LTD benefits.
For the same reason, the court rejects plaintiff's argument that the court cannot reach the enrollment issue because the claims administrator has not considered that issue and that instead the issue must be remanded for further administrative procedures. "Because the court is not reaching the merits of [LINA's] decision to deny benefits, [LINA] may raise [the] affirmative defense[ ] even if [it] w[as] not raised during the administrative process." Upadhyay,
In Leeson v. Transamerica Disability Income Plan,
In the ERISA context, there is no freestanding equitable estoppel cause of action. Instead, the Supreme Court "has instructed [courts] to analyze equitable estoppel as a form of 'appropriate equitable relief' under § 1132(a)(3)(B)." Gabriel v. Alaska Elec. Pension Fund,
The purported "representations" would also contradict the plan's "Policy Changes" provision. Ex. A at 32 ("No agent may change the Policy or waive any of its provisions.").
Plaintiff's counsel's request for attorneys' fees is DENIED. See Simonia v. Glendale Nissan/Infiniti Disability Plan,
Reference
- Full Case Name
- Brenda SPIES v. LIFE INSURANCE COMPANY OF NORTH AMERICA
- Status
- Published