Hodges v. Life Ins. Co. of N. Am., Ins. Co.
Opinion
Lou Hodges submitted a claim for long-term-disability (LTD) benefits to Life Insurance Company of North America (LINA) through his employer's group-insurance plan. Although LINA approved his claim, Hodges asserted that LINA should have classified him as a "sales" employee under the group-insurance policy, which would have entitled him to more benefits. This led Hodges to sue LINA. The district court remanded for further factfinding, but LINA once again reached the same result. The district court then
*672
reversed LINA's decision, concluding that Hodges qualified as a salesperson under the policy. LINA now appeals that ruling. Exercising jurisdiction under
BACKGROUND
Until 2012, Hodges worked for Endo Pharmaceuticals, Inc. as a cryotherapy technician. That year a degenerative eye condition forced him to retire. He participated in Endo's employee-welfare-benefit plan, for which Endo had appointed LINA as the administrator. In 2011, LINA issued to Endo a group LTD insurance policy (the Policy), governed by the Employee Retirement Income Security Act of 1974 (ERISA),
The Policy divides employees into two classes: Class 1, which includes "[a]ll active, Full-time and part-time Employees of the Employer, excluding Sales personnel, regularly working a minimum of 20 hours per week"; and Class 2, which includes "[a]ll active, Full-time Employees of the Employer classified as Sales Personnel regularly working a minimum of 20 hours per week."
Before leaving the company, Hodges submitted a claim under the Policy. After granting him short-term-disability benefits, LINA informed Hodges that it would begin evaluating his eligibility for LTD benefits. LINA eventually concluded that Hodges was medically eligible for LTD benefits, but later sought information from Hodges and Endo about Hodges's job description and duties to determine whether he qualified as "sales personnel" under the Policy. In a telephone interview, Hodges explained to a LINA claim manager that "he was a technician, but often times did things to sell the compan[y']s products."
On March 21, 2012, LINA informed Hodges that it had approved his claim for LTD benefits but that it deemed him a Class 1 employee, not a Class 2 salesperson. Hodges objected to this classification, arguing that he "sold products while out in the field" and that the classification would significantly reduce his benefits.
2
In November 2012, Hodges filed an administrative appeal asking LINA to reconsider its decision to classify him as a Class 1 employee. Hodges attached several supporting documents to his appeal. First, he submitted e-mails from two senior Endo officials referring to the "bonuses" that Hodges and other cryotherapy technicians had earned selling the company's products and services.
Before deciding the appeal, LINA asked Endo for more information about Hodges's job classification and duties. Lori Capozzi, Endo's benefits consultant, responded that "Hodges was not classified as 'sales,' " that "[h]e worked in a mobile unit that permitted him to perform medical tests at doctor[s'] offices based on a pre-determined schedule," and that "he was paid a 'bonus' for those additional tests."
The Employer has confirmed Mr. Hodges['s] occupation as a CryoTherapy Technician is not classified as a sales position with the employer. According [to] the Employer, Mr. Hodges worked in a mobile unit that permitted him to perform medical tests at doctor[s'] offices based on a pre-determined schedule. If he was able to incorporate and schedule a few more tests during his work week, he was paid a bonus for those additional tests. According to the [d]efinition of Covered Earnings under Class 1, earnings do not include bonus[es], commissions, overtime pay or extra compensation, [and] therefore would not be considered as part of the Disability Benefits Calculation.
On March 28, 2013, Hodges sent LINA a letter requesting further reconsideration
*674
of his Class 1 classification and protesting that "the extent of [LINA's] consideration" of his first appeal "involved a single e-mail to Endo's benefits consultant Lori Capozzi inquiring into whether the company classified Mr. Hodges's position as a sales position."
In April 2014, Hodges filed suit in the United States District Court for the District of Colorado. In February 2017, the district court, having concluded that the Policy failed to reserve to LINA discretion to decide employee-classification questions, reviewed LINA's decision de novo and ruled that LINA had breached its fiduciary duty to Hodges by "accept[ing] Endo's bare assertion that Hodges was not 'Sales personnel' without requiring documentation or a justification for that assertion."
On remand, Hodges submitted three additional documents, which governed Endo's "Incentive Compensation Plan" for cryotherapy technicians.
[Hodges] was a C[ry]oTherapy Technician whose job it was to operate C[ry]o equipment. His [job description] does not classify hi[m] as a sales employee, nor are any sales responsibilities included in the job description. The record reflects that Hodges did not participate in a sales incentive plan. The plan he did participate in ... was based on the number of procedures he performed. The record also reflects that no part of his pay was tied to sales. It is true that he was asked to provide one lead a month for sales reps to call on. All that was required was to provide a lead, there was no requirement that the lead result in sales.
Hodges asked the district court to reopen the case. The court agreed and, in June 2018, it ruled that LINA had once again failed to adequately investigate Hodges's employment classification. Concluding that a second remand would be futile, the district court determined that
*675
Hodges was a salesperson under the ordinary meaning of that term, reversed LINA's contrary decision, and awarded Hodges Class 2 benefits "retroactive to the date his long term disability benefits commenced."
ANALYSIS
LINA raises two issues. First, LINA argues that the Policy gives it discretion to decide whether Hodges is a salesperson. If so, we would apply the arbitrary-and-capricious standard of review to its decision denying Hodges Class 2 benefits, not the de novo standard. But second, LINA contends that it doesn't matter what standard of review we apply: Hodges is not a Class 2 salesperson under the Policy. We consider each issue in turn.
I. Standard of Review
In an ERISA case like this one, the appellate standard of review contains two layers: first, the standard of review applicable to the plan administrator's denial of benefits; and second, the standard of review applicable to the district court's ruling-including its determination of what standard of review to apply to the administrator's denial of benefits. When, as here, "the district court's determination of the standard of review [applicable to the denial of benefits] did not require it to resolve any disputed historical facts, we do not defer to its determination but decide de novo what [that] standard of review should be."
Hancock v. Metro. Life Ins. Co.
,
We review de novo a plan administrator's denial of benefits "unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan."
Firestone Tire & Rubber Co. v. Bruch
,
*676
To enjoy deferential judicial review of its benefits decision, the administrator of an ERISA plan must reserve its discretion "in explicit terms" in the plan document.
As proof that the Policy grants it discretion to decide whether Hodges was a salesperson, LINA quotes three Policy provisions. Primarily, LINA relies on language in the Policy's "Claims Procedures" section, which states that "[t]he Plan Administrator has appointed the Insurance Company as the named fiduciary for deciding claims for benefits under the Plan" and that "[t]he Insurance Company has 45 days from the date it receives a claim for disability benefits ... to determine whether or not benefits are payable in accordance with the terms of the Policy." Appellant's App. vol. 2 at 312. LINA also cites two other portions of the Policy using similar language: (1) the "Termination of Disability Benefits" section, which states, in part, that an employee's benefits will terminate when "[LINA] determines he or she is not [d]isabled," id. at 304; and (2) the "Reporting Requirements" provision, which provides that "[t]he Employer must, upon request, give [LINA] any information required to determine who is insured, the *677 amount of insurance in force[,] and any other information needed to administer the plan of insurance," id. at 306.
LINA zeroes in on the word "determine" in each provision. See Appellant's Opening Br. at 27-29. LINA maintains that this wording "is consistent with the sort of plan language that this Court has found to trigger the deferential standard of review." Id. at 29; see generally id. at 28-31 (citing Eugene S. , Nance , McGraw , and Chambers ). But Hodges counters that in those cases applying the deferential standard, "the [plan] language emphasize[d] the specific definition or decision as to which the insurer or plan [administrator] reserve[d] discretion." Appellee's Response Br. at 36. We agree with Hodges.
Under our ERISA jurisprudence, "it is essential to focus precisely on what decision is at issue, because a plan may grant the administrator discretion to make some decisions but not others."
Nance
,
Consistent with this principle, each of the cases LINA relies on identified a
specific issue
that the administrator retained discretion to determine. In
Chambers
, plan language "exclud[ing] from coverage 'medical or surgical procedures which in the judgment of [the administrator] are experimental' " granted the administrator "discretion to determine whether to deny a claimant insurance benefits for an 'experimental' procedure."
Here, by contrast, the Policy does not require "proof satisfactory to" LINA.
See
Nance
,
We acknowledge that we have often interpreted plan language as granting discretion to the administrator over all decisions that arise in the claims process, including fact determinations and the interpretation of terms. But such cases involve clear and unambiguous discretion-conveying language-for instance, language reserving to the administrator the discretion "to construe the terms of the Plan, to resolve any ambiguities, and to determine any questions which may arise with the Plan's application or administration, including but not limited to determination of eligibility for benefits,"
Martinez v. Plumbers & Pipefitters Nat'l Pension Plan
,
In other cases, we have construed narrower plan language to convey discretion to the administrator to interpret all policy terms (though not necessarily to resolve factual questions).
See, e.g.
,
Pratt v. Petroleum Prod. Mgmt., Inc. Emp. Sav. Plan & Tr.
,
In short, nothing in the Policy grants LINA the discretion to conclude who qualifies as a salesperson. Rather, by stating that LINA "determines" eligibility, the Policy merely clarifies that LINA, and no one else, decides in the first instance whether to award benefits. As the Seventh Circuit put it, "All plans require an administrator first to determine whether a participant is entitled to benefits before paying them; the alternative would be to hand money out every time someone knocked on the door ...."
Diaz v. Prudential Ins. Co. of Am
.,
The plan language that LINA quotes simply directs
who
makes the initial benefits decision-in this case, the plan administrator, rather than the employer or employee-but we cannot stretch that language into a conveyance of any discretionary authority. If LINA wanted to reserve discretion to decide other aspects of a claim (such as whether an employee qualifies as a salesperson), then it should have done so explicitly. Thirty years have passed since the Supreme Court first held that de novo judicial review applies unless the benefit plan "gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan."
See
Firestone
,
[P]lan drafters who wish to convey discretion to plan administrators are ill-advised to rely on language that is borderline in accomplishing that task. ... [A]s more and more courts emphasize the need for clear language to convey discretion, courts that have found borderline language acceptable in the past may assume that plan drafters who have not clarified the language were not intent on conveying discretion.
Nance
,
*680
Cosey v. Prudential Ins. Co. of Am.
,
In sum, LINA has failed to meet its burden to show that it is entitled to deference in deciding who qualifies as a salesperson under the Policy.
See
Eugene S.
,
II. Whether Hodges Qualifies as a Salesperson
"In deciding whether an ERISA employee welfare benefit plan provides for vested benefits, we apply general principles of contract construction."
Deboard v. Sunshine Min. & Ref. Co.
,
According to Hodges, a "salesperson" is one "whose job involves selling or promoting commercial products." Appellee's Response Br. at 48 (citing Oxford English Dictionary). LINA has not disputed this definition, either in the district court or on appeal, and this definition comports with this court's understanding of the term,
see
Oxford English Dictionary (online ed. 2018) (defining "salesman" as "[a] man whose business it is to sell goods or conduct sales"); Merriam-Webster (online ed. 2019) (defining "salesman" as "one who sells in a given territory, in a store, or by telephone"). The Supreme Court recently endorsed this "ordinary meaning" definition of "salesman."
See
Encino Motorcars, LLC v. Navarro
, --- U.S. ----,
After due consideration, we conclude that Hodges qualified as a Class 2 salesperson. We agree with the district court, which summarized the supporting evidence as follows:
Hodges had responsibilities to sell and promote Endo's commercial products and services at every available juncture ... [and] could only have more [cryotherapy ] cases to treat if he had successfully sold new doctors on Endo's products and services or sold existing doctors on performing more cryotherapy procedures. Also, ... the "Summary of Purpose" in the description of his job stated that part of Hodges' duties was to "[a]ssist in the growth and development of existing and new business lines." ... Hodges was also supposed to "market the technology" and was required "to submit a minimum of [one] lead a month for new cryo[therapy] users, new applications for existing cryo[therapy] users, or any other lead for any of Endo's business." ... The record reflects that Hodges received a significant portion from bonuses when he did sell products and services, and these earnings were designate[d] as bonuses on pay stubs. ... As his counsel noted, Hodges "received benefits for the leads that he provided for prospective cryotherapy customers-he was given a bonus of $ 3,000 for every $ 100,000 of pathology work that a doctor performed using Endo's equipment and services, and he received a monthly bonus for every case that he worked on. ... [T]hese substantial sales responsibilities and sales-driven compensation would cause a reasonable insured to believe that he was Sales Personnel-and to devote his efforts to sales in order to increase his compensation ....
The three Incentive Compensation Plans also support a finding that Hodges had sales responsibilities .... These plans provided bonuses, also referred to as "incentive compensation payments," to employees like Hodges who recruit[ed] new physicians and convince[d] those physicians to treat cases using Endo's methods. ... While LINA insists that those plans cannot be indicative of sales responsibilities because they "expressly apply to those 'performing cryotherapy procedures,' not sales personnel" ... LINA never explains why the two are mutually exclusive.
Appellant's App. vol. 1 at 280-81.
Clearly, Hodges's job "involved selling" Endo's products. The record contains numerous
*682
e-mails and presentations from Endo supervisors emphasizing to cryotherapists the importance of "help[ing] growth" by "[a]sk[ing] [their] partners if they know of any other doc[tor] that might be interested in performing cryo[therapy]," "[m]ak[ing] sure that [they] always have literature," and "[b]e[ing] persistent [because] they might say no a couple of times."
CONCLUSION
Consistent with the foregoing, we affirm the ruling of the district court.
Both the Class 1 and Class 2 definitions of earnings specifically exclude "commissions, overtime pay, or extra compensation." Appellant's App. vol. 2 at 291, 294.
Hodges estimates that he would collect an additional $ 902 per month if he were classified as a Class 2 salesperson.
The IRS treats bonuses as "supplemental wages" and taxes them differently than "regular wages."
See
See also
Stephanie C. v. Blue Cross Blue Shield of Massachusetts HMO Blue, Inc.
,
Our "comparatively liberal" approach puts us on the minority side of a circuit split. Most circuits have expressly rejected
Nance
's interpretation of "proof satisfactory to the administrator."
See
Cosey v. Prudential Ins. Co. of Am.
,
Other circuits apply the same principle.
See, e.g.
,
Knopick v. Metro. Life Ins. Co.
,
Indeed, many of our cases have construed plan language to grant all-encompassing discretion when it does so explicitly.
See, e.g.
,
Kellogg v. Metro. Life Ins. Co.
,
See, e.g.
,
Dycus v. Pension Ben. Guar. Corp.
,
See, e.g.
,
Null v. Cmty. Hosp. Ass'n
,
Even if the Policy had granted discretion, LINA concedes that, because it is both the claim administrator and the funder of the LTD benefits, it has a conflict of interest, so it would not enjoy the benefit of pure arbitrary-and-capricious review.
See
Metro. Life Ins. Co. v. Glenn
,
Reference
- Full Case Name
- Lou HODGES, Plaintiff - Appellee, v. LIFE INSURANCE COMPANY OF NORTH AMERICA, a Pennsylvania Insurance Company, Defendant - Appellant.
- Cited By
- 20 cases
- Status
- Published