Ruppert v. Atlas Air Inc et al

3:19-cv-00152Akd27.12.2019

Gesamter Gesetzestext

WO IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ALASKA
THOMAS RUPPERT, )
)
Plaintiff, )
)
vs. )
)
ATLAS AIR, INC. LONG TERM )
DISABILITY PLAN; HARTFORD LIFE )
AND ACCIDENT INSURANCE CO., )
) No. 3:19-cv-0152-HRH
Defendants. )
_______________________________________)
O R D E R
This is an ERISA action, in which plaintiff Thomas Ruppert seeks judicial review of
an adverse decision by defendant Hartford Life and Accident Insurance Co. Plaintiff has
timely filed his opening brief,1 to which defendant has responded.2 Oral argument was not
requested and is not deemed necessary.
1Docket No. 15.
2Docket No. 19.
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Facts
Plaintiff was employed by Atlas Air Inc. as a pilot from 1999 to 2018.3 Atlas Air is
the sponsor and plan administrator of the Atlas Long Term Disability Plan, which provides
Long Term Disability (LTD) benefits to its pilots and air crew pursuant to a group policy of
insurance issued by defendant. Defendant is the claims administrator of the Plan.
Defendant determined that plaintiff became disabled on June 1, 2018,4 and on
September 21, 2018, plaintiff’s claim for LTD benefits was approved.5 Plaintiff was advised
that his LTD benefits were “intended to supplement income you may receive as a result of
your disability or retirement” and that “any other income benefits you receive may reduce
your LTD benefits.”6 Plaintiff was further advised that “[o]ther income can include, but is
not limited to, any Social Security benefits you or your family receives[.]”7 Plaintiff was also
advised that defendant’s “records indicate you may qualify for Social Security Disability
(SSD) benefits. Your LTD policy requires you to apply for SSD benefits. . . .”8
3Admin. Rec. at 19, Exhibit A, Docket No. 13.
4Admin. Rec. at 67, Exhibit A, Docket No. 13. Plaintiff was disabled due to
seborrheic keratosis, which caused serious vision problems. Admin. Rec. at 19, Exhibit A,
Docket No. 13.
5Admin. Rec. at 67, Exhibit A, Docket No. 13.
6Id.
7Id.
8Admin. Rec. at 69, Exhibit A, Docket No. 13.
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On September 25, 2018, plaintiff was advised that he was entitled to Social Security
Retirement benefits of $2,461 per month, beginning in July 2018.9 Plaintiff provided this
information to defendant in October 2018.10
On November 6, 2018, defendant informed plaintiff that his Social Security
Retirement benefits were “Other Income Benefits” under the Plan and thus his monthly LTD
benefits of $10,000 would be reduced by $2,461.50, beginning on July 1, 2018.11
Plaintiff appealed this decision, arguing that Social Security Retirement benefits were
not “Other Income Benefits” under the Plan.12 On April 29, 2019, defendant denied
plaintiff’s appeal, having “determined the offset for Social Security Retirement (SSR)
benefits is appropriate under the terms of the” Plan.13
On May 28, 2019, plaintiff commenced this action, in which he seeks review of
defendant’s final determination.
Standard of Review
“District courts review a decision to deny or terminate benefits under an ERISA plan
‘under a de novo standard unless the benefit plan gives the administrator or fiduciary
9Admin. Rec. at 3, Exhibit A, Docket No. 13.
10Id.
11Admin. Rec. at 73, Exhibit A, Docket No. 13.
12Admin. Rec. at 92, Exhibit A, Docket No. 13.
13Id.
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discretionary authority to determine eligibility for benefits or to construe the terms of the
plan.’” Gatti v. Reliance Standard Life Ins. Co., 415 F.3d 978, 981 (9th Cir. 2005) (quoting
Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989)). Here, the Plan gave
defendant the “full discretion and authority to determine eligibility for benefits and to
construe and interpret all terms and provisions of the Policy.”14 Thus, the court reviews
defendant’s determination that an offset for Social Security Retirement benefits was
appropriate under the Plan for an abuse of discretion.
Plaintiff’s contention that the court should review defendant’s determination under
the de novo standard is simply wrong. In the Ninth Circuit, “‘[w]here an ERISA Plan grants
discretionary authority to determine eligibility for benefits or to construe the terms of the
plan, a plan administrator’s interpretation of a plan is reviewed for abuse of discretion.’”
O’Rourke v. N. Calif. Electrical Workers Pension Plan, 934 F.3d 993, 998 (9th Cir. 2019)
(quoting Lehman v. Nelson, 862 F.3d 1203, 1216 (9th Cir. 2017)).
“Under” the abuse of discretion “standard, [defendant’s] interpretation of Plan
language is entitled to a high level of deference and will not be disturbed unless it is ‘not
grounded on any reasonable basis.’” Tapley v. Locals 302 and 612 of Int’l Union of
Operating Engineers-Employers Const. Industry Retirement Plan, 728 F.3d 1134, 1139 (9th
Cir. 2013) (quoting Oster v. Barco of Cal. Emps.’ Ret. Plan, 869 F.2d 1215, 1218 (9th Cir.
1988)). “The analysis is not based on ‘whose interpretation of the plan documents is most
14The Plan at 52, Exhibit B, Docket No. 13-4.
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persuasive, but whether the [administrator’s] interpretation is unreasonable.’” Moyle v.
Liberty Mut. Retirement Ben. Plan, 823 F.3d 948, 958 (9th Cir. 2016) (quoting Canseco v.
Constr. Laborers Pension Tr., 93 F.3d 600, 606 (9th Cir. 1996)). “When reviewing
interpretive challenges for abuse of discretion, the [c]ourt closely reads contested terms and
‘appl[ies] contract principles derived from state law [,] . . . guided by the policies expressed
in ERISA and other federal labor laws.’” Tapley, 723 F.3d at 1139 (quoting Richardson v.
Pension Plan of Bethlehem Steel Corp., 112 F.3d 982, 985 (9th Cir. 1997)). Defendant will
have abused its discretion if it “construe[d] provisions of [the P]lan in a way that clearly
conflicts with the plain language of the Plan, render[ed] nugatory other provisions of the
Plan, or lack[ed] any rational nexus to the primary purpose” of the Plan[.]” Id. (internal
citations omitted).
“The manner in which a reviewing court applies the abuse of discretion standard . . .
depends on whether the administrator has a conflicting interest.” Montour v. Hartford Life
& Acc. Ins. Co., 588 F.3d 623, 629 (9th Cir. 2009). “In the absence of a conflict, judicial
review of a plan administrator’s benefits determination involves a straightforward application
of the abuse of discretion standard.” Id. But, if the plan administrator is operating under a
conflict of interest, the court “must take into account the administrator’s conflict of interest
as a factor in the analysis.” Id. at 630. Here, defendant’s “dual role as plan administrator,
authorized to determine the amount of benefits owed, and insurer, responsible for paying
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such benefits, creates a structural conflict of interest.” Stephan v. Unum Life Ins. Co. of
America, 697 F.3d 917, 929 (9th Cir. 2012).
“The level of skepticism with which a court views a conflicted administrator’s
decision may be low if a structural conflict of interest is unaccompanied, for example, by any
evidence of malice, of self-dealing, or of a parsimonious claims-granting history.” Abatie
v. Alta Health & Life Ins. Co., 458 F.3d 955, 968 (9th Cir. 2006). But, the court may view
a conflicted administrator’s decision with a great deal of skepticism if, for example, there is
evidence that
the administrator provide[d] inconsistent reasons for denial,
fail[ed] adequately to investigate a claim or ask[ed] the plaintiff
for necessary evidence, fail[ed] to credit a claimant’s reliable
evidence, or has repeatedly denied benefits to deserving
participants by interpreting plan terms incorrectly or by making
decisions against the weight of evidence in the record.
Id. at 968–69 (internal citations omitted).
Defendant argues that the court should view its decision with a low level of skepticism
and offers evidence in the form of a declaration from its Director of Group Insurance Claims,
Adam Garcia, in support. Garcia avers that defendant “maintains a separate appeals unit for
the consideration of claims that have been denied by the claims department on its initial
review” and that “the individual responsible for the appeal reviews the claim, and all
evidence, without affording deference to the initial adverse benefit determination.”15 Garcia
15Declaration of Adam Garcia [etc.] at 2, ¶¶ 3, 5, Docket No. 20.
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further avers that defendant “does not provide Ability Analysts, or Appeals Specialists with
incentives, remuneration, bonuses, awards, achievements, or other recognition based in
whole or in part upon the denial or termination of claims”16 and that defendant’s “claims
decision-makers are paid fixed salaries and performance bonuses that are wholly unrelated
to the number of claims paid or claims denied.”17 Garcia further avers that defendant’s
“Ability Analysts and Appeals Specialists are evaluated on the quality and accuracy of their
claims decisions in accordance with the applicable plan/policy documents. Hartford does not
discourage its claim decision-makers from paying claims that are entitled to payment
pursuant to the applicable plan provisions.”18 Finally, Garcia avers that defendant’s “claims
department[] and appeals unit are completely separate business units from the financial and
underwriting departments.”19 Defendant argues that Garcia’s averments are evidence that
it has taken steps to ensure that its structural conflict does not affect its claims decisions and
thus the court should afford the conflict of interest little, if any, weight.
Plaintiff however argues that Garcia’s declaration is irrelevant because the de novo
standard of review applies here, but as explained above, the abuse of discretion standard
applies here. To the extent that Garcia’s declaration is relevant, plaintiff argues that other
16Id. at 3, ¶ 11.
17Id.
18Id. at 4, ¶ 12.
19Id. at 4, ¶ 13.
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courts have rejected defendant’s assertion of unbiased claims handling. But the cases to
which plaintiff cites do not support his argument. In Kouns v. Hartford Life and Accident
Insurance Co., 780 F. Supp. 2d 578, 585 (N.D. Ohio 2011), there was “no evidence . . .
showing that the [structural] conflict affected Hartford’s decision” but because “the effects
of such a conflict are exceedingly difficult—if not impossible—to prove,” the court
“weigh[ed] this conflict as a factor against Hartford. . . .” Moreover, the court found
Hartford had abused its discretion in terminating Kouns’ LTD benefits, not because of any
interpretation of plan language, but rather because of Hartford’s treatment of evidence in the
record such as a medical opinion, an employability analysis, and the fact that the Social
Security Administration had found Kouns disabled. Id. at 585-90. In Gaeth v. Hartford Life
Insurance Company, 538 F.3d 524, 527 (6th Cir. 2008), the other case cited by plaintiff, the
court did not even discuss a conflict of interest and the issue before the court of appeals was
whether the district court’s award of attorney fees to Gaeth was proper “even though it did
not find that Gaeth [was] still entitled to disability benefits under the plan.”
Here, the evidence before the court shows that defendant has taken steps to prevent
its structural conflict of interest from affecting its benefits decisions and there is no evidence
that defendant has repeatedly denied benefits by interpreting plan terms incorrectly or
otherwise engaged in self-dealing. Thus, the court will view defendant’s final determination
that the Social Security Retirement benefits offset was proper with a low level of skepticism.
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Discussion
The Plan provides that monthly LTD Benefits are calculated as follows:
1) multiply Your Monthly Income Loss by the Benefit
Percentage;
2) compare the result with the Maximum Benefit; and
3) from the lesser amount, deduct Other Income Bene-
fits.[20]
The Plan defines “Other Income Benefits” as follows:
Other Income Benefits means the amount of any benefit for loss
of income, provided to You or Your family, as a result of the
period of Disability for which You are claiming benefits under
The Policy. This includes any such benefits for which You or
Your family are eligible or that are paid to You or Your family,
or to a third party on Your behalf, pursuant to any:
1) temporary, permanent disability, or impairment
benefits under a Workers’ Compensation Law, the
Jones Act, occupational disease law, similar law,
or substitutes or exchanges for such benefits;
2) governmental law or program that provides
disability or unemployment benefits as a result of
Your job with Your Employer;
3) plan or arrangement of coverage, whether insured
or not, which is received from Your Employer as
a result of employment by or association with
Your Employer or which is the result of member-
ship in or association with any group, association,
union, or other organization;
4) mandatory “no fault” automobile insurance plan;
5) disability benefits under:
a) the United States Social Security Act or
alternative plan offered by a state or mu-
nicipal government;
20The Plan at 21, Exhibit B, Docket No. 13-4.
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Case 3:19-cv-00152-HRH Document 27 Filed 12/27/19 Page 9 of 17
b) the Railroad Retirement Act;
c) the Canada Pension Plan, the Canada Old
Age Security Act, the Quebec Pension
Plan or any provisional pension or disabil-
ity plan; or
d) similar plan or act;
that You, Your Spouse and/or children, are eligi-
ble to receive because of Your Disability; or
6) disability benefit from the Department of Veter-
ans Affairs, or any foreign or domestic govern-
mental agency:
a) that begins after You become Disabled; or
b) that You were receiving before becoming
Disabled, but only as to the amount of any
increase in the benefit attributed to Your
Disability.
Other Income Benefits also means the amount of any payments
that are made to You or Your family, or to a third party on Your
behalf, pursuant to any:
1) disability benefit under Your Employer’s Retire-
ment Plan;
2) temporary, permanent disability or impairment
benefits under a Workers’ Compensation Law, the
Jones Act, occupational disease law, similar law
or substitutes or exchanges for such benefits;
3) portion of a judgement or settlement of a claim or
lawsuit that represents or compensates for Your
loss of earnings, less Our pro rata share of any
associated reasonable attorneys’ fees and court
costs;
4) retirement benefit from a Retirement Plan that is
wholly or partially funded by employer contribu-
tions, unless:
a) You were receiving it prior to becoming
Disabled; or
b) You immediately transfer the payment to
another plan qualified by the United States
Internal Revenue Service for the funding
of a future retirement;
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Case 3:19-cv-00152-HRH Document 27 Filed 12/27/19 Page 10 of 17
(Other Income Benefits will not include the
portion, if any, of any such retirement benefit that
was funded by Your after-tax contributions.); or
5) retirement benefits under:
a) the United States Social Security Act or
alternative plan offered by a state or mu-
nicipal government;
b) the Railroad Retirement Act;
c) the Canada Pension Plan, the Canada Old
Age Security Act, the Quebec Pension
Plan or any provincial pension or disability
plan; or
d) similar plan or act;
that You, Your Spouse and/or children receive
because of Your retirement, unless you were
receiving them prior to becoming Disabled.[21]
The court “begin[s] its inquiry with the plain language of the Plan, interpreting it ‘in
an ordinary and popular sense as would a person of average intelligence and experience.’”
Tapley, 728 F.3d at 1140 (quoting Gilliam v. Nev. Power Co., 488 F.3d 1189, 1194 (9th Cir.
2007)). Plaintiff argues that it would not be clear to a person of average intelligence and
experience reading the definition of “Other Income Benefits” that LTD benefits could be
reduced by the receipt of Social Security Retirement benefits, even though such benefits are
listed in subpart 5a of the second paragraph of the definition.
First, plaintiff contends that the inclusion of Social Security Retirement benefits as
“Other Income Benefits” is inconsistent with the first provision in the definition. That
definition begins: “Other Income Benefits means the amount of any benefit for loss of
21The Plan at 31-32, Exhibit B, Docket No. 13-4.
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income, provided to You or Your family, as a result of the period of Disability for which You
are claiming benefits under The Policy.”22 Because Social Security Retirement benefits are
not benefits one receives as a result of a disability, plaintiff argues that a person of average
intelligence and experience would not understand such benefits to be included in the “Other
Income Benefits” definition.
Plaintiff however is ignoring the fact that the “Other Income Benefits” definition
includes two paragraphs, each of which are followed by numbered subparts. The first
paragraph lists six types of “Other Income Benefits” that a beneficiary might receive because
of his disability. The second paragraph lists five types of income that are “also” included in
the definition of “Other Income Benefits.” By using the term “also” in the second paragraph,
the Plan plainly indicates that what follows is different from and in addition to what is set out
in the first paragraph. Thus, including Social Security Retirement benefits as “Other Income
Benefits” in the second paragraph is not inconsistent with the definition of “Other Income
Benefits” in the first paragraph, as plaintiff argues.
Plaintiff next argues that a person of average intelligence and experience would be
misled or confused by the placement of the parenthesized statement just before subpart 5a:
(Other Income Benefits will not include the portion, if any, of
any such retirement benefit that was funded by Your after-tax
contributions.); or
5) retirement benefits under:
22Id. at 31 (emphasis added).
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a) the United States Social Security Act or
alternative plan offered by a state or mu-
nicipal government[.23]
Plaintiff argues that a person of average intelligence and experience reading this portion of
the definition would be lead to believe that “Other Income Benefits” do not include Social
Security Retirement benefits. Plaintiff argues that the parenthesized statement appears to be
an introductory paragraph for a list of benefits that are not “Other Income Benefits.” Plaintiff
argues that at the very least, the “Other Income Benefits” definition violates 29 C.F.R. §
2520.102–2(b), which provides in relevant part that “[a]ny description of exception,
limitations, reductions, and other restrictions of plan benefits shall not be minimized,
rendered obscure or otherwise made to appear unimportant.” As the Ninth Circuit has
explained, “‘the insurer should be expected to set forth any limitations on its liability clearly
enough for a common layperson to understand; if it fails to do this, it should not be allowed
to take advantage of the very ambiguities that it could have prevented with greater
diligence.’” Simkins v. NevadaCare, Inc., 229 F.3d 729, 736 (9th Cir. 2000) (quoting Kunin
v. Benefit Trust Life Ins. Co., 910 F.2d 534, 540 (9th Cir. 1990)). This is in keeping with
ERISA itself which provides that a summary plan description “shall be written in a manner
calculated to be understood by the average plan participant, and shall be sufficiently accurate
and comprehensive to reasonably apprise such participants and beneficiaries of their rights
and obligations under the plan.” 29 U.S.C. § 1022(a).
23Id. at 32.
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Plaintiff compares this case to Saltarelli v. Bob Baker Group Medical Trust, 35 F.3d
382, 383 (9th Cir. 1994), which involved a pre-existing condition exclusion. The court
explained that
[t]he Baker Group Summary Plan Description, which was
provided to participants such as Saltarelli, covers 43 pages in
single-spaced typescript. The preamble states that “[t]he Plan is
subject to all terms, provisions and conditions recited on the
following pages.”
Among the Baker Group plan provisions is an exclusion
for “pre-existing conditions.” However, an insured reading the
table of contents of the plan summary would find no heading for
this critically important item. The only arguably relevant
heading apparent from the table of contents, “Eligibility Rules:
Employee Eligibility and Effective Date,” contains no reference
to it at all. The “Medical Care Benefits” chapter in the body of
the document does reveal a subsection entitled “Exclusions and
Limitations,” but the pre-existing conditions exclusion receives
no mention here either.
Instead, the exclusion can be found only in the midst of
the “Definitions” chapter. Even then, it requires a coordinated
reading of three separate definitions: those for “Pre–Existing
Condition,” “Illness,” and “Injury.”
Id. at 385. In other words, “Baker Group chose to bury one of the plan’s most significant
provisions amidst definitions, rather than forthrightly stating the pre-existing conditions
exclusion in the operative clauses of the plan description.” Id. The court thus held that
“since Baker Group’s attempted exclusion was not clear, plain, and conspicuous enough to
negate layman Saltarelli’s objectively reasonable expectations of coverage, it was
unenforceable. . . .” Id. at 387. Similarly here, plaintiff argues that the court should find that
defendant’s inclusion of Social Security Retirement benefits as one of the benefits that would
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reduce a beneficiary’s LTD benefits was not “clear, plain, and conspicuous enough” for a lay
person to understand and thus defendant should not be allowed to rely on this provision.
Plaintiff is suggesting that a person of average intelligence and experience would read
the following portion of the Plan without regard to the punctuation:
(Other Income Benefits will not include the portion, if any, of
any such retirement benefit that was funded by Your after-tax
contributions.); or
5) retirement benefits under:
a) the United States Social Security Act or
alternative plan offered by a state or mu-
nicipal government[.24]
In other words, plaintiff argues that a person of average intelligence and experience would
not understand the import of the semicolon before the “or.”
But, a person of average intelligence and experience would read the entire second
paragraph of the “Other Income Benefits” section of the Plan and understand that what is in
parentheses is not an introduction to a list of benefits that are not considered “Other Income
Benefits,” but rather that it goes with subpart 4 and that subpart 5a is part of the list set out
in the second paragraph of the “Other Income Benefits” definition. A person of average
intelligence and experience would read the Plan language in the same way as defendant did,
or at least could read it in the same way, which means that defendant had a reasonable basis
for its interpretation of the Plan language.
24The Plan at 32, Exhibit B, Docket No. 13-4.
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Plaintiff’s other arguments are unavailing. Plaintiff makes much of the fact that the
Plan spells out in some detail how the receipt of Social Security Disability benefits will affect
a beneficiary’s LTD benefits25 and seems to be suggesting that because the Plan did not do
the same for Social Security Retirement benefits, a beneficiary would not expect his LTD
benefits to be reduced by the receipt of Social Security Retirement benefits. But what the
Plan says about Social Security Disability benefits has no bearing on this case, which
involves an offset for Social Security Retirement benefits. A person of average intelligence
and experience would understand that there is a difference between Social Security Disability
benefits and Social Security Retirement benefits.
Plaintiff also compares the language in the Plan to that in Fuller v. Liberty Life
Assurance of Boston, 302 F. Supp. 2d 525 (W.D.N.C. 2004). There, the plan defined
“‘Benefits from other income’” as “includ[ing] ‘[t]he amount of any Disability Benefits, or
Retirement Benefits the Participant voluntarily elects to receive as retirement payment under
the Employer’s Retirement Plan” and “[t]he amount of Disability and/or Retirement Benefits
under the United States Social Security Act.” Id. at 528-29. Plaintiff argues that this
illustrates that it is not difficult to draft a plan that clearly allows for a reduction for Social
Security Retirement benefits. But, plaintiff argues that is not what defendant has done here.
Plaintiff argues that courts routinely refuse to allow reductions of LTD benefits when such
reductions are not clearly delineated in the plan, and plaintiff urges the court here to do
25Id. at 26-27.
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likewise. See Hannington v. Sun Life and Health Ins. Co., 711 F.3d 226, 234 (1st Cir. 2013)
(holding that an offset for VA disability benefits was improper because the plan did not
expressly include such benefits in its definition of Other Income Benefits and such disability
benefits are “dissimilar” to Social Security Disability benefits); Riley v. Sun Life and Health
Ins. Co., 657 F.3d 739, 740 (8th Cir. 2011) (same); Lee v. Dayton Power and Light Co., 604
F. Supp. 987, 994 (D. C. Ohio 1985) (holding that offset for Social Security benefits received
by spouse or children not appropriate because plan never mentioned such benefits). But in
these cases, the offset at issue was not even mentioned in the plan. Here, in contrast, the Plan
lists Social Security Retirement benefits as “Other Income Benefits” and does so in a way
that a person of average intelligence and experience would understand that the receipt of such
benefits would result in a reduction in LTD benefits.
The Plan is neither confusing nor ambiguous. Social Security Retirement benefits are
clearly “Other Income Benefits” which will be deducted when calculating the amount of
LTD benefits available under the Plan.
Conclusion
Viewing defendant’s final determination with a low level of skepticism, the court
concludes that defendant did not abuse its discretion in determining that an offset for Social
Security Retirement benefits was appropriate under the Plan.
DATED at Anchorage, Alaska, this 27th day of December, 2019.
/s/ H. Russel Holland
United States District Judge
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