Miller v. Monumental Life Ins. Co.

• Citation: 761 F.Supp.2d 1123
• Decision Date: 31 March 2009
• Docket Number: No. CIV 04–0970 JB/RHS.,CIV 04–0970 JB/RHS.
• Parties: Rodney MILLER, Plaintiff,v.MONUMENTAL LIFE INSURANCE COMPANY, and Nasra TPA, Inc. and its successor, HCC Administrators, Inc. and/or Gallagher Bassett Services, Inc., Defendants.
• Court: U.S. District Court — District of New Mexico

761 F.Supp.2d 1123

Rodney MILLER, Plaintiff,

v.MONUMENTAL LIFE INSURANCE COMPANY, and Nasra TPA, Inc. and its successor, HCC Administrators, Inc. and/or Gallagher Bassett Services, Inc., Defendants.

No. CIV 04–0970 JB/RHS.

United States District Court, D. New Mexico.

March 31, 2009.

James Rawley, Albuquerque, NM, for Plaintiff.Bruce S. McDonald, Lucinda Siembieda, Law Offices of Bruce S. McDonald, Albuquerque, NM, and Bernie E. Hauder, Adkerson, Hauder & Bezney P.C., Dallas, TX, for Defendants.

MEMORANDUM OPINION AND ORDER

JAMES O. BROWNING, District Judge.

THIS MATTER comes before the Court on: (i) Monumental Life Insurance Company's Supplemental Brief on Sole Cause Issue, filed December 17, 2007 (Doc. 50) (“Brief”); (ii) Plaintiff Rodney Miller's Supplemental Memorandum of Law in Support of Motion for Summary Judgment, filed January 7, 2008 (Doc. 52) (“Memo.”); (iii) Monumental Life Insurance Company's Reply and Motion to Strike Plaintiff's Supplemental Brief, filed January 11, 2008 (Doc. 54) (“Reply”); and (iv) Plaintiff Rodney Miller's Response to Monumental's Motion to Strike, filed January 25, 2008 (Doc. 56) (“Response”). The Court held a hearing on February 8, 2008. The primary issues are: (i) whether the Court should find that the accident in question in this case was the sole-cause of Plaintiff Rodney Miller's disability; (ii) whether the Court should strike portions of Miller's brief in which he requests attorney's fees; (iii) whether, if the Court declines to strike the request for attorney's fees, the Court should award Miller attorney's fees; and (iv) whether the Court should remand the case to the administrator so that a record can be developed on the sole cause issue. While the Court finds that the language in the Policy regarding “sole” and “direct” cause is unambiguous, and imposes the requirements that the disability resulted directly from the work injury and not from any other source, the Court does not believe the record is sufficiently developed for the Court to make a fair determination on the sole-cause issue. The Court will therefore remand the case to the Plan Administrator. The Court will also decline to strike Miller's request for attorney's fees and will not grant attorney's fees at this time.

FACTUAL BACKGROUND

The facts underlying this lawsuit are largely laid out in the Court's Memorandum Opinion and Order, entered June 30, 2005 376 F.Supp.2d 1238 (D.N.M.2005) (“June 2005 MOO ”). In September 1997, Miller was injured in a motor vehicle accident. The primary determination the Court must make at this time is whether the injuries from the accident were the sole cause of Miller's disability. The Court will therefore focus on the facts that pertain to that issue.

1. The Policy.

Miller's employer, Aycock Transportation, established a Plan under the Employee Retirement Income Security Act, 29 U.S.C. § 1132 (“ERISA”). See Brief at 1. Monumental Life Insurance Company issued a Master Group Policy to Aycock Transportation, and a Certificate of Insurance under the Master Group Policy to Miller, that provided certain medical, Temporary Total Disability, and Continuous Total Disability (“CTD”) benefits. See Reply at 1. The Policy provides that Monumental Life will pay CTD Benefits when: (i) it receives proof that the Insured is Totally Disabled; (ii) the Insured Person has been granted a Social Security Disability (“SSD”) Award for such disability; and (iii) the Total Disability “resulted solely and directly from Injury.” Master Policy at 10, filed April 29, 2005 (Doc. 28) (“Policy”). The Policy defines Total Disability for purposes of the CTD to mean that “the Insured Person is unable to perform every duty pertaining to any occupation for which he is or may become qualified by education, training or experience and has been granted a Social Security Disability Award.” Id. at 5. The insurance is no longer offered. See Reply at 8. Thus, the Policy states that Monumental Life would pay monthly CTD Benefits if the Total Disability “resulted solely and directly from Injury.” Policy at 10. The primary issue in the briefing at this point is whether the Total Disability “resulted solely and directly from the Injury.”

It is undisputed that the Plan gave the administrator no discretion and that the Court's review of the denial of benefits is de novo. See Brief at 2. The Court recognized these principles in its order granting Monumental Life's motion for summary judgment, see June 2005 MOO, 376 F.Supp.2d at 1248–49, and the United States Court of Appeals for the Tenth Circuit also recognized these principles in its opinion, see Miller v. Monumental Life Ins., 502 F.3d 1245, 1250 (10th Cir.2007).

Aycock Transportation was the ERISA plan sponsor, and ERISA required Aycock Transportation, Monumental Life, HCC, or any other entity, to provide Miller with a summary plan description. Miller states that he was not provided with a “summary plan description.” Reply at 2 & n. 1. There is also no evidence whether Aycock Transportation provided a “summary plan description.” Id.

2. Miller's Pre–Accident Condition.

Miller had some medical conditions that pre-dated the work injury. See Memo. at 13. There is also no evidence in the record when the other conditions arose. See Reply at 2. Nevertheless, those conditions did not prevent him from working as a truck driver. See Memo. at 13. It is undisputed that Miller was physically able to work before the accident of September 15, 1997, and was working as a truck driver. See Memo. at 2. Miller was able to perform all the truck-driving duties that his employer required before the accident. See id.

It is also undisputed that, on September 15, 1997, while employed by Aycock Transportation and while in the course and scope of his employment with Aycock Transportation, Miller was involved and injured in a motor vehicle accident. See id. The accident caused a back injury. See Memo. at 10. Miller contends that it is further undisputed that, since the motor vehicle accident, Miller became and has been totally disabled, and unable to work and to continue employment. See Memo. at 2. Miller contends that Monumental Life “concedes [he] is totally disabled.” Memo. at 2. Monumental Life contends that it has not conceded or admitted that Miller is totally disabled. See Reply at 1.

Miller admits that he became disabled “due to the combined effects of chronic back pain associated with facet arthropathy with cervical and lumbar radiculopathy, carpal tunnel syndrome, bi-polar affective disorder and valvular heart disease with valve replacement.” Defendants' Notice of Removal, Complaint for ERISA Plan Benefits ¶ 8, at 6, filed August 27, 2004 (Doc. 1) (“Complaint”).

3. The SSA's Findings.

Miller applied for SSD and for Supplemental Security Income (“SSI”) benefits. See Brief at 2. The Social Security Administration (“SSA”) denied Miller's request for SSD benefits, but found that he met the requirements for SSI benefits, found that he was entitled to those benefits up through at least June 1, 2005, and approved his request for SSI benefits. See Exhibit 5 to Motion for Summary Judgment, Notice of Decision—Favorable at 1, dated March 1, 2001 (“SSI Decision”) (granting SSI benefits); Exhibit 4 to Motion for Summary Judgment, Notice of Decision—Unfavorable at 1, dated August 28, 2003 (denying Miller SSD benefits). The SSA paid Miller a “Supplemental Security Income Award.” SSI Decision at 1.

In the decision on Miller's request for SSI benefits, the SSA framed the general issue the Administrative Law Judge (“ALJ”) was to determine as:

[W]hether the claimant is disabled under Section 1414(a)(3)(A) of the Social Security Act. The specific issue is whether he is under a disability, which is defined as the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months.

SSI Decision at 1. The ALJ determined that “the medical evidence establishes that claimant has the following severe impairments: chronic neck and back pain associated with facet arthropathy with cervical and lumbar radiculopathy, carpel tunnel syndrome, bipolar affective disorder and valvular heart disease with valve replacement.” SSI Decision at 3. Although the ALJ found that none of these impairments met the criteria of any listed impairment, the ALJ concluded that, because Miller was unable to perform the physical and mental requirements of any past relevant work, because Miller had no transferrable skills to work he could perform, and because Miller could not make an adjustment to any work that exists in significant numbers in the national economy, Miller was disabled within the framework of medical-vocational rule 201.00(h). SSI Decision at 3. The ALJ also found that Miller was under a disability, as defined in the Social Security Act, which continued for a sufficient period of time to qualify for the SSI benefit. See id. at 4. Accordingly, Miller received a monthly SSI Award from May 1, 2001 through June 1, 2005. See Brief at 2.4. The Administrative Record.

Miller submitted a claim for CTD benefits under the Policy. See Brief at 2. It is undisputed that Miller's claim was the first and only claim the Plan Administrator or Monumental Life ever faced where an insured received an SSI Award and sought Continuous Disability Benefits (“CDB”) under the policy. See Reply at 8. Monumental Life was not the Plan Administrator or third-party administrator. See Reply at 4 n. 2. Monumental Life did not administer or make the decisions on Miller's claim for benefits under the Policy. See id.

In the letter setting forth her decision to deny Miller CTD benefits, the Plan Administrator did not mention sole cause, and she gave no inclination regarding whether Miller was Totally Disabled, as defined in the Policy. See Letter from...