Mitchell v. First Unum Life Ins. Co.
| Citation | 65 F.Supp.2d 686 |
| Decision Date | 01 April 1998 |
| Docket Number | No. C-1-95-80.,C-1-95-80. |
| Parties | Jeffrey W. MITCHELL, Plaintiff, v. FIRST UNUM LIFE INSURANCE COMPANY, et. al., Defendants. |
| Court | U.S. District Court — Southern District of Ohio |
Robert Armand Perez, Cincinnati, OH, for plaintiff.
Jack Frederick Fuchs, Thompson Hine & Flory, Cincinnati, OH, for defendant.
The parties to this action have consented to the entry of final judgment by the undersigned United States Magistrate Judge. (Doc. 82). This matter is currently before the Court on the following motions and responsive memoranda: (1) defendant First Unum Life Insurance Company's motion for summary judgment on the second amended complaint (Doc. 92); (2) plaintiff Jeffrey Mitchell's memorandum in opposition to summary judgment (Doc. 101); (3) plaintiff's supplement of the record (Doc. 93); (4) defendant Unum's reply to plaintiff's supplement (Doc. 94); (5) plaintiff's sur-reply (Doc. 96); (6) plaintiff's motion to strike affidavits (Doc. 100); (7) defendant's memorandum in opposition to the motion to strike (Doc. 103); (8) plaintiff's reply (Doc. 104); (9) plaintiff's second supplement of the record (Doc. 107); (10) defendant's response to plaintiff's second supplement (Doc. 108); (11) plaintiff's reply to his second supplement (Doc. 110); and (12) defendant's notices of supplemental authority. (Docs.112, 113). Also before the Court are the parties' proposed findings of fact and conclusions of law submitted for consideration on the parties' previous cross-motions for summary judgment as to the amended complaint. (Docs.39, 40). Furthermore, to the extent that the parties' previous cross-motions for summary judgment are applicable to the claims in the second amended complaint, the Court may refer to arguments set forth therein. (See Docs. 6, 14, 24, 48).
Plaintiff Jeffrey Mitchell is a former employee of Businessland, Inc. (Doc. 39, proposed findings of fact and conclusions of law annotated by defendant, p. 1; Doc. 40, proposed findings of fact and conclusions of law annotated by plaintiff, p. 1). Businessland was subsequently bought out and plaintiff became an employee of Businessland's successor in interest, JWP, Inc. (JWP). (Doc. 90, second amended complaint, ¶¶ 3, 4). As a JWP employee, plaintiff was a participant in an ERISA welfare benefit plan that provided, among other things, group long term disability (LTD) insurance.1 (Doc. 39, p. 1; Doc. 40, p. 1). Defendant Unum is the insurance company that issued the long term disability policy under which plaintiff sought benefits. The policy, issued by Unum to JWP as Policy Number 454506, had an effective date of October 1, 1991. .
Plaintiff was first employed by Businessland in March of 1991. (Deposition of Jeffrey Mitchell, p. 8).2 At that time, the Unum LTD policy was not in effect. On June 29, 1991, Mitchell was injured at work when he strained his lower back. (Id). Mitchell went on disability leave in July 1991, and returned to work on February 10, 1992. (Id. at 11). On March 19, 1992, plaintiff suffered a second injury to his back during the course of his employment by attempting to stop a computer from falling off a table. ). Following this injury, plaintiff sought and received worker's compensation benefits.
Plaintiff was orally informed by Sharon Sloane, JWP's human resources representative, that he was not eligible for disability benefits under the Unum policy until he reached maximum medical improvement (MMI) for purposes of his worker's compensation benefits. ). After reaching MMI, plaintiff completed a claim form dated March 15, 1994, and submitted the form to his employer on June 21, 1994. ). JWP forwarded the form to Unum which received plaintiff's notice and proof of claim for his March 19, 1992 injury on June 27, 1994. (Id., Employer Statement, pp. 119-21).
Defendant initially denied plaintiff's claim on the grounds that, "it was not submitted within the time frame specified in the contract." (Id., p. JM00060). By letter dated August 22, 1994, plaintiff sought an administrative appeal of defendant's decision denying benefits. (Id., p. JM00067). Upon review, defendant issued a letter again denying plaintiff's claim for benefits based on untimely notice and proof of claim. (Id., p. JM00001). The letter states in pertinent part:
... This claim was denied as it was not received within the time limit specified by policy provisions.... You have indicated that Mitchell did provide actual notice of disability to his company through the human resources administrator; however, notice must be given directly to Unum. You have indicated that the plan administrator informed him that he was not eligible for disability insurance through Unum as long as he was receiving Worker's Compensation benefits. However, as indicated in the contract, the plan administrator cannot act as an agent of Unum's, and therefore, their actions cannot be construed as the actions of Unum.... [W]e cannot base our decision on the actions of the plan administrator.
(Id).
As an employee of Businessland, plaintiff was a member of Class Four of the five classes of eligible employees under the Unum policy. (. While the policy went into effect on October 1, 1991, the eligibility effective date for Class Four employees was January 1, 1992.(Id). The policy provides that "[a]n employee in a eligible class will be eligible for insurance on the later of: (1) the policy effective date; or (2) the day after the employee completes the waiting period." (Id., § III Eligibility and Effective Dates, P. JM00093). For employees whose eligibility effective date starts after the policy effective date, such as Class Four employees, the waiting period extends until the first of the month following thirty days of active employment. (Id., § I, Policy Specifications, p. JM00079). The Policy also provides that the effective date for an employee will be delayed if the employee is not in active employment because of a disability. (Id., § III, Eligibility and Effective Dates, p. JM00093). Under such circumstances, the employee's insurance starts "on the date the employee returns to active employment." (Id).
The policy defines "insured" as "an employee under this policy" and further defines employee as "a person in active employment with the employer." ). According to the policy, for plaintiff to be in "active employment" he must be working on a full-time basis, paid regular earnings, and working at least thirty hours per week at the employer's usual place of business or at a location to which the employer requires him to travel. (. The policy also contains a limited exclusion for claims related to a pre-existing condition. (Id., § IV, Benefits, p. JM00100). A disability that is "caused by, contributed to by (sic), or resulting from a pre-existing condition" is not covered under the policy unless it begins after the insured has been covered under the policy for twelve months or unless, after the effective date, the insured completes a period of three consecutive months during which he has not received medical treatment. (Id).
The policy's general provisions set forth the procedure for filing both notice and proof of a claim for disability benefits. (Id., § VI, General Policy Provisions, ¶ F, p. JM00106). The policy provides in pertinent part:
1. Notice
Written notice of a claim for benefits must be given to the Company within 30 days of the date disability starts, if that is possible. If that is not possible, the Company must be notified as soon as it is reasonably possible to do so.
...
2. Proof
Proof of claim must be given to the Company. This must be done no later than 90 days after the end of the elimination period.
If it is not possible to give proof of claim within these time limits, it must be given as soon as reasonably possible.
Proof of continued disability and regular attendance of a physician must be given to the Company within thirty days of the request for the proof.
(Id).
Finally, the policy states that "[u]nder no circumstances will the policyholder be deemed an agent of the [Unum]." (Id., ¶ L, p. JM00107). Thus, the policy may be changed only with the approval of an officer or registrar of Unum and any such approval must be in writing and endorsed on or attached to the policy itself. (Id., ¶ B, p. JM00105). Other persons, including agents of Unum, lack authority to change the policy or waive any part of it. (Id).
Plaintiff brings this action pursuant to the Employee Retirement Income Security Act (ERISA), 29 U.S.C. § 1001, et seq. for review of defendant Unum's administrative decision denying him long term disability benefits.3 Before the parties consented to final disposition by the undersigned United States Magistrate Judge, defendant Unum moved for summary judgment as to plaintiff's original and amended complaint and plaintiff filed a cross-motion for summary judgment. (Docs.6, 14, 24, 48). On March 8, 1996, the District Court denied the parties' cross-motions for summary judgment, finding that genuine issues of fact existed concerning construction of the insurance contract. (Doc. 52). On March 28, 1996, defendant filed an answer to the amended complaint and filed a counterclaim against plaintiff for recoupment. (Doc. 55). Subsequently, both parties moved for reconsideration of the Court's March 8, 1996 Order in light of the...
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