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McIlhaney v. Anthem Life Insurance Company Long Term Disability Plan

August 9, 2010

MARILYN MCILHANEY, PLAINTIFF(S),
v.
ANTHEM LIFE INSURANCE COMPANY LONG TERM DISABILITY PLAN; ANTHEM LIFE INSURANCE COMPANY LIFE INSURANCE PLAN, ANTHEM LIFE INSURANCE COMPANY IN ITS CAPACITY OF ADMINISTRATOR OF THE ANTHEM LIFE INSURANCE COMPANY LONG TERM DISABILITY PLAN, DEFENDANT(S).



The opinion of the court was delivered by: Christina A. Snyder United States District Judge

FINDINGS OF FACT AND CONCLUSIONS OF LAW

INTRODUCTION

This matter came on for trial to the Court on June 11, 2010. Tracy Collins, of the Law Offices of Tracy Collins appeared for plaintiff Marilyn McIlhaney, and Brian M. Stolzenbach of Seyfarth Shaw LLP appeared for defendants Anthem Life Insurance Company Long Term Disability Plan, Anthem Life Insurance Company Life Insurance Plan, Anthem Life Insurance Company, in its capacity of Administrator of the Anthem Life Insurance Company Long Term Disability Plan.

This case involves two separate claims under the Employee Retirement Income Security Act, 29 U.S.C. 1001, et seq. ("ERISA"). The first is a claim for benefits under an ERISA plan pursuant to Section 502(a)(1)(B) of ERISA, 29 U.S.C. § 1132(a)(1)(B). The second is a claim for monetary penalties under Section 502(c)(1) of ERISA, 29 U.S.C. § 1132(c)(1), for an alleged failure to provide plan documents to a plan participant as required by the statute.

Plaintiff seeks recovery of long term disability benefits and continued life coverage under waiver of the premium under ERISA-governed, self-funded employee benefit plan sponsored by Anthem Insurance Companies, Inc. Although plaintiff was approved for short term disability work after she left work on September 28, 2007, she was denied long term disability benefits.

At issue are four plan documents, a certificate for LTD benefits (AR 1-35), a certificate for life coverage (AR 36-58), a Summary Plan Description ("SPD") for STD (AR 769-782) and an SPD for the Wellpoint Flexible Benefits Plan, which incorporates LTD and life benefits, but not STD (AR 448-480).

FINDINGS OF FACT

I. Plaintiff Marilyn McIlhaney and the WellPoint Flexible Benefits Plan

1. Plaintiff Marilyn McIlhaney was employed by WellPoint as a Senior Project Manager and, as a result of that employment, was a participant in the WellPoint Flexible Benefits Plan ("the Plan").*fn1 (AR 207.)

2. The Plan provides various benefits through various component Benefit Programs, including, among several others, a Long Term Disability (LTD) Benefit Program ("the LTD Program") and an Associate Group Life, Accidental Death/Disability Benefit, and Dependent Life Program ("the Life Program"). (AR 453.) This lawsuit involves claims by plaintiff for LTD benefits and life insurance benefits under the Plan; therefore, only the LTD and Life Programs are relevant to the case.

3. The terms of the LTD and Life Programs are described in separate documents, which (along with descriptions of the various other component benefit programs) are incorporated into the overarching plan document by reference. (AR 453 ["Each of the component Benefit Programs . . . is described in its summary plan description. The summary plan descriptions for the Benefit Programs are incorporated into this Plan and are available on the HR intranet site."]; AR 1-35 [LTD Program summary plan description]; AR 36-58 [Life Program summary plan description].)

4. The LTD Program provides for disability payments to eligible participants beginning only after the individual has been continuously disabled for an "elimination period" of 180 days. (AR 4, 17.)

5. The LTD Program requires a claimant to submit "objective" medical evidence of the cause of her disability and initially defines "disability" as follows: "You are not able to perform some or all of the material and substantial duties of you[r] regular occupation, and you have at least a 20% loss in your pre-disability earnings." (AR 16, 29.) That is, at the outset of the LTD period, the individual need be disabled only from her own occupation to qualify for LTD benefits.

6. The LTD Program further states that the Plan "will continue payment to you beyond 24 months if due to the same sickness or injury . . . [y]ou are not able to perform the material and substantial duties of any gainful occupation. . . . OR . . . while you are not able to perform some or all of the material and substantial duties of your regular occupation, you are working in any occupation and have at least a 20% loss in your pre-disability earnings." (AR 16, 29.) In other words, after the first two years, the individual generally must be disabled from all occupations to continue receiving LTD benefits.

7. In addition, the LTD Program does not pay benefits after 24 months in cases of disability "due to mental illness, substance abuse, or self-reported symptoms." (AR 25.) The Plan states that "[e]xamples of self-reported symptoms include, but are not limited to headaches, pain, [and] fatigue." (AR 26.)

8. The Life Program contains a "waiver of premium" provision that allows a person who is "totally disabled" to continue life insurance coverage under Plan without paying premiums. (AR 46.) A "total disability" for this purpose is defined by the Plan as a "condition which, as certified by a physician . . . is due to an illness or injury [that] prevents the [individual] from performing the material and substantial duties of any occupation for wage or profit." (AR 46.)

9. Unlike disability benefits under the LTD Program, the waiver of premium provision is not capped at two years for mental illnesses or self-reported symptoms. (AR 36-58.)

II. The Plan Administrator

10. Anthem Insurance Companies, Inc. is the Plan Sponsor and Plan Administrator, and it funds the Plan benefits relevant to this lawsuit. (AR 454.)

11. The Plan gives the Plan Administrator "discretionary authority to interpret the Plan in order to make eligibility and benefit determinations as it may determine in its sole discretion. The Plan Administrator also has the discretionary authority to make factual determinations as to whether any individual is entitled to receive any benefits under the Plan." (AR 463.)

12. Anthem Insurance Companies, Inc. has delegated its responsibility for making benefit determinations under the LTD and Life Programs to defendant Anthem Life Insurance Company ("Anthem Life"). (AR 463, 479.) In fact, by the express terms of the Plan, Anthem Life is designated as the "Benefit Program Plan Administrator" for those two aspects of the Plan. (Id.)

III. The Short Term Disability Plan

13. During her employment with WellPoint, plaintiff was also a participant in the WellPoint Short Term Disability Plan ("the STD Plan"), which is completely separate from the WellPoint Flexible Benefits Plan. (AR 448-80; AR 769-82.)

14. The STD Plan provides disability benefits for a maximum of 180 days to participants afflicted by "a condition which renders the [participant] unable to perform substantially all of the normal duties of his or her job." (AR 774, 775.)

15. Decisions on claims for benefits under the STD Plan are made by the Leave of Absence (LOA) Team within WellPoint's Human Resources Department. (AR 771-74, 777; see also, e.g., AR 433-34.)

IV. Plaintiff's Initial Absence and Her Claim for STD Benefits

16. Plaintiff's last day at work was September 28, 2007, after she was diagnosed with Legionnaire's disease, a type of pneumonia (i.e., lung infection) caused by Legionella bacteria. (AR 207, 259.)

17. Plaintiff was initially treated for her pneumonia by pulmonologist Ronald Popper, who saw her in his office on September 27, October 1, 11, and 29, and November 19, 2007. (AR 389-90, 393-96, 407.)

18. Based on information from plaintiff and Dr. Popper, Robin Moody of the WellPoint Human Resources Department initially approved plaintiff for disability benefits under the STD Plan from the day she had left work through November 30, 2007. (AR 399, 410.)

19. Because plaintiff continued to experience an unexplained low-grade fever, Dr. Popper eventually referred plaintiff to infectious disease specialist Jeffrey Galpin, who first saw her for this problem on November 30, 2007. (AR 429.)

20. On December 13, 2007, Moody, who was managing plaintiff's absence from an employee relations perspective as well as a benefits perspective, referred her file to Leave of Absence Clinical Consultant Lynn Vincz, R.N., to "review for [her] thoughts on the [diagnosis] of [Legionnaire's] disease so [Moody could] advise local [human resources]." (AR 412.)

21. On December 18, 2007, Vincz prepared a memorandum for Moody generally discussing the nature of Legionnaire's disease and suggesting that plaintiff's STD benefits be extended from December 1, 2007, until Dr. Galpin cleared her to return to work. (AR 418-19.)

22. On December 27, 2007, Moody approved plaintiff for an extension of disability benefits under the STD Plan ...


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