United States District Court, N.D. California
ORDER GRANTING DEFENDANT'S MOTION FOR SUMMARY
JUDGMENT RE: DKT. NOS. 32, 37
HAYWOOD S GILLIAM JR., UNITED STATES DISTRICT JUDGE.
before the Court are the parties' motions for summary
judgment. Dkt. Nos. 32, 37. The Court held a hearing on the
motions on June 27, 2019. Dkt. No. 46. Having considered the
parties' arguments, the Court GRANTS
Defendant's motion for summary judgment and
DENIES AS MOOT Plaintiff's cross motion
for summary judgment.
Patricia White filed this Employee Retirement Income Security
Act of 1974 (“ERISA”) action on March 29, 2018
against Defendants Anthem Life Insurance Company
(“Anthem”), Merced Systems, Inc. (“Merced
Systems”), and Merced Systems Health and Welfare Plan.
Dkt. No. 1 (“Compl.”). Ms. White voluntarily
dismissed Defendants Merced Systems and Merced Systems Health
and Welfare Plan on January 23, 2019, making Anthem the only
remaining Defendant. Dkt. No. 31.
White was a participant in Merced System's employee
welfare plan, governed by ERISA and issued by Anthem (the
“Plan”). Dkt. No. 37-1, Declaration of Zanita
Miller (“Miller Decl.”) ¶ 3. The Plan
provides benefits for qualifying long-term injuries and/or
illnesses. Dkt. No. 37-2, Ex. A at 023. As outlined in
the “Anthem Life Group Long Term Disability Insurance
Benefits Guide” (“Plan Guidelines”), when
submitting a claim for benefits, a participant must include a
“Written Proof of Disability or other loss” which
should have information from a participant's physician
about the participant's medical conditions. Id.
Anthem denies a benefits claim, a participant may appeal by
sending a request “in writing . . . no more than 180
days after You receive notice of Our claim decision.”
Id. at 048. Anthem will advise a beneficiary of its
determination within forty-five days after it receives a
participant's request for review. Id. Its
decision will be in writing and will include a notice to the
participant of her right to bring a civil action.
Id. Per the Plan Guidelines, a participant may only
commence “[l]egal action with respect to a claim that
has been denied, in whole or in part, ” after she has
obtained Anthem's “reconsideration of that
claim.” Id. Legal action cannot be taken
“more than 3 years after Written Proof of loss was
Plaintiff's Coverage Under the Plan
October 11, 2012, in a written letter to Ms. White, Anthem
approved her long-term disability benefits claim after
determining that her condition met the qualifying definition
of disability under the Plan. Dkt. No. 37-3, Ex. B at 004.
The letter informed Ms. White that her long-term disability
coverage became payable on April 2, 2012, and would expire
after twenty-four months, on April 2, 2014, after which she
would have to prove that she was “unable to perform any
occupation for which you are qualified by your education,
training, or experience” to continue receiving
long-term disability benefits. Id.
March 2014, Ms. White made a request to continue her
long-term disability benefits. See Dkt. No. 36 at
¶ 851. Before receiving any determination from Anthem,
Plaintiff's counsel sent a letter dated September 25,
2014 to Anthem, requesting that Anthem “inform me
immediately of the status of Ms. White's benefits
claim” and provide a copy of the claim file and other
requested documentation. Id. Plaintiff's counsel
also “reserve[d] Ms. White's rights under ERISA and
the benefits plan to appeal, in the event that Anthem has
made any adverse determination.” Id.
Plaintiff's counsel made clear that the letter was
“(obviously) not a full statement of her appeal,
” and said that Ms. White “will be able to make
and support that full statement of her appeal only after we
have received the claim file and information requested
letter dated October 1, 2014, Anthem denied Ms. White's
request for disability benefits beyond the two-year period.
Dkt. No. 33 at ¶ 189-93. The letter explained that
Anthem carefully reviewed her medical information and
determined that based on a “complete review of the
medical documentation, ” Ms. White had the capacity to
perform “gainful sedentary work” and therefore
did not meet the Plan's definition “of disability
beyond 24 months.” Id. at 190-92. In the
letter, Anthem also reiterated the procedures Ms. White had
to follow if she wished to appeal Anthem's decision.
Id. at 192. Specifically, Ms. White had “180
days [from] receipt of this letter” to file an appeal
in writing, and had the right to bring an “action in
federal court under ERISA Section 502(a) if you file an
appeal and your request for benefits is denied following our
parties do not dispute that Ms. White did not appeal
Anthem's decision denying her continuing long-term
benefits after receiving Anthem's October 1, 2014 letter.
On April 30, 2015, in response to an April 22, 2015 letter
from Plaintiff's counsel requesting an explanation of
what was needed to “perfect” Ms. White's
claim, Anthem informed Ms. White that the period for appeal
had passed. Dkt. No. 37-3, Ex. B at 007 (“The [October
1, 2014] letter also advised that Ms. White had 180 days,
from receipt of the letter, to submit an appeal if she
disagreed with the claim decision. This period has now
White brought this action seeking review of Anthem's
denial of her continuing long-term disability benefits.
See Compl. ¶ 1. She alleges three causes of
action: (1) benefits due under the Plan pursuant to ERISA
Section 502(a)(1)(B); (2) breach of fiduciary duties under
ERISA; and (3) statutory penalties under ERISA Section
502(a)(1)(A). See Id. ¶¶ 3-17.