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White v. Anthem Life Insurance Co.

United States District Court, N.D. California

September 4, 2019




         Pending 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.

         I. BACKGROUND

         Plaintiff 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.

         A. The Plan

         Ms. 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.[1] 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. at 046.

         If 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 required.” Id.

         B. Plaintiff's Coverage Under the Plan

         On 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.[2] Id.

         In 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 below.” Id.

         By 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 review.” Id.

         The 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 passed.”).

         Ms. 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.

         II. ...

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