United States District Court, N.D. Alabama, Eastern Division
E. OTT, CHIEF UNITED STATES MAGISTRATE JUDGE
action, Plaintiff Joey Horton (“Horton”) brings a
claim pursuant to the Employee Retirement Income Security Act
of 1974 (“ERISA”), 29 U.S.C. § 1001 et
seq., challenging Defendant United of Omaha Life
Insurance Company's (“United of Omaha”)
denial of his long-term disability and continuation of life
insurance benefits claims. (Doc. 1, ¶ 2
(“Complaint or “Compl.”)). United of Omaha
contends that Horton did not timely exhaust his
administrative remedies as to its “final determination
that he was no longer disabled under the terms of the
applicable long-term disability policy” prior to filing
this case. (Doc. 31 at 1; See also
Doc.32). On that basis, United of Omaha asks the
court to enter judgment in its favor on its motion for
summary judgment. (Doc. 32). For the reasons set forth below,
the court finds the defendant's motion for summary
judgment is due to be granted.
years, Horton, a 55-year old man, worked as a quality
engineer at American Furuwaka, Inc. (Doc. 1, ¶ 6). He
installed and repaired machinery and equipment for the
company. (Id.). Horton suffers from “coronary
artery disease, congestive heart failure, high cholesterol,
dyslipidemia, hypertension, diabetes mellitus type II,
peripheral neuropathy, joint pain, degenerative disc disease,
chronic back pain, and depression.” (Doc. 36-1, ¶
3). According to Horton, he “take[s] medications that
affect [his] everyday living and [his] ability to
function.” (Id., ¶ 4). Horton claims that
his “disabilities force[d] him to stop working”
at the company as of March 25, 2011. (Doc. 1, ¶ 6). And
since that time, Horton maintains that he has been
“critically ill, ” “hospitalized numerous
times.” (Doc. 36-1, ¶¶ 5-6).
American Furuwaka employee, Horton participated in the
company's employee welfare benefit plan (the
“Plan”). (Doc. 30-4, pp. 173-74). United of Omaha
administered the Plan. (Doc. 1, ¶ 2; Doc. 32, ¶
The Plan provided Horton with short-term disability
(“STD”); long-term disability
(“LTD”); life and accidental death and
dismemberment insurance (“LADD”); and voluntary
term life insurance (“VTLP”). (Docs. 30-2; 30-7;
30-16 & 17; 30-19; 40-1). Each policy of the Plan sets
forth its coverage terms, as well as procedures for appealing
adverse benefit determinations. (Docs. 30-2; 30-7; 30-16
& 17; 30-19; 40-1). For instance, under the STD and LTD
policies, an insured must “appeal within 180 days
following [the] receipt of notification of an Adverse Benefit
Determination.” (Doc. 30-2, p. 24; Doc. 30-7, p. 32).
According to United of Omaha, if an insured does not appeal
an adverse benefits determination within United of
Omaha's allotted timeframe, barring special
circumstances, that decision is final and binding. (Doc.
30-9, p. 3).
Termination of STD and LTD Benefits
long after Horton stopped working at American Fukuwara,
United of Omaha approved Horton's application for STD
benefits. (Doc. 30-4, pp. 173-176).From April 2, 2011 to
September 30, 2011, United of Omaha paid Horton $600.93 per
week in STD benefits. (Doc. 30-4, pp. 3-5, 7). But pursuant
to the Plan, after United of Omaha pays an insured STD
benefits for 26 weeks, an STD claim converts into an LTD
claim. (Doc. 30-2, pp. 4, 11; Doc. 30-4, pp. 3-5). On October
1, 2011, Horton's STD claim converted into an LTD claim.
(Doc. 30-4, pp. 3-5; Doc. 30-12, pp. 1-2; Doc. 30-11, p. 74).
United of Omaha assigned Horton LTD claim number
“111020007802.” (Doc. 1-2, p. 2; Doc. 12, pp.
1-2; Doc. 30-9, p. 26).
paying monthly LTD benefits to an insured for two years,
under the LTD policy, United of Omaha will continue extending
LTD benefits only if the insured is “disabled.”
(Doc. 30-7, p. 39). That is, an insured must be “unable
to perform all the [m]aterial [d]uties of any [g]ainful
[o]ccupation.” (Doc. 30-7, p. 39). On November 15,
2013, after disbursing $833.01 per month in LTD benefits for
two years to Horton, United of Omaha notified Horton by
letter that it was terminating his LTD benefits. (Doc. 1-2;
Doc. 30-9, pp. 26-31). In that letter, United of Omaha
provided the LTD policy number and Horton's LTD claim
number. (Doc. 1-2; Doc. 30-9, p. 26). Based on Horton's
more recent medical records, United of Omaha determined that
Horton was not disabled, as defined by the LTD policy. (Doc.
30-9, pp. 26-31). United of Omaha advised Horton not only of
his right to appeal, but also the steps to do so. (Doc. 30-9,
p. 30). In particular, United of Omaha's November 15,
2013 letter warned Horton that if it did not “receive
[Horton's] appeal within 180 days from the date [he]
received t[he] [November 15, 2013] letter, ” the
termination of his LTD benefits would be final. (Doc. 30-9,
Life Insurance Benefits
United of Omaha reviewed Horton's LTD claim, it
considered simultaneously Horton's life waiver of premium
benefits (“LWOP” or “life insurance
benefits”) claim under the Life Policies. (Doc. 30-21,
p. 30). At first, United of Omaha determined that Horton
qualified for a LWOP. (Doc. 32, ¶ 15). But in a March
19, 2013 letter, United of Omaha reversed that determination,
concluding that Horton “no longer qualified for waiver
of premium coverage based on the any occupation provisions of
the policy.” (Doc. 30-21, pp. 42-45). In other words,
because Horton could “perform the physical and mental
demands of a sedentary occupation” and was not
“totally disabled, ” pursuant to the Life
Policies, Horton was no longer eligible to receive life
insurance benefits. (Id., p. 42). As with the
November 15, 2013 LTD benefits termination letter, the March
19, 2013 LWOP termination letter informed Horton how to
appeal United of Omaha's decision. (Id. pp.
43-44). The letter also listed in the subject line the Life
Policies and Horton's LWOP claim number. (Id.,
April 22, 2013, Horton appealed United of Omaha's adverse
LWOP determination, citing to the Life Policies' numbers.
(Doc. 30-21, p. 36). The subject line says, “Appeal the
Denial of Life Insurance, ” and the first line of
Horton's appeal states, “Please accept this as my
appeal to the life insurance denial from Mutual of Omaha Life
Insurance Company!” (Doc. 30-21, p. 36). On May 3,
2013, referencing the Life Policies and Horton's LWOP
claim number, United of Omaha acknowledged receipt of
Horton's LWOP appeal. (Doc. 30-21, p. 65). On December
10, 2013, Omaha upheld its denial of his LWOP claim. (Doc.
1-3, pp. 2- 4). The letter references Horton's LWOP claim
number; and the first line of the letter states that it
concerns Horton's “appeal for continuation of life
insurance benefits.” (Id., p. 2). The letter
concluded that the medical evidence in Horton's claim
file did not support disability under the Life Policies and
that the denial of LWOP benefits determination was final.
(Id., p. 4). The letter informed Horton that he had
exhausted his administrative remedies with regard to his LWOP
benefits and that Horton had “the right to bring a
civil action suit.” (Id.).
contends that when he received United of Omaha's December
10, 2013 final decision letter relating to the Life Policies,
he believed “that [the letter] related to all his
claims with Omaha, ” including his STD and LTD claims.
(Doc. 35, p. 6). Horton states that he was “critically
ill” and “frequently” hospitalized in 2013
and 2014, and that he was taking medication that affected his
cognitive abilities as well as his memory, which, Horton
alleges, affected his ability to appeal and impaired his
reading comprehension. (Doc. 36-1, ¶¶ 4-6).
alleges that he retained legal counsel to pursue his LTD
benefits shortly after being released from the hospital.
(Doc. 35, pp. 6, 22-23). On August 22, 2014, Horton, through
counsel, wrote to United of Omaha. (Doc. 30-21, pp. 7- 9). In
the subject line of that letter, it is undisputed that
counsel for Horton referenced the Life Policies and
Horton's LWOP claim number. (Doc. 1-4, p. 2; Doc. 30-21,
p. 7). Counsel wrote that her firm had “been retained
to represent Mr. Horton in his claim for disability
benefits.” (Doc. 1-4, p. 2). Horton sought “a
copy of any Plan document that govern[s] [his] claim and all
other documents that [Horton] must be furnished pursuant to a
request under 29 U.S.C. §
1024(b)(4).”(Doc. 1-4, p. 2). In addition, Horton's
August 22, 2014 inquiry requested that United of Omaha
confirm whether Horton “has exhausted all
administrative rights to appeal.” (Id., p. 2).
Furthermore, in the accompanying privacy release to the
August 22, 2014 letter, although Horton cited to the Life
Policies and his LWOP claim number, Horton wrote that he was
“seeking a reassessment of my claim for Long Term
Disability benefits.” (Doc. 1-4, p. 4; Doc. 30-21, p.
September 15, 2014, United of Omaha responded to Horton's
August 22, 2014 letter, “providing information only for
[Horton's] waiver of premium claims.”
1-5; Doc. 35, pp. 6-7; Doc. 30-21, pp. 4-6). That letter also
confirmed that Horton had exhausted his appeal rights with
respect to the Life Policies. (Doc. 32, pp. 10-11; Doc. 35,
pp. 6-7; Doc. 30-21, pp. 4-6). But as with the subject line
of Horton's August 22, 2014 letter, the reference line in
Omaha's September 15, 2014 response letter dealt only
with Horton's Life Policies and Horton's LWOP claim
number. (Doc. 1-5; Doc. 30-21, pp. 4-6). The September 15,
2014 letter did not discuss Horton's STD or LTD policies.
(Doc. 1-5; Doc. 30-21, pp. 4-6).
Appeal of LTD Benefits
March 10, 2015, Horton appealed United of Omaha's
termination of his LTD benefits. (Doc. 1-6; Doc. 30-9, pp.
9-10). In the subject line of Horton's letter, he
referenced the LTD disability policy as well as his LTD
policy number. (Doc. 1-6; Doc. 30-9, p. 9). Horton stated
that, on December 10, 2013, while he received information
related to the Life Policies, he did not receive information
pertaining to his LTD claim. (Doc. 1-6; Doc. 30-9, p. 9).
Horton also said that he had “previously requested that
Mutual of Omaha clarify [Horton's] appeal rights on his
disability claim.” (Doc. 1-6; Doc. 30-9, p. 9).
“[G]iven the apparent confusion, ” Horton
requested copies of his ...