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Garrison v. Lincoln National Life Insurance Co.

United States District Court, N.D. Alabama, Western Division

February 22, 2018

JASON GARRISON, Plaintiff,
v.
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY, Defendant.

          MEMORANDUM OF OPINION

          L. Scott Coogler United States District Judge

         Before the Court is Defendant, The Lincoln National Life Insurance Company's (“Lincoln”) motion for summary judgment. (Doc. 20.) Plaintiff Jason Garrison (“Garrison”) brings this action pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001 et seq., challenging Defendant Lincoln National Life Insurance Company's (“Lincoln's”) denial of his long-term disability (Count I) and denial of waiver of life insurance premiums (Count II). Defendant's motion has been fully briefed and is ripe for decision. For the reasons stated below, the Motion (doc. 20) is due to be GRANTED.

         I. Background [1]

         Garrison, a 37 year old male, was an employee of Collision Center Payroll, Inc., also known as Joe Hudson's Collision Center (“Collision Center”), as an automobile body technician. As an employee, Garrison was a participant in a welfare benefit plan funded, in part, by group insurance policies issued by Lincoln. Lincoln issued two pertinent insurance policies to the Collision Center, each with an effective date of May 1, 2014: a long-term disability (“LTD”) policy, and a life insurance policy (collectively the “Policies”). See Administrative Record (“AR”) 46, 688.

         A. The Disability Policy

         The Disability Policy provides insurance coverage if an insured employee becomes totally or partially disabled. See AR 49-52. To receive a Total Disability Monthly Benefit under it, the Insured Employee must meet four qualifications:

BENEFIT. [Lincoln] will pay a Total Disability Monthly Benefit to an Insured Employee, after the completion of the Elimination Period, if he or she:
(1) is Totally Disabled;
(2) becomes Disabled while insured for this benefit;
(3) is under the Regular Care of a Physician; and
(4) at his or her own expense, submits proof of continued Total Disability and Physician's care to the Company upon request.

AR 69. In order to determine whether an insured employee has met the first qualification, Lincoln looks to the definition of “Total Disability” or “Totally Disabled” in the Disability Policy:

TOTAL DISABILITY or TOTALLY DISABLED will be defined as follows:
1. During the Elimination Period and Own Occupation Period, it means that due to an Injury or Sickness the Insured Employee is unable to perform each of the Main Duties of his or her Own Occupation.
2. After the Own Occupation Period, it means that due to an Injury or Sickness the Insured Employee is unable to perform each of the Main Duties of any occupation which his or her training, education, or experience will reasonably allow.
The loss of a professional license, an occupational license or certification, or a driver's license for any reason does not, by itself, constitute Total Disability.

AR 56 (emphasis in original). Lincoln looks to the Schedule of Benefits to determine the Elimination Period and Own Occupation Period. See AR 55. Thus, for the duration of the Elimination Period plus Own Occupation Period, Lincoln assesses the Insured Employee's ability to perform the Main Duties of his Own Occupation; thereafter, the question becomes his ability to perform the Main Duties of any occupation for which he is qualified. See AR 56.

         “Main Duties, ” are defined as “job tasks” that “are normally required to perform” the occupation and “could not reasonably be modified or omitted.”[2] AR 54. Main Duties are defined to “include those job tasks: (1) as described in the U.S. Department of Labor Dictionary of Occupational Titles; and (2) as performed in the general labor market and national economy.” Id. The Disability Policy specifically notes that “Main Duties are not limited to those specific job tasks as performed for a certain firm or at a certain work site.” Id. (emphasis original).

         The burden of proving a disability is placed on the employee. See AR 60 (“Proof of claim must be provided at the Insured Employee's own expense” and “must show the date the Disability began, its cause and degree.”). Among other items, such proof must include “a completed statement by the attending Physician” describing the Insured Employee's medical restrictions and “any other items [Lincoln] may reasonably require.” Id. Insured Employees are also required to provide proof of “continued Disability” within 45 days of Lincoln's request for it. Id.

         In determining the validity of a claim, like in other administrative and interpretative functions, Lincoln is endowed with broad discretionary authority:

COMPANY'S DISCRETIONARY AUTHORITY. Except for the functions that this Policy clearly reserves to the Policyholder or Employer, [Lincoln] has the authority to manage this Policy, interpret its provisions, administer claims and resolve questions arising under it. [Lincoln]'s authority includes (but is not limited to) the right to:
(1) establish administrative procedures, determine eligibility and resolve claims questions;
(2) determine what information [Lincoln] reasonably requires to make such decisions; and
(3) resolve all matters when an internal claim review is requested. Any decision [Lincoln] makes, in the exercise of its authority, shall be conclusive and binding; subject to the Insured Employee's rights to request a state insurance department review or to bring legal action.

AR 62. In the event that Lincoln denies a claim, it provides written notice to the insured of the reasons for the denial, and the right to appeal. See AR 61. The policy includes an explicit requirement that, “[b]efore bringing a civil legal action under the federal labor law known as ERISA, . . . the plan participant or beneficiary must first seek two administrative reviews of the adverse claim decision.” AR 62 (emphasis added). Garrison was an Insured Employee under the Disability Policy and was subject to a 180-day Elimination Period followed by a 24-month Own Occupation Period. See AR 1, 50. Under the Policy, where all other conditions are met, Long-Term Disability Benefits for a Total Disability qualify an Insured Employee to receive 60% of his prior monthly salary, with a maximum of $6, 000 per month. See Id. Where all of the above conditions were met and Garrison showed a Total Disability, he qualified for a monthly benefit of $4, 250. See AR 1.

         B. The Life Insurance Policy

         The Life Insurance Policy provides voluntary life insurance coverage for employees and dependents. See AR 692-94. Under the “EXTENSION OF DEATH BENEFIT” provision:

         Life insurance will be continued, without payment of premiums, for an Insured Person who:

(1) becomes Totally Disabled while insured under this policy and before reaching age 60;
(2) remains Totally Disabled for at least 6 months in a row; and
(3) submits satisfactory proof within the 7th through 12th months of disability; or
(a) as soon as reasonably possible after that; but
(b) not later than the 24th month of disability, unless he or she was legally incapacitated.

AR 707 (emphasis in original). Where these qualifications are met, the Insured Employee's life insurance, and any for his dependents, will be continued in the amount that was in effect on the day the Total Disability began. See Id. For purposes of determining eligibility for the Extension of Death Benefit, the Life Insurance Policy defines “Total Disability or Totally Disabled” as “mean[ing] an Insured Person” who:

(1) is unable, due to sickness or injury, to engage in any employment or occupation for which such Insured Person is or becomes qualified by reason of education, training, or experience; and
(2) is not engaging in any gainful employment or occupation.

Id. (emphasis added). Lincoln may require “the Insured Person . . . to submit further proof of his or her continued Total Disability” at his own expense. Id. The “life insurance extended under this section . . . terminate[s] automatically on . . . the day the Insured Person ceases to be Totally Disabled.” Id. Akin to the Disability Policy, the Life Insurance Policy gives Lincoln broad discretionary authority in determining whether a person is eligible for the Extension of Death Benefit, as well as other administrative and interpretative functions, by providing:

COMPANY'S DISCRETIONARY AUTHORITY. Except for the functions that this Policy clearly reserves to the Group Policyholder or Employer, [Lincoln] has the authority to:
(1) manage this Policy and administer claims under it; and
(2) interpret the provisions and resolve questions arising under this Policy.
[Lincoln]'s authority includes (but is not limited to) the right to:
(1) establish and enforce procedures for administering this Policy and administer claims under it;
(2) determine Employees' eligibility for insurance and entitlement to benefits;
(3) determine what information [Lincoln] reasonably requires to make ...

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