Arnone v. Aetna Life Insurance Co.

860 F.3d 97, 2017 WL 2675293, 2017 U.S. App. LEXIS 11055
CourtCourt of Appeals for the Second Circuit
DecidedJune 22, 2017
DocketDocket No. 15-2322
StatusPublished
Cited by27 cases

This text of 860 F.3d 97 (Arnone v. Aetna Life Insurance Co.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Second Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Arnone v. Aetna Life Insurance Co., 860 F.3d 97, 2017 WL 2675293, 2017 U.S. App. LEXIS 11055 (2d Cir. 2017).

Opinion

SUSAN L. CARNEY, Circuit Judge:

Section 5-335 of the New York General Obligations Law provides that personal injury settlements “shall be conclusively presumed” not to include “any compensation for the cost of health care services, loss of earnings or other economic loss[es]” that “have been or are obligated to be paid or reimbursed by an insurer.” N.Y. Gen. Oblig. Law § 5-335(a). When section 5-335 is applied, it effectively bars an insurer from reducing the benefits owed to an insured by the amounts the insured receives from a personal injury [100]*100settlement.1 In this appeal, we consider whether section 5-335 applies to payments made in settlement of a personal injury suit brought in a New York court by a New York resident injured in New York, even though the governing benefit plan provides that the law of a state other than New York controls the plan’s construction.

In brief summary, appellant Salvatore Arnone, a New York resident, sustained serious injuries while working in New York at the site of a customer of his employer. He filed for, and received, long-term disability benefits related to the injury through his employer’s benefit plan (the “Plan”), which was governed by the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et seq. Aetna Life Insurance Company (“Aetna”), a Connecticut company and national insurer that is registered to do business in New York, is both the Plan’s insurer and its claims administrator.

Arnone brought a personal injury suit in New York state court against his employer’s customer and settled the suit for $850,000. In light of the settlement, Aetna reduced Arnone’s disability benefits by a portion of the settlement proceeds. Taking the position that the settlement included compensation duplicative of Arnone’s disability benefits and citing a Plan provision regarding offsetting payments from other sources, Aetna maintained that the Plan permitted it to reduce its benefit payment obligation.

Arnone sued Aetna to recover the offset benefits. In moving for summary judgment, he invoked section 5-335. The District Court (Feuerstein, J.) denied Ar-none’s motion, reasoning that section 5-335 had no bearing on the amount of Arnone’s benefit entitlement in light of the Plan’s choice of law provision designating Connecticut law as controlling the Plan’s construction. Arnone appeals this determination. Aetna defends the District Court’s reasoning, and further argues that ERISA preempts section 5-335 as an impermissible state regulation of the Plan. Aetna also contends that Arnone forfeited his right to invoke section 5-335 in this lawsuit by fading to rely on it during Aetna’s claims administration process.

We conclude that, when applied, section 5-335 prohibits Aetna’s reduction in Ar-none’s disability benefits. We further decide that neither ERISA’s preemptive force nor the Plan’s choice of law provision compels a different conclusion. We also reject Aetna’s issue forfeiture argument. Thus, as to Arnone’s entitlement to the past and ongoing benefits that Aetna has withheld on the ground that they are du-plicative of Arnone’s personal injury settlement, the District Court erred in granting Aetna’s motion for summary judgment and denying Arnone’s motion for summary judgment. Arnone is entitled to the unpaid benefits. For these reasons, the District Court’s judgment is REVERSED IN PART, as to that issue, and the cause is REMANDED for the entry of a revised judgment consistent with this opinion.

BACKGROUND

The facts set forth here are undisputed. Arnone is a former account executive for Konica Minolta Business Solutions U.S.A., Inc. (“Konica”) who worked out of Konica’s office in Melville, New York. In June 2009, Arnone was working at the site of one of Konica’s customers, Meopta U.S.A., Inc. (“Meopta”), in Hauppauge, New York, when he slipped in a puddle of water and [101]*101fell about four feet, hitting his head, lower back, and neck on a cinder block wall. Arnone reported that, as a result of the fall, he experienced pain, limitations in the range of motion in his cervical and lumbar spine, radiculopathy,2 and difficulty sitting or standing for prolonged periods. Several months after the fall, Arnone returned to work, but in December 2009 he stopped working—this time permanently—because of his injuries.

Konica had established for its employees a group long-term disability plan (the “Plan”) that qualified as an employee welfare benefit plan under ERISA. Konica had also purchased from Aetna a group insurance policy designed to allow Konica to fund benefits under the Plan and engaged Aetna as the Plan’s claims administrator. Arnone was a Plan participant.

Under ERISA, “benefits plans must be ‘established and maintained pursuant to a written instrument.’” M & G Polymers USA, LLC v. Tackett, — U.S.-, 135 S.Ct. 926, 933, 190 L.Ed.2d 809 (2015) (quoting 29 U.S.C. § 1102 (a)(1)). We understand the parties to agree that the written terms of the Plan comprise the insurance policy issued by Aetna to Konica, Joint App’x (“J.A.”) 91-123, the “Booklet” apparently issued to employees as their “Certificate of Coverage,” J.A. 124-42, and the “Summary of Coverage” document accompanying it, J.A. 143-52. We accept the parties’ characterization for present purposes. See, e.g., Gibbs ex rel. Estate of Gibbs v. CIGNA Corp., 440 F.3d 571, 573 (2d Cir. 2006) (determining that the terms of a plan were expressed in an employer’s plan description and an insurer’s policy materials); Ruiz v. Cont’l Cas. Co., 400 F.3d 986, 990-91 (7th Cir. 2005) (collecting cases and holding that an employer’s disability insurance policy, together with certificates issued to employees, constituted ERISA plan documents).

The Plan provides that the amount of a participant’s long-term disability benefit payment is a function of, amohg other factors, the number that is 60 percent of the individual’s “monthly predisability earnings,” reduced by “other income benefits” due from other sources. J.A. 125, 145. It defines “other income benefits” to include “[disability, retirement, or unemployment benefits required or provided for under any law of a government.” J.A. 127. This category encompasses, for example:

disability benefits under any state or federal workers’ compensation law or any other like law, which are meant to compensate the worker for any one or more of the following: loss of past and future wages; impaired earning capacity; lessened ability to compete in the open labor market; any degree of permanent impairment; and any degree of loss of bodily function or capacity.

J.A. 127-28. The list of “other income benefits” also includes “[disability payments which result from the act or omission of any person whose action caused [the Plan participant’s] disability.” J.A. 128. In contrast, the term “other income benefits” does not include disability benefits being received from particular enumerated sources before the date of disability under the Plan, or from “individual disability income policies” or “severance pay.” J.A. 129. ■

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Bluebook (online)
860 F.3d 97, 2017 WL 2675293, 2017 U.S. App. LEXIS 11055, Counsel Stack Legal Research, https://law.counselstack.com/opinion/arnone-v-aetna-life-insurance-co-ca2-2017.