Barnes v. UNUM Life Insurance Co. of America

621 F. Supp. 2d 1097, 2009 U.S. Dist. LEXIS 47979, 2009 WL 1574421
CourtDistrict Court, D. Oregon
DecidedJune 4, 2009
DocketCivil Case 04-1203-KI
StatusPublished
Cited by3 cases

This text of 621 F. Supp. 2d 1097 (Barnes v. UNUM Life Insurance Co. of America) is published on Counsel Stack Legal Research, covering District Court, D. Oregon primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Barnes v. UNUM Life Insurance Co. of America, 621 F. Supp. 2d 1097, 2009 U.S. Dist. LEXIS 47979, 2009 WL 1574421 (D. Or. 2009).

Opinion

OPINION AND ORDER

KING, District Judge:

Plaintiff Fred Barnes seeks to recover disability benefits from defendant Unum Life Insurance Company of America (“Unum”). Before the court is plaintiffs Motion for Summary Judgment (# 47) and defendant’s Motion for Summary Judgment (# 58).

Plaintiff asserts he is entitled to Long Term Disability (“LTD”) benefits from March 29, 2002, the date his benefits were due but not paid, through the date of judgment, and that he is entitled to continue to receive a monthly LTD benefit so long as he remains disabled.

For the following reasons, I deny plaintiffs motion and grant defendant’s motion.

FACTUAL BACKGROUND

Plaintiff was employed by Leed Electric, Inc. (“Leed”) and is a beneficiary under the NECA Members’ Group Long Term *1100 Disability Plan (the “Plan”), 1 a policy insured by Unum.

Plaintiff was diagnosed in 1999 with liposarcoma, a cancer of deep soft tissue, of the right thigh. Plaintiff underwent a surgical resection, radiation therapy and chemotherapy. He continued to work during this time.

Plaintiff stopped working at Leed on May 1, 2001. By this time, he was the vice president of the company. Leed paid plaintiff sick pay until December 28, 2001. At some point in 2001, plaintiff moved to Grants Pass. He may have moved as early as February 2001 because, in a clinic note at that time, one of plaintiffs doctors indicated that plaintiff “is to followup with a primary care physician down closer to home in Grants Pass.” Deck of Megan Glor, Ex. B at 23 (hereinafter, “Ex. B”). In any event, plaintiff had moved to Grants Pass by July 2001. He asserts it was not a permanent move until the fall of 2001. Darlene Duran, in charge of payroll at Leed, stated that plaintiff attempted to return to work in August 2001 but that he was unable to finish the estimates or concentrate on his work because of his medical problems. Plaintiff says he moved so that his wife and children could be close to family if he did not recover and so that the family could care for his ill father-in-law.

Plaintiff assumed ownership of his father-in-law’s auto parts business in Grants Pass. He stated he has never been an employee of the business, but that he was an investor and that he worked approximately ten hours per month securing financing and signing documents. There is evidence he worked more hours than he reported. In the summer of 2002, for example, he told Susan Wrona-Sexton, the psychiatric mental health nurse practitioner who treated plaintiff, that he was “beginning to engage in his old habits of getting deeply into the business and working excess hours” and that he was busy with the business which is why he had not completed disability papers. Id. at 197, 222. They discussed his going to work later or taking time off in the afternoon and closing the business on Sundays so that he would have a day to himself. Id. at 256. In October, plaintiff informed Wrona-Sexton that the business had hired another person so he could decrease the “excessive time he needs to be there.” Id. at 259.

Plaintiff applied for LTD benefits under the Plan on April 23, 2002, alleging that he had been unable to work due to liposarcoma. The Plan defines a disability as follows: “You are disabled when Unum determines that: you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury.” Deck of Megan Glor, Ex. A at 15 (bold in original) (hereinafter, “Ex. A”).

Once LTD benefits have been paid for 24 months, the insured is entitled to benefits if he is unable to “perform the duties of any gainful occupation” for which he is “reasonably fitted by education, training or experience.” Id. at 15. “Gainful occupation” is defined, in relevant part, to be “an occupation that is or can be expected to provide you with an income within 12 months of your return to work, that exceeds 60% of your indexed monthly earnings ....” Id. at 38.

In a telephone call with Unum on May 31, 2002, plaintiff described his disabling *1101 condition as an inability to climb or handle rough terrain and stairs; he explained that he had stopped working in the fall of 2001. He also informed Unum that no doctor had suggested he stop working.

On July 31, 2002, Unum notified plaintiff by telephone and letter that it had denied his claim, but that he could appeal within 180 days of the date he received the denial letter. Unum did not send the letter by any means that could be tracked and plaintiff does not remember when he received the letter.

Plaintiff also applied for a waiver of his life insurance premium, which Unum denied on August 8, 2002.

Plaintiff appealed both decisions (denial of LTD benefits and denial of application for waiver of life insurance premium) on February 7, 2003. His appeal of the LTD benefits denial was submitted 191 days after Unum sent its denial letter to plaintiff. Unum notified plaintiff in a letter dated March 28, 2003 that this appeal was untimely. Plaintiff also appealed Unum’s denial of his waiver of life insurance premium claim and that appeal was timely. Unum evaluated that claim on the merits and upheld the denial.

Plaintiff asked for reconsideration of the LTD benefits claim denial on September 2, 2003. On September 16, 2003, Unum explained that “[i]n calculating the time in which to appeal a decision, we add an additional ten days, which is [a] sufficient amount of time for an Insured to receive correspondence____ [T]he appeal was received more than 190 days from the letter dated July 31, 2002, which is beyond the allotted timeframe. [W]e are upholding our prior decision to deny reconsideration of Mr. Barnes’ [LTD] claim.” Ex. B at 394.

In November 2003, Unum entered into a Regulatory Settlement Agreement (“RSA”) with the Department of Labor. Pursuant to the terms of the RSA, Unum offered to reassess plaintiffs claim and plaintiff accepted that offer. Unum reviewed plaintiffs entire file.

During the reassessment pursuant to the RSA, the instant action was stayed.

On July 13, 2007, Unum denied plaintiffs claim. Unum explained that, “in order to be eligible for coverage, an employee must be actively at work and working a minimum of 30 hours per week. As Mr. Barnes stopped working at Leed Electric on 5/1/01, he would no longer be considered an active employee and his coverage would end at that time, unless he is considered disabled under the policy.” Id. at 986.

The remainder of the denial letter reads in pertinent part as follows:

Mr. Barnes would have to be considered disabled as of 5/1/01 in order to be eligible for benefits. A review of the medical records has demonstrated that, subsequent to his surgery for liposarcoma in 1999, Mr. Barnes continued to be active and continued to function in his capacity as Manager/Estimator/Vice President at Leed Electric. He subsequently took himself out of work on 5/1/01 without certification of disability by a physician.

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Related

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215 F. Supp. 3d 942 (C.D. California, 2016)
Holifield v. Unum Life Insurance Co. of America
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640 F. Supp. 2d 1224 (C.D. California, 2009)

Cite This Page — Counsel Stack

Bluebook (online)
621 F. Supp. 2d 1097, 2009 U.S. Dist. LEXIS 47979, 2009 WL 1574421, Counsel Stack Legal Research, https://law.counselstack.com/opinion/barnes-v-unum-life-insurance-co-of-america-ord-2009.