Bilyeu v. Morgan Stanley Long Term Disability Plan

683 F.3d 1083, 2012 WL 2333629, 2012 U.S. App. LEXIS 12554
CourtCourt of Appeals for the Ninth Circuit
DecidedJune 20, 2012
Docket10-16070
StatusPublished
Cited by50 cases

This text of 683 F.3d 1083 (Bilyeu v. Morgan Stanley Long Term Disability Plan) is published on Counsel Stack Legal Research, covering Court of Appeals for the Ninth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Bilyeu v. Morgan Stanley Long Term Disability Plan, 683 F.3d 1083, 2012 WL 2333629, 2012 U.S. App. LEXIS 12554 (9th Cir. 2012).

Opinions

Opinion by Judge FISHER; Partial Concurrence and Partial Dissent by Judge RAWLINSON.

[1086]*1086OPINION

FISHER, Circuit Judge:

Leah A. Bilyeu appeals the district court’s dismissal of her claim challenging the termination of her long-term disability benefits under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1132. Bilyeu also challenges the district court’s grant of summary judgment in favor of First Unum Life Insurance Company (Unum) on Unum’s counterclaim for restitution of overpaid benefits. We have jurisdiction under 28 U.S.C. § 1291, and we vacate and remand.

We vacate the judgment in favor of Unum on Bilyeu’s claim for denial of benefits. We hold that the district court abused its discretion by dismissing this claim for failure to exhaust administrative remedies. The exhaustion requirement should have been excused because Bilyeu acted reasonably in light of Unum’s ambiguous communications and failure to engage in a meaningful dialogue.

We also vacate the judgment in favor of Unum on Unum’s counterclaim for reimbursement of overpaid long-term disability benefits. Unum has not shown that it is seeking equitable relief because it has not satisfied the elements for an equitable lien by agreement, which is the only form of equitable relief Unum has asserted. These elements are not satisfied because the particular fund subject to the lien, having been dissipated, is no longer in Bilyeu’s possession. Unum thus seeks only the imposition of personal liability against Bilyeu, to be paid out of her general assets. That is quintessentially legal, rather than equitable, relief.

I. BACKGROUND

Bilyeu was employed by Discover Financial Services from 1987 through April 2004. Compl. ¶8. Morgan Stanley Long-Term Disability Plan (the Plan) provides benefits for long-term disabilities to Discover employees. Id. ¶¶ 4-5. Unum is the Plan’s claim administrator, and also the insurer and payor of Plan benefits. Id. ¶¶ 6-7.

Alleging she suffered from several medical conditions that prevented her from materially performing the duties of any occupation, Bilyeu filed a long-term disability (LTD) claim with Unum in April 2004. Id. ¶¶ 9-10. These conditions included Behget’s disease, fatigue and anxiety. Id. ¶¶ 12-18; Clerk’s Record 13-2 at 3. Unum approved the claim in October 2004. Compl. ¶ 11. Under the Plan, benefits for disabilities arising from mental illness are limited to 24 months. Id. ¶ 19. Unum concluded that Bilyeu’s disability was subject to the mental illness limitation. Id. Bilyeu disputed that conclusion. Id. ¶¶ 12-20.

Nearing the 24-month deadline, Dr. Sharon Hogan, a medical consultant for Unum, called Bilyeu’s treating physician, Dr. Kenneth Proefrock, to discuss her medical condition. Clerk’s Record 15.1 at 5-7. On December 6, 2006, Dr. Hogan sent a summary of the conversation to Dr. Proefrock, asking him to respond within 10 business days if he believed the letter inaccurately summarized their conversation. Id. at 6. The letter reflected disagreement between Dr. Hogan and Dr. Proefrock regarding the nature of Bilyeu’s limitations. Dr. Hogan believed “Bilyeu’s fatigue in large part arises from her anxiety and depression, since her Behget’s is not very active.” Id. at 6. It was Dr. Proefrock’s opinion, however, “that her fatigue is mainly physical.” Id. Dr. Hogan also believed that Bilyeu “should have full-time sedentary work capacity,” an assessment with which Dr. Proefrock disagreed. Id. at 5; Clerk’s Record 13-2 at 3.

On December 27, 2006, Unum sent Bilyeu a termination of benefits letter. [1087]*1087Clerk’s Record 13-2. Unum terminated benefits under the Plan provision limiting disability benefits due to mental illness to 24 months. Id. at 3. The letter reported that, although “fatigue can result from Behcet’s, ... your anxiety and depression are the more likely causes of your fatigue.” Id. It said, “because your claim is subject to a 24 month mental [illness] limitation and we have now provided 24 months of benefits, we will stop paying benefits on your claim as of December 03, 2006 and your claim will be closed at this time.” Id. at 4. The letter also recorded Unum’s conclusion that “you have full time sedentary work capacity” and thus “no longer meet the definition of disability from a physical perspective.” Id. The letter noted Dr. Proefroek’s contrary determination that Bilyeu was unable to return to work. Id. at 3.

The letter then advised Bilyeu:

If you have additional information to support your request for disability benefits, it must be sent to my attention for further review at the address noted on this letterhead, within 180 days of the date you receive this letter.
However, if you disagree -with our determination and want to appeal this claim decision, you must submit a written appeal. This appeal must be received by us within 180 days of the date you receive this letter.

Id. at 4. The “address noted on this letterhead” was:

First Unum Life Insurance Company
The Benefits Center
PO Box 100158
Columbia, SC 29202-3158
Phone: 1-800-858-8843
Fax: 1-800-447-2498
www.unumprovident.com

Id. at 1.

After receiving Unum’s termination of benefits letter, Bilyeu asked Dr. Proefrock to respond to the letter. Compl. ¶ 22. Dr. Proefrock did so, writing a letter to Unum on April 19, 2007. Id. ¶ 23. Dr. Proefrock’s letter was addressed “To Whom It May Concern” and, it appears, faxed to 1-800^47-2498 — the number listed in the letterhead of Unum’s December 27, 2006 termination of benefits letter as the place to send “additional information to support your request for disability benefits.” Clerk’s Record 15-1 at 2-4.

Unum construed Dr. Proefrock’s letter as “new information,” but concluded that it did not “change [the] prior decision” to terminate benefits. Id. at 9. Unum, however, never communicated this conclusion to Bilyeu or, for that matter, contacted Bilyeu or Dr. Proefrock at all in response to the letter. Compl. ¶ 27.

In November 2008, Bilyeu filed a complaint against Unum, alleging that Unum wrongfully terminated benefits under the 24-month mental illness limitation because “[t]he substantial weight of the medical opinion contained in the claim file reasonably supports a finding that [her] disability is not due to ‘mental illness,’ rather, it is due to an autoimmune condition which was exacerbated by anxiety and mental/emotional stressors in [her] life.” Id. ¶20. The complaint sought a reinstatement of benefits under 29 U.S.C. § 1132(a)(1)(B). Id. at ¶ 44.

Unum filed an answer and a counterclaim. In its counterclaim, Unum sought reimbursement of overpaid long-term disability benefits.

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683 F.3d 1083, 2012 WL 2333629, 2012 U.S. App. LEXIS 12554, Counsel Stack Legal Research, https://law.counselstack.com/opinion/bilyeu-v-morgan-stanley-long-term-disability-plan-ca9-2012.