Dames v. Paul Revere Life Insurance

49 F. Supp. 2d 1194, 1999 U.S. Dist. LEXIS 10223, 1999 WL 458775
CourtDistrict Court, D. Oregon
DecidedJune 15, 1999
DocketCV-98-1397-ST
StatusPublished
Cited by3 cases

This text of 49 F. Supp. 2d 1194 (Dames v. Paul Revere Life Insurance) 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
Dames v. Paul Revere Life Insurance, 49 F. Supp. 2d 1194, 1999 U.S. Dist. LEXIS 10223, 1999 WL 458775 (D. Or. 1999).

Opinion

OPINION

STEWART, United States Magistrate Judge:

INTRODUCTION

Plaintiff, Diane Dames (“Dames”), brings this action under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 USC §§ 1001-1461, to recover long-term disability benefits under a group disability plan sponsored by Dames’ former employer, Imagebuilder Software, Inc. (“Imagebuilder”). Defendant, The Paul Revere Life Insurance Company (“Paul Revere”), is the claims administrator of the policy. Paul Revere stopped paying disability benefits to Dames because of a 24-month limitation on benefits for psychiatric disorders. Dames contends that she does not have a psychiatric disorder but instead has a physical illness, fi-bromyalgia, entitling her to continued benefits.

This court has federal question jurisdiction over the ERISA claims under 28 USC § 1331. All parties have consented to allow a Magistrate Judge to enter final orders and judgment in this case in accordance with FRCP 73 and 28 USC § 636(c). Now before the court is Paul Revere’s partial motion for summary judgment (docket # 19) on the issue of the proper standard of review. For the reasons set forth below, the court will review Paul Revere’s claim decision under the arbitrary and capricious standard.

UNDISPUTED FACTS

I. Dames’ Claim

Dames worked as an office manager at Imagebuilder from November 11, 1993 until November 16, 1995. In August 1995, Dames claimed that she was totally disabled due to depression. In October 1995, Paul Revere began paying Dames long-term disability benefits under “Other Limitations” provision of the group disability policy between Paul Revere and Image-builder effective January 1, 1992 (“1992 policy”). This provision states: “[f]or any disability which is caused or contributed to by a psychiatric disorder ..., benefits are payable for up to twenty-four months whether or not [the participant is] hospital confined.” Plaintiffs Exhibit (“Ex”) A, p. 17.

On October 13, 1997, Dr. Gary L. Sulta-ny, M.D., examined Dames and diagnosed her as having fibromyalgia, commenting that: “She does qualify for the usual criteria.” Plaintiffs Ex B, p. 2.

On October 30, 1997, Dames saw Dr. Andre Barkhuizen, M.D. “searching for information regarding fibromyalgia and treatment of this condition.” Plaintiffs Ex C, p. 1. After an examination, Dr. Bark-huizen “educated the patient regarding the pathogenesis of fibromyalgia.” Id at 3.

The 24-month benefit period expired on October 31, 1997, and Paul Revere terminated Dames’ benefits effective that day. In a letter dated January 21, 1998, the claims examiner stated:

We have reviewed the information submitted by you for review from Dr. Pal-trow, Dr. Reynolds, Dr. Sultany, and Dr. Barkhuizen, as well as reviewing your file in its entirety. Although Dr. Sulta-ny and Dr. Barkhuizen’s notes from October 13, 1997 and October 30, 1997, respectively, would suggest fibromyalgia as the current diagnosed impairment, this diagnosis was not described during your 24 month benefit period. Dr. Graham’s notes for the period of 1995 to 1997 do not describe a diagnosis of Fi- *1197 bromyalgia, but rather Depressive Disorder, as does Dr. Eaton’s February 12, 1996 Psychiatric Assessment. In addition, Dr. Henderson’s April 15, 1996 letter notes, “the patient has presented with complaints of severe anxiety, episodic depression, and a variety of physical symptoms, which from my analysis so far, certainly appear to be related to her severe anxiety”. Neither Dr. Pal-trow’s April 8, 1996 consultation report nor his November 7, 1996 Psychiatric Assessment refer to a diagnosis of Fi-bromyalgia, but rather a diagnosis of depression. Dr. Paltrow’s letter of July 7, 1997 as well as October 24, 1997, which are in reference to your physical symptoms, do not define any diagnosis. Based on the information received, it is our opinion that although a physical diagnosis of fibromyalgia may be present at this time, the evidence in the file supports a disability during the time of your claim which was caused or contributed to by a psychiatric condition.

Plaintiffs Ex E, p. 1.

II. Policy language

The 1992 policy states:

We may change the Group Policy if we receive a written request from the policyholder. All changes that are made are stated in riders or amendments to the Group Policy. These documents must be signed by both our President or Secretary and the policyholder. Your consent is not needed to make a policy change.

Affidavit of Lori R. Metz (“Metz Aff’), Ex A, p. 44.

In December 1995, Imagebuilder’s Vice President of Finance signed a request for an amendment, to reduce the maximum long-term disability benefits. Paul Revere’s President signed the amended policy. The amended policy, effective February 1, 1996 (“1996 policy”), includes an “ERISA Attachment” which states that Paul Revere

will make all decisions regarding your eligibility for benefits and benefit determinations and will do so in accordance with the terms and conditions of the Group Policy. [Paul Revere] has full, final, complete, conclusive and exclusive discretion to determine eligibility for coverage and benefits under the Group Policy, to determine the amount of any benefits payable under the Group Policy and to construe and interpret the terms and conditions of the Group Policy and all related documents.

Affidavit of Vicki J. Miller, p. 39.

Dames did not receive a copy of the 1996 policy.

DISCUSSION

Paul Revere argues that the 1996 policy between Paul Revere and Imagebuilder confers discretion on Paul Revere to make benefits determinations. Thus, according to Paul Revere, this court should deny Dames’ request for discovery outside the administrative record and review the decision to terminate Dames’ benefits for an abuse of discretion. Dames responds that: (1) because the ERISA Attachment was not part of the 1992 policy Dames received, its grant of discretion to Paul Revere is inapplicable in this case; and (2) even if the ERISA Attachment applies to Dames’ claim, this court should apply a de novo standard of review because the administrative record reveals that Paul Revere’s inherent financial conflict influenced its benefits determination. Thus, according to Dames, she is entitled to further discovery.

I. Legal Standards

A. Standards of Review

In actions to recover benefits due under an ERISA plan administrator denying benefits, the court employs a de novo standard of review “unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan.” Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989).

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Bluebook (online)
49 F. Supp. 2d 1194, 1999 U.S. Dist. LEXIS 10223, 1999 WL 458775, Counsel Stack Legal Research, https://law.counselstack.com/opinion/dames-v-paul-revere-life-insurance-ord-1999.