Fleisher v. Standard Insurance

679 F.3d 116, 53 Employee Benefits Cas. (BNA) 1225, 2012 WL 1739710, 2012 U.S. App. LEXIS 9907
CourtCourt of Appeals for the Third Circuit
DecidedMay 17, 2012
Docket11-2490
StatusPublished
Cited by347 cases

This text of 679 F.3d 116 (Fleisher v. Standard Insurance) is published on Counsel Stack Legal Research, covering Court of Appeals for the Third Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Fleisher v. Standard Insurance, 679 F.3d 116, 53 Employee Benefits Cas. (BNA) 1225, 2012 WL 1739710, 2012 U.S. App. LEXIS 9907 (3d Cir. 2012).

Opinions

OPINION OF THE COURT

VANASKIE, Circuit Judge.

Robert Fleisher, D.M.D., filed suit against the Standard Insurance Company (“Standard”), alleging, inter alia, a violation of § 502(a)(1)(B) of the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1132(a)(1)(B). The suit arises out of Standard’s decision to reduce Fleisher’s monthly long-term disability (“LTD”) benefits by the amount of the monthly benefits he receives under a separate LTD insurance policy issued to him by the North American Company for Life and Health Insurance (“North American”). Fleisher disputes Standard’s decision that the North American Policy constitutes “group insurance coverage,” and that the monthly payment he receives under that Policy is therefore “Deductible Income” under the Standard Policy. The District Court, applying the deferential abuse of discretion standard of review, granted Standard’s motion to dismiss. Specifically, it found that Standard’s determination to offset the North American monthly benefit of $1,500 from Standard’s monthly obligation of $10,000 is supported by substantial evidence and not unreasonable. Fleisher now appeals this decision. For the reasons stated herein, we will affirm the decision of the District Court.

I.

During the course of his career as a dentist, Fleisher obtained LTD insurance coverage under two separate policies. In [119]*119July 1979, Fleisher obtained coverage under a policy issued by North American (“North American Policy”) to the American Association of Endodontics (“AAE”), of which Fleisher is a member. The North American Policy provides for LTD benefits of $1,500 per month.

In August 2002, Fleisher became eligible for LTD insurance coverage under a group policy issued by Standard (“Standard Policy”) to his employer, Endodontics, Ltd., P.C. (“Endodontics”). The LTD coverage offered by Fleisher’s employer is an employee benefit governed by ERISA. See Shaw v. Delta Air Lines, 463 U.S. 85, 91 n. 5, 103 S.Ct. 2890, 77 L.Ed.2d 490 (1983) (“An ‘employee welfare benefit plan’ [governed by ERISA] includes any program that provides benefits for contingencies such as illness, accident, disability, death, or unemployment.”). The Standard Policy provides for monthly LTD benefits equal to a percentage of the plan participant’s pre-disability earnings, which in Fleisher’s case was a maximum of “$10,000 before reduction by Deductible Income.” (A.61.) The Policy defines “Deductible Income” to include “[a]ny amount you [a plan participant] receive or are eligible to receive because of your disability under another group insurance coverage.” (A.72) (emphasis added). The Standard Policy excludes from “Deductible Income” benefits paid under “any individual disability insurance policy.” (A.72.) The Policy does not define either “another group insurance coverage” or “individual disability insurance policy.”

In January 2008, Fleisher became disabled and claimed LTD benefits under both the Standard and the North American policies. Shortly after Fleisher began collecting under both policies, Standard reduced his monthly benefits from $10,000 to $8,500 based on its determination that the North American Policy constitutes “another group insurance coverage,” and that the $1,500 in benefits he receives under it is therefore “Deductible Income.” Fleisher filed an administrative appeal of Standard’s decision, arguing that the North American Policy qualifies as an individual disability insurance policy, and therefore is not subject to deduction. By letter dated July 11, 2008, Standard rejected Fleisher’s appeal and continued making the deduction.

On May 26, 2010 Fleisher filed a Complaint in the United States District Court for the District of New Jersey, asserting individual and class claims for wrongful denial of benefits under ERISA, along with various state law claims. After Standard moved to dismiss the Complaint, Fleisher filed an Amended Complaint on September 8, 2010. After Standard moved to dismiss the Amended Complaint, Fleisher filed a Second Amended Complaint (“SAC”) on October 1, 2010.1 The SAC asserts three ERISA claims: breaches of fiduciary duty (Count I) and contract (Count III), both pursuant to § 502(a)(3), 29 U.S.C. § 1132(a)(3), and breach of contract pursuant to § 502(a)(1)(B) (Count II). The SAC seeks restitution for the deductions previously taken as well as injunctive relief to govern future deduction decisions.

Standard moved to dismiss the SAC pursuant to Fed.R.Civ.P. 12(b)(6). On May 2, 2011, the District Court granted Standard’s motion. The District Court initially concluded that the benefits offset determination was governed by “the deferential abuse of discretion standard.” (A.14.) Applying that narrow standard of review, the Court held that Fleisher could not show that Standard’s decision reflected [120]*120an unreasonable interpretation or application of the Standard Policy. The District Court recognized that there was a conflict of interest arising from the fact that Standard both paid benefits and made the offset decision, and that such a conflict had to be considered in deciding whether Standard had abused its discretion. It concluded, however, that Standard’s interpretation of pertinent policy provisions was not so close as to make the conflict of interest a determinative factor. The Court also dismissed Fleisher’s § 502(a)(3) claims for breaches of fiduciary duty and contract, concluding that Standard’s conduct was not improper.

II.

We have jurisdiction over this appeal pursuant to 28 U.S.C. § 1291. We exercise plenary review over a district court’s grant of a motion to dismiss pursuant to Rule 12(b)(6). Gelman v. State Farm Mut. Auto. Ins. Co., 583 F.3d 187, 190 (3d Cir.2009). Accordingly, we must “ ‘accept all factual allegations as true, construe the complaint in the light most favorable to the plaintiff, and determine whether, under any reasonable reading of the complaint, the plaintiff may be entitled to relief.’ ” Fowler v. UPMC Shadyside, 578 F.3d 203, 210 (3d Cir.2009) (quoting Phillips v. Cnty. of Allegheny, 515 F.3d 224, 233 (3d Cir.2008)). To survive a motion to dismiss, a complaint must contain sufficient factual allegations, taken as true, to “state a claim to relief that is plausible on its face.” Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570, 127 S.Ct. 1955, 167 L.Ed.2d 929 (2007); see also Ashcroft v. Iqbal, 556 U.S. 662, 129 S.Ct. 1937, 1949, 173 L.Ed.2d 868 (2009) (holding that the plausibility pleading standard articulated in Twombly applies to all civil actions).

III.

Fleisher’s coverage under the Standard Policy, an employee welfare benefit plan, is governed by ERISA, 29 U.S.C. §§ 1001, et seq.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
679 F.3d 116, 53 Employee Benefits Cas. (BNA) 1225, 2012 WL 1739710, 2012 U.S. App. LEXIS 9907, Counsel Stack Legal Research, https://law.counselstack.com/opinion/fleisher-v-standard-insurance-ca3-2012.