FUTAMURA ESTATE OF FUTAMURA v. Unum Life Ins. Co. of America

305 F. Supp. 2d 1181, 32 Employee Benefits Cas. (BNA) 2655, 2004 U.S. Dist. LEXIS 7059, 2004 WL 360908
CourtDistrict Court, W.D. Washington
DecidedFebruary 17, 2004
DocketC02-2509Z
StatusPublished
Cited by1 cases

This text of 305 F. Supp. 2d 1181 (FUTAMURA ESTATE OF FUTAMURA v. Unum Life Ins. Co. of America) is published on Counsel Stack Legal Research, covering District Court, W.D. Washington primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
FUTAMURA ESTATE OF FUTAMURA v. Unum Life Ins. Co. of America, 305 F. Supp. 2d 1181, 32 Employee Benefits Cas. (BNA) 2655, 2004 U.S. Dist. LEXIS 7059, 2004 WL 360908 (W.D. Wash. 2004).

Opinion

ORDER

ZILLY, District Judge.

Background

On January 9, 2001, Robert Futamura visited a medical physician, Dr. Lammert, complaining of a one to two year chronic cough. Hong Deck, docket no. 33, Ex. C. Dr. Lammert determined that Mr. Futa-mura’s cough was likely caused by allergies that had affected Mr. Futamura in the past. Id.

On February 7, 2001, Mr. Futamura started a new job at Sakson & Taylor, which provided him with coverage under a long-term disability insurance policy issued and administered by UNUM Life Insurance Policy of America (“UNUM”). The policy contained the following provisions:

*1184 When making a benefits determination under the policy, UNUM has discretionary authority to determine your eligibility for benefits and to interpret the terms and provisions of the policy.
Your plan does not cover any disabilities caused by, contributed to by, or resulting from your.. .pre-existing condition. You have a preexisting condition for sickness or injury if:
— you receive medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; or you had symptoms for which an ordinarily prudent person would have consulted a health care provider in the 3 months just prior to your effective date of coverage; and
— your disability begins in the first 12 months after your effective date of coverage.

Hong Decl., docket no. 33, Ex. A, U/A 0751, 0761-0762. The preexisting condition exclusion extended back to November 7, 2000, thereby encompassing Mr. Futa-mura’s January 2001 visit to Dr. Lammert.

On March 8, 2001, Mr. Futamura returned to Dr. Lammert for a follow-up visit. Lammert Deck, docket no. 38, Ex. B. His cough was slightly worse, and he reported additional symptoms — pain in the left buttocks, radiating pain down the left side, inability to play soccer because of pain. Id. Dr. Lammert ordered a diagnostic X-ray of Mr. Futamura’s chest that revealed an irregular mass on the perihilar region of his lung. Subsequent testing confirmed that Mr. Futamura was suffering from non-small cell lung cancer. Hong Deck, docket no. 33, Ex. D. Mr. Futamu-ra’s cancer was advanced and aggressive, which led him to make a claim for disability under the UNUM policy. Id. at Ex. E. Mr. Futamura completed the claim form in May 2001. Id. Robert Futamura died on March 24, 2002.

Mr. Futamura’s claim was initially reviewed by Nurse Ruth Brown on April 2, 2002, approximately one week after his death. Fox Deck, docket no. 37, Ex. 2. Nurse Brown was not aware of Mr. Futa-mura’s earlier visit to Dr. Lammert, and found that Mr. Futamura did not have a preexisting condition under the terms of the policy. Id. Mr. Futamura’s claim was later reviewed by Dr. Wanda Lopez on April 17, 2002. Id. at Ex. 6. Unlike Nurse Brown, Dr. Lopez was aware of the January 10, 2001 visit to Dr. Lammert. Id. Based on that visit, Dr. Lopez concluded on a more likely than not basis that Mr. Futamura was seen for symptoms related to his lung cancer diagnosis within the preexisting condition period. Id. Dr. Lopez made the following findings:

Clmt was seen by Dr. Lambert c/o of 1-2 years history of chronic cough with productive white mucus. On physical exam, he was found to have breath sounds 3/4 with no wheezes or ronch and significant cough with forced expiration. A [Pulmonary Function Test] was obtained which was found to be negative. He was treated as a case of chronic rhinitis and allergies. He was seen on a follow up visit on March 8, 2001, with similar complains of worsening and persistent chronic cough. Chest x-rays done on that day showed an irregular mass of 6x8 cm in size in the anterior right perihilar region. A follow up chest ct done on March 15, 2001 confirmed the presence of a mass. A bronchoscopy done later on confirmed [sic] the diagnosis of NSCLCA.
Conclusion, Clmt was seen during the pre-x period complaining of chronic cough for one to two years duration. Further investigation of these symptoms a month later led to the diagnosis of *1185 lung cancer which is the same condition for which the elmt was seeking disability. This is a typical presentation for such an advanced stage of cancer to present with long standing history of chronic cough. Therefore, it is more likely than not that the symptoms that the clmt experience during the pre-x and for which he seek medical care whre [sic] related to the lung cancer.

Fox Deck, docket no. 37, Ex. 6.

UNUM sent a letter to Mr. Futamura’s surviving family the next day, April 18, posthumously denying his claim based on the preexisting claim clause of the policy. Id., Ex. 3. UNUM concluded that, based on its review of the medical records, Mr. Futamura had symptoms of cancer during the preexisting period and “therefore received medical treatment, consultation, and care services including diagnostic measures for a condition which he is now claiming disability.” Id., Ex. 3, pg. 2.

Mr. Futamura’s family appealed UNUM’s denial of benefits, which was denied on August 16, 2002. Id. at Ex. 4. UNUM reiterated that Mr. Futamura had complained of a chronic cough for one to two years, and that investigation of these symptoms eventually “led to the diagnosis of non small cell lung cancer.” Id., Ex. 4, pg. 2. UNUM affirmed the conclusion that the symptoms for which “Mr. Futamura sought and received treatment during the pre-existing period were related to the lung cancer.” Id., Ex. 4, pg. 2. This action was filed by Mr. Futamura’s estate to recover the disability benefits under ERISA.

Discussion

Defendant’s summary judgment motion cannot proceed without first determining the applicable standard of review. The disability benefits policy gives UNUM the discretion to determine eligibility, and courts are generally required to review such policies under the abuse of discretion standard. See Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989) (where an ERISA plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or construe the terms of the plan, the Court must apply the deferential “abuse of discretion” standard of review). However, if a benefit plan gives discretion to an administrator or fiduciary who is operating under a conflict of interest, that conflict of interest must be weighed as a factor in determining whether there is an abuse of discretion. Id. at 115, 109 S.Ct. 948.

The Ninth Circuit has interpreted Firestone to suggest that when an insurance company administers a plan and simultaneously profits by denial of coverage, there is an apparent conflict of interest. Regula v. Delta Family-Care Disability Survivor-ship Plan,

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347 F. Supp. 2d 944 (W.D. Washington, 2004)

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305 F. Supp. 2d 1181, 32 Employee Benefits Cas. (BNA) 2655, 2004 U.S. Dist. LEXIS 7059, 2004 WL 360908, Counsel Stack Legal Research, https://law.counselstack.com/opinion/futamura-estate-of-futamura-v-unum-life-ins-co-of-america-wawd-2004.