Hargrave v. Commonwealth General Corporation's Long Term Disability Plan

430 F. App'x 256
Court of Appeals for the Fifth Circuit·Decided May 13, 2011·No. No. 10-30720·Published·Cited by 1 cases

Opinion

JERRY E. SMITH, Circuit Judge: *

Commonwealth General Corporation’s Long-Term Disability Plan1 appeals a summary judgment in favor of Donna Hargrave granting disability benefits pursuant to § 502(a)(1)(B) of the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1132(a)(1)(B). The main issue is which of two versions of the Plan applies. Commonwealth argues that, under a 1998 version of the Plan, it may offset a tort settlement Hargrave received in 1994 against her 2006-2011 benefits, and Hargrave contends that it may not do so under a 1991 version of the Plan. Because Commonwealth’s determination that it may offset pre-1998 tort settlements against the payment of post-1998 disability benefits under the 1998 version of the Plan is legally correct, we vacate and remand.

I.

Hargrave was employed by Commonwealth Insurance Company, where she was covered for disabilities under the Plan, which she paid for through payroll deductions. In June 1991, she was seriously injured in a car accident. In March 1992, after a determination that she was totally disabled, Commonwealth granted her monthly disability benefits.

In 1994, Hargrave settled her tort claims against the person allegedly responsible for the accident. Under the terms of that settlement, she received a lump sum of $445,000 and $1,939.96 per month for 240 months from the tortfeasor’s insurer.2 The Plan in effect in 1991 through 1997 (“the 1991 Plan”) did not allow Commonwealth to offset tort settlement proceeds against Hargrave’s monthly disability benefits. The 1991 Plan did state, however, that the “company reserves the right to change or discontinue this Plan.”

The 1991 Plan was amended in 1998 (“the 1998 Plan”) to provide, in a section titled “Effect of Other Income on Benefits,” that disability benefits “will be reduced to the extent that you qualify for benefits payments from ... disability payments which result from the act or omission of any person whose action caused your disability. These payments may be from insurance or other sources.” The 1998 Plan further states that “[a]ny of these ‘Other Income Benefits’ that date back to a prior date during a certified period of disability may be allocated on a retroactive basis.” It then explains that, if the claims administrator determines there has been an overpayment of benefits, it may “reduce, by the amount of overpayment, any future benefit payment made to or on behalf of you or your dependent(s).” Failure to reimburse an overpayment “will result in suspension of benefits until reimbursement has occurred.” In addition, the 1998 Plan includes an amendment limiting the timing of any legal action against Commonwealth to three years from the initial denial of a claim.

In September 2005, Sally Kalnas, claims manager for. Commonwealth, wrote Har[258] grave advising her that Commonwealth was “unable to issue your benefits check” because Hargrave was receiving workers’ compensation payments that should have been offset.3 Kalnas requested information about those benefits “to avoid any further overpayment situation.” Despite the language in Kalnas’s letter, Commonwealth continued to pay Hargrave monthly benefits.

Hargrave submitted information to Commonwealth showing that the payments she was receiving were tort settlement payments. Kalnas responded in June 2006 that, because of the settlement income Hargrave was receiving, there was an overpayment in her disability benefits. Kalnas’s letter, citing the 1998 Plan, stated that the disability benefits should have been offset since 1994 by the lump sum settlement proceeds Hargrave had received. The letter explained that, as a result of the failure to offset the settlement proceeds from 1994 onward, Hargrave had been overpaid $82,185, and her future monthly benefits would be withheld for five years to recoup that overpayment.4

Hargrave responded in May 2007 that none of the 1991 Plan’s terms required the offsetting of tort settlement proceeds; she attached a page of the 1991 Plan to her letter. Kalnas replied in June and explained that, under the 1998 Plan, benefits would be reduced to the extent Hargrave qualified for “benefit payments from ... disability payments which result from the act or omission of any person whose action caused your disability.” Kalnas acknowledged that the 1998 Plan does not “specifically list ‘settlement of a tort claim,’ ” but she nevertheless concluded that the provision Hargrave cited covered tort settlements.

Hargrave sent another letter to Kalnas in December 2007 arguing that Kalnas’s “reliance on the 1998 Plan is incorrect,” because it went into effect “long after [Hargrave]’s accident, disability, and tort settlement.” Hargrave requested “further explanation” of the decision to deny Hargrave’s benefits pursuant to the 1998 Plan rather than the 1991 Plan. Kalnas responded in January 2008, stating only that she was enclosing a copy of the 1998 Plan and telling Hargrave that she was waiting for an answer from AEGON “in regards to any amendments during the time frame in question” that would affect her determination.5

In June 2008, Hargrave wrote to Kalnas stating that she was still waiting for a response and restating her argument that the 1991 Plan should apply. Kalnas responded that same month stating that she would “have to direct” Hargrave to AE-GON, which was now in possession of Hargrave’s file and policy; Kalnas provided a [259] contact person, Tina Ohl.6 Hargrave sent Ohl a letter repeating her arguments that the 1991 Plan should apply, but Ohl never responded.

Hargrave sued AEGON in state court in May 2009. AEGON removed the case to federal court, and, in June 2009, Hargrave amended her complaint to include Commonwealth as a defendant. After Commonwealth stipulated that it was the proper defendant, the court dismissed Hargrave’s claims against AEGON without prejudice. The district court then denied Commonwealth’s motion to dismiss, without citing legal authority, because it believed deciding in Commonwealth’s favor would be unfair. Hargrave filed a motion for partial summary judgment seeking to recover the monthly benefits Commonwealth had withheld, which the district court granted without stating reasons.

II.

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Hargrave v. Commonwealth General Corporation's Long Term Disability Plan, 430 F. App'x 256 (5th Cir. 2011).

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