Hodges v. Life Ins. Co. of N. Am., Ins. Co.

920 F.3d 669
Court of Appeals for the Tenth Circuit·Decided April 2, 2019·No. 18-1279·Published·Cited by 20 cases

Opinion

PHILLIPS, Circuit Judge.

Lou Hodges submitted a claim for long-term-disability (LTD) benefits to Life Insurance Company of North America (LINA) through his employer's group-insurance plan. Although LINA approved his claim, Hodges asserted that LINA should have classified him as a "sales" employee under the group-insurance policy, which would have entitled him to more benefits. This led Hodges to sue LINA. The district court remanded for further factfinding, but LINA once again reached the same result. The district court then *672 reversed LINA's decision, concluding that Hodges qualified as a salesperson under the policy. LINA now appeals that ruling. Exercising jurisdiction under 28 U.S.C. § 1291 , we affirm.

BACKGROUND

Until 2012, Hodges worked for Endo Pharmaceuticals, Inc. as a cryotherapy technician. That year a degenerative eye condition forced him to retire. He participated in Endo's employee-welfare-benefit plan, for which Endo had appointed LINA as the administrator. In 2011, LINA issued to Endo a group LTD insurance policy (the Policy), governed by the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. §§ 1000 - 1461. Under "Claims Procedures," the Policy names LINA the fiduciary for deciding claims as well as appeals of denied claims. Appellant's App. vol. 2 at 312. The Policy allows LINA "45 days from the date it receives a claim for disability benefits ... to determine whether or not benefits are payable in accordance with the terms of the Policy." Id.

The Policy divides employees into two classes: Class 1, which includes "[a]ll active, Full-time and part-time Employees of the Employer, excluding Sales personnel, regularly working a minimum of 20 hours per week"; and Class 2, which includes "[a]ll active, Full-time Employees of the Employer classified as Sales Personnel regularly working a minimum of 20 hours per week." Id. at 290 . The Policy entitles all covered employees to monthly disability payments worth 60% of their average pre-disability earnings, but it defines the pay of sales personnel more broadly than that of non-sales personnel. Specifically, the Class 2 definition of earnings includes payments "received from bonuses or target incentive compensation bonus[es]," but the Class 1 definition "does not include amounts received as bonus[es]." 1 Id . Despite favoring sales personnel in the provision of benefits, however, the Policy defines neither "sales" nor "sales personnel."

Before leaving the company, Hodges submitted a claim under the Policy. After granting him short-term-disability benefits, LINA informed Hodges that it would begin evaluating his eligibility for LTD benefits. LINA eventually concluded that Hodges was medically eligible for LTD benefits, but later sought information from Hodges and Endo about Hodges's job description and duties to determine whether he qualified as "sales personnel" under the Policy. In a telephone interview, Hodges explained to a LINA claim manager that "he was a technician, but often times did things to sell the compan[y']s products." Id. at 516 . And in an e-mail to another LINA claim manager, an Endo representative "confirmed" that Hodges "received monthly sales bonuses based on the number of cases he treated," which totaled "$ 9[,]800 for the nine months he worked in 2011." Id. vol. 5 at 1226. But the representative also stated, "These earnings are not part of the overall bonus or [incentive compensation] program at Endo and were not included in the premium calculation." Id.

On March 21, 2012, LINA informed Hodges that it had approved his claim for LTD benefits but that it deemed him a Class 1 employee, not a Class 2 salesperson. Hodges objected to this classification, arguing that he "sold products while out in the field" and that the classification would significantly reduce his benefits. 2 Id. vol. 2 *673 at 494. About 70% of Hodges's earnings came from his base salary, and about 30% came from sales-driven compensation, including bonuses.

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Hodges v. Life Ins. Co. of N. Am., Ins. Co., 920 F.3d 669 (10th Cir. 2019).

920 F.3d 669 (Hodges v. Life Ins. Co. of N. Am., Ins. Co.) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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