James J. Galman v. The Prudential Insurance Company of America

254 F.3d 768, 26 Employee Benefits Cas. (BNA) 1850, 2001 U.S. App. LEXIS 15415, 2001 WL 721708
Court of Appeals for the Eighth Circuit·Decided June 28, 2001·No. 00-1748·Published·Cited by 40 cases

Opinions

LOKEN, Circuit Judge.

After suffering a second heart attack on July 2, 1997, trial attorney James J. Gal-man applied for benefits under his law firm’s Employee Long Term Disability Plan, alleging that the stress of litigation and trial work aggravated and accelerated his coronary artery heart disease, rendering him totally disabled. The Plan is funded by a group insurance contract issued by The Prudential Insurance Company of America. Prudential initially denied Gal-man’s application in October 1997. Two weeks later, Galman invoked Prudential’s internal appeals procedure, while simultaneously filing this action for wrongful denial in state court and returning to work. Prudential removed the action to federal court under ERISA. See Lyons v. Philip Morris Inc., 225 F.3d 909, 912 (8th Cir.2000); 29 U.S.C. § 1132(a)(1)(B). The district court1 stayed the lawsuit while Gal-man exhausted his remedy under the Plan. In May 1999, Prudential denied Galman’s appeal. The district court then granted summary judgment in favor of Prudential, concluding that Galman was not totally disabled as defined by the Plan because he had returned to work. Galman appeals, arguing that the district court erred in refusing to separately review Prudential’s initial denial of his claim, and that his return to work was involuntary and therefore an improper basis for finding him not totally disabled. We affirm.

I.

Galman has been a practicing trial attorney for more than thirty years. He has a history of heart problems, including heart attacks in November 1987 and July 1997 and two angioplasty procedures on October 14, 1997, two days before Prudential’s initial denial of his application for long-term disability benefits. The Plan defines total disability as follows:

“Total Disability” exists when Prudential determines that all of these conditions are met:
(1) Due to Sickness or accidental Injury ... [y]ou are not able to perform, for wage or profit, the material and substantial duties of your occupation....
(2) You are not working at any job for wage or profit.
(3) You are under the regular care of a Doctor.

In support of his application for benefits, Galman submitted his medical records and [770] opinions by two treating physicians that he was totally disabled because the stress of working as a trial attorney subjected him to the “risk of aggravating or accelerating his heart condition.” In reviewing the application, Prudential obtained reports from two reviewing physicians, who concluded that Galman was not totally disabled from his work as a trial attorney. Prudential’s initial denial in October 1997 stated, “there' is no evidence to support the hypothesis that his work as a trial attorney aggravated his preexisting coronary artery disease.” Prudential denied Galman’s appeal in May 1999 because “there is no documented impairment which would prevent Mr. Galman from performing the material and substantial duties of his occupation,” and because he “has demonstrated the ability to continue to work in his occupation as a Trial Attorney since October, 1997.”

The district court reviewed Prudential’s benefits denial de novo, a ruling Prudential does not challenge on appeal. See Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989); Herzberger v. Standard Ins. Co., 205 F.3d 327 (7th Cir.2000); Bounds v. Bell Atl. Enters. Flexible Long-Term Disability Plan, 32 F.3d 337, 339 (8th Cir.1994). The district court granted Prudential’s motion for summary judgment because Galman was working in May 1999 and therefore did not meet the definition of “total disability” in the Plan. Galman then filed a motion to alter or amend the judgment, arguing he was at least entitled to long-term disability benefits for the month before he returned to work on October 26, 1997. The district court denied that motion because “[tjhis issue was not raised in the parties’ summary judgment motions.” Galman challenges both rulings on appeal.

II.

Galman first argues that the district court erred when it refused to rule on the validity of Prudential’s initial benefits denial in mid-October 1997. He asserts that the initial denial compelled him to return to work to support his family and therefore, if this ruling escapes judicial review, ERISA fiduciaries will have an incentive “to initially deny claims, force employees back into the workplace, and then deny the claim again on appeal on the basis that the employee is working.” Gal-man urges us to overturn the initial denial and conclude he was totally disabled prior to returning to work on October 26, and to award him one month’s benefits, prejudgment interest, and an attorney’s fee.

Framing the argument in this fashion seriously distorts the issue. ERISA provides that every plan must provide a benefits appeal procedure. See 29 U.S.C. § 1133(2). In this circuit, benefit claimants must exhaust this procedure before bringing claims for wrongful denial to court. See Kinkead v. Southwestern Bell Corp. Sickness & Acc. Disability Benefit Plan, 111 F.3d 67, 68 (8th Cir.1997). Exhaustion serves many important purposes — giving claims administrators an opportunity to correct errors, promoting consistent treatment of claims, providing a non-adversarial dispute resolution process, decreasing the cost and time of claims resolution, assembling a fact record that .will assist the court if judicial review is necessary, and minimizing the likelihood of frivolous lawsuits. See Kinkead, 111 F.3d at 68; Conley v. Pitney Bowes, 34 F.3d 714, 718 (8th Cir.1994). As the district court recognized, these purposes are best served if the reviewing court reviews the claims administrator’s final decision to deny a claim, rather than the initial denial [771] that was reconsidered during the internal appeal.2

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James J. Galman v. The Prudential Insurance Company of America, 254 F.3d 768, 26 Employee Benefits Cas. (BNA) 1850, 2001 U.S. App. LEXIS 15415, 2001 WL 721708 (8th Cir. 2001).

254 F.3d 768 (James J. Galman v. The Prudential Insurance Company of America) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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