Kouzmanoff v. Unum Life Ins. Co. of Am.

374 F. Supp. 3d 1076
CourtDistrict Court, D. Colorado
DecidedMarch 15, 2019
DocketCivil Action Nos. 17-cv-0721-RM-STV; 17-cv-0976-RM-STV
StatusPublished
Cited by7 cases

This text of 374 F. Supp. 3d 1076 (Kouzmanoff v. Unum Life Ins. Co. of Am.) is published on Counsel Stack Legal Research, covering District Court, D. Colorado primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Kouzmanoff v. Unum Life Ins. Co. of Am., 374 F. Supp. 3d 1076 (D. Colo. 2019).

Opinion

RAYMOND P. MOORE, United States District Judge

This consolidated matter alleges failure to pay disability benefits and arises under the Employee Retirement Income Security Act ("ERISA") and other employer obligations. Plaintiff Marc Kouzmanoff is a former sales representative for Thomson Reuters Holdings, Inc. ("Thomson Reuters"). He developed diabetes in 2001 and, in 2016, applied for disability benefits pursuant to short-term and long-term plans ("STD Policy" and "LTD Policy") administered by Unum Life Insurance Company of America ("Unum"), asserting that performing the duties of his employment involved a high risk of injury or mortality due to his inability to control his blood sugar. Unum denied both benefit types, and Kouzmanoff filed separate actions against Thomson Reuters and Unum that have since been consolidated. (ECF No. 23.)1 Kouzmanoff's pleadings square against Unum for breach of fiduciary duty under ERISA and Thomson Reuters for breach of contract and pursuant to the Colorado Wage Act.

Before the Court is the administrative record in the Unum case (AR, ECF Nos. 69, 69-1, 75) and Thomson Reuters's Motion for Partial Summary Judgment (PSJ-Motion, ECF No. 78 ),2 both of which are *1079fully briefed. No party has moved to supplement the administrative record, or objected to the authenticity or veracity of any part thereof. These matters are ripe for review.

I. BACKGROUND

Kouzmanoff, born on October 6, 1951, worked for Thomson Reuters for 30 years-from July 10, 1986 to October 6, 2016. (AR 5, 134.) As a "Field Account Manager," he communicated with and drove to Colorado businesses to present, demonstrate, and sell Thomson Reuters's legal, tax, and accounting products. (Id. at 444.)3 The essential functions of the job included consistently achieving business objectives and sales revenue targets, working in a highly competitive environment under a quota system, managing relationships with high-end firms and corporations, working within urgent timelines, and travelling (sometimes overnight). (Id. at 166.) According to Kouzmanoff, he often worked 18-hour days but started voluntarily reducing his hours in either 2014 or 2015. (Id. at 346.)

A. Relevant Disability Benefit Policies

This case centers on two separate benefit plans: the STD Policy and LTD Policy. The STD Policy-which is not a plan under ERISA-is self-funded by Thomson Reuters and "replaces a portion of [a claimant's] income in the event a sickness or injury prevents [him] from working for a period of time." (Statement4 ¶ 1-2, ECF No. 86-1 (citing STD Policy, ECF No. 47-1, at 1).) However, the STD Policy does not provide benefits regarding a disability "caused by, contributed by, or resulting from [an] occupational sickness or injury." (STD Policy at 3.) Under the STD Policy, qualifying claimants are entitled to benefits of 100% of weekly earnings for the first six weeks of disability and 80% of weekly earnings for the following 19 weeks. (STD Policy at 5.) Pursuant to an elimination period, a claimant must be continuously disabled for seven days in order to be eligible for benefits. (STD Policy at 3.)

The STD Policy is administered by Unum: "When making a benefit determination under the [STD] Policy, U[num] has the exclusive and final discretionary authority to determine your eligibility for benefits and to interpret and enforce the terms and provisions of the [STD] Policy." (STD Policy at 8; see also Am. Compl. ¶ 4, ECF No. 55.) Whether or not Unum or Thomson Reuters is more appropriately dubbed its "administrator" in name,5 Thomson Reuters pays Unum to administer the STD Policy (Statement ¶ 12) and *1080the parties agree that Unum is its administrator. (Statement ¶ 2; ECF No. 85, at 2.) But while Unum administers the STD Policy, Thomson Reuters retained the exclusive right to discontinue it at any time: "Thomson Reuters reserves the right to modify, amend, suspend, or terminate, in whole or in part, any of the provisions of this Policy at any time for any reason or for no reason." (STD Policy at 1.) "[C]overage under the Policy ends ... the date the Policy is cancelled[,]" but "if the Policy is cancelled, the cancellation will not affect a payable claim." (Id. at 2.)

Kouzmanoff was also a beneficiary of the LTD Policy, of which Thomson Reuters was policyholder and Unum benefits provider. (AR 45; Unum Answer ¶ 2, ECF No. 13.) Like the STD Policy, the LTD Policy provides financial protection in the event of disability, but over a longer term. (AR 46.) Its elimination period is the later of 180 days or the end of short-term benefits under the STD Policy. (Id. at 47-48.) The LTD Policy offers employees several coverage options. Relevant here, benefits could include up to 66.6667% of monthly earnings-to a maximum benefit of $15,000 per month-for up to 42 months, minus any deductible sources of income. (Id. at 7, 11, 48, 61.)

Both policies set forth the relevant definitions and procedures governing a claimant's path to benefits. Under both, an employee is "disabled," and therefore entitled to benefits,6 when Unum determines that he is "limited from performing the material and substantial duties of [his] regular occupation due to [a] sickness or injury; and [the employee] ha[s] a 20% or more loss in [ ] earnings due to that same sickness or injury." (Statement ¶ 5; AR 60.)

Both policies require the same information as proof of claim. A claimant must show (1) that he is under the regular care of a physician; (2) appropriate documentation of his weekly earnings; (3) the date his disability began; (4) the cause of his disability; (5) the extent of his disability, including restrictions and limitations preventing him from performing his regular occupation; and (6) the name and address of any hospital, institution or other treatment source, including all attending physicians' names and addresses. (AR 50; STD Policy at 7.)7

The policies provide appeal processes. Pursuant to the STD Policy, after making a negative determination, Unum provides a notice of denial in writing, giving the specific reason(s) for the denial; the policy provision(s) on which the denial is based; an explanation of a right to appeal; and the claim review procedure. (STD Policy at 8.) The LTD Policy provides that, after denying a claim, Unum will provide that same information and, additionally, any material or information necessary to complete the claim and why such information is necessary; disclose any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination; and describe a claimant's right to obtain information about those procedures and the right to bring a lawsuit under Section 502(a) of ERISA following an adverse determination from Unum on appeal. (AR 82-83.) In support of a LTD Policy appeal, the claimant may submit new information, and Unum affords no deference to the prior determination. (Id. at 83.) Moreover, Unum reviews appeals via different personnel than who made the initial determination. (Id. at 83-84.)

*1081B. Kouzmanoff's Diabetes and Unum's Denial of STD and LTD Policy Benefits

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374 F. Supp. 3d 1076, Counsel Stack Legal Research, https://law.counselstack.com/opinion/kouzmanoff-v-unum-life-ins-co-of-am-cod-2019.