McNutt v. J.A. Jones Construction Co.

33 F. Supp. 2d 1375, 1998 U.S. Dist. LEXIS 20543, 1998 WL 919658
CourtDistrict Court, S.D. Georgia
DecidedDecember 16, 1998
DocketCV 196-162
StatusPublished
Cited by1 cases

This text of 33 F. Supp. 2d 1375 (McNutt v. J.A. Jones Construction Co.) is published on Counsel Stack Legal Research, covering District Court, S.D. Georgia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
McNutt v. J.A. Jones Construction Co., 33 F. Supp. 2d 1375, 1998 U.S. Dist. LEXIS 20543, 1998 WL 919658 (S.D. Ga. 1998).

Opinion

ORDER

BOWEN, Chief Judge.

In the above-captioned case brought pursuant to the- Employee Retirement Income Security Act of 1974 (ERISA), Defendants have filed a Motion for Summary Judgment. Upon consideration of 'the briefs submitted by counsel and oral argument, Defendants’ Motion for Summary Judgment is hereby GRANTED IN PART and DENIED IN PART for the reasons set forth below.

*1376 I. Background

On August 2, 1990, a tractor-trailer collided with Plaintiffs disabled pickup truck on I-20, east of Columbia, South Carolina. Plaintiff was seriously injured in the collision. Plaintiff did not go to the hospital immediately after the accident, but he did see Dr. Ben Estes, an Augusta neurosurgeon the following day. Dr. Estes continued to treat Plaintiff after the accident, seeing him forty-three times during the next several years. Dr. Estes contends that Plaintiff is disabled as a result of the injuries he suffered in the accident.

At the time of the accident, Plaintiff was employed as a project superintendent with Defendant Metric Constructors, Inc. (Metric), a unit of Jones Group, Inc. (Jones). Defendant Aetna Life Insurance Company (Aetna) provided health, life, and long-term disability coverage under a group plan with Jones. Plaintiff seeks to recover long-term disability benefits he believes Defendants owe him under this disability insurance policy. Plaintiff also alleges that a penalty should be assessed against the Defendants pursuant to ERISA for their refusal to provide him with the claim forms necessary to file his disability claim.

There are two primary documents detailing Plaintiffs disability insurance policy: the booklet “Your Group Plan” and a brochure “Disability Benefits.” Jones provided Plaintiff with copies of both documents. The “Disability Benefits” brochure is designated the Summary Plan Description (SPD) pursuant to ERISA, and the “Your Group Plan” booklet provides more detail about the policy. The SPD indicates that plan participants should refer to other policy documents for details about the plan. 1 The SPD does not provide any deadlines for filing long-term disability claims and does not indicate any consequences for failing to file a proof of loss within a specific time period. The SPD also fails to mention any contractual statute of limitations applying to claims or any other terms which would disqualify an insured from receiving benefits for failure to comply with plan deadlines.

Time limits for filing a claim, however, are listed in the “Your Group Plan” brochure. Specifically, “Your Group Plan” states:

Written proof of total disability under long term disability coverage must be given to the Insurance Company within 90 days after the end of the waiting period shown in the Plan Summary____Late proof may be accepted only if, under the particular circumstances, it was furnished as soon as was reasonably possible, and in any event except in the absence of your legal capacity, within one year after' the time it was otherwise required. No action at law or equity may be brought to recover on any group policy after three years from the time written proof is required to be furnished.

On October 2, 1991, Plaintiff filed his first written proof of loss. This proof of loss was made after the 90-day deadline had passed but within the one-year grace period for filing proof of loss statements. Plaintiff filed suit on September 12, 1996, four years (even if the grace period is used) after he was required to file written proof under the contractual statute of limitations. This late filing violated the three-year contractual statute of limitations stated in the “Your Group Plan” brochure.

Jones and Aetna’s contractual relationship is governed by the terms of the Administrative Services Contract (ASC). The ASC provides that:

Aetna in performing its obligations under this Contract is acting only as agent of the Contractholder and the rights and responsibilities of the parties shall be determined in accordance with the law of agency except as otherwise herein provided. The Contractholder hereby delegates to Aetna authority to make determinations on behalf of the Contractholder with respect to benefit payments under the Plan and to pay such benefits. In connection with such determinations, Aetna acknowledges that it is- acting as fiduciary solely for benefit determination, benefit processing and review, and appeals of denied claims for ben *1377 efits under the Federal “Employee Retirement Income Security Act of 1974” (ERISA). For the purposes of ERISA and any applicable state legislation of similar nature, the Contractholder shall, however, be deemed the Administrator of the Plan.

During the first five years of a participant’s disability, Jones pays any disability benefits from its own funds, and Aetna provides claim services pursuant to the administrative services contract. If an insured is still disabled after five years, Aetna pays the insured’s disability payment from its own funds.

Defendant contends that the plan delegates discretionary authority for determining the validity of claims to Aetna under the ASC. Plaintiff, however, contends that Nelson Taylor of Jones Group makes the initial determinations concerning the filing of a claim, eligibility for disability benefits, and whether to give a claim form to a plan participant or beneficiary.

The plan also includes a definition of “total disability” that defines the term as a function of an insured’s ability to work. Defendants contend that Plaintiff failed to meet the definition of a totally disabled employee. The “Your Group Plan” brochure defines “total disability” as follows:

During the first 24 months of a period of disability, you will be considered unable to work if you cannot work at the type of occupation in which you normally engage. After the first 24 months of a period of total disability, you will be considered unable to work only if you are unable to work at any reasonable occupation.

As a project superintendent with Metric, Plaintiff contends that his job involved operating heavy construction equipment and explosives as well as paperwork and record keeping. After his accident, Plaintiff remained at home for two weeks before returning to work and working twenty-one days. Plaintiff contends that he only returned to work in order to complete a project under his supervision. After returning to work, Plaintiff took vacation time on November 7, 1990, and told Metric that he intended to stay on vacation until December 11, 1990. Plaintiff contends that he took this vacation because he was unable to perform his job without severe pain and that the pain made him unable to concentrate and focus on his work. Before Plaintiffs vacation expired, however, he was laid off effective November 30,1990.

On October 2, 1991, Plaintiff sent the person in charge of group insurance at Metric, Harriet Pratt, Dr. Estes’s medical report. In this letter, Plaintiff also requested the proper forms necessary for him to apply for long-term disability benefits. On December 2, 1991, C. Nelson Taylor, the Employee Benefits.

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Bluebook (online)
33 F. Supp. 2d 1375, 1998 U.S. Dist. LEXIS 20543, 1998 WL 919658, Counsel Stack Legal Research, https://law.counselstack.com/opinion/mcnutt-v-ja-jones-construction-co-gasd-1998.