Newsom v. Reliance Stnrd Life Ins

CourtCourt of Appeals for the Fifth Circuit
DecidedFebruary 18, 2022
Docket21-10519
StatusPublished

This text of Newsom v. Reliance Stnrd Life Ins (Newsom v. Reliance Stnrd Life Ins) is published on Counsel Stack Legal Research, covering Court of Appeals for the Fifth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Newsom v. Reliance Stnrd Life Ins, (5th Cir. 2022).

Opinion

Case: 20-10994 Document: 00516209171 Page: 1 Date Filed: 02/18/2022

United States Court of Appeals for the Fifth Circuit United States Court of Appeals Fifth Circuit

FILED February 18, 2022 No. 20-10994 Lyle W. Cayce Clerk James W. Newsom,

Plaintiff—Appellee,

versus

Reliance Standard Life Insurance Company,

Defendant—Appellant. consolidated with _____________

No. 21-10519 _____________

James W. Newsom,

Defendant—Appellant.

Appeals from the United States District Court for the Northern District of Texas USDC No. 3:19-CV-1446 Case: 20-10994 Document: 00516209171 Page: 2 Date Filed: 02/18/2022

No. 20-10994 c/w No. 21-10519

Before Higginbotham, Stewart, and Wilson, Circuit Judges. Cory T. Wilson, Circuit Judge: This is an Employee Retirement Income Security Act (ERISA) case. Lereta, LLC maintained an ERISA-governed benefits plan that provided short-term disability (STD) and long-term disability (LTD) to its employees, including James W. Newsom. Reliance Standard Life Insurance Company issued the policies that funded these benefits and served as the benefits claims administrator. Newsom filed this suit following Reliance’s determination that he was ineligible for LTD benefits. The parties agreed to a trial upon submission of documentary evidence but disagreed upon the issues properly before the district court. The district judge entered an order in favor of Newsom, both finding that he was eligible for LTD benefits and awarding them. Reliance appealed. We affirm the judgment of the district court as to Newsom’s eligibility for LTD benefits and alleged date of disability. But we vacate the judgment as to Newsom’s entitlement to LTD benefits and remand with instructions for the district court to remand Newsom’s claim to the administrator for further proceedings consistent with this opinion. I. In 2017, Newsom worked as a software architect for Lereta, where he had been employed for 23 years. He had health problems dating back to 1999, including chronic fatigue syndrome, fibromyalgia, depression, and attention deficit hyperactivity disorder. By September 2017, his health deteriorated to the point that he could no longer work a 40-hour week. Lereta reduced Newsom’s scheduled work week to 32 hours (eight hours per day, Monday through Thursday), which was still considered full time. But Newsom was unable consistently to work even a full 32-hour week. He was last scheduled

2 Case: 20-10994 Document: 00516209171 Page: 3 Date Filed: 02/18/2022

No. 20-10994 c/w No. 21-10519 to work 32 hours the week of October 16–20, 2017. Thereafter, Lereta placed Newsom on part-time status, scheduling him for less than 30 hours per week. Newsom continued to work part time until January 30, 2018, when he became unable to work at all. On February 22, 2018, Newsom submitted an Initial Statement of Claim for STD benefits to Reliance. Reliance did not receive that paperwork, so he resubmitted it on March 23, 2018. On the claim form, Newsom listed his last day of work as January 30, 2018, and noted that he was “first unable to work because of [his] disability” on January 29, 2018. Newsom’s treating physician likewise indicated that Newsom became “continuously unable to work” on January 29, 2018. However, Newsom’s physician also estimated that he would be able to return to work by August 1, 2018. Lereta indicated on the claim form that Newsom had worked four days per week for seven hours per day (28 hours/week) before he stopped working altogether. Based on this information, Reliance initially denied Newsom’s STD claim, referencing January 31, 2018, as the date of loss and noting that Lereta indicated Newsom had been working only 28 hours per week prior to that date, meaning he did not qualify as a full-time active employee and thus did not qualify for benefit coverage. Citing the termination language in the STD policy, Reliance explained that Newsom was no longer “eligible” for coverage because he was not working “full time” prior to becoming disabled. Certain provisions of the applicable Reliance policies 1 are particularly pertinent to Newsom’s claim and Reliance’s evaluation of it, as they set forth who was eligible for benefits and defined covered disabilities:

1 The provisions are excerpted from Reliance’s LTD policy. Reliance’s STD policy is substantially similar; however, its definition of “Partially Disabled” is distinct from that in the LTD policy, in that the STD policy defines the term as “the Insured is

3 Case: 20-10994 Document: 00516209171 Page: 4 Date Filed: 02/18/2022

No. 20-10994 c/w No. 21-10519 ELIGIBLE CLASSES: Each active, Full-time employee of LERETA, . . . effective November 1, 2015, as amended through January 1, 2018, except any person employed on a temporary or seasonal basis . . . . ... “Full-time” means working for you for a minimum of 30 hours during a person’s regular work week. ... “Totally Disabled” and “Total Disability” mean, that as a result of an Injury or Sickness: (1) during the Elimination Period and for the first 24 months for which a Monthly Benefit is payable, an Insured cannot perform the material duties of his/her Regular Occupation; (a) “Partially Disabled” and “Partial Disability” mean that as a result of an Injury or Sickness an Insured is capable of performing the material duties of his/her Regular Occupation on a part- time basis or some of the material duties on a full- time basis. An Insured who is Partially Disabled will be considered Totally Disabled, except during the Elimination Period; (b) “Residual Disability” means being Partially Disabled during the Elimination Period. Residual Disability will be considered Total Disability; and (2) after a Monthly Benefit has been paid for 24 months, an Insured cannot perform the material duties of Any Occupation. We consider the Insured Totally Disabled if due to an Injury or Sickness he or she is capable of only

unable to perform the material duties of his/her own job and is under the regular care of a Physician.”

4 Case: 20-10994 Document: 00516209171 Page: 5 Date Filed: 02/18/2022

No. 20-10994 c/w No. 21-10519 performing the material duties on a part-time basis or part of the material duties on a full-time basis. ... TERMINATION OF INDIVIDUAL INSURANCE: The insurance of an Insured will terminate on . . . the date the Insured ceases to meet the Eligibility Requirements . . . . (Emphasis added). Critically for this case, the policies did not define “regular work week.” Relying on these policy provisions, Newsom appealed Reliance’s initial denial of his STD claim, contending that Reliance had incorrectly determined his date of “disability,” i.e., when Newsom could no longer “perform the material duties of his/her regular [o]ccupation.” He asserted the true date of disability occurred the week of October 16, 2017—his last scheduled 32-hour work week—because his disability required him to work a reduced schedule (28 hours/week) after that week. Newsom further contended that the number of hours that he actually worked per week was irrelevant because his “regular” work week, i.e., his schedule set by Lereta, was full time (30+ hours/week) through the week of October 16, 2017. Upon further review, Reliance’s STD claim examiner agreed, determining that Newsom’s date of disability was October 23, 2017. Reliance thus paid Newsom STD benefits for the 26-week maximum STD benefit period (October 30, 2017 (Newsom’s eighth day of disability, per the terms of the policy) to April 30, 2018). 2 Newsom also applied for LTD benefits. But Reliance’s LTD examiner denied Newsom’s claim. As with Newsom’s initial STD denial, the LTD examiner determined that Newsom’s date of disability was January

2 Newsom received partial disability benefits from October 30, 2017 to January 29, 2018, when he became unable to work at all.

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Bluebook (online)
Newsom v. Reliance Stnrd Life Ins, Counsel Stack Legal Research, https://law.counselstack.com/opinion/newsom-v-reliance-stnrd-life-ins-ca5-2022.