Osborn ex rel. Petit v. Metropolitan Life Insurance

160 F. Supp. 3d 1238, 2016 U.S. Dist. LEXIS 16859, 2016 WL 589863
CourtDistrict Court, D. Oregon
DecidedFebruary 11, 2016
DocketNo. 3:15-cv-00605-MO
StatusPublished
Cited by4 cases

This text of 160 F. Supp. 3d 1238 (Osborn ex rel. Petit v. Metropolitan Life Insurance) is published on Counsel Stack Legal Research, covering District Court, D. Oregon primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Osborn ex rel. Petit v. Metropolitan Life Insurance, 160 F. Supp. 3d 1238, 2016 U.S. Dist. LEXIS 16859, 2016 WL 589863 (D. Or. 2016).

Opinion

OPINION AND ORDER

MOSMAN, JUDGE.

The issue is the appropriate standard of review to apply in review of Defendant MetLife’s decision to deny coverage for Plaintiff Christeen Osborn’s claim for Accidental Death and Dismemberment insurance. The parties have filed motions for partial summary judgment on this issue. Specifically, Plaintiff Osborn moves for an order that de novo review will be applied while Defendant MetLife contends that the standard of review is abuse of discretion. I find the appropriate standard of review in this case is abuse of discretion. I DENY Plaintiff Osborn’s Motion [14] and GRANT Defendant MetLife’s Motion [15].

I. FACTS

This is an ERISA benefits case in which Plaintiff Christeen Osborn, M.D., claims that MetLife wrongfully denied her claim for $1.25 million in accidental death and [1242]*1242dismemberment (“AD & D”) benefits under the Providence Health & Services Welfare Benefit Plan (the Program). The Program is an ERISA-governed welfare benefit plan which consists of several component plans, including a Participating Life and AD & D Insurance Plan. Documents like the Program are typically prepared by employers in order to provide an overall structure to the menu of benefits available to its employees. This type of document often incorporates by reference the various group health, life, and disability insurance policies that provide the actual coverage for the employees. Benefits under the Program’s Participating Life and Insurance Plan are funded through a group life and AD & D insurance policy that MetLife issued to Dr. Osborn’s employer, Providence Health & Services (PHS), the Program’s sponsor and administrator.

In July 2012, Dr. Osborn was involved in a bicycling accident. In January 2013, she applied for AD & D benefits, claiming to be entitled under the Program’s brain damage provision. In November 2013, MetLife determined that Dr. Osborn was not entitled to AD & D benefits because her brain injury did not result in a complete inability to perform the substantial and material activities of everyday life. Dr. Osborn appealed MetLife’s denial of benefits, and in January 2015, MetLife denied Dr. Osborn’s appeal. Dr. Osborn then brought this action under ERISA’s civil enforcement provision, 29 U.S.C. § 1132(a)(1)(B).

II. DISCUSSION

For claims brought under ERISA’s civil enforcement provision, 29 U.S.C. § 1132(a)(1)(B), a threshold issue is whether the standard of review is de novo or abuse of discretion. Unless the ERISA plan documents contain an unambiguous grant of discretionary authority, the default standard for reviewing the denial of benefits under an ERISA plan is de novo. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). Dr. Osborn asserts three independent reasons why the standard of review should be de novo in this ease: 1) the relevant plan documents do not contain the unambiguous grant of discretionary authority required to overcome the de novo presumption; 2) there is a conflict between the Certificate of Insurance and the Program and therefore the terms of the Certificate of Insurance, which does not contain an unambiguous grant of discretion, controls; and 3) any conveyance of discretionary authority is void under Washington law. I find these arguments are unpersuasive under the present circumstances. For the following reasons, I hold that Met-Life’s denial of benefits will be reviewed for abuse of discretion.

A. Unambiguous Grant of Discretion to the Plan Administrator

Dr. Osborn first argues MetLife does not carry its burden to demonstrate that the language of the Program plainly and unambiguously grants discretionary authority to the plan administrator to construe the terms of the Program’s Participating Life and AD & D Insurance Plan and make benefit determinations. “The default is that the administrator has no discretion, and the administrator has to show that the plan gives it discretionary authority in order to get any judicial deference to its decision.” Kearney v. Standard Ins. Co., 175 F.3d 1084, 1089 (9th Cir.1999) (en banc). When a court assesses the applicable standard of review, “the starting point is the wording of the plan.” Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 962-63 (9th Cir.2006) (en banc). No magic words need appear in the plan document to confer discretion. See id. at 963 (citations omitted). Ultimately, however, the grant of discretionary authority to the plan [1243]*1243administrator must be unambiguous. Sandy v. Reliance Standard Life Ins. Co., 222 F.3d 1202, 1207 (9th Cir.2000) (“[U]n-less plan documents unambiguously say in sum or substance that the Plan Administrator or fiduciary has authority, power, or discretion to determine eligibility or to construe the terms of the Plan, the standard of review will be de novo.”). An unambiguous grant of discretionary authority is one that is so clear it cannot be interpreted to have any other meaning. Kear-ney, 175 F.3d at 1090. Plan terms which merely identify the administrator’s tasks but bestow no power to interpret the plan are insufficient to confer discretionary authority. Ingram v. Martin Marietta Long Term Disability Income Plan for Salaried Employees of Transferred GE Operations, 244 F.3d 1109, 1113 (9th Cir.2001).

MetLife contends that both Section 9.2 and Supplement E of the Program plainly and unambiguously grant discretionary authority to the plan administrator sufficient to trigger abuse of discretion review. Section 9.2 of the Program, entitled “Claims Procedure for ERISA Participating Plans,” provides that “[b]enefits shall be paid under the Program only if the Program Administrator or Claims Administrator determines in its discretion that the applicant is entitled to them.” (The Program, Doc. 18, Ex. A at 38 (emphasis added).) Dr. Osborn argues that while Section 9.2 may constitute a grant of discretionary authority to determine eligibility for benefits, it does not grant the administrator discretion to construe the terms of the plan, and the latter is what is necessary to overcome the default de novo review. In support of this argument, Dr. Osborn relies on Abatie, in which the Ninth Circuit stated that “ERISA plans are insufficient to confer discretionary authority on the administrator when they do not grant any power to construe the terms of the plan.” 458 F.3d at 964. While at first blush this language appears to support Dr. Osborn’s argument that a grant of discretion must necessarily include authority to interpret the terms of the plan, a closer review of Abatie

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160 F. Supp. 3d 1238, 2016 U.S. Dist. LEXIS 16859, 2016 WL 589863, Counsel Stack Legal Research, https://law.counselstack.com/opinion/osborn-ex-rel-petit-v-metropolitan-life-insurance-ord-2016.