Patrick L. Gallagher v. Reliance Standard Life Insurance Company

305 F.3d 264, 29 Employee Benefits Cas. (BNA) 1963, 2002 U.S. App. LEXIS 20354, 2002 WL 31115606
CourtCourt of Appeals for the Fourth Circuit
DecidedSeptember 25, 2002
Docket01-2467
StatusPublished
Cited by114 cases

This text of 305 F.3d 264 (Patrick L. Gallagher v. Reliance Standard Life Insurance Company) is published on Counsel Stack Legal Research, covering Court of Appeals for the Fourth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Patrick L. Gallagher v. Reliance Standard Life Insurance Company, 305 F.3d 264, 29 Employee Benefits Cas. (BNA) 1963, 2002 U.S. App. LEXIS 20354, 2002 WL 31115606 (4th Cir. 2002).

Opinion

Reversed and remanded with instructions by published opinion. Judge WILLIAMS wrote the opinion, in which Judge GREGORY and Judge STAMP joined.

OPINION

WILLIAMS, Circuit Judge.

Reliance Standard Life Insurance Company (Reliance) appeals the district court’s entry of summary judgment in favor of Patrick L. Gallagher in this action for wrongful denial of benefits under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C.A. § 1001 et seq. (West 2001). The issues on appeal are (1) whether the district court erred in applying an abuse of discretion standard to Reliance’s decision to deny benefits and (2) whether the district court erred by reversing Reliance’s decision to deny benefits and entering summary judgment in Gallagher’s favor. We conclude that Reliance’s decision to deny benefits to Gallagher is subject to de novo review and uphold Reliance’s decision under this standard of review. Accordingly, we reverse the district court’s entry of summary judgment in Gallagher’s favor and remand for entry of judgment in Reliance’s favor.

I.

Gallagher worked as a corporate officer and publisher for Goodwill Publishing, Inc. (GWP) for 26 years. His job required three to four hours a day of sedentary work, such as word processing, and some international travel. Gallagher suffered on and off from back pain during most of the time he was employed by GWP. In 1986, Gallagher sought medical treatment for pain in his lumbar spine. When his condition did not improve, he underwent a suction discectomy. The surgery improved Gallagher’s condition, but walking, standing, and sitting remained difficult. In 1990, Gallagher began treatment at the Key Biscayne Medical Clinic and eventually took a leave of absence to enroll in a six-week rehabilitation program. Dining this time, Gallagher began to suffer nerve pain in his neck and left arm and was diagnosed with diffuse degenerative disc disease, disc herniation, and spurring on the facets 1 throughout his lumbar spine. In 1997, *268 Gallagher's cervical spine pain became "severe." (J.A. at 936.) Dr. Eismont, a neurosurgeon, diagnosed Gallagher as suffering from arthritic changes and stenosis. 2 Because of the pain caused by his chronic back condition, Gallagher resigned from his job on May 2, 1993.

Gallagher is covered by GWP's long-term disability policy (the Plan), an employee welfare benefit plan governed by ERISA and funded by Reliance. GWP is the Plan Administrator, and Reliance is a fiduciary with responsibility for making claims determinations. On July 10, 1998, GWP foiwarded Gallagher's disability benefit application to Reliance. On February 2, 1999, Reliance denied Gallagher's claim because it determined that his medical condition did not meet the definition of total disability under the Plan. On February 25, 1999, the Social Security Administration found Gallagher to be totally disabled under the Social Security regulations. On June 3, 1999, Gallagher requested Reliance to review the denial of his disability benefits under the Plan and submitted additional materials to support his claim. On October 13, 1999, Reliance, after conducting an independent review, determined that denial of benefits was appropriate based on Gallagher's failure to satisfy the definition of total disability. Specifically, Reliance concluded that Gallagher could perform one or more of the material duties of his regular occupation. Having exhausted his administrative remedies, Gallagher initiated this ERISA action in the United States District Court for the Western District of North Carolina. The district court con-eluded that Reliance had abused its discretion and entered summary judgment in favor of Gallagher. Reliance filed a timely notice of appeal.

II.

We examine the district court's grant of summary judgment de novo, applying the same legal test as the district court. Elliott v. Sara Lee Corp., 190 F.3d 601, 605 (4th Cir.1999). It is well-established that a court reviewing the denial of disability benefits under ERISA initially must decide whether a benefit plan's language grants the administrator or fiduciary discretion to determine the claimant's eligibility for benefits, and if so, whether the administrator acted within the scope of that discretion. Feder v. Paul Revere Life Ins. Co., 228 F.3d 518, 522 (4th Cir.2000); see also Johannssen v. District No. 1-Pacific Coast District, 292 F.3d 159, 168 (4th Cir.2002) (explaining that if the language of the plan grants the administrator or fiduciary discretion to determijie eligibility for benefits under the plan, the reviewing court determines whether a denial of benefits was an abuse of discretion). 3 No specific phrases or terms are required in a plan to preclude a de novo standard of review. Feder, 228 F.3d at 522 ("[I]f the terms of a plan indicate a clear intention to delegate final authority to determine eligibility to the plan administrator, then this Court will recognize discretionary authority by implication."). The plan's intention to confer discretion on the plan administrator or fiduciary, however, must be clear. Sandy v. Reliance Standard Life Ins. Co., 222 F.3d 1202, 1207 (9th Cir.2000) ("Nei *269 ther the parties nor the courts should have to divine whether discretion is conferred.”). If a plan does not clearly grant discretion, the standard of review is de novo. Feder, 228 F.3d at 524. Any ambiguity in an ERISA plan “is construed against the drafter of the plan, and it is construed in accordance with the reasonable expectations of the insured.” Bynum v. Cigna Healthcare, Inc., 287 F.3d 305, 313-14 (4th Cir.2002). Of course, because de novo review is more rigorous, if a reviewing court upholds a benefits decision under de novo review, it also would uphold it under a deferential standard. Feder, 228 F.3d at 522 (explaining that under the deferential standard, the reviewing court should uphold an administrator’s decision if it is reasonable, even if the court would have reached a different conclusion).

With these principles in mind, we must determine whether the following language in the plan grants Rebanee discretion to determine Gallagher’s ehgibility for benefits: “We will pay a Monthly Benefit if the Insured ... submits satisfactory proof of Total Disability to us.” 4 (J.A. at 89.) There are two possible ways to interpret this language: (1) that Gallagher must submit to Reliance satisfactory proof of his disabibty or (2) that he must submit proof of his disability that is satisfactory to Reliance. 5

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Bluebook (online)
305 F.3d 264, 29 Employee Benefits Cas. (BNA) 1963, 2002 U.S. App. LEXIS 20354, 2002 WL 31115606, Counsel Stack Legal Research, https://law.counselstack.com/opinion/patrick-l-gallagher-v-reliance-standard-life-insurance-company-ca4-2002.