Penny Grosz-Salomon v. Paul Revere Life Insurance Company, a Provident Company Cross-Appellee

237 F.3d 1154, 2001 Daily Journal DAR 1007, 25 Employee Benefits Cas. (BNA) 1769, 2001 Cal. Daily Op. Serv. 783, 2001 U.S. App. LEXIS 1152, 2000 WL 33128619
CourtCourt of Appeals for the Ninth Circuit
DecidedJanuary 29, 2001
Docket99-55812, 99-55960
StatusPublished
Cited by186 cases

This text of 237 F.3d 1154 (Penny Grosz-Salomon v. Paul Revere Life Insurance Company, a Provident Company Cross-Appellee) is published on Counsel Stack Legal Research, covering Court of Appeals for the Ninth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Penny Grosz-Salomon v. Paul Revere Life Insurance Company, a Provident Company Cross-Appellee, 237 F.3d 1154, 2001 Daily Journal DAR 1007, 25 Employee Benefits Cas. (BNA) 1769, 2001 Cal. Daily Op. Serv. 783, 2001 U.S. App. LEXIS 1152, 2000 WL 33128619 (9th Cir. 2001).

Opinion

T.G. NELSON, Circuit Judge:

This case requires us to decide whether the district court properly reviewed Paul Revere Life Insurance Company’s decision to terminate Penny Grosz-Salomon’s disability insurance benefits for an abuse of discretion, and if so, whether the court’s determination that Paul Revere abused that discretion in denying benefits withstands scrutiny. For the reasons explained below, we hold that the district court erred in applying the abuse of discretion rather than de novo standard of review. However, because this error inured exclusively to Grosz-Salomon’s detriment and she nonetheless prevailed, we affirm.

I

In August 1992, the law firm of Reznik & Reznik (“Reznik”) purchased a long-term disability policy for its employees from Paul Revere Life Insurance Company (“Paul Revere”). Immediately thereafter, Reznik distributed to its employees a Benefit Summary that it had received from Paul Revere. 2 About a year later, in October 1993, Paul Revere contacted Reznik’s managing partner, Alan Kheel, and informed him that a Retirement Security Benefit (“RSB”) had inadvertently been included in Reznik’s policy. In order to correct that error, Paul Revere presented Kheel with a policy amendment, which Kheel signed. Paul Revere then supplied Reznik with a revised Benefit Summary, which Reznik again distributed. Unlike its predecessor, the revised Benefit Summary contained a paragraph giving Paul Revere “full, final, conclusive and binding power to construe and interpret the policy ... in order to make claims determinations.” Kheel did not execute an amendment authorizing this change.

Between the original issuance of the policy and the execution of the October 1993 amendment to remove the RSB, one of Reznik’s attorneys became disabled. Penny Grosz-Salomon, a senior trial attorney, 3 filed a claim on September 1, 1993, after pregnancy complications began interfering with her work. Grosz-Salomon’s complications worsened as her pregnancy progressed, and after her daughter’s birth, doctors discovered Grosz-Salomon had two herniated disks in her lower back. Grosz-Salomon notified Paul Revere of her back condition, which she claimed caused severe pain and numbness and prevented her from walking, sitting, or standing for prolonged periods of time. Reports from three doctors buttressed her claim.

Following the requisite ninety-day elimination period, Paul Revere accepted Grosz-Salomon’s claim for long-term disability benefits and began paying her $9,917 per month. Soon after, Paul Revere initiated an investigation of whether Grosz-Salomon was disabled under the plan. As part of this investigation, it intermittently sent a field representative to interview Grosz-Salomon and required her to submit to an independent medical examination (“IME”) and a functional capacity evaluation (“FCE”). The doctor who performed the 1995 IME concluded that Grosz-Salomon was “temporarily totally disabled,” while the occupational therapists who- performed the 1997 FCE recommended that Grosz-Salomon “[r]eview options for returning to [the] legal profession as a corporate lawyer ..., insurance lawyer or a less demanding area of law that would not need as much handling of materials ..., prolonged sit-standing ..., and working greater than 8-9 hours as in trial work.”

*1158 Between 1995 and 1997, Paul Revere surreptitiously videotaped Grosz-Salomon on several occasions. Upon viewing this videotape, Paul Revere’s Associate Medical Director concluded that Grosz-Salomon “does not have an impairment that would preclude the duties of a lawyer.” Another of its medical consultants opined that Grosz-Salomon “could perform her occ[upation] at least part time now, and shortly work up to full time.” Neither of these two doctors, however, examined Grosz-Salomon, and neither opined that she could function full-time as a trial lawyer.

In December 1997, Paul Revere concluded that Grosz-Salomon was not disabled within the meaning of Reznik’s policy and wrote to inform her of this decision. Although Paul Revere now admits that this decision was based in part on its two in-house doctors’ “medical consultations,” it did not advise Grosz-Salomon of this fact at the time. Indeed, Paul Revere did not produce the records of these consultations until sometime after August 1998, when its final denial of Grosz-Salomon’s claim prompted her to file suit.

The district court granted summary judgment for Grosz-Salomon. The court did not resolve whether the amended Benefit Summary language controlled because the court concluded that even if it did not, the abuse of discretion standard of review applied. The court found that Paul Revere’s denial of Grosz-Salomon’s claim constituted such an abuse of discretion. Accordingly, it ordered Paul Revere to pay damages and reinstate Grosz-Salomon’s benefits effective January 1,1998.

In denying Paul Revere’s subsequent motion to stay execution of the judgment pending appeal, the district court acknowledged that under Kearney v. Standard Insurance Co., 4 a Ninth Circuit case that postdated its judgment, it should not, in fact, have applied abuse of discretion review. Rather, de novo review was appropriate. The court found that its error was harmless, however, because even under the stricter standard, Grosz-Salomon showed that Paul Revere violated the plan’s terms in denying her benefits. Paul Revere appeals, and Grosz-Salomon cross-appeals.

We review de novo both the district court’s application of the standard of review in an ERISA case and its conclusion that the ERISA plan administrator abused its discretion. 5

II

Firestone Tire & Rubber Co. v. Bruch 6 instructs courts to review an ERISA plan administrator’s benefits determination de novo “unless the benefit plan gives the administrator ... discretionary authority to determine eligibility for benefits or to construe the terms of the plan,” in which case abuse of discretion review applies. 7 Here the original plan lacks such discretionary language. It simply states that Paul Revere “ha[s] the right to require written proof of financial loss” and that “[pjayment of benefits may be contingent upon receipt of satisfactory proof of financial loss.” Although this court once considered such a statement sufficient to confer discretion, 8 it is clear that it no longer does so. 9 The revised Benefit Summary, *1159 however, indisputably does confer discretion. It states that Paul Revere “has the full, final, conclusive and binding power to construe and interpret the policy under the plan ... to make claims determinations.” Thus, to decide which standard of review applies, we must first decide which version of the plan governs.

A. Which Plan Applies?

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237 F.3d 1154, 2001 Daily Journal DAR 1007, 25 Employee Benefits Cas. (BNA) 1769, 2001 Cal. Daily Op. Serv. 783, 2001 U.S. App. LEXIS 1152, 2000 WL 33128619, Counsel Stack Legal Research, https://law.counselstack.com/opinion/penny-grosz-salomon-v-paul-revere-life-insurance-company-a-provident-ca9-2001.