Safdi v. Covered Employer's Long Term Disability Plan Under the Union Central Employee Security Benefit Trust

631 F. App'x 304
CourtCourt of Appeals for the Sixth Circuit
DecidedNovember 24, 2015
Docket14-3598
StatusUnpublished
Cited by1 cases

This text of 631 F. App'x 304 (Safdi v. Covered Employer's Long Term Disability Plan Under the Union Central Employee Security Benefit Trust) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Safdi v. Covered Employer's Long Term Disability Plan Under the Union Central Employee Security Benefit Trust, 631 F. App'x 304 (6th Cir. 2015).

Opinion

OPINION

JULIA SMITH GIBBONS, Circuit Judge.

Alan Safdi (“Safdi”) received long-term disability benefits for seven years before they were terminated. After several administrative appeals, Safdi sued for bene *306 fits owed under the private right of action created by the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1132(a), and the Union Central Life Insurance Company (“Union Central”) counterclaimed to recover alleged overpayments pursuant to § 1132(a)(3)(B). The district court granted Safdi’s motion for summary judgment on Union Central’s counterclaim. On cross-motions for judgment, the district court ultimately entered judgment for Union Central on Safdi’s claim. Both parties appealed. After oral argument, we suggested that the parties attempt mediation, which resolved the cross-appeal from the dismissal of Union Central’s counterclaim. For the reasons stated herein, we affirm the judgment of the district court to dismiss Safdi’s case.

I.

A.

Since 1983, Safdi has practiced with Greater Cincinnati Gastroenterology Associates Physicians, Inc. (“GCGA”), where he also served as an officer. In 1998, GCGA purchased group disability insurance for its doctors through Union Central. The primary document for the plan, the Union Central Master Policy (“the Policy”), described benefits for employees “in Active Full-Time Employment” with a covered employer. DE 32-1, Policy, Page ID # 4225. The Policy defined “Active Full-Time Employment” as follows:

You must be:
1. working for the Covered Employer on a full-time basis and paid regular earnings;
2. performing Your normal duties, if it is a scheduled work day;
3. working at least the number of hours shown in the Coverage Schedule; and
4.working at Your normal place of employment or at some other location where the Covered Employer’s business requires You to travel.

Id. The earliest Coverage Schedule in the record set the third condition at thirty (30) hours per week.

The Policy contained six options under which an employee of a participating employer would receive benefits. All options paid out only after an employee qualified for benefits after an “Elimination Period,” which for GCGA’s policy lasted ninety (90) days. The first four options required that the employee be “Totally Disabled” for varying lengths of time. Each option defined “Totally Disabled” as “unable to perform the material and substantial duties of Your Own Occupation due to an Injury or Sickness” for a certain number of months. Id. at 4229. The fifth option paid benefits for “Partial Disability” and is not relevant to this case.

The last scenario, Option VI, paid benefits for “Residual Disability,” which the Policy defined as follows:

Residual Disability means as a result of Injury or Sickness which caused Disability, You are unable to perform the material and substantial duties of Your Own Occupation on a full-time basis, and You are:
1. performing at least one. of the material duties of Your Own Occupation or another occupation on a full-time or part-time basis; or
2. performing each of the material duties of Your Own Occupation or another occupation on a part-time basis....

Id. at 4230.

The Policy clarified the Residual Disability option through a series of questions and corresponding answers. For example, in response to the question, “Can You *307 Work During the Elimination Period?”, the Policy noted that an employee could work during the Elimination Period and still receive Residual Disability benefits. Id. The Policy responded to the question, “What Are the Requirements to Qualify for a Residual Disability Benefit?”, as follows:

If You are Residually Disabled and have Current Monthly Earnings in excess of 20% of Your Average Monthly Earnings, You will be paid a Residual Disability Benefit if ...
1. You satisfy the Elimination Period
2. You submit satisfactory Proof of Disability to Us that You are Resid-ually Disabled as defined in this Plan; and,
3. You are earning less than 80% of Your Average Monthly Earnings.

Id. at 4231.

Nowhere does the Policy explicitly define “Recurrent Disability.” However, the Policy lends meaning to Recurrent Disability in another question-and-response set, as stated in full:

What Happens If Your Disability Reoccurs After You Return to Work Full Time? A Recurrent Disability will be treated as part of a prior Disability if You suffer a subsequent Disability which is:
1. due to the same cause or a cause related to the prior Disability; and
2. less than 6 months has elapsed.
If more than 6 months has elapsed from the time You ceased to receive Disability Benefits under this Plan and You suffer a subsequent Disability which is due to the same or a cause related to a prior Disability, a Recurrent Disability will be treated as a new period of Disability, and You will be required to complete a new Elimination Period.
The Recurrent Disability provision will cease to apply on the earlier of the following dates:
1. the date You become eligible for benefits under any other Group Long Term Disability Policy; or
2. the date You are no longer covered under the terms of this Plan.

Id. at 4236.

The Policy next explains the termination of Monthly Benefits:

When Does the Monthly Benefit Terminate? Your Monthly Benefit will continue to be paid until the earliest of the following dates occurs:
1. the date You are no longer Disabled;
5. the date Your Current Monthly Earnings exceed 80% of Your Indexed Average Monthly Earnings ....

Id. The Policy defined “Monthly Benefits” as “a monthly sum payable to You or on Your behalf while You are Disabled.” Id. at 4228.

B.

While covered under the Policy, Safdi underwent surgery for prostate cancer in May 2002. He experienced several serious complications from this surgery, which forced him to reduce his workload at GCGA significantly, from 75 to 80 hours per week to about 30 to 40 hours per week. As a result, Safdi lost income due to fewer hours billed. Initially, GCGA’s separate short-term disability plan made up for Saf-di’s lost income, but after this expired he filed a claim for benefits under the Policy. 1

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Bluebook (online)
631 F. App'x 304, Counsel Stack Legal Research, https://law.counselstack.com/opinion/safdi-v-covered-employers-long-term-disability-plan-under-the-union-ca6-2015.