Sanford v. Life Insurance

1 F. Supp. 3d 829, 2014 U.S. Dist. LEXIS 25197, 2014 WL 794368
CourtDistrict Court, M.D. Tennessee
DecidedFebruary 27, 2014
DocketNo. 2:12-0056
StatusPublished
Cited by3 cases

This text of 1 F. Supp. 3d 829 (Sanford v. Life Insurance) is published on Counsel Stack Legal Research, covering District Court, M.D. Tennessee primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Sanford v. Life Insurance, 1 F. Supp. 3d 829, 2014 U.S. Dist. LEXIS 25197, 2014 WL 794368 (M.D. Tenn. 2014).

Opinion

MEMORANDUM

KEVIN H. SHARP, District Judge.

This is an action under 29 U.S.C. § 1132(a)(1)(B) of the Employee Retire[831]*831ment Income Security Act (“ERISA”) to obtain judicial review of the denial of short- and long-term disability (STD and LTD) benefits. The case presents the issue of whether Defendant Life Insurance Company of North , America (“LINA”) could properly determine that, under the language of the applicable Plans, Plaintiff Edward Sanford was not eligible for disability benefits because at the time his injury he had already voluntarily resigned from his job. Given the deferential standard of review which must be utilized, the Court finds that it should and accordingly will grant LINA’s “Motion for Judgment on the Administrative Record” (Docket No. 18) and deny Plaintiffs “Motion for Judgment on the ERISA Record” (Docket No. 16).

I. BACKGROUND

Plaintiff was employed as the Chief Executive Officer/Administrator for LifePoint Hospitals, Inc. and, by virtue of that employment, was covered by both STD and LTD insurance policies underwritten by LINA. By letter dated October 4, 2010, Plaintiff informed his employer that his employment would terminate thirty days hence, unless an agreement was reached as to an earlier date.

On November 3, 2010, Plaintiff resigned. At the time of his resignation, he had four weeks of accrued Paid Time Off and he continued to be paid his regular salary for the pay periods October 31 through November 27, 2010. From that pay, his employer deducted premiums for disability insurance, as well as premiums for life insurance, medical insurance, vision insurance, and other employee benefits, just as it had on prior payroll checks.1

On November 8, 2010, five days after Plaintiff resigned, he flew his plane to Louisiana and, while stepping off the wing, fell approximately three feet to the ground. He went to the hospital the following day and was diagnosed as having suffered an L5 burst fracture in his back which required surgery. He was later found to have compression fractures at other levels of the lumbar spine for which he underwent kyphoplasties on January 7 and February 24, 2010. It was subsequently determined that he had multiple myeloma.

In April 2011, Plaintiff filed for STD and LTD benefits. By letter dated June 16, 2011, LINA denied LTD benefits, writing:

Your employer returned records indicating your last day worked was 11/3/2010, and that you had voluntarily resigned effective this same date. Premiums were paid through 11/3/2010, per this same record.
The following clause in the policy refers to the effective coverage and indicates termination of eligibility.
Termination of Insurance
An Employee’s coverage will end on the earliest of the following dates:
1. the date the Employee is eligible for coverage under a plan intended to replace this coverage;
2. the date the Policy is terminated;
8. the date the Employee is no longer in an eligible class;
4. the day after the end of the period of which premiums are paid;
5. the date the Employee is no longer in Active Service;
6. the date benefits end for failure to comply with the terms and conditions of the Policy.
Because you received treatment (11/8/2010) for a diagnosis that began after your employment ended [832]*832(11/3/2010), you are not eligible for LTD coverage.

(Docket No. 23-1 at 146). STD benefits were denied by LINA on July 28, 2011, for identical reasons.

Plaintiff appealed the denial of benefits on September 30, 2011, claiming that he continued to pay premiums after his resignation through at least November 27, 2010,2 and stating that he was receiving his accrued Paid Time Off3 at the time he became disabled. Shortly thereafter, a LINA Appeals Specialist wrote Wendi Hester, the Senior Director of Compensation and Benefits at LifePoint Hospitals, asking whether Plaintiff “was using vacation time through 11/08/2011,” to which she replied:

Our records indicate that November 3rd was the last day of employment for Mr. Edwards. When he terminated employment he had 4 weeks of accrued Paid Time Off that was paid to him, but his last day of employment was 11/3.
I have a message in to the CEO at the facility where Mr. Sanford worked to confirm this.

(Docket No. 23-4 at 31 & 32). A few days later, LINA was informed by Ms. Hester that the CEO had confirmed “that Mr. Sanford’s last day of employment was November 3rd” and that she had “obtained a copy of his signed resignation letter indicating the same.” (Id. at 31).

LINA confirmed its denial of STD benefits by letter addressed to Plaintiffs counsel dated November 22, 2011. In pertinent part, the letter read:

We have received confirmation from LIFEPOINT HOSPITALS, INC. that November 3, 2010 was the last day of employment for your client. When he terminated employment he had 4 weeks of accrued Paid Time Off that was paid to him, but his last day of employment was November 3, 2010. This means that the November 3, 2010 was the last date that your client was in Active Service. The medical records from Our Lady of The Lake Regional Medical Center indicate that your client sustain [sic] his injuries on November 8, 2010 after falling from a [sic] airplane wing and was subsequently admitted on November 9, 2010.
The information outlined above falls [sic] indicates that your client was not in Active Service at the time of his injury on November 8, 2010, therefore your client’s claim has been denied. Because we determined your client was not in Active Service at the time of injury, we did not continue our evaluation of your client’s disability. At this time, your claim has been closed and no benefits are payable.

(Docket No. 23-1 at 158-59).

On December 6, 2011, LINA also denied Plaintiffs claim for LTD benefits. In a letter explaining the decision, LINA wrote:

We based our decision on Mr. Sanford’s claim for benefits upon Policy language and all documents contained in his claim file were viewed as a whole.
We are aware that your client has been off work since November 8, 2010 due to complications from multiple myelomas and compression fracture of the lumbar spine. Please note that according to your client’s employer, Lifepoint Hospi[833]*833tal, Mr. Sanford’s last day of work was November 3, 2010 as your client voluntarily terminated his employment. This information has been confirmed by his employer including the CEO of the facility where your client worked. Mr. Sanford’s employer also has a signed and dated letter of resignation indicating November 3, 2010 as his last date of employment.

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Bluebook (online)
1 F. Supp. 3d 829, 2014 U.S. Dist. LEXIS 25197, 2014 WL 794368, Counsel Stack Legal Research, https://law.counselstack.com/opinion/sanford-v-life-insurance-tnmd-2014.