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Robert Lafferty v. Unum Life Insurance Company of America

February 29, 2012


The opinion of the court was delivered by: : (Judge Munley)


Before the court for disposition are cross motions for summary judgment in this case wherein Plaintiff Robert Lafferty seeks long term disability benefits under his employer's plan pursuant to the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001 et seq. Defendant Unum Life Insurance Company of America both insured and administered the plan. The issue we must decide is whether defendant abused its discretion in denying the benefits. The parties have briefed their respective positions and, the motions are ripe for decision.


The general background facts are undisputed. Defendant issued to plaintiff's employer a group insurance policy including coverage for long term disability. Plaintiff sought long term disability benefits under the policy alleging a disabling cardiac disorder. Defendant denied the benefits on the basis that plaintiff's cardiac disorder was a pre-existing condition and thus not covered under the policy.*fn1 After exhausting his administrative remedies, plaintiff instituted the instant action alleging that he is indeed entitled to the long term disability benefits. Plaintiff's complaint seeks the following relief: 1) an order that defendant pay him long term disability benefits; 2) prejudgment interest on the award until the date of the judgment; 3) attorney's fees and costs; and 4) other and further relief as the court deems just and proper. (Doc. 1, Compl. Ad Damnum Clause, foll. ¶ 21). At the close of discovery both parties moved for summary judgment. They both argue that the administrative record supports their respective positions. After a careful review, we find that the plaintiff should be awarded benefits.


As this case is brought pursuant to 29 U.S.C. § 1132(a)(1)(B), we have jurisdiction under 28 U.S.C. § 1331 ("The district courts shall have original jurisdiction of all civil actions arising under the Constitution, laws, or treaties of the United States.)"*fn2

Summary judgment standard of review

Granting summary judgment is proper if the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to judgment as a matter of law. See Knabe v. Boury, 114 F.3d 407, 410 n.4 (3d Cir. 1997) (citing FED. R. CIV. P.

56(c)). "[T]his standard provides that the mere existence of some alleged factual dispute between the parties will not defeat an otherwise properly supported motion for summary judgment; the requirement is that there be no genuine issue of material fact." Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 247-48 (1986) (emphasis in original).

In considering a motion for summary judgment, the court must examine the facts in the light most favorable to the party opposing the motion. Int'l Raw Materials, Ltd. v. Stauffer Chem. Co., 898 F.2d 946, 949 (3d Cir. 1990). The burden is on the moving party to demonstrate that the evidence is such that a reasonable jury could not return a verdict for the non-moving party. Anderson, 477 U.S. at 248 (1986). A fact is material when it might affect the outcome of the suit under the governing law. Id. Where the non-moving party will bear the burden of proof at trial, the party moving for summary judgment may meet its burden by showing that the evidentiary materials of record, if reduced to admissible evidence, would be insufficient to carry the non-movant's burden of proof at trial. Celotex v. Catrett, 477 U.S. 317, 322 (1986). Once the moving party satisfies its burden, the burden shifts to the non-moving party, who must go beyond its pleadings, and designate specific facts by the use of affidavits, depositions, admissions, or answers to interrogatories showing that there is a genuine issue for trial. Id. at 324.

ERISA standard of review

In reviewing decisions of ERISA plan administrators or fiduciaries we apply a deferential abuse of discretion standard of review.*fn3 Estate of Schwing v. The Lilly Health Plan, 562 F.3d 522, 525 (3d Cir. 2009) (citing Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 115-16 (2008)). If the entity deciding to grant or deny benefits has any conflict of interest, we consider that conflict as one of several factors in determining whether the administrator or the fiduciary abused its discretion. Id.

An abuse of discretion has occurred where the plan administrator's decision is "without reason, unsupported by substantial evidence or erroneous as a matter of law." Doroshow v. Hartford Life and Accident Ins. Co., 574 F.3d 230, 234 (3d Cir. 2009). "This scope of review is narrow and the court is not free to substitute its own judgment for that of [the plan administrator] in determining eligibility for plan benefits." Id. (internal quotation marks and citation omitted).


The issue before the court is whether the defendant abused its discretion in denying long term disability benefits to plaintiff on the basis that his alleged disability amounted to a "pre-existing" condition, and thus was not covered by the plan. The parties agree that the disability insurance plan is an employee benefit plan within the meaning of, and governed by, ERISA. The parties do not dispute most of the pertinent facts. Plaintiff served in a management position at Bon Secours Community Hospital ("Bon Secours"). Bon Secours had a long term disability benefit plan insured and administered by the defendant. Generally, the plan provides that a management employee is "disabled" when he is "limited from performing the material and substantial duties of [his] own job due to [his] sickness or injury." (Doc. 21, Def. Appx. at 200) (emphasis removed).*fn4 Plaintiff worked the required number of hours per week in his management position to be covered by the plan. (Pl.'s Statement of Material Facts ("Pl. SOF") ¶ 6; Def. Answer to Pl. SOF ¶ 6). The policy excludes pre-existing conditions from coverage. (Pl. SOF ¶ 7). If an ...

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