United States District Court, W.D. Pennsylvania
RONALD P. BOYLES, JR., Plaintiff,
AMERICAN HERITAGE LIFE INSURANCE COMPANY d/b/a ALLSTATE BENEFITS a/k/a ALLSTATE LIFE INSURANCE COMPANY OF NEW YORK, JEFFREY AZZATO, ST. MARYS INSURANCE AGENCY, INC., and UNUM LIFE INSURANCE COMPANY OF AMERICA a/k/a UNUM GROUP, Defendants.
GIBSON, UNITED STATES DISTRICT JUDGE
case arises under the Employee Retirement Income Security Act
of 1974 (ERISA) from the denial of disability benefits to
Plaintiff Robert P. Boyles, Jr. (“Boyles”) by
American Heritage Life Insurance Co. (“AHL”) and
Unum Life Insurance Company of America (“Unum”).
Pending before the Court are AMERICAN HERITAGE LIFE INSURANCE
COMPANY'S MOTION FOR SUMMARY JUDGMENT (ECF No. 60) and
UNUM'S MOTION FOR SUMMARY JUDGMENT ON THE ADMINISTRATIVE
RECORD (ECF No. 64). The parties have developed their
respective positions as to the Concise Statements of Material
Facts and submitted numerous exhibits (including the
administrative records of AHL and Unum, filed under seal)
(ECF Nos. 61, 66-70, 74, 75, 77) and have thoroughly briefed
the legal issues (ECF Nos. 62, 65, 71, 72, 73, 76, 80). The
motions are now ripe for disposition. For the reasons that
follow, the motions are GRANTED.
Jurisdiction and Venue
Court has jurisdiction over this matter pursuant to 28 U.S.C.
§ 1331, as Plaintiff's claims arise under federal
law. Venue is proper in this judicial district pursuant to 29
U.S.C. § 1132(e)(2).
initiated the instant action by filing a twenty-count
complaint (the Original Complaint) in the Court of Common
Pleas of Blair County, Pennsylvania, on September 29, 2015.
(See ECF No. 1-2.) Defendants AHL, Unum, Azzato, and
St. Marys removed the action to this Court on October 22,
2015. (See ECF No. 1.) Defendants then filed several
motions related to Plaintiff's Original Complaint. These
motions were denied as moot because on November 24, 2015,
Plaintiff filed a twelve-count First Amended Complaint
(“FAC”). (See ECF No. 26). Defendants
then filed motions to dismiss portions of the FAC. On July
25, 2016, the Court issued a Memorandum Opinion and Order
which: (1) granted the partial motions to dismiss filed by
AHL and Unum and dismissed counts II, IV, VI and VII of the
FAC; and (2) granted in part and denied in part the motions
filed by Defendants Azzato and St. Marys, and dismissed
counts IX and X of the FAC.
AHL, and Unum agreed that no discovery was necessary between
them and the case should be decided on the respective
administrative records. Pursuant to the Court's Initial
Scheduling Order (ECF No. 43), AHL and Unum filed summary
judgment motions as to the ERISA claims and Plaintiff has
filed his responses thereto.
stage of the case, the Court must view any disputed facts in
the light most favorable to Boyles, the non-moving party.
However, the facts in this case are largely undisputed. The
following recitation is based primarily on Plaintiff's
briefs (ECF Nos. 72, 73).
Ronald Boyles was employed by St. Marys as a commercial
insurance producer from 2006-when St. Marys acquired
Boyles' family-operated insurance company, Boyles
Insurance Agency-until his employment was terminated in
November 2013. By virtue of that employment, Boyles
participated in an employee welfare benefit plan sponsored
and administered by St. Marys. From January 1, 2010 through
July 31, 2013, the plan was insured by a policy underwritten
by AHL. Effective August 1, 2013, St. Marys switched coverage
to a policy underwritten by Unum.
had a history of back problems, which required multiple
surgeries. On September 25, 2012, Boyles had surgery to
reposition a medical device that was implanted in his back.
In December 2012, Boyles expressed interest in filing a
disability claim to Azzato, the President of St. Marys.
Azzato informed Boyles that, due to Boyles' long-time
commitment to the agency and his work ethic, St. Marys would
continue to pay Boyles his full salary while he recovered.
Azzato stated that he considered Boyles to be on a type of
“full-paid medical leave” from December 2012
through November 22, 2013, when his employment terminated.
October 2012 through May 2013, Boyles would come into the
office or work from home, as his condition allowed. On
January 10, 2013, Boyles tripped over an electrical cord in
his office and injured his left shoulder and wrist, and
sustained a concussion. On May 10, 2013, Boyles had shoulder
surgery. After that time, Boyles only worked a few hours per
week. St. Marys did not use time clocks. Azzato estimated
that Boyles' actual hours worked were approximately 10-20
hours per week from May to November, 2013. Azzato terminated
Boyles' employment on November 22, 2013.
December 19, 2013, Boyles submitted a disability claim to
AHL. It was denied initially by AHL for the stated reason
that his condition resulted from the January 10 workplace
accident. Boyles filed three appeals, all of which were
rejected by AHL. The overarching basis for the denials was
that Boyles continued to receive his full salary, and thus
did not satisfy the definition of “disability”
under the terms of the AHL policy. AHL's processing of
the claim will be discussed in more detail below.
10, 2014, Boyles submitted a disability claim to Unum. On
December 26, 2014, Unum denied the claim for the stated
reason that Boyles was not in “active employment”
on August 1, 2013 (the date the Unum policy became
effective), and thus, was not covered under the policy. The
denial letter from Unum also referenced the policy's
“continuity of coverage” provision and determined