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Davies v. First Reliance Standard Life Insurance Co.

United States District Court, M.D. Pennsylvania

March 9, 2017

KRISTEN ANN DAVIES, Plaintiff,
v.
FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY, Defendant,

          MEMORANDUM

          Hon. John E. Jones III Judge.

         Presently pending before the Court are the parties' cross motions for summary judgment. (Docs. 13, 19). Plaintiff Kristen Ann Davies initiated this action under the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001, et. seq. (“ERISA”), alleging that Defendant First Reliance Standard Life Insurance Company (“First Reliance”) arbitrarily and capriciously denied her ongoing disability benefits. (Doc. 1). Plaintiff filed a motion for summary judgment on October 14, 2016, along with a brief in support. (Docs. 13, 14). First Reliance filed a brief in opposition on November 28, 2016 (Doc. 16), including argument in support of its own cross motion for summary judgment that was formally filed later. (Doc. 19). Plaintiff filed a brief in opposition to First Reliance's cross motion on December 14, 2016. (Doc. 17). First Reliance filed a brief in reply on January 4, 2017. (Doc. 23). While Plaintiff did not file a brief in reply with regard to her own motion for summary judgment, the time for filing has long passed (See Local Rule 7.7) and she inherently included reply argument in her opposition to First Reliance's motion. Therefore, the motions are fully briefed and ripe for our review. For the following reasons, we shall grant summary judgment in favor of First Reliance.

         I. BACKGROUND

         First Reliance sold a group long term disability insurance policy, LTD 118674 (the “Policy”), to Plaintiff's employer, Forest Laboratories, Inc. (Doc. 13, ¶ 4). Prior to claiming disability, Plaintiff worked for Forest Laboratories, Inc. as a Pharmaceutical Detailer, which is a light level occupation. (Doc. 15, p. 20, ¶ 2). The relationship between First Reliance, Forest Laboratories, Inc., and Plaintiff is governed by ERISA. (Doc. 13, at ¶ 5).

         The Policy includes the following provision: “[t]he claims review fiduciary has the discretionary authority to interpret the Plan and the insurance policy to determine eligibility for benefits.” (Id., at ¶ 9). First Reliance granted itself discretion as the “claims review fiduciary” and “is solely responsible for claim handling, claim reviews, and claim decisions.” (Id., at ¶¶ 9-10). The Policy defines “Total Disability” as follows:

“‘Totally Disabled' and ‘Total Disability' mean, that as a result of an Injury or Sickness:
(1) during the Elimination Period and for the first 24 months for which a Monthly Benefit is payable, an Insured cannot perform the material duties of his/her Regular Occupation;
(a) ‘Partially Disabled' and ‘Partial Disability' mean that as a result of an Injury or Sickness an Insured is capable of performing the material duties of his/her Regular Occupation on a part-time basis or some of the material duties on a fulltime basis. An Insured who is Partially Disabled will be considered Totally Disabled, except during the Elimination Period;
(b) ‘Residual Disability' means being Partially Disabled during the Elimination Period. Residual Disability will be considered a Total Disability; and
(2) after a Monthly Benefit has been paid for 24 months, an Insured cannot perform the material duties of Any Occupation. We consider the Insured Totally Disabled if due to an Injury or Sickness he or she is capable of only performing the material duties on a part-time basis or part of the material duties on a Full-time basis.”

         (AR0010).[1] The Policy also includes the following limitation, which we will refer to as the “Mental/Nervous limitation”:

MENTAL OR NERVOUS DISORDERS: Monthly Benefits for Total Disability caused by or contributed to by mental or nervous disorders will not be payable beyond an aggregate lifetime maximum duration of twenty-four (24) months unless the Insured is in a Hospital or Institution at the end of the twenty-four (24) month period. The Monthly Benefit will be payable while so confined, but not beyond the Maximum Duration of Benefits. . .

         Mental or Nervous Disorders are defined to include disorders which are diagnosed to include a condition such as:

(1) bipolar disorder (manic depressive syndrome);
(2) schizophrenia;
(3) delusional (paranoid) disorders;
(4) psychotic disorders;
(5) depressive ...

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