Robison v. Life Insurance Company of North America, No. 3:2015cv01331 - Document 36 (N.D. Cal. 2016)
Court Description: ORDER GRANTING MOTION FOR SUMMARY JUDGMENT by Judge Jon S. Tigar granting 24 Motion for Summary Judgment. (wsn, COURT STAFF) (Filed on 5/3/2016)
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Robison v. Life Insurance Company of North America Doc. 36 1 2 3 4 UNITED STATES DISTRICT COURT 5 NORTHERN DISTRICT OF CALIFORNIA 6 7 RODNEY ROBISON, Case No. 15-cv-01331-JST Plaintiff, 8 v. ORDER GRANTING MOTION FOR SUMMARY JUDGMENT 9 10 LIFE INSURANCE COMPANY OF NORTH AMERICA, Defendant. 11 United States District Court Northern District of California Re: ECF No. 24 12 Before the Court is Defendant Life Insurance Company of North America’s (“LINA”) 13 14 Motion for Summary Judgment. ECF No. 24. The Court will grant the motion. 15 I. 16 BACKGROUND Plaintiff Rodney Robison brought this action under the Employee Retirement Income 17 Security Act (“ERISA”), 29 U.S.C. § 1001 et seq., seeking to recover accidental death and 18 dismemberment benefits allegedly due to him resulting from the death of his stepson, Cody 19 Brown, who was killed in an automobile accident on October 27, 2014. ECF No. 16. Mr. Brown 20 was born on June 19, 1994. ECF No. 25-1 at 1. He was 20 years and four months old at the date 21 of his death. 22 At the time of Mr. Brown’s death, Plaintiff was enrolled in an accidental death and 23 dismemberment insurance policy (“the Policy”) offered by LINA with a benefit limit of $10,000 24 for dependents. ECF No. 25-7 (the Policy); ECF No. 25-8 (enrollment summary). The Policy 25 covers “a sudden, unforeseeable, external event that results, directly and independently of all other 26 causes, in a Covered Injury or Covered Loss and” occurred “while the Covered Person is insured 27 under this Policy.” ECF No. 25-7 at 9. A “Covered Person” is defined as “[a]n eligible person . . . 28 for whom an enrollment form has been accepted by [LINA] and required premium has been paid Dockets.Justia.com 1 when due and for whom coverage under this Policy remains in force. The term Covered Person 2 shall include, where th[e] Policy provides coverage, an eligible Spouse and eligible Dependent 3 Children.” Id. It is undisputed that Plaintiff submitted an enrollment form for Mr. Brown at least 4 as of 2012, ECF No. 25-8, and that all required premiums had been paid when due as of the time 5 of the accident on October 27, 2014. 6 7 8 9 10 United States District Court Northern District of California 11 12 13 14 15 16 17 The Policy goes on to define “Dependent Children” as follows: An Employee’s unmarried child who meets the following requirements: 1. A child from live birth to 19 years old; 2. A child who is 19 or more years old but less than 23 years old, enrolled in a school as a full-time student and primarily supported by the Employee; 3. A child who is 19 or more years old, primarily supported by the Employee and incapable of self-sustaining employment by reason of mental or physical handicap. Proof of the child’s condition and dependence must be submitted to Us within 31 days after the date the child ceases to qualify as a Dependent Child for the reasons listed above. During the next two years, We may, from time to time, require proof of the continuation of such condition and dependence. After that, We may require proof no more than once a year. ECF No. 25-7 at 10. According to the Policy, “[i]nsurance becomes effective for an Employee’s eligible 18 dependents if the Employee applies and agrees to make required contributions within 31 days of 19 the date his dependents become eligible . . . .” Id. at 10. The Policy provides that “[t]he insurance 20 on a Covered Person will end on the earliest date below: . . . 2. the next premium due date after the 21 date the Covered Person is no longer in a Covered Class or satisfies eligibility requirements under 22 this Policy; . . . 4. the next premium due date after the Covered Person attains the maximum Age 23 for insurance under this Policy . . . .” Id. at 13. 24 The parties do not dispute that Mr. Brown worked for Certified Tire & Service Center 25 (“Certified Tire”) in Livermore, CA from July 9, 2014 to August 5, 2014. ECF No. 24 at 7; ECF 26 No. 28 at 6. Nor do the parties dispute that Mr. Brown stopped working at Certified Tire in 27 August 2014 due to a work-related back injury. Id. The parties do, however, dispute the extent of 28 2 1 Mr. Brown’s injuries and the degree to which these injuries rendered Mr. Brown unable to work.1 Plaintiff submitted his claim to LINA on October 31, 2014. ECF No. 25-9 at 1. Plaintiff 2 3 submitted a revised claim form later that same day. Id. at 2–4. LINA wrote Plaintiff several 4 letters between November 2014 and December 2015 seeking additional documentation regarding 5 Plaintiff’s claim. See, e.g., ECF No. 27-9 at 43; ECF No. 27-2 at 27. On January 12, 2016, LINA 6 wrote to Plaintiff, informing him that it had determined that the benefit was not payable. ECF No. 7 27-2 at 13–18. The letter included the definition of “Dependent Child” quoted above and 8 explained that “Cody Brown was not enrolled in a school as a full-time student at the time of his 9 death, nor was he incapable of self-sustaining employment by reason of mental or physical handicap. He does not meet the definitions of Dependent Child as defined under the 11 United States District Court Northern District of California 10 policies . . . .” Id. at 16. The letter also stated that “[t]he available medical records were reviewed 12 by staff Medical Director Norton Hall, MD who opined that the ‘clinical notes of Mr. Brown’s 13 attending physician, Dr. Ng, of 10/6/16, 9/9/14 and 8/12/14’ were ‘devoid of any documented, 14 significant, quantified, positive, neuromusculovasculoskelatal or clinical finding, physical 15 impairment or functional loss.” Id. 16 II. JURISDICTION Plaintiff’s cause of action arises under ERISA, a federal statute. The Court therefore has 17 18 federal question jurisdiction over this matter pursuant to 28 U.S.C. § 1331. 19 III. LEGAL STANDARD “ERISA was enacted ‘to promote the interests of employees and their beneficiaries in 20 21 employee benefit plans,’ and ‘to protect contractually defined benefits.’” Firestone Tire & Rubber 22 Co. v. Bruch, 489 U.S. 101, 113 (1989) (internal citations omitted). ERISA “permits a person 23 denied benefits under an employee benefit plan to challenge that denial in federal court.” 24 Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 108 (2008). “ERISA’s civil-enforcement 25 provision . . . allows a claimant ‘to recover benefits due to him under the terms of his plan [and] to 26 27 28 Because the Court’s ruling does not turn on the extent of Mr. Brown’s work-related injuries, the Court will not further analyze the parties’ disputed positions related to Mr. Brown’s work-related injuries at this juncture. 3 1 1 enforce his rights under the terms of the plan.’” Muniz v. Amec Const. Mgmt., Inc., 623 F.3d 2 1290, 1294 (9th Cir. 2010) (quoting 29 U.S.C. § 1132(a)(1)(B)). 3 “[A] denial of benefits challenged under § 1132(a)(1)(B) is to be reviewed under a de novo 4 standard unless the benefit plan gives the administrator or fiduciary discretionary authority to 5 determine eligibility for benefits or to construe the terms of the plan.” Firestone, 489 U.S. at 115. 6 In this case, the parties agree that de novo review is appropriate. See ECF No. 24 at 13; ECF No. 7 28 at 5. Under de novo review, “the court simply proceeds to evaluate whether the plan 8 administrator correctly or incorrectly denied benefits with no deference given to the 9 administrator’s decision.” Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 963 (9th Cir. 10 United States District Court Northern District of California 11 2006) (en banc). ERISA’s “statutory scheme . . . ‘is built around reliance on the face of written plan 12 documents.’” U.S. Airways, Inc. v. McCutchen, 133 S. Ct. 1537, 1548 (2013) (quoting Curtiss- 13 Wright Corp. v. Schoonejongen, 514 U.S. 73, 83 (1995)). “Courts construe ERISA plans, as they 14 do other contracts,” with reference to “ordinary principles of contract interpretation.” U.S. 15 Airways, 133 S.Ct. at 1548–49 (2013). Ambiguities are construed against the drafter and in favor 16 of the insured. Kearney v. Standard Ins. Co., 175 F.3d 1084, 1090 (9th Cir. 1999). “[W]hen the 17 court reviews a plan administrator’s decision under the de novo standard of review, the burden of 18 proof is placed on the claimant.” Muniz, 623 F.3d at 1294. 19 Summary judgment is proper when a “movant shows that there is no genuine dispute as to 20 any material fact and the movant is entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a). 21 “A party asserting that a fact cannot be or is genuinely disputed must support the assertion by” 22 citing to depositions, documents, affidavits, or other materials. Fed. R. Civ. P. 56(c)(1)(A). A 23 party also may show that such materials “do not establish the absence or presence of a genuine 24 dispute, or that an adverse party cannot produce admissible evidence to support the fact.” Fed. R. 25 Civ. P. 56(c)(1)(B). An issue is “genuine” only if there is sufficient evidence for a reasonable 26 fact-finder to find for the non-moving party. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248– 27 49 (1986). A fact is “material” if the fact may affect the outcome of the case. Id. at 248. “In 28 considering a motion for summary judgment, the court may not weigh the evidence or make 4 1 credibility determinations, and is required to draw all inferences in a light most favorable to the 2 non-moving party.” Freeman v. Arpaio, 125 F.3d 732, 735 (9th Cir. 1997). Where the party moving for summary judgment would not bear the burden of proof at trial, 4 that party bears the initial burden of either producing evidence that negates an essential element of 5 the non-moving party’s claim, or showing that the non-moving party does not have enough 6 evidence of an essential element to carry its ultimate burden of persuasion at trial. If the moving 7 party satisfies its initial burden of production, then the non-moving party must produce admissible 8 evidence to show that a genuine issue of material fact exists. See Nissan Fire & Marine Ins. Co. v. 9 Fritz Cos., 210 F.3d 1099, 1102–03 (9th Cir. 2000). The non-moving party must “identify with 10 reasonable particularity the evidence that precludes summary judgment.” Keenan v. Allan, 91 11 United States District Court Northern District of California 3 F.3d 1275, 1279 (9th Cir. 1996). Indeed, it is not the duty of the district court to “to scour the 12 13 14 15 16 17 18 record in search of a genuine issue of triable fact.” Id. “A mere scintilla of evidence will not be sufficient to defeat a properly supported motion for summary judgment; rather, the nonmoving party must introduce some significant probative evidence tending to support the complaint.” Summers v. Teichert & Son, Inc., 127 F.3d 1150, 1152 (9th Cir. 1997) (citation and internal quotation marks omitted). If the non-moving party fails to make this showing, the moving party is entitled to summary judgment. Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986). IV. Defendant argues that Plaintiff cannot recover under the Policy because “the undisputed 19 20 21 22 23 24 25 26 27 28 DISCUSSION evidence proves that Mr. Brown was not insured under the [] Policy at the time of his death on October 27, 2014.” ECF No. 24 at 18. According to Defendant, Mr. Brown was covered as a “Dependent Child” until he turned nineteen, but “coverage terminated shortly after he turned nineteen years old on June 19, 2013 which was more than a year and four months before his accident.” Id. /// /// /// /// 5 1 2 The Group Policy defines a “Covered Person” to include “an eligible Spouse and eligible Dependent Children.” ECF No. 25-7 at 9. “Dependent Children,” in turn, are defined as: An Employee’s unmarried child who meets the following requirements: 3 4 1. A child from live birth to 19 years old; 5 2. A child who is 19 or more years old but less than 23 years old, enrolled in a school as a full-time student and primarily supported by the Employee; 6 7 3. A child who is 19 or more years old, primarily supported by the Employee and incapable of self-sustaining employment by reason of mental or physical handicap. Proof of the child’s condition and dependence must be submitted to Us within 31 days after the date the child ceases to qualify as a Dependent Child for the reasons listed above. During the next two years, We may, from time to time, require proof of the continuation of such condition and dependence. After that, We may require proof no more than once a year. 8 9 10 United States District Court Northern District of California 11 12 13 Id. at 10. The parties do not dispute that Mr. Brown turned nineteen on June 19, 2013. ECF No. 24 14 at 19; ECF No. 28. Likewise, the parties do not dispute that Mr. Brown was not “enrolled in a 15 school as a full-time student” at the time of his death. ECF No. 24 at 19; ECF No. 28 at 4. 16 Accordingly, Mr. Brown was not covered as a “Dependent Child” under the first or second prongs 17 of the Group Policy’s definition of “Dependent Children.” The parties do, however, dispute 18 whether Mr. Brown was covered under the third prong, as a “child who is 19 or more years old, 19 primarily supported by the Employee and incapable of self-sustaining employment by reason of 20 mental or physical handicap.” ECF No. 25-7 at 10. 21 While the Court doubts whether Mr. Brown’s inability to work temporarily due to his 22 work-related injuries rendered him “incapable of self-sustaining employment by reason of mental 23 or physical handicap,” the Court need not decide this issue because Plaintiff never submitted 24 “[p]roof of [Mr. Brown’s purported] condition and dependence . . . within 31 days after the date 25 [Mr. Brown] cease[d] to qualify as a Dependent Child” by reason of his turning nineteen, as is 26 required by the third prong of the Policy’s definition of “Dependent Children.” Id. As Defendant 27 argues, “[n]either Plaintiff nor anyone else submitted any information to LINA within 31 days of 28 Mr. Brown’s 19th birthday proving that Mr. Brown was ‘incapable of self-sustaining employment 6 1 by reason of mental or physical handicap.’” ECF No. 24 at 20. Defendant’s argument is 2 supported by a letter sent to Plaintiff by an “accident specialist” at Cigna (of which LINA is a 3 subsidiary) on September 15, 2015, stating: “[o]ur records indicate that proof of Cody Brown’s 4 condition and dependence was not submitted to us after Cody Brown turned age 19 or at any time 5 prior to his death.” ECF No. 27-2 at 35. 6 Plaintiff does not contend that he submitted proof to LINA of any “mental of physical 7 handicap” which Mr. Brown may have had, which could have rendered him “incapable of self- 8 sustaining employment” within 31 days after the date Mr. Brown turned nineteen. ECF No. 28 at 9 7–8. Rather, Plaintiff argues that the requirement that proof be submitted to LINA within 31 days “is contrary to the [Group Policy’s separate] provision that ‘insurance becomes effective for an 11 United States District Court Northern District of California 10 Employee’s eligible dependents if the Employee applies and agrees to make required contributions 12 within 31 days of the date his dependents become eligible . . . .” ECF No. 28 at 7 (quoting ECF 13 No. 25-7 at 12). While the Court agrees with Plaintiff that “[t]here is nothing in this [latter] 14 provision that requires providing notice of disability,” nothing in the latter provision negates the 15 requirement under the third prong of “Dependent Child” definition requiring that “proof of the 16 child’s condition and dependence must be submitted to [LINA] within 31 days after the date the 17 child ceases to qualify as a Dependent Child” once he turns nineteen. 18 Plaintiff also argues that “any requirement for having to [re-enroll a child] into the plan 19 [after the child turns nineteen] would not meet the reasonable expectations of the insured.” Id. at 20 7. Plaintiff cites no authority on point, except for Peterson v. Am. Life & Health Ins. Co., for the 21 general proposition that “[u]nder the ‘reasonable expectations’ doctrine, as a matter of federal 22 common law governing ERISA contracts, even an unambiguous exclusion may be unenforceable 23 unless it is sufficiently ‘clear, plain, and conspicuous’ to overcome a layperson’s reasonable 24 expectations.” 48 F.3d 404, 411 (9th Cir. 1995). However, as Peterson makes clear, the 25 reasonable expectations doctrine only applies when “a provision in an insurance policy is . . . not 26 sufficiently conspicuous.” Id. Here, the requirement that proof be submitted of a child’s 27 condition and dependence within 31 days after the child turns nineteen appears in the sentence 28 directly following (and in the same paragraph as) the sentence defining “Dependent Children” to 7 1 include “[a] child who is 19 or more years old, primarily supported by the Employee and 2 incapable of self-sustaining employment by reason of mental or physical handicap.” ECF No. 25- 3 7 at 10. Accordingly, the Court concludes that the proof requirement is sufficiently conspicuous 4 that the reasonable expectations doctrine does not apply. 5 Given that Plaintiff bears the burden of proof to show that benefits were due to him under 6 the Policy, Muniz, 623 F.3d at 1294, the Court concludes that Plaintiff’s claim fails because he has 7 not presented the Court with any evidence that he submitted proof of Mr. Brown’s “condition and 8 dependence” within 31 days of his nineteenth birthday as required by the Policy. See Staats v. 9 Goodyear Tire & Rubber Co., No. 05-cv-1386, 2006 WL 2707969, at *4 (N.D. Cal. Sept. 19, 2006) (granting defendant’s motion for summary judgment in ERISA case based on the fact that 11 United States District Court Northern District of California 10 “even if the plaintiff’s daughter’s condition had sufficiently changed by the summer of 2002, and 12 the change was properly documented, so that she was eligible based on the disabling condition for 13 continued medical coverage, the plaintiff failed to provide the defendant with the required notice 14 of her changed status within 31 days of its occurrence.”). Because no genuine issue of material 15 fact exists regarding Mr. Brown’s not being covered by the Policy as a “Dependent Child,” the 16 Court grants Defendant’s motion for summary judgment. CONCLUSION 17 18 Defendant’s motion for summary judgment is granted. 19 IT IS SO ORDERED. 20 21 22 Dated: May 3, 2016 ______________________________________ JON S. TIGAR United States District Judge 23 24 25 26 27 28 8
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