United States District Court, S.D. Ohio, Western Division, Dayton
ENTRY AND ORDER GRANTING DEFENDANT'S MOTION FOR
JUDGMENT ON THE ADMINISTRATIVE RECORD (DOC. 5), DENYING
PLAINTIFF'S MOTION FOR JUDGMENT ON THE ADMINISTRATIVE
RECORD (DOC. 11), AND TERMINATING CASE
M. ROSE UNITED STATES DISTRICT JUDGE.
case is before the Court on the Motions for Judgment on the
Administrative Record (Docs. 5, 11) filed by Defendant
ReliaStar Life Insurance Company, Inc.
(“ReliaStar”) and Plaintiff Randy Smith
(“Smith”), respectively. Smith brought this
action under the Employee Retirement Income Security Act of
1974, 29 U.S.C. § 1001, et seq. (ERISA), for
review of the denial of disability benefits under his
employer-provided life insurance plan. Smith seeks reversal
of the denial of benefits and an order remanding this matter
for payment of benefits. ReliaStar, the issuer of the plan,
seeks a judgment upholding the denial of benefits. Smith and
ReliaStar agree on the standard of review and their Motions
are fully briefed. (Docs. 10, 12, 13.) As discussed below,
the Court finds that ReliaStar's denial of benefits was
neither arbitrary nor capricious and therefore
GRANTS ReliaStar's Motion (Doc. 5) and
DENIES Smith's Motion (Doc. 11) for
Judgment on the Administrative Record.
Court's review is limited to the administrative record at
the time that ReliaStar's ERISA review committee issued
its decision. Accordingly, the Court “may not consider
new evidence or look beyond the record that was before the
plan administrator.” Wilkins v. Baptist Mem'l
Healthcare Sys., Inc., 150 F.3d 609, 615 (6th Cir.
1998); see also Crews v. Central States, 788 F.2d
332 (6th Cir. 1986). The following facts are taken from that
was employed as a Coater Team Operator at Appvion, Inc.
(“Appvion”). (Doc. 5-2 at 2.) Smith participated
in the Appvion, Inc. Group Life Insurance Plan (“the
Plan”), which was issued by ReliaStar. (Doc. 5-3 at 3.)
The Plan provides qualified employees Basic Life Insurance
and Accidental Death and Dismemberment Insurance
(“Basic Life Insurance”) and a Total and
Permanent Disability Income Benefit (“Benefit”)
equal to the value of the Basic Life Insurance in force on
the date that the employee becomes totally disabled.
(Id. at 4.)
Plan provides that the Benefit will be paid if the employee
is permanently disabled. (Id. at 9.) To qualify for
the Benefit, the employee must meet the following three
You are insured for this benefit on the date you became
totally disabled. You become permanently disabled before age
65. ReliaStar Life receives proof, within 12 months or as
soon as reasonably possible after the date you become totally
disabled, that you are permanently disabled.
(Id.) The Plan defines permanently disabled as a
“total disability, which is expected to continue for 10
years or for the rest of the disabled person's expected
lifetime, whichever is shorter.” (Id. at 19.)
The Plan defines totally disabled as “your inability,
due to sickness or accidental injury, to work at or perform
the material and substantial duties of any job suited to your
education, training or experience.” (Id.)
October 24, 2016, Smith filed a Waiver of Premium Disability
Claim (“Smith's Claim”). (Doc. 5-2 at 4-5.)
Smith identified his conditions as chronic back and body
pain, osteoarthritis, heart trouble, and fibromyalgia.
(Id. at 4.) His last date of work was April 19,
2016. (Id. at 5.) Smith noted that he had been
approved for disability payments under the Social Security
Administration. (Id.) Smith attached a form titled
Attending Physician's Statement of Disability, which was
completed by Smith's treating physician, Dr.
O'Connell. (Id. at 8-10.) On the form, in
response to the question, “Is patient totally disabled
FOR ALL OCCUPATIONS?” Dr. O'Connell responded,
“No.” (Id. at 8.) Conversely, when
asked, “Is patient totally disabled FOR PATIENT'S
REGULAR OCCUPATION?” Dr. O'Connell responded,
“Yes.” (Id.) Dr. O'Connell noted
that Smith would need a nonphysical job. (Id.) Dr.
O'Connell indicated that Smith's back problems were
permanent. (Id. at 9.)
November 9, 2016, ReliaStar sent a letter to Smith notifying
him that he was not eligible for the Benefit. (Doc. 5-4 at
1.) ReliaStar stated:
Under the terms of this policy, you may be eligible for this
benefit if you are permanent[ly] and totally disabled. The
policy states that Permanent Disability is “expected to
continue for 10 years or for the rest of the disabled
person's expected lifetime, whichever is shorter”.
Total Disability is, “your inability, due to sickness
or accidental injury, to work at or perform the material and
substantial duties of any job suited to your education,
training or experience”.
According to the medical information contained in the
Attending Physician's Statement you are not totally
disabled for all occupations. Because you could work in some
capacity, you do not meet the definition of total disability
as contained in this policy. Therefore, you are not eligible
for the Total and Permanent Disability Income Benefit and we
must deny your claim.
November 21, 2016, Smith appealed the denial of his Claim for
the Benefit. (Doc. 5-2 at 12-13.) His appeal attached medical
records, including Smith's treatment history with Dr.
O'Connell, a psychologist, ...