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Smith v. Reliastar Life Insurance Company, Inc.

United States District Court, S.D. Ohio, Western Division, Dayton

May 10, 2018

RANDY SMITH, Plaintiff,
v.
RELIASTAR LIFE INSURANCE COMPANY, INC., Defendant.

          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

          THOMAS M. ROSE UNITED STATES DISTRICT JUDGE.

         This 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.

         I. BACKGROUND

         The 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 administrative record.

         Smith 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.)

         The 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 conditions:

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.)

         On 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.)

         On 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.

(Id.)

         On 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, ...


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