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Harrison v. Unitedhealth Group

United States District Court, S.D. West Virginia, Charleston Division

March 28, 2018

UNITEDHEALTH GROUP, et al, Defendants.



         Pending before the Court is Plaintiff Suzette Harrison's Motion for Judgment on Administrative Record, (ECF No. 13), and Defendant Standard Insurance Company's Motion for Summary Judgment, (ECF No. 14). For the reasons discussed herein, the Court GRANTS the Motion for Summary Judgment, DENIES the Motion for Judgment on Administrative Record, and DISMISSES this case from the docket of the Court.

         I. BACKGROUND

         Plaintiff Suzette Harrison (“Ms. Harrison”), a former registered nurse, was formerly employed as a medical case manager for UnitedHealth Group (“UHG”). (ECF No. 1-1 at 5.) Ms. Harrison participated in an employee welfare benefit plan (“the Plan”) established by UHG. Administrative Record at * 00793 (hereinafter “AR ___”). UHG, through the Plan, is the policyholder of a group long-term disability insurance policy (“the policy”) purchased from Defendant Standard Insurance Company (“Standard”). (AR 00012.) Standard is both the insurer responsible for paying claims made by Plan participants and the plan administrator who determines which participants are eligible for benefits. (AR 00033-00034.) The policy, as a component of the Plan, is subject to the regulatory provisions of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq. (“ERISA”).

         It is uncontested that Ms. Harrison was a qualified participant in the Plan and was covered by the policy beginning in October 2013 when she was forced to cease working due to complaints of low back and leg pain. (ECF No. 15 at 3-4; AR 00112-00116, 00121-00123.) Following the cessation of working, Ms. Harrison received short-term disability benefits from October 8, 2013 to April 5, 2014, which Standard approved and paid for under the Plan while she underwent treatment. (AR 00628-00634.) In April 2014, Ms. Harrison had a spinal cord stimulator implanted to relieve her pain. (AR 00638-00642, 00651-00655.) In May 2014, after Ms. Harrison's short-term benefits expired, Standard awarded her long-term disability benefits, which lasted until December 2015 when Standard terminated the benefits. (AR 00709-00712, 01089- 01093.)

         Standard contends that following Ms. Harrison's medical procedure, Ms. Harrison progressed to the point where a current medical evaluation of Ms. Harrison's abilities showed that there was insufficient medical evidence to demonstrate that she lacked the functional capacity to perform the Material Duties of her Own Occupation within the scope of her license, and was therefore no longer eligible for payments of Plan benefits. (AR 01090-01092.) Following the termination decision by Standard, Ms. Harrison submitted an administrative appeal of the decision to close her claim. (AR 01135-01150.) Upon review, Standard determined that the medical evidence did not support a conclusion that would find Ms. Harrison's condition severe enough to prevent her from working in her Own Occupation, and as such, resulted in Standard upholding its prior decision. (AR 01219-01231.) Ms. Harrison contests Standard's findings, and alleges that Standard's review process was flawed and tainted by a structural conflict of interest. (See ECF No. 13 at 2.)

         Having exhausted all of her administrative remedies, Ms. Harrison appealed Standard's decision and filed the instant Complaint in the Circuit Court of Kanawha County, West Virginia, which Standard removed to this Court. Ms. Harrison asks this Court to order payment by Standard of long-term disability benefits, or to enter judgment for benefits wrongfully denied. (ECF No. 13.) Standard asks this Court to affirm its decision that Ms. Harrison is no longer qualified as disabled, and to confirm its decision to stop providing long-term benefits. (ECF No. 14.)

         Ms. Harrison filed a Motion for Judgment on Administrative Record on May 30, 2017. (ECF No. 13.) Standard filed a response on June 13, 2017, (ECF No. 17), to which Ms. Harrison replied on June 20, 2017, (ECF No. 18.) Standard filed its Motion for Summary Judgment on May 30, 2017. (ECF No. 14.) Ms. Harrison filed a response on June 13, 2017, (ECF No. 16), to which Standard replied on June 20, 2017, (ECF No. 19). As such, the parties' cross-motions are ripe for review by this Court.


A plaintiffs' § 1132 claim challenging a denial of benefits is analogous to a claim arising under the common law of trusts. See Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 113, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). Accordingly, a jury trial is inappropriate, and such claims are properly decided through cross-motions for summary judgment on the basis of the administrative record that was relied upon by the plan administrator who denied the benefits claim. See Berry v. Ciba-Geigy Corp., 761 F.2d 1003, 1007 (4th Cir. 1985), In re Vorpahl, 695 F.2d 318, 320 (8th Cir. 1982).

Caldwell v. Std. Ins. Co., No. 2:14-cv-25242, 2015 U.S. Dist. LEXIS 112122, at *4-5 (S.D. W.Va. August 25, 2015).

         Rule 56 of the Federal Rules of Civil Procedure governs motions for summary judgment. That rule provides that a court should grant summary judgment if “there is no genuine issue as to any material fact and the movant is entitled to judgment as a matter of law.” Fed.R.Civ.P. 56(a). Summary judgment is inappropriate, however, if there exist factual issues that reasonably may be resolved in favor of either party. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 250 (1986). “Facts are ‘material' when they might affect the outcome of the case, and a ‘genuine issue' exists when the evidence would allow a reasonable jury to return a verdict for the nonmoving party.” The News & Observer Publ'g Co. v. Raleigh-Durham Airport Auth., 597 F.3d 570, 576 (4th Cir. 2010). When construing such factual issues, the Court must view the evidence “in the light most favorable to” the party opposing summary judgment. Adickes v. S.H. Kress & Co., 398 U.S. 144, 157 (1970); see also Liberty Lobby, 477 U.S. at 255 (“The evidence of the non-movant is to be believed, and all justifiable inferences are to be drawn in his favor.” (citation omitted)).

         The moving party may meet its burden of showing that no genuine issue of fact exists by use of “depositions, answers to interrogatories, answers to requests for admission, and various documents submitted under request for production.” Barwick v. Celotex Corp., 736 F.2d 946, 958 (4th Cir. 1984). Once the moving party has met its burden, the burden shifts to the nonmoving party to “make a showing sufficient to establish the existence of an element essential to that party's case, and on which that party will bear the burden of proof at trial.” Celotex Corp. v. Catrett, 477 U.S. 317, 322 (1986). If a party fails to make a sufficient showing on one element of that party's case, the failure of proof “necessarily renders all other facts immaterial.” Id. at 323.

         “[A] party opposing a properly supported motion for summary judgment may not rest upon mere allegation or denials of his pleading, but must set forth specific facts showing that there is a genuine issue for trial.” Liberty Lobby, 477 U.S. at 256. “The mere existence of a scintilla of evidence” in support of the nonmoving party is not enough to withstand summary ...

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