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Popov v. University Physicians & Surgeons, Inc.

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

March 27, 2019

GENKA POPOV, an individual, Plaintiff,
UNIVERSITY PHYSICIANS & SURGEONS, INC., LONG TERM DISABILITY PLAN, an employee Welfare Benefit Plan; THE NORTHWESTERN MUTUAL LIFE INSURANCE COMPANY, a Wisconsin Corporation; and DOES 1 through 5, inclusive, Defendants.



         Pending before the Court are the Motions for Summary Judgment submitted by Defendants University Physicians & Surgeons, Inc., Long Term Disability Plan (the “Plan”) and Northwestern Mutual Life Insurance Company (“Northwestern”), [1] and Plaintiff Genka Popov.[2] Plaintiff alleges, in her complaint, claims against Defendants under only one cause of action: violation of § 502 (a)(1)(B)[3] of the Employee Retirement Income Security Act (“ERISA”). See Compl., ECF No. 1, at 6.

         Defendants now move for summary judgment on the single count Plaintiff has asserted against them, arguing that Northwestern's decision to deny Plaintiff's claim for benefits is entitled to deference, and its findings should not be disturbed because of the reasonableness of its investigation. See Mem. in Supp. of Defs.' Mot. for Summ. J., ECF No. 14, at 18-24. Plaintiff also moves for summary judgment on its single count, arguing that Defendant Northwestern is biased, failed to consider some of her injuries, and was incorrect in determining that she is not entitled to benefits. See Mem. in Supp. of Pl.'s Mot. for Summ. J., ECF No. 12, at 8-17.

         The parties have fully briefed the issues and the motions are now ripe for adjudication. As explained below, the Court GRANTS Defendants' Motion for Summary Judgment, and DENIES Plaintiff's Motion for Summary Judgment.

         I. Background

         Plaintiff worked for Marshall Health as a pathology technician, preparing tissue slides. See ECF No. 11-2, at 186, 192-93. She ceased work on April 18, 2016, and sought disability benefits under the Plan based on complaints of carpal tunnel syndrome, neck pain, and back pain. See Id. at 166, 180, 184. Defendant Northwestern evaluated her medical records, consulted with a physician, and determined that the medical testing and clinical examination findings failed to support that Plaintiff satisfied the Plan's definition of a “Disability.” See Id. at 160-63.

         On February 2, 2017, Plaintiff, through counsel, timely submitted an administrative appeal of Defendant Northwestern's denial of her claim. See Id. at 147. In her appeal, for the first time, Plaintiff also claimed to be disabled from a broken arm and other injuries sustained in a fall during European travel on July 29, 2016, more than three months after she stopped working for Marshall Health. See Id. at 147-151. Defendant Northwestern upheld its decision to deny her claim for multiple reasons. See Id. at 126-135. Most relevant, Defendant Northwestern found that, under the terms of the Plan, Plaintiff's coverage terminated when she stopped working and ceased to be a participating member, and thus her injuries from the July 29, 2016, incident were irrelevant. See Id. at 133.

         On May 2, 2017, more than one month after Defendant Northwestern's appellate determination, Plaintiff faxed to Defendant Northwestern a letter from Marshall Health, dated April 6, 2017. See Id. at 122. In the letter, Marshall Health stated that Plaintiff's employment terminated August 1, 2016, and that her “employer paid Long Term Disability benefit, through North Western Mutual, ended as of 08/31/2016.” See Id. at 123. Plaintiff did not request further administrative review of her claim, and filed a complaint the following day, May 3, 2017, in the Southern District of West Virginia Case. See Compl., at 5.

         Defendant Northwestern then initiated and agreed to further administrative review of Plaintiff's ongoing eligibility for coverage under the Plan at the time of her fall on July 29, 2016. See Compl., at 5; ECF No. 1-4. Plaintiff then dismissed her initial lawsuit and Defendant Northwestern proceeded with a second administrative review, limited to evaluating whether Plaintiff's Plan coverage remained in force at the time of her fall on July 29, 2016. See ECF No. 1-6. On September 28, 2017, Defendant Northwestern advised Plaintiff that it was upholding the determination that she was no longer covered under the Plan at the time of her fall on July 29, 2016. See Id. Plaintiff then re-filed her lawsuit on February 12, 2018, and all parties filed their motions for summary judgment on June 12, 2018. See Compl.; ECF Nos. 12, 13.

         II. Standard of Review

         A. Motion for Summary Judgment

         To obtain summary judgment, the moving party must show that no genuine issue as to any material fact remains and that the moving party is entitled to judgment as a matter of law. Fed.R.Civ.P. 56(a). In considering a motion for summary judgment, a court will not “weigh the evidence and determine the truth of the matter[.]” Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 249 (1986). Instead, a court will draw any permissible inference from the underlying facts in the light most favorable to the nonmoving party. Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 587-88 (1986). Any inference, however, “must fall within the range of reasonable probability and not be so tenuous as to amount to speculation or conjecture.” JKC Holding Co. v. Wash. Sports Ventures, Inc., 264 F.3d 459, 465 (4th Cir. 2001) (citation omitted). Therefore, summary judgment will not be granted if a reasonable jury could return a verdict for the non-moving party on the evidence presented. See Anderson, 477 U.S. at 247-48.

         B. Administrator's Decision

         Under ERISA, courts must review an administrator's decision to deny pension plan benefits de novo, unless the plan itself confers discretionary authority upon the administrator “to determine eligibility for benefits or to construe the terms of the plan.” Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). When an administrator possesses such discretion, courts may review the eligibility determination only for an abuse of discretion. See id; Barron v. UNUM Life Ins. Co. of Am., 260 F.3d 310, 315 (4th Cir. 2001). In considering whether an administrator abused its discretion, the Fourth Circuit identified, in Booth v. Wal-Mart Stores, Inc. Assoc. Health & Welfare Plan, 201 F.3d 335 (4th Cir. 2000), multiple non-exclusive factors that a court may consider:

(1) the language of the plan; (2) the purposes and goals of the plan; (3) the adequacy of the materials considered to make the decision and the degree to which they support it; (4) whether the fiduciary's interpretation was consistent with other provisions in the plan and with earlier interpretations of the plan; (5) whether the decisionmaking process was reasoned and principled; (6) whether the decision was consistent with the procedural and substantive requirements of ERISA; (7) any external standard relevant to the exercise of discretion; and (8) the fiduciary's motives and any conflict of interest it may have.

201 F.3d at 342-43.

         III. ...

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