United States District Court, D. Nebraska
AMENDED MEMORANDUM AND ORDER
F. BATAILLON SENIOR UNITED STATES DISTRICT JUDGE
matter is before the court on the parties' cross motions
for summary judgment, Filing Nos. 56, 58 and
Although styled as cross-motions for summary judgement this
is an action for judicial review of an administrative
determination denying benefits under the Employee Retirement
Income Security Act ("ERISA"), 29 U.S.C. §
1001 et seq. The plaintiff alleges defendants
wrongfully denied her claim for life insurance benefits under
a policy provided by late husband's employer. She seeks a
reversal of that determination. The defendants move for a
judgment affirming the decision.
plaintiff alleges five claims. She first seeks the statutory
penalty for failure to provide plan documents, specifically,
the Summary Plan Description ("SPD") under 29
U.S.C. § 1132(c) from defendant Ford Motor
Company. Filing No. 32, First Amended Complaint at
5. She next seeks an award of benefits pursuant to 29 U.S.C.
§1132(a)(1)(B) from defendants MetLife Group, Inc. and
Metropolitan Life Insurance Company
("Metropolitan"). The plaintiff also asserts three
claims for equitable relief under 29 U.S.C. § 1132(a)(3)
against both Ford and Metropolitan and seeks relief in the
nature of surcharge, reformation and equitable estoppel.
motion, Met Life seeks dismissal of the plaintiffs claims. It
asks the court to affirm Metropolitan's determination.
Metropolitan argues its claim determination was not an abuse
of discretion. It also contends that the plaintiffs breach of
fiduciary duty claims are improper under ERISA and are barred
by the decedent's allegedly inequitable acts.
Ford seeks dismissal of the plaintiffs penalty claim as well
as her claims for breach of fiduciary duty. Ford argues it
substantially complied with ERISA requirements to provide the
SPD and contends that because the plaintiff has a remedy for
the benefits she seeks under Section (a)(b)(1), there is no
need for a duplicative equitable claim.
plaintiff seeks a summary judgment against defendant Ford for
damages in the amount of the statutory penalty for failure to
timely provide plan documents. Further, she asserts she is
entitled to judgment in her favor on her claims for benefits
and breaches of fiduciary duty under 29 U.S.C. §§
1132 (a)(1)(B) and (a)(3). She urges the court to reverse the
decision denying the plaintiff's claim for optional life
facts are gleaned in part from the parties' statements of
undisputed facts, the administrative record and affidavits
submitted in connection with the motions. See Filing
No. 53-1, Administrative Record (Restricted) ("Admin.
R."); Filing No. 57, Ford's Brief at 5, 7-14; Filing
No. 60, Metropolitan Brief at 2-8; Filing No. 67,
Plaintiff's Brief at 1-5; Filing No. 68, Ford Reply Brief
at 3-4; Filing No. 69, Metropolitan Reply Brief at 3-4;
Filing No. 70, Plaintiff's Reply Brief at 1-4. The
administrative record filed by Metropolitan includes a copy
of the Ford Motor Co. Life and Accidental Death and
Disability Policy ("the Plan") and screenshots of
the online version of the Summary Plan Document
("SPD") for the Plan. See Filing No. 53-1,
Adm. R. at 120-141. In addition to the Plan documents, the
record contains 27 pages of Metropolitan internal records,
numerous medical records authorization forms, the
decedent's medical records dating back to 2008, and
correspondence to and from the plaintiff's
counsel. Id. 142-169.
undisputed that Ford Motor Company is the Plan Sponsor and
Plan Administrator of the Plan. Metropolitan is the insurer
and claim administrator under the Plan. The parties agree
Metropolitan issued Group Insurance Policy Nos. 113729-1-G,
113729-G and 113729-16-G to Ford Motor Company. Ford's
SPD states that: "The Plan Administrator and
Metropolitan have discretionary authority to construe,
interpret, apply and administer the Plan. Decisions of the
Plan Administrator and Metropolitan are final and conclusive,
and are only subject to the arbitrary and capricious standard
of judicial review." Filing No. 53-1, Admin. R. 138
& 139. Ford provided Basic Life Insurance to employees at
no cost to them, but employees had to pay the cost of any
Optional Life Insurance they elected. Id. at 123.
plaintiff is the widow of Jose Monarrez ("the
decedent"), who died on June 4, 2015, of
"hypertensive and atherosclerotic heart disease."
Filing No. 53-1, Admin. R. at 188. The decedent was employed
by Ford as a customer service representative beginning on
October 1, 2013. Monarrez enrolled in the Plan when he first
became eligible, and benefits were effective on or after
November 1, 2013. He requested both basic life insurance
coverage in the amount of one and a half times his base
annual earnings of $37, 077.60 (or $55, 616.00) and optional
employee life insurance coverage in the amount of two and a
half times his base annual earnings, which amounted to $92,
694. Id. at 186-87, 504. After he submitted his
application for Optional Life Insurance, premiums were
withheld thereafter by Ford and forwarded to Metropolitan.
Id. at 123-24.
Monarrez's death, Metropolitan paid the basic life
benefit of $55, 616 to the plaintiff, his widow. Id.
at 144. Metropolitan denied the plaintiffs claim for optional
life insurance benefits. Id. at 153, 414-15.
respect to optional life insurance, the Plan provides:
complete the enrollment process when first eligible for
Optional Life Insurance and Optional Accident Insurance under
the Flexible Benefits Plan, such insurance will take effect
• for any amount which You are not
required to give evidence of Your insurability, such
insurance will take effect on the later of the date You
become eligible for such insurance and the first day of the
calendar month following the date You complete the Enrollment
Process, if You are Actively at Work on that date. You are
not required to give evidence of Your
insurability for Optional Accident Insurance.
• for any amount for which You are
required to give evidence of Your
insurability and We determine that You are insurable, such
insurance will take effect on the first day of the calendar
month following the date We approve Your evidence of
insurability, if You are Actively at Work on that date.
Id. at 57 (emphasis in original). The Plan defines
Proof as follows:
Proof means Written evidence satisfactory to Us that a person
has satisfied the conditions and requirements for any benefit
described in this certificate. When a claim is made for any
benefit described in this certificate, Proof must establish:
the nature and extent of the loss or condition; Our
obligation to pay the claim; and the claimant's right to
Proof must be provided at the claimant's expense.
Id. at 54.
provides that employees are eligible to enroll in optional
life insurance on the date of hire or rehire and
"Coverage is effective the first of the month following
enrollment date or the first of the month following approval
of Statement of Health, whichever is later."
Id. at 123. The coverage effective date the first of
the month following approval of a Statement of Health form
(if required). Id. Proof of good health for optional
life insurance is described as follows:
Proof of Good Health - Optional Life
If you elect coverage or increase your coverage when first
eligible, during annual enrollment or due to a Qualified
Event, you must provide proof of your good health before the
election or increase will be effective.
The process of providing proof of good health involves
answering five questions about your health status. Depending
on your answers to these questions, you may also need to
complete a more detailed questionnaire (i.e., a Statement of
Health form). In addition to a Statement of Health, medical
records or a physical examination may be required at your
expense. Any life insurance elections that require proof of
good health will not go into effect until evidence of
insurability is received and approved by MetLife. MetLife
makes all decisions regarding approvals.
Id. at 125. Neither insurability, good health, nor
statement of health are defined in the Plan documents.
plaintiff filed a claim under the policy on September 21,
2015. Id. at 189-90. Metropolitan responded with a
letter stating an investigation was necessary with respect to
the claim for optional benefits. Id. at 195, 207.
Metropolitan also contacted Ford's third-party
administrator for confirmation of the decedent's
enrollment in the Plan. Id. at 193-98. The response
indicated that the optional life coverage was elected during
the 2013 new hire enrollment. Id. at 193. The record
contains several screenshots of computer images with typed
notations showing that Monarrez was a "new-hirerehire
eff 10-1-13, " and had Optional Life coverage effective
on November 1, 2013. Id. at 200. Another screenshot
indicates an annual enrollment effective Januaryl, 2015.
Id. at 199.
internal records show the following task was assigned to
Metropolitan employee Edward Sullivan, who is identified in
the record as a Senior Client Services Consultant:
Insured enrolled in Optional Life coverage as new hire on
11/1/2013 for 2.5 of base annual earnings ($92, 694.00). Per
Plan Master under [Medical Evidence of Insurability or] MEOI:
New hire participants who enroll initially eligible are
subject to MEOI. All amounts require medical questions. Can
you please provide me with his questionnaire or confirm that
he answered No to all medical questions.
Id. at 506. The reason for the request is shown as
"MEOI Provisions Need assistance Obtaining enrollment
History from Employer." Id. On October 8, 2015,
Sullivan emailed the following to Terrence Davis and Robert
We suddenly seem to have more frequent inquiries from our
group life claims office. This one is regarding JOSE L
MONARREZ, SSN [redacted], who died on June 4, 2015. The claim
amount we need more information on is $92, 694.00 of Optional
Life Insurance that was effective November 1, 2013.
Can one of you provide me with a screen print of the
enrollment history and the answers to the five medical
questions? With this being within the two-year contestability
period, we'll need his responses to the five medical
questions he should have answered at the time of his
enrollment. If you provide this in the format of an Excel
file, please include the questions, answers, the
employee's name, and the date/time of the web
transaction. We need all of this information included for the
purpose of documenting the claim file.
Id. at 239 (redaction added). Rob Skulnik, Client
Service Manager, HR Outsourcing Solutions, Xerox HR Services,
LLC, responded that "This [participant] made this
election as a new hire back in 2013. He was not required to
answer the questions. Do you want a screen shot of that
election?" Id. at 205. The following day,
Sullivan again emailed Skulnik, asking him to double check
the new hire enrollment for the medical questions.
Id. at 204. After several more requests for the
information, Skulnik responded "We have no record of
this [participant answering the EOI questions."
Id. at 203. On October 19, 2015, Sullivan again
emailed Skulnik asking for information. Id. at 202.
Skulnik replied "Ed, we are still researching into
further but this appears to be an isolated case and our
research so far shows the questions were asked but not
recorded in our system." Id.
records also contain screenshots headed "MetLife Life
Claim Request Entered" and additional notations
indicating "WebMaker - Application" and a web
address. Id. at 500-507. Those records and computer
generated notices of comments to workflow show a Claim
Inquiry was completed on October 15, 2015 as follows:
"The [Third Party Administrator or] TPA responded via
email that the medical questions were not asked when this
person enrolled as a new hire. The GLIF plan is correct -
MEOI is required for new hire enrollments and the questions
should have been asked. Please see attached[, ]"
apparently referring to the screenshots set out above.
Id. at 198, 507.
created on October 21, 2015 by Edward Sullivan state:
The employer's TPA [third party administrator] has
indicated they are still researching the case further but
this appears to be an isolated case and their research so far
shows the questions were asked but not recorded in their
system. In order for the coverage to go into effect, the TPA
states their programming requires "no" responses to
all questions; otherwise, coverage would have been pended for
MetLife approval of a SOH. Please see the attached email
Id. at 505. Notes created by Tamara Wurz, identified
as a Life Claim Examiner, to Edward Sullivan dated November
30, 2015, state:
Would you please check to see if they are able to provide us
with evidence of the data that they do have-is there
something showing that the 5 medical questions had been asked
but the answers not recorded? also, can they show us an
example of an enrollment where the answers to the medical
questions were recorded so that we could compare?"
Id. at 503. An email dated December 1, 2015, from
Terrence Davis at Xerox HR Solutions to Edward Sullivan later
states "I was able to find some more info on this. The
election was processed through a CSR via IVR enrollment. In
the attached, I've highlighted the recorded questions and
answers for optional life as of 11/5/2013." Id.
at 234. The record contains no explanation of the meaning of
those terms. Following that email, the administrative record
contains a spreadsheet, a listing of questions-some
incomplete, a sheet of computer data sets in columns and 27
separately listed date and time stamps each indicating
"11/5/2013 7:17:59." Id. at
12/07/2015, Sullivan states:
Upon further review, the TPA found the medical questions and
answers had been recorded after all. I was informed that the
person who handled the initial inquiry may not have been
accessing the correct table to obtain the data. Please see
the attached email. The Excel file provided has the questions
in rows 20 -28 and the ...