Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_15-cv-01331/USCOURTS-cand-3_15-cv-01331-3/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 29:1001 E.R.I.S.A.: Employee Retirement

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United States District Court

Northern District of California

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

RODNEY ROBISON,

Plaintiff,

v.

LIFE INSURANCE COMPANY OF 

NORTH AMERICA,

Defendant.

Case No. 15-cv-01331-JST 

ORDER GRANTING MOTION FOR 

SUMMARY JUDGMENT

Re: ECF No. 24

Before the Court is Defendant Life Insurance Company of North America’s (“LINA”) 

Motion for Summary Judgment. ECF No. 24. The Court will grant the motion.

I. BACKGROUND

Plaintiff Rodney Robison brought this action under the Employee Retirement Income 

Security Act (“ERISA”), 29 U.S.C. § 1001 et seq., seeking to recover accidental death and 

dismemberment benefits allegedly due to him resulting from the death of his stepson, Cody 

Brown, who was killed in an automobile accident on October 27, 2014. ECF No. 16. Mr. Brown 

was born on June 19, 1994. ECF No. 25-1 at 1. He was 20 years and four months old at the date 

of his death.

At the time of Mr. Brown’s death, Plaintiff was enrolled in an accidental death and 

dismemberment insurance policy (“the Policy”) offered by LINA with a benefit limit of $10,000 

for dependents. ECF No. 25-7 (the Policy); ECF No. 25-8 (enrollment summary). The Policy

covers “a sudden, unforeseeable, external event that results, directly and independently of all other 

causes, in a Covered Injury or Covered Loss and” occurred “while the Covered Person is insured 

under this Policy.” ECF No. 25-7 at 9. A “Covered Person” is defined as “[a]n eligible person . . . 

for whom an enrollment form has been accepted by [LINA] and required premium has been paid 

Case 3:15-cv-01331-JST Document 36 Filed 05/03/16 Page 1 of 8
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when due and for whom coverage under this Policy remains in force. The term Covered Person 

shall include, where th[e] Policy provides coverage, an eligible Spouse and eligible Dependent 

Children.” Id. It is undisputed that Plaintiff submitted an enrollment form for Mr. Brown at least 

as of 2012, ECF No. 25-8, and that all required premiums had been paid when due as of the time 

of the accident on October 27, 2014.

The Policy goes on to define “Dependent Children” as follows:

An Employee’s unmarried child who meets the following 

requirements:

1. A child from live birth to 19 years old;

2. A child who is 19 or more years old but less than 23 years old, 

enrolled in a school as a full-time student and primarily supported 

by the Employee;

3. A child who is 19 or more years old, primarily supported by the 

Employee and incapable of self-sustaining employment by reason of 

mental or physical handicap. Proof of the child’s condition and 

dependence must be submitted to Us within 31 days after the date 

the child ceases to qualify as a Dependent Child for the reasons 

listed above. During the next two years, We may, from time to time, 

require proof of the continuation of such condition and dependence. 

After that, We may require proof no more than once a year.

ECF No. 25-7 at 10.

According to the Policy, “[i]nsurance becomes effective for an Employee’s eligible 

dependents if the Employee applies and agrees to make required contributions within 31 days of 

the date his dependents become eligible . . . .” Id. at 10. The Policy provides that “[t]he insurance 

on a Covered Person will end on the earliest date below: . . . 2. the next premium due date after the 

date the Covered Person is no longer in a Covered Class or satisfies eligibility requirements under 

this Policy; . . . 4. the next premium due date after the Covered Person attains the maximum Age 

for insurance under this Policy . . . .” Id. at 13.

The parties do not dispute that Mr. Brown worked for Certified Tire & Service Center 

(“Certified Tire”) in Livermore, CA from July 9, 2014 to August 5, 2014. ECF No. 24 at 7; ECF 

No. 28 at 6. Nor do the parties dispute that Mr. Brown stopped working at Certified Tire in 

August 2014 due to a work-related back injury. Id. The parties do, however, dispute the extent of 

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Mr. Brown’s injuries and the degree to which these injuries rendered Mr. Brown unable to work.1

Plaintiff submitted his claim to LINA on October 31, 2014. ECF No. 25-9 at 1. Plaintiff 

submitted a revised claim form later that same day. Id. at 2–4. LINA wrote Plaintiff several 

letters between November 2014 and December 2015 seeking additional documentation regarding 

Plaintiff’s claim. See, e.g., ECF No. 27-9 at 43; ECF No. 27-2 at 27. On January 12, 2016, LINA 

wrote to Plaintiff, informing him that it had determined that the benefit was not payable. ECF No. 

27-2 at 13–18. The letter included the definition of “Dependent Child” quoted above and 

explained that “Cody Brown was not enrolled in a school as a full-time student at the time of his 

death, nor was he incapable of self-sustaining employment by reason of mental or physical 

handicap. He does not meet the definitions of Dependent Child as defined under the 

policies . . . .” Id. at 16. The letter also stated that “[t]he available medical records were reviewed 

by staff Medical Director Norton Hall, MD who opined that the ‘clinical notes of Mr. Brown’s 

attending physician, Dr. Ng, of 10/6/16, 9/9/14 and 8/12/14’ were ‘devoid of any documented, 

significant, quantified, positive, neuromusculovasculoskelatal or clinical finding, physical 

impairment or functional loss.” Id.

II. JURISDICTION

Plaintiff’s cause of action arises under ERISA, a federal statute. The Court therefore has 

federal question jurisdiction over this matter pursuant to 28 U.S.C. § 1331.

III. LEGAL STANDARD

“ERISA was enacted ‘to promote the interests of employees and their beneficiaries in 

employee benefit plans,’ and ‘to protect contractually defined benefits.’” Firestone Tire & Rubber 

Co. v. Bruch, 489 U.S. 101, 113 (1989) (internal citations omitted). ERISA “permits a person 

denied benefits under an employee benefit plan to challenge that denial in federal court.” 

Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 108 (2008). “ERISA’s civil-enforcement 

provision . . . allows a claimant ‘to recover benefits due to him under the terms of his plan [and] to 

 

1 Because the Court’s ruling does not turn on the extent of Mr. Brown’s work-related injuries, the 

Court will not further analyze the parties’ disputed positions related to Mr. Brown’s work-related 

injuries at this juncture.

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enforce his rights under the terms of the plan.’” Muniz v. Amec Const. Mgmt., Inc., 623 F.3d 

1290, 1294 (9th Cir. 2010) (quoting 29 U.S.C. § 1132(a)(1)(B)).

“[A] denial of benefits challenged under § 1132(a)(1)(B) is to be reviewed under a de novo

standard unless the benefit plan gives the administrator or fiduciary discretionary authority to 

determine eligibility for benefits or to construe the terms of the plan.” Firestone, 489 U.S. at 115. 

In this case, the parties agree that de novo review is appropriate. See ECF No. 24 at 13; ECF No. 

28 at 5. Under de novo review, “the court simply proceeds to evaluate whether the plan 

administrator correctly or incorrectly denied benefits with no deference given to the 

administrator’s decision.” Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 963 (9th Cir. 

2006) (en banc).

ERISA’s “statutory scheme . . . ‘is built around reliance on the face of written plan 

documents.’” U.S. Airways, Inc. v. McCutchen, 133 S. Ct. 1537, 1548 (2013) (quoting CurtissWright Corp. v. Schoonejongen, 514 U.S. 73, 83 (1995)). “Courts construe ERISA plans, as they 

do other contracts,” with reference to “ordinary principles of contract interpretation.” U.S. 

Airways, 133 S.Ct. at 1548–49 (2013). Ambiguities are construed against the drafter and in favor 

of the insured. Kearney v. Standard Ins. Co., 175 F.3d 1084, 1090 (9th Cir. 1999). “[W]hen the 

court reviews a plan administrator’s decision under the de novo standard of review, the burden of 

proof is placed on the claimant.” Muniz, 623 F.3d at 1294. 

Summary judgment is proper when a “movant shows that there is no genuine dispute as to 

any material fact and the movant is entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a).

“A party asserting that a fact cannot be or is genuinely disputed must support the assertion by” 

citing to depositions, documents, affidavits, or other materials. Fed. R. Civ. P. 56(c)(1)(A). A 

party also may show that such materials “do not establish the absence or presence of a genuine 

dispute, or that an adverse party cannot produce admissible evidence to support the fact.” Fed. R. 

Civ. P. 56(c)(1)(B). An issue is “genuine” only if there is sufficient evidence for a reasonable 

fact-finder to find for the non-moving party. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248–

49 (1986). A fact is “material” if the fact may affect the outcome of the case. Id. at 248. “In 

considering a motion for summary judgment, the court may not weigh the evidence or make 

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credibility determinations, and is required to draw all inferences in a light most favorable to the 

non-moving party.” Freeman v. Arpaio, 125 F.3d 732, 735 (9th Cir. 1997).

Where the party moving for summary judgment would not bear the burden of proof at trial, 

that party bears the initial burden of either producing evidence that negates an essential element of 

the non-moving party’s claim, or showing that the non-moving party does not have enough 

evidence of an essential element to carry its ultimate burden of persuasion at trial. If the moving 

party satisfies its initial burden of production, then the non-moving party must produce admissible 

evidence to show that a genuine issue of material fact exists. See Nissan Fire & Marine Ins. Co. v. 

Fritz Cos., 210 F.3d 1099, 1102–03 (9th Cir. 2000). The non-moving party must “identify with 

reasonable particularity the evidence that precludes summary judgment.” Keenan v. Allan, 91 

F.3d 1275, 1279 (9th Cir. 1996). Indeed, it is not the duty of the district court to “to scour the 

record in search of a genuine issue of triable fact.” Id. “A mere scintilla of evidence will not be 

sufficient to defeat a properly supported motion for summary judgment; rather, the nonmoving 

party must introduce some significant probative evidence tending to support the complaint.” 

Summers v. Teichert & Son, Inc., 127 F.3d 1150, 1152 (9th Cir. 1997) (citation and internal 

quotation marks omitted). If the non-moving party fails to make this showing, the moving party is 

entitled to summary judgment. Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986).

IV. DISCUSSION

Defendant argues that Plaintiff cannot recover under the Policy because “the undisputed 

evidence proves that Mr. Brown was not insured under the [] Policy at the time of his death on 

October 27, 2014.” ECF No. 24 at 18. According to Defendant, Mr. Brown was covered as a 

“Dependent Child” until he turned nineteen, but “coverage terminated shortly after he turned 

nineteen years old on June 19, 2013 ‒ which was more than a year and four months before his 

accident.” Id.

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The Group Policy defines a “Covered Person” to include “an eligible Spouse and eligible 

Dependent Children.” ECF No. 25-7 at 9. “Dependent Children,” in turn, are defined as:

An Employee’s unmarried child who meets the following 

requirements:

1. A child from live birth to 19 years old;

2. A child who is 19 or more years old but less than 23 years old, 

enrolled in a school as a full-time student and primarily supported 

by the Employee;

3. A child who is 19 or more years old, primarily supported by the 

Employee and incapable of self-sustaining employment by reason of 

mental or physical handicap. Proof of the child’s condition and 

dependence must be submitted to Us within 31 days after the date 

the child ceases to qualify as a Dependent Child for the reasons 

listed above. During the next two years, We may, from time to time, 

require proof of the continuation of such condition and dependence. 

After that, We may require proof no more than once a year.

Id. at 10.

The parties do not dispute that Mr. Brown turned nineteen on June 19, 2013. ECF No. 24 

at 19; ECF No. 28. Likewise, the parties do not dispute that Mr. Brown was not “enrolled in a 

school as a full-time student” at the time of his death. ECF No. 24 at 19; ECF No. 28 at 4. 

Accordingly, Mr. Brown was not covered as a “Dependent Child” under the first or second prongs 

of the Group Policy’s definition of “Dependent Children.” The parties do, however, dispute 

whether Mr. Brown was covered under the third prong, as a “child who is 19 or more years old, 

primarily supported by the Employee and incapable of self-sustaining employment by reason of 

mental or physical handicap.” ECF No. 25-7 at 10.

While the Court doubts whether Mr. Brown’s inability to work temporarily due to his 

work-related injuries rendered him “incapable of self-sustaining employment by reason of mental 

or physical handicap,” the Court need not decide this issue because Plaintiff never submitted 

“[p]roof of [Mr. Brown’s purported] condition and dependence . . . within 31 days after the date 

[Mr. Brown] cease[d] to qualify as a Dependent Child” by reason of his turning nineteen, as is 

required by the third prong of the Policy’s definition of “Dependent Children.” Id. As Defendant 

argues, “[n]either Plaintiff nor anyone else submitted any information to LINA within 31 days of 

Mr. Brown’s 19th birthday proving that Mr. Brown was ‘incapable of self-sustaining employment 

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by reason of mental or physical handicap.’” ECF No. 24 at 20. Defendant’s argument is 

supported by a letter sent to Plaintiff by an “accident specialist” at Cigna (of which LINA is a 

subsidiary) on September 15, 2015, stating: “[o]ur records indicate that proof of Cody Brown’s 

condition and dependence was not submitted to us after Cody Brown turned age 19 or at any time 

prior to his death.” ECF No. 27-2 at 35. 

Plaintiff does not contend that he submitted proof to LINA of any “mental of physical 

handicap” which Mr. Brown may have had, which could have rendered him “incapable of selfsustaining employment” within 31 days after the date Mr. Brown turned nineteen. ECF No. 28 at 

7–8. Rather, Plaintiff argues that the requirement that proof be submitted to LINA within 31 days 

“is contrary to the [Group Policy’s separate] provision that ‘insurance becomes effective for an 

Employee’s eligible dependents if the Employee applies and agrees to make required contributions 

within 31 days of the date his dependents become eligible . . . .” ECF No. 28 at 7 (quoting ECF 

No. 25-7 at 12). While the Court agrees with Plaintiff that “[t]here is nothing in this [latter] 

provision that requires providing notice of disability,” nothing in the latter provision negates the 

requirement under the third prong of “Dependent Child” definition requiring that “proof of the 

child’s condition and dependence must be submitted to [LINA] within 31 days after the date the 

child ceases to qualify as a Dependent Child” once he turns nineteen. 

Plaintiff also argues that “any requirement for having to [re-enroll a child] into the plan 

[after the child turns nineteen] would not meet the reasonable expectations of the insured.” Id. at 

7. Plaintiff cites no authority on point, except for Peterson v. Am. Life & Health Ins. Co., for the 

general proposition that “[u]nder the ‘reasonable expectations’ doctrine, as a matter of federal 

common law governing ERISA contracts, even an unambiguous exclusion may be unenforceable 

unless it is sufficiently ‘clear, plain, and conspicuous’ to overcome a layperson’s reasonable 

expectations.” 48 F.3d 404, 411 (9th Cir. 1995). However, as Peterson makes clear, the 

reasonable expectations doctrine only applies when “a provision in an insurance policy is . . . not 

sufficiently conspicuous.” Id. Here, the requirement that proof be submitted of a child’s 

condition and dependence within 31 days after the child turns nineteen appears in the sentence 

directly following (and in the same paragraph as) the sentence defining “Dependent Children” to 

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include “[a] child who is 19 or more years old, primarily supported by the Employee and 

incapable of self-sustaining employment by reason of mental or physical handicap.” ECF No. 25-

7 at 10. Accordingly, the Court concludes that the proof requirement is sufficiently conspicuous 

that the reasonable expectations doctrine does not apply.

Given that Plaintiff bears the burden of proof to show that benefits were due to him under 

the Policy, Muniz, 623 F.3d at 1294, the Court concludes that Plaintiff’s claim fails because he has 

not presented the Court with any evidence that he submitted proof of Mr. Brown’s “condition and 

dependence” within 31 days of his nineteenth birthday as required by the Policy. See Staats v. 

Goodyear Tire & Rubber Co., No. 05-cv-1386, 2006 WL 2707969, at *4 (N.D. Cal. Sept. 19, 

2006) (granting defendant’s motion for summary judgment in ERISA case based on the fact that 

“even if the plaintiff’s daughter’s condition had sufficiently changed by the summer of 2002, and 

the change was properly documented, so that she was eligible based on the disabling condition for 

continued medical coverage, the plaintiff failed to provide the defendant with the required notice 

of her changed status within 31 days of its occurrence.”). Because no genuine issue of material 

fact exists regarding Mr. Brown’s not being covered by the Policy as a “Dependent Child,” the 

Court grants Defendant’s motion for summary judgment.

CONCLUSION

Defendant’s motion for summary judgment is granted.

IT IS SO ORDERED.

Dated: May 3, 2016

______________________________________

JON S. TIGAR

United States District Judge

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