Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caDC-97-07095/USCOURTS-caDC-97-07095-0/pdf.json

Parties Involved:
Fortis Benefits Insurance Company
Appellee
Andrea Heller
Appellant

Document Text:

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United States Court of Appeals

FOR THE DISTRICT OF COLUMBIA CIRCUIT

Argued March 17, 1998 Decided May 1, 1998

No. 97-7095

Andrea Heller,

Appellant

v.

Fortis Benefits Insurance Company,

Appellee

Appeal from the United States District Court

for the District of Columbia

(No. 92cv00549)

Joseph F. Cunningham argued the cause and filed the

briefs for appellant.

Jennifer Rand Stein argued the cause for appellee, with

whom Grace E. Speights was on the brief.

Before: Wald, Silberman and Rogers, Circuit Judges.

Opinion for the Court filed by Circuit Judge Rogers.

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Rogers, Circuit Judge: Andrea Heller appeals the grant

of summary judgment to Fortis Benefits Insurance Company

("Fortis") on her claim that the company improperly denied

her disability benefits and breached its fiduciary duty in

violation of the Employee Retirement Income Security Act of

1974 ("ERISA"), 29 U.S.C. ss 1001-1461 (1994). After paying Heller disability benefits for five years, Fortis determined

that she no longer qualified as disabled under its plan and

terminated her benefits. The district court approved this

termination and further ordered Heller to reimburse Fortis

for disability payments for which she had not actually been

eligible. Because Heller failed to present a genuine issue of

material fact regarding her qualification for disability benefits

under Fortis' plan, and because we hold that restitution was

an available remedy for the company under ERISA and that

the district court did not abuse its discretion in ordering the

award, we affirm.

I.

Heller worked as a marketing representative for McCue

Systems, Inc. ("McCue"), beginning in March 1985. The job

was stressful, and she injured her back, neck, and shoulder

by carrying heavy computer equipment on numerous business

trips. In January 1986, she filed for disability under McCue's

health benefits plan, which provided for insurance coverage

from Fortis.1 In order to qualify as "totally disabled" under

the plan and thus be eligible for payments, she had to be

"unable to perform the material duties of ... her regular

occupation or employment." Agreeing that she qualified for

payments as a "totally disabled" person under this definition,

Fortis approved Heller's claim. She accordingly received

disability benefits from Fortis for five years, from 1986

through 1991.

__________

1 McCue purchased the plan from the Mutual Benefit Insurance Company, which was succeeded as the company responsible

for administering the plan by Fortis in 1991. For ease of reference,

we refer to Heller's insurer throughout as "Fortis."

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Under Heller's plan, however, the standards for her eligibility for benefits changed after five years and, by letter of

February 4, 1991, Fortis informed Heller that it would review

her continued entitlement to benefits. As Heller's plan provided, a person is "totally disabled" if

A. Occupation Test

(i) during the first 60 months of any One Period of Total

Disability, the Person Insured is under the regular care

and attendance of a Licensed Physician (other than him

or herself) and unable to perform the material duties of

his or her regular occupation or employment; and

(ii) after the first 60 months of any One Period of Total

Disability, the Person Insured is unable to perform the

material duties of any and every gainful occupation or

employment for which the person is or becomes reasonably fitted by education, training or experience.

While a Person Insured meets these requirements, limited employment will not interrupt the Qualifying Period

or the Period of Total Disability.

B. Earnings Test

If a Person Insured is working, and is not disabled by

the Occupation Test definition of Total Disability, we will

consider the Person Insured to be "Totally Disabled"

during any month when he or she is not able, because of

Injury, sickness or pregnancy, to earn more than 50% of

his or her Monthly Earnings.

Fortis advised Heller that it would investigate the merits of

her continued claim for benefits and that "the issuance of any

further benefits should not be construed as an admission of

liability on our part to continue benefits indefinitely beyond

the first sixty months of disability."

Thereafter, Fortis commissioned Crawford & Company

("Crawford"), an employment consulting firm, to interview

Heller, assess whether she could perform any jobs, and

conduct a labor market survey to determine what jobs might

be available for her. In its "Initial Vocational Assessment"

report on March 22, 1991, Crawford concluded that Heller

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"possesses many transferable skills from her work history

that would be useful in other less physically demanding types

of work," based on her experience, college education, and

sales skills. From May 10 through June 5, 1991, Crawford

conducted a "Labor Market Survey" that indicated that Heller "has good transferrable skills that apply to different types

of jobs that are presently available in the labor market, and

those are too numerous to list here, but include customer

service, bank positions, any retail, etc." Crawford listed ten

sales positions for which Heller might be particularly suited.2

Additionally, Fortis dispatched its in-house investigator to

determine whether Heller was working at her husband's law

firm during the time that she was receiving disability benefits. The investigator determined that Heller spent some

time at the firm during the workday, and he also found some

documents implying that she worked there--for instance, a

letter referring to her editing assistance. However, neither

Heller's social security and tax records nor the law firms's

records provided documentation of such employment or income; nor did she ever notify Fortis of any return to work or

receipt of new income.

Finally, Fortis assembled the medical reports on Heller

from examinations since the onset of her disability. Three

physicians pronounced her fit for certain kinds of employment. In 1987, Dr. Philip Pulaski concluded that he "would

have a hard time, at least from the neurologic perspective,

continuing to back up her claims of disability." In 1989, Dr.

John Devor concluded that "[m]ost of the time, [Heller]

probably would not have more than a slight handicap working

either as an outside salesperson or an inside salesperson." In

1990, Dr. Louis Levitt concluded: "In my opinion the patient

is not totally disabled from gainful employment." In addition,

Dr. Raymond Drapkin, Heller's attending physician, who had

been of the opinion that Heller had been disabled, agreed on

January 23, 1991, in response to a questionnaire sent by

Fortis, that Heller was a good candidate for vocational reha-

__________

2 Relying on telephone calls made one year after Crawford

completed its survey, Heller disputes the availability of these jobs.

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bilitation. On September 6, 1991, in response to another

questionnaire, Dr. Drapkin further agreed that Heller could

be available for "light work duty" and was "OK" for "sedentary work." He answered in the affirmative the question

whether she could "possibly return to work on a full-time

basis as an inside salesperson where she is not require[d] to

travel or lift heavy equipment and where she is allowed to

alternate her position when necessary."

Based on its investigation, Fortis concluded that Heller

satisfied neither the plan's Occupation Test nor its Earnings

Test, and therefore was unqualified to receive benefits. By

letter of January 15, 1992, Fortis notified Heller of the

termination of her benefits. After outlining the medical

information and the information provided by Crawford, the

letter stated: "Based on the medical information and the

results of the Labor Market Survey, benefits could be denied

on these findings alone[;] however we also have information

documenting that [Heller] has worked ... since 12/19/88." In

addition to terminating her benefits, Fortis demanded repayment of "benefits that were not due." The letter did not

advise her of any right to appeal the benefits determination.

Heller sent a number of documents to Fortis, to which

Fortis responded both in writing and by telephone conversation with Heller's attorney that it would treat the documents

as an appeal of its benefits determination. Nonetheless, two

days after receiving this notice from Fortis, Heller filed suit

alleging, among other things, violation of ERISA, specifically,

29 U.S.C. s 1132(a)(1)(B), which provides that "[a] civil action

may be brought ... by a participant or beneficiary ... to

recover benefits due to him under the terms of his plan, to

enforce his rights under the terms of the plan, or to clarify

his rights to future benefits under the terms of the plan." 29

U.S.C. s 1132(a)(1)(B) (1994). Fortis counterclaimed for restitution of benefits paid Heller after January 1991. The

district court resolved the case on cross-motions for summary

judgment, ruling in Fortis' favor on both Heller's claim and

its counterclaim. The court found that Fortis was entitled to

$19,811.00 in restitution, the amount erroneously paid to

Heller after her fifth year of receiving benefits.

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II.

On appeal Heller contends that the district court erred in

granting summary judgment against her because Fortis denied her a meaningful review process in violation of 29 U.S.C.

s 1133. She also contends that the district court failed to

apply either test for "total disability" properly in the context

of a motion for summary judgment. Under the Occupation

Test, she maintains, the severity of her disability presented a

material question of fact. Furthermore, she maintains that

the district court could not have concluded that she failed the

Earnings Test on the basis of sparse medical evidence and

undocumented allegations that she was working at her husband's law firm. Finally, she contends that the district court

erred in awarding Fortis restitution. Our review of the grant

of summary judgment, as well as the denial of Heller's own

motion for summary judgment, is de novo. See Henke v.

Department of Commerce, 83 F.3d 1445, 1448 (D.C. Cir.

1996); Tao v. Freeh, 27 F.3d 635, 638 (D.C. Cir. 1994).

Rule 56(c) of the Federal Rules of Civil Procedure provides

that a court shall grant a motion for summary judgment if

"the pleadings, depositions, answers to interrogatories, and

admissions on file, together with the affidavits, if any, show

that there is no genuine issue as to any material fact and that

the moving party is entitled to a judgment as a matter of

law." Fed. R. Civ. P. 56(c). Facts are deemed "material" if a

dispute over them "might affect the outcome of the suit under

the governing law." Anderson v. Liberty Lobby, Inc., 477

U.S. 242, 248 (1986). A factual dispute is "genuine" where

"the evidence is such that a reasonable jury could return a

verdict for the nonmoving party." Id. The moving party has

the burden of demonstrating the absence of a genuine issue of

fact for trial. See id. at 256. If the moving party satisfies

this burden, Rule 56(e) provides:

When a motion for summary judgment is made and

supported as provided in this rule, an adverse party may

not rest upon the mere allegations or denials of the

adverse party's pleading, but the adverse party's response, by affidavits or as otherwise provided in this

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rule, must set forth specific facts showing that there is a

genuine issue for trial. If the adverse party does not so

respond, summary judgment, if appropriate, shall be

entered against the adverse party.

Fed. R. Civ. P. 56(e).

A.

Because Heller made her disability claim through an insurance plan offered by her employer, this coverage case is

governed by ERISA. See 29 U.S.C. ss 1002(1), 1003(a)

(1994). Section 503 of ERISA provides that

every employee benefit plan shall--

(1) provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the

plan has been denied, setting forth the specific reasons

for such denial, written in a manner calculated to be

understood by the participant, and

(2) afford a reasonable opportunity to any participant

whose claim for benefits has been denied for a full and

fair review by the appropriate named fiduciary of the

decision denying the claim.

Id. s 1133. Initial claims handling must be completed within

time limits prescribed by the Secretary of Labor. See 29

C.F.R. s 2560.503-1(e) (1997). If a claim is denied, the

fiduciary reviewing the denial must act promptly and within

time periods prescribed by the Secretary of Labor following

any request for review by the plan participant. See id.

s 2560.503-1(h). The Secretary has fixed that time period in

most cases at 120 days:

A decision by an appropriate named fiduciary shall be

made promptly, and shall not ordinarily be made later

than 60 days after the plan's receipt of a request for

review, unless special circumstances (such as the need to

hold a hearing, if the plan procedure provides for a

hearing) require an extension of time for processing, in

which case a decision shall be rendered as soon as

possible, but not later than 120 days after receipt of a

request for review.

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Id. s 2560.503-1(h)(1)(i). If the decision is not rendered

within the 120-day period, the claim is deemed denied on

review, see id. s 2560.503-1(h)(4), and the claimant may

"bring a civil action to have the merits of his application

determined, just as he may bring an action to challenge an

outright denial of benefits," Massachusetts Mut. Life Ins. Co.

v. Russell, 473 U.S. 134, 144 (1985). Delay in the processing

of an application or appeal does not, however, give rise to a

private right of action for compensatory or punitive relief.

See id.

The relevant regulations also provide that the notice required by section 1133 includes "appropriate information as to

the steps to be taken if the participant or beneficiary wishes

to submit his or her claim for review." 28 C.F.R. s 2560.503-

1(f)(4). Fortis never advised Heller of her right to appeal in

its denial letter. However, this would not necessarily render

summary judgment in favor of Fortis inappropriate given its

substantial compliance with section 503 of ERISA and its

accompanying regulations. See, e.g., Brehmer v. Inland Steel

Indus. Pension Plan, 114 F.3d 656, 662 (7th Cir. 1997); Kent

v. United of Omaha Life Ins. Co., 96 F.3d 803, 807 (6th Cir.

1996). Indeed, "when claim communications as a whole are

sufficient to fulfill the purposes of Section 1133 the claim

decision will be upheld even if a particular communication

does not meet those requirements. Kent, 96 F.3d at 807.

Here, before Heller filed her lawsuit, she was informed of her

right to appeal and that appeal proceedings were being

commenced. Fortis advised Heller through her present attorney on February 19, 1993, a month after sending the

termination later, that it would treat various documents sent

by her as an appeal. Thus, although the initial letter from

Fortis informing Heller of the denial of her disability benefits

did not conform to the requirements of the regulations, "the

procedures, when viewed in light of the myriad communications between claimant, her counsel and the insurer, [appear]

sufficient to meet the purposes of Section 1133 in insuring

that the claimant understood the reasons for the denial of

[her benefits] as well as her rights to review of the decision."

Id. at 807.

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In any event, Heller now asserts that even if Fortis had

resolved her appeal, the established review process was essentially meaningless because it consisted merely of the

claims adjuster's reconsideration of his own work. But we

have no occasion to determine whether Fortis' procedural

shortcomings violated 29 U.S.C. s 1133 and its attendant

regulations, and, if so, what remedy might be appropriate,

because Heller never attempted to make use of Fortis' appeal

process. While the insurer offered to treat Heller's correspondence as an appeal of its denial of benefits, Heller did not

wait to see how the appeal would be resolved. Instead, she

filed her lawsuit two days after Fortis' February 19th offer.

Not only did she shortcut any review that might have occurred, but she even asserted in her complaint that she had

exhausted her administrative remedies. Under the circumstances, she cannot establish that she was denied "a fair

opportunity for review" of her claim because she never gave

Fortis a chance to complete its review. Id. at 807. Nor can

she show that Fortis' processing of her claim denial prejudiced her because she immediately filed suit against the

insurer. See Hancock v. Montgomery Ward Long Term

Disability Trust, 787 F.2d 1302, 1308 (9th Cir. 1986). By

doing so before exhausting the remedies provided by her

insurer, Heller's position now is no different than it would

have been if Fortis had neglected to process her correspondence as an appeal. See 29 C.F.R. s 2560.503-1(h). In

either event, her next move would have been to file suit in the

district court. See Massachusetts Mut. Life Ins. Co., 473

U.S. at 144.

B.

Under the Occupation Test in Fortis' plan, insureds are

considered "totally disabled" (after the first five years of

disability) if they are "unable to perform the material duties

of any and every gainful occupation or employment for which

the person is or becomes reasonably fitted by education,

training or experience." Heller contends that there was a

genuine issue of material fact whether she was unable to

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perform the duties of any gainful occupation and whether

there were any job opportunities for which she was reasonably fitted.

Heller's examining and treating physicians agreed, however, that she was able to work in 1992, and she presented no

evidence to contravene the Crawford report that jobs were

available to her. "Courts review ERISA-plan benefit decisions on the evidence presented to the plan administrators,

not on a record later made in another forum," Block v. Pitney

Bowes Inc., 952 F.2d 1450, 1455 (D.C. Cir. 1992), and all the

evidence available to Fortis when it made its claim decision

suggested that Heller was able to work as a medical matter,

at least in a sedentary occupation. Not only had three

outside medical examiners concluded that she was not disabled, but her own attending physician, Dr. Drapkin, also

advised Fortis that Heller was ready for "light work duty"

and "sedentary work." Because Dr. Drapkin's January 15,

1997, declaration that he had always thought his patient was

disabled, regardless of his earlier conclusions as to her suitability for sedentary work, was unavailable to Fortis before it

denied Heller's claim for further benefits on January 15, 1992,

that declaration may not be considered now. See id. Hence,

there is no genuine factual dispute about the medical conclusions available to Fortis at the time it terminated Heller's

benefits. Those medical conclusions unanimously indicated

that Heller was capable of some work.

Nor was there a genuine question of material fact as to the

availability of employment for which Heller would have been

"reasonably fitted by education, training or experience," as

required by the plan. Heller was confronted with Crawford's

vocational assessment indicating that she was a good candidate for employment in inside sales because she had transferrable skills, a college education, and job experience. Heller

presented Fortis with nothing to challenge that assessment

other than speculation that it would be difficult at her age for

her "realistically" to get one of the inside sales jobs, and that

the jobs might pay minimum wage. Her evidence that none

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ly it did not indicate that similar jobs were unavailable.

Therefore, although "the burden of proof is upon the insured

as to questions of coverage and disability," 20 John Alan

Appleman & Jean Appleman, Insurance Law and Practice

s 11376 (1980) (footnote omitted) (citing cases); cf. Perdue v.

Burger King Corp., 7 F.3d 1251, 1254 n.9 (5th Cir. 1993),

Heller did not provide Fortis with evidence suggesting that

she had "an impairment which would prevent [her] from

performing some identifiable job," See McKenzie v. General

Telephone Co., 41 F.3d 1310, 1317 (9th Cir. 1994). Heller did

not present any evidence to Fortis sufficient to establish her

right to benefits under the company's Occupation Test.

Nor can Heller prevail under the alternative Earnings

Test. Under that test, an insured who "is not able, because

of Injury, sickness or pregnancy, to earn more than 50% of

his or her Monthly Earnings" before going on disability is

entitled to benefits. The most important part of this definition for Heller is the phrase "able ... to earn." Crawford's

analysis of Heller's employment prospects concluded that she

was qualified for a number of available inside sales jobs, and

listed a number of examples paying base salaries between

$20,000 to $35,000 per year. The wages from these jobs

exceeded 50% of the roughly $35,000 that Heller made when

she was working for McCue prior to her disability.3 Again,

Heller has presented no evidence to show that she could not

find a job that would pay at least 50% of the salary she

earned at McCue, despite her obligation to do so. See Fed. R.

Civ. P. 56(e).

__________

3 Indeed, under Fortis' interpretation of its Occupation Test, a

"gainful" occupation is an occupation that pays at least the amount

of the gross monthly long-term disability benefit that the claimant

receives from Fortis--in Heller's case, $1801 per month. Thus,

when it denied Heller's claim under that test, Fortis necessarily

found that Heller could earn at least $1801 per month, which is

more than one half of Heller's average monthly salary at McCue

and thus sufficient to satisfy the Earnings Test. As noted, Heller

has not presented evidence sufficient to sustain a claim against

Fortis' application of its Occupation Test.

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For these reasons, the district court properly concluded

that the medical and occupational evidence before Fortis at

the time of its decision to terminate benefits was sufficient to

support that decision. Because Heller has presented no

contradictory evidence, we need not reach other disputed but

nonmaterial issues of fact, such as whether Heller actually

was working for her husband's law firm, in order to affirm

the grant of summary judgment.

III.

This circuit has not previously decided whether there is a

cause of action for restitution under ERISA. Fortis filed its

counterclaim for restitution pursuant to ERISA's provision

that "[a] civil action may be brought ... by a ... fiduciary

(A) to enjoin any act or practice which violates any provision

of this subchapter or the terms of the plan, or (B) to obtain

other appropriate equitable relief ... to redress such violation." 29 U.S.C. s 1132(a)(3). As the Third Circuit concluded in Luby v. Teamsters Health, Welfare & Pension Trust

Funds, 944 F.2d 1176 (3d Cir. 1991), "[a]lthough ERISA itself

does not explicitly provide a statutory right of restitution, it is

clear that Congress intended federal courts to fashion a

federal common-law under ERISA, and this permits application of a federal common-law doctrine of unjust enrichment."

Id. at 1186. A number of courts have created an unjust

enrichment remedy, permitting ERISA fiduciaries such as

Fortis to seek restitution against third parties who wrongly

or mistakenly receive money to which the plan is entitled.

See, e.g., Blue Cross & Blue Shield of Ala. v. Weitz, 913 F.2d

1544, 1548-49 (11th Cir. 1990); Provident Life & Accident

Ins. Co. v. Waller, 906 F.2d 985, 994 (4th Cir. 1990). But see

NYSA-ILA GAI Fund v. Poggi, 617 F. Supp. 847, 849

(S.D.N.Y. 1985). As the district court correctly concluded,

this furthers the goal of ERISA to safeguard "the corpus of

funds set aside" under the plan.4 Luby, 944 F.2d at 1186; see

__________

4 While Luby itself is different from the instant case to the

extent that it involved a mistaken payment to a nonbeneficiary

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also Printing Industry of Ill. Employee Benefit Trust v.

Stout, 157 F.R.D. 448, 451 (N.D. Ill. 1994) ("[D]enial of a

federal cause of action would ultimately undermine ERISA's

goal of expanding pension and welfare benefit plan coverage."). Accordingly, we hold that Fortis could properly seek

restitution under ERISA.

The question remains whether the district court properly

granted Fortis restitution. Here, the scope of our review is

more limited than with regard to whether restitution was a

possible remedy; we only review awards of restitution for

abuse of discretion. See United States v. Rezaq, 134 F.3d

1121, 1141 (D.C. Cir. 1998). Generally, restitution is an

appropriate remedy where there is unjust enrichment:

three elements encompass the equitable remedy of unjust enrichment and quasi-contract: the plaintiff must

show that (1) he had a reasonable expectation of payment, (2) the defendant should reasonably have expected

to pay, or (3) society's reasonable expectations of person

and property would be defeated by nonpayment.

Waller, 906 F.2d at 993-94 (citing Colin Kelly Kaufman,

Corbin on Contracts s 19A, at 50 (Supp. 1989)). Heller

contends that the restitution ordered by the district court was

unfair essentially because she had not been notified that the

company would seek restitution until it terminated her payments. Her plan did not specifically provide for restitution

and Fortis never expressly stated that its payment of the

benefits after the five year term expired was conditional. Yet

the district court was presented with evidence that Fortis had

previously notified Heller in writing that its payment of

benefits after the first five years could not be deemed an

admission of liability. Reasonably viewed, Fortis thereby

notified Heller that it expected reimbursement for benefits

for which she was not eligible. It is true that the plan did not

expressly provide for restitution, but nothing in the plan

__________

instead of a disputed payment to a beneficiary, the principle remains the same. In both cases the recipient of the money receives

benefits to which she is not entitled, a cost unfairly borne by the

other members of the plan. See Weitz, 913 F.2d at 1548.

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prohibited such recovery by Fortis. While it might well be

preferable for the plan to be explicit on the point, notice by

letter may well afford more effective notice than a provision

buried in a lengthy policy statement. The district court,

therefore, did not abuse its discretion in ordering restitution

in such circumstances.

Accordingly, we affirm the judgment.

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