FILED U.S. COURT OF AP P E A LS E LE V EN T HC IRC U IT April 29, 2008 THOMAS K. KAH

N CLERK [ DO NO T P UB L I S H] I N THE UN I TE D STATE S C OU RT OF APPE ALS F O R T H E E L E V E N T H C IR C U IT

________________________ N o. 07- 15698 N on -A rgum entC al endar

________________________ D . C . D ocketN o. 02 -011 40 -C V -J E C -1 G R E G O R Y L . T I P P I T T , P la in tif f - A p p e lla n t, v ersu s R E L I A N C E S T A N D A R D L I F E I N S U R A N C E C O M P A N Y , M U N I CH A M ERI CA N REA SSU RA N CE CO M PA N Y G RO U P LO N G TERM D I S A B I L I T Y I N S U R A N C E P L A N , D e f e n d a n ts - A p p e lle e s .

________________________ A pp ea l fr om the U ni t ed S t at es D i stri ctC ou rt f o rth e N o r th e rn D is tr ic t o f G e o r g ia

_________________________ ( A p r i l29, 2008) B efo re B IR C H , D U B IN A an d C A RN E S , C i rcu i tJu d g es. P E R C U R I A M:2

G r e gory T i ppi ttappe a l s the di s tr i c tc our t ’ s e ntry of j udgm e nti n f

a vorof R el i ance S t andard L i fe Insura nce C om pany and M un i ch A m er i ca n R ea ss urance C om pa ny G r oup L ong T e r m D i s abi l i ty I ns ur a nc e P l a n i n hi s a c t i on f orw r ongf

ul deni al of benefi t s und erthe E m pl oyee R et i re m entIncom e S ec uri ty A ct(E R IS A ), 2 9 U .S .C . § 1 0 0 1 e t s e q . I. T i ppi tti s a f

or m e ra s s i s t a ntm a na ge rof c om put e ri nf

or m a t i on s y s t e m s f

or M un i ch. W hi l e e m pl oyed there , he enrol l ed i n the M un i ch A m er i ca n R ea ss urance C o m p a n y G r o u p L o n g T e r m D is ab ility I n s u r a n c e P la n ( “M A R C P la n ” ) , w h ic h is i nsured and adm i ni st er ed by R el i ance . T he pl an prom i se d h i m benefi t s i f he w as t ot a l l y di s abl e d thr oughoutthe “ e l i m i na t i on pe r i od, ” w hi c h i s de f i ne d a s 180 c o n s e c u tiv e d a y s f

r o m th e tim e h e c la im e d to b e d is ab le d . O n J a nua ry 7, 2000, T i ppi ttr e s i gne d f r om hi s j ob. T hr e e da y s l a t e rhe appl i ed for di sabi l i ty benef i t s und erthe M A R C P l an, cl ai m i ng thathe suff er ed f r om “ pr ogr e s s i ve l y i nc r e a s i ng s y m pt om s of j oi ntpa i n, c l us t e rhe a da c he s , a nd fa t i gu e. ” T i pp i tt ’ s doct ors l at erdi agno se d h i m as havi ng Sj ög re n’ s s yndrom e, an aut oi m m un e di se as e a ff ec t i ng m oi sture- prod uci ng ce l l s, and u nd i ff er ent i at ed spon dyl oarthrop athy, an i nfl am m at ory j oi ntdi se as e s i m i l art o arthri t i s. R el i ance deni ed hi s c l ai m on the grou nd s thathe w as no tt ot al l y di sabl ed because he w as3

s till c ap ab le o f

p e r f o r m in g th e m a

jo r ity o f h is jo b ’s m a te r ia l d u tie s . T ip p itt a dm i ni s tr a t i ve l y appe a l e d thi s de c i s i on, a nd R e l i a nc e , a f t e rf ur the rc ons i de r a t i on, uphe l d i t s or i gi na l de ni a l . T i ppi tta s ke d f ory e ta nothe rr e vi e w , a nd, a l though not ob l i gat ed t o d o so, R el i ance consi dere d T i pp i tt ’ s c l ai m ye tagai n and deni ed i tye t a g a in . T h is tim e it c o n c lu d e d th a t T ip p itt w a s n o t f u lly d is ab le d b e c a u s e h e c o u ld st i l l perf orm atl ea ston e of hi s m at er i al du t i es . T i pp i ttas ked for ye tanot her r e v ie w o f

h is c la im , b u t R e lia n c e in f o r m e d h im th a t its d e c is io n w a s f in a l. T i ppi tts ue d unde rE R I S A . T he di s tr i c tc our tc onduc t e d a be nc h tr i a l a nd foun d thatR el i ance had correc t l y deni ed coverage bec ause T i pp i tt“ coul d p er form som e of the du t i es of [hi s j ob ] du ri ng the three ho urs of s edent ary w ork . . . that [he] coul d com pl et e. ” T i pp i ttappeal ed, and w e r ever se d. T i pp i ttv. R el i ance S t andard L i fe Ins. C o. , 45 7 F . 3d 12 27 (11th C i r. 20 06 ). W e di d so aft er c onc l udi ng tha t“ w e c a nnota c c e ptthe l e ga l [ pr e m i s e ] w hi c h i s tha ta ny one w ho ca n p er form som e of hi s dut i es du ri ng som e of the w ork d ay i s part i al l y di sabl ed a n d th e r e f

o r e n o t to ta lly d is ab le d .” I d . a t 1 2 3 7 . W e e x p la in e d th a t if T ip p itt, dur i ng the e l i m i na t i on pe r i od, c oul d pe r f or m a l l of

hi s dut i e s e i the rdur i ng the thr e e - hourpe r i od ors om e othe rs ubs t a nt i a l f r a c t i on of

the w or k da y , he w oul d be on l y part i al l y di sabl ed and t here fore no tt ot al l y di sabl ed. Id. T he ca se w as r e m a n d e d to p e r m it th e d is tr ic t c o u r t to m a k e th e n e c e s s a ry f a c tf in d in g s .4

O n r e m a nd, the di s tr i c tc our tm a de f i ndi ngs a nd a ga i n e nt e r e d j udgm e ntf or the de f e nda nt s . I n thi s appe a l , T i ppi ttc ont e nds the di s tr i c tc our te rr e d by : ( 1) m i s i nt e rpr e t i ng the t e r m “ pa r t - t i m e ” i n T i ppi tt ’ s M A R C P l a n pol i c y ; ( 2) f i ndi ng tha tT i ppi ttc oul d pe r f

or m a l l of

hi s j ob dut i e s f

ora thr e e - hourpe r i od e a c h da y ; ( 3) c ons i de r i ng the r e a s ons f orde ny i ng hi s c l a i m tha tR e l i a nc e of f e r e d i n l i t i ga t i on ra ther than t ho se art i cul at ed i n the l ett erdenyi ng hi s c l ai m ; and (4) fi nd i ng that R el i an ce’ s d en i al o f T i p p i tt ’ s cl ai m w as n o tarb i trary an d cap ri ci o u s. W e ad d ress the s e c ont e nt i ons i n turn. II. T i pp i ttfi rs tcont ends thatthe di stri ctcourterre d b y m i si nt erpret i ng the t erm

“ pa r tt i m e ” i n hi s i ns ur a nc e pol i c y . H e a r gue s tha tthe t e r m “ pa r tt i m e ” i n the defi ni t i on of part i al di sabi l i ty i s a m bi gu ou s and , as such, shou l d b e c on strued a ga i ns tR e l i a nc e a s the dr a f t i ng pa r ty . S e e L e e v. B l ue C r os s / B l ue S hi e l d, 10 F . 3d 1 5 4 7 , 1 5 5 1 ( 1 1 th C i r . 1 9 9 4 ) ( “ Ha v i n g d e t e r m i n e d th a tth e p l a n i s a m b i g u o u s , we hol d tha tappl i c a t i on of

the rul e of

c ontr a pr of

e r e nt e m i s appr opr i a t e i n r e s ol vi ng am bi gu i t i es i n i nsurance c on tra ct s r egul at ed by E R IS A . ”) . T he M A R C P l an po l i cy s ta te s th a t a n in s u r e d is p a r tia lly d is ab le d w h e n a n in ju ry o rs ic k n e s s r e n d e r s h im “c ap ab le o f

p e r f o r m in g th e m a te r ia l d u tie s o f h is /h e rr e g u la ro c c u p a tio n o n a p a r tt i m e bas i s or s om e of the m at er i al du t i es on a f ul l -t i m e bas i s. ” B ec ause “ ful l -t i m e”5

m e a n s w o r k in g “a m in im u m o f 3 0 h o u r s d u r in g a p e r s o n ’s r e g u la rw o r k w e e k ,” T i pp i ttre as on s that“ part -t i m e” shou l d m ea n b ei ng abl e t o w ork a subst ant i al num be rof

hour s butl e s s tha n 30 a w e e k. T he di s tr i c tc our tc onc l ude d tha tdur i ng the el i m i nat i on peri od T i pp i ttcoul d p er form al l of hi s w ork d ut i es for onl y three h o u rs p er d ay, a t o t al o f a fi ft een h o u rs each w o rk w eek . Itfo l l o w s, T i p p i ttsays, th a t b e c a u s e h e w a s u n ab le to w o r k a s u b s ta n tia l n u m b e ro f h o u r s h e c o u ld n o t m ee tthe part -t i m e r equi re m ent , and h e m ustbe consi dere d t o h ave been c o m p le te ly d is ab le d . I n T ip p itt’s f

ir s t ap p e a l w e c o n c lu d e d th a t a n in s u r e d w a s n o t to ta lly d i s ab l e d i f

h e c o u l d “ p e r f

o r m a l l o f

th e d u t i e s o f

[ h i s ] o c c u p a t i o n ‘ o n a p a r t - t i me basi s, ’ ” w hi ch m ea ns ca rryi ng ou ttho se du t i es for “ a s ub st ant i al partof the w ork d ay. ” T i p p i tt , 4 5 7 F . 3 d at1 2 3 7 . W e w en to n t o say th ata th ree-h o u r p eri o d i s a s ubs t a nt i a l pa r tof

the w or k da y . I d. U nde rthe l a w of the c a s e doc tr i ne , w e a r e not f r e e t o r e vi s i ttha thol di ng. S e e A l pha m e d, I nc . v. B . B r a un M e d. , I nc . , 367 F . 3d 1 2 8 0 , 1 2 8 6 ( 1 1 th C ir . 2 0 0 4 ) . T h e r e f o r e , th e d is tr ic t c o u r t d id n o t e rrin de t e r m i ni ng tha ti f

T i ppi ttc oul d pe r f

or m a l l of

hi s dut i e s f

ora thr e e - hourpe r i od e a c h da y he w a s onl y pa r t i a l l y di s abl e d, notf ul l y di s abl e d. III. T i pp i ttnextcont ends that , even un der the defi ni t i on of “ part -t i m e” appl i ed6

by the di stri ctcourt , i terre d w hen i tfoun d thathe coul d w ork p artt i m e. F eder al R u le o f C iv il P r o c e d u r e 5 2 ( a ) p r o v id e s th a t a d is tr ic t c o u r t’s f in d in g s o f

f a c t in a c tio n s tr ie d w ith o u t a ju ry m a y n o t b e r e v e r s e d u n le s s c le a r ly e rr o n e o u s . T h is r e qui r e s us t o gi ve “ due r e ga r d . . . t o the oppor tuni ty of the tr i a l c our tt o j udge of th e c r e d ib ility o f

th e w itn e s s e s .” F e d . R . C iv . P . 5 2 ( a ) . “I f th e d is tr ic t c o u r t's fi nd i ng s of f

ac tar e ‘ pl ausi bl e i n l i gh tof the re cord vi ew ed i n i t s e nt i re ty, ’ the court of appe a l s m us ta c c e ptthe m e ve n i f i ti s ‘ c onvi nc e d tha tha d i tbe e n s i tt i ng a s the tr i e rof f a c t , i tw oul d ha ve w e i ghe d the e vi de nc e di f f e r e nt l y . ’ ” U ni t e d S t a t e s v. F i de l i ty C api t a l C orp. , 920 F . 2d 827, 836 n. 36 ( 11th C i r . 1991) ( quot i ng A nde r s on v . C ity o f

B e s s e m e rC ity , 4 7 0 U .S . 5 6 4 , 5 7 4 , 1 0 5 S . C t. 1 5 0 4 , 1 5 1 1 ( 1 9 8 5 ) ) . T i pp i ttar gu es thatno thi ng i n the re cord cont ra di ct s the evi dence thathe w as t o t a l l y d i s ab l e d th r o u g h o u tth e e l i m i n a t i o n p e r i o d . We d i s a g r e e . F o u ro f h i s o wn p h y s ic ia n s w h o e v a lu a te d h im s ta te d th a t h e c o u ld w o r k th r e e h o u r s p e rd a y . W hi l e othe rdoc t or s be l i e ve d he c oul d onl y w or k one hourpe rda y , the c hoi c e of w hi c h t o be l i e ve i s l e f

tt o the di s tr i c tc our t . U ni t e d S t a t e s v. R a m i r e z - C hi l e l , 289 F . 3d 744, 749 ( 11th C i r . 2002) ( “ C r e di bi l i ty de t e r m i na t i ons a r e ty pi c a l l y the pr ovi nc e of

the f a c tf i nde rbe c a us e the f

a c tf i nde rpe r s ona l l y obs e r ve s the t e s t i m ony a nd i s thus i n a be tt e rpos i t i on tha n a r e vi e w i ng c our tt o a s s e s s the cr edi bi l i ty of w i tness es . ”) . T here i s a l so evi dence— T i pp i tt ’ s ow n sel f-7

e va l ua t i on— tha thi s pa i n w a s “ m i l d” a nd “ m ode r a t e ” a tva r i ous poi nt s dur i ng the el i m i nat i on peri od , ra ther than d ebi l i t at i ng . T he tri al courthad suffi ci entevi dence upon w hi c h t o ba s e i t s c onc l us i on tha tT i ppi ttw a s nott ot a l l y di s abl e d thr oughout th e el i m i n at i o n p eri o d ; i td i d n o tcl earl y err i n i t s p red i cat e fi n d i n g s. T i ppi ttne xta r gue s tha tthe di s tr i c tc our tf a i l e d t o t a ke i nt o a c c ountthe e f f e c ts o f h is p a in m e d ic a tio n w h e n d e te r m in in g w h e th e rh e w a s d is ab le d . T h is is th e f irst ti m e h e h as m ad e th is p o in t. A s a n ap p ellate co u rt, w e d o n o t co n sid er“a l e g a l i s s u e o rth e o ry r a i s e d f o rth e f i r s tt i me o n ap p e a l . ” U n i t e d St a t e s v . S. F abri ca t i ng C o. , 76 4 F . 2d 78 0, 78 1 (11 th C i r. 19 85 ). T here fore , w e w i l l no tre ac h th e m e r its o f

th is a r g u m e n t. I V. T ip p itt a ls o c o n te n d s th a t a d is tr ic t c o u r t s h o u ld o n ly c o n s id e rth e r a tio n a le f o rd e n y i n g th e i n s u r e d ’ s c l a i m b e n e f i t s th a tth e i n s u r e ra r t i c u l a t e s w h e n i ti n f o r ms the i ns ur e d of

i t s de c i s i on. I n s uppor tof thi s pr opos i t i on, T i ppi ttc i t e s ourde c i s i on i n Ma r e c e k v . B e l l S o u th S e r v i c e s I n c . , 4 9 F . 3 d 7 0 2 ( 1 1 th C i r . 1 9 9 5 ) , i n wh i c h we st at ed thatan em pl oyer ’ s “ fa ctual fi nd i ng s a nd po stho c e xp l anat i on s [ w er e] w ith o u t m e r it.” I d . a t 7 0 6 . H e a ls o r e lie s o n a S ix th C ir c u it o p in io n , U n iv e r s ity H o s p ita ls v . E m e r s o n E le c tr ic C o ., 2 0 2 F .3 d 8 3 9 ( 6 th C ir . 2 0 0 0 ) , w h ic h s a y s th a t, w hen d et erm i ni ng w hether a n i nsurerm eti t s obl i gat i on s und era pol i cy , a c ou rt8

s houl d notc ons i de re vi de nc e i n the r e c or d tha ti s s i m pl y a pos t - hoc e xpl a na t i on of a n a dm i ni s tr a t i ve de c i s i on. I d. a t849 n. 7. A s s um i ng tha tthe di s tr i c tc our tdi d c ons i de rr e a s ons f orR e l i a nc e ’ s de ni a l of T ip p it ’s claim th at R elian ce g av e a fterth e f ac t, d o in g so w as n o t err o r. T ip p itt’ s re l i ance on M ar ec ek i s m i spl ac ed. T he fa ctthatthe po st -hoc expl anat i on s i n that c a s e w e r e notc onvi nc i ng doe s notm e a n tha ta c our tc a nnotc ons i de rpos t - hoc ex p l an at i o n s ab o u tw h y an i n su rer d en i ed th e p l ai n t i ff’ s cl ai m ; t o th e co n trary, M a r e c e k s p e c if

ic a lly c o n s id e r e d a n d e x a m in e d th o s e p o s t- h o c e x p la n a tio n s . M a r a c e k, 49 F . 3d a t706. A di s tr i c tc our tm a y c hoos e nott o a c c or d s e l f - s e r vi ng p o s t- h o c e x p la n a tio n s m u c h w e ig h t f o rth e r e a s o n s u n d e r ly in g T ip p itt’s a r g u m e n t, buti ti s note rr ort o c ons i de rthe m . S e e ge ne r a l l y U ni v. H os ps . , 202 F . 3d a t849 n. 7 ( e xpl a i ni ng w hy the c our tc hos e nott o c ons i de ri ns ur e r s ’ pos t - hoc j us t i f i c a t i ons of deni al s of c ov er age) . V. F in ally, T ip p itt co n ten d s th at th e d istrict co u rt’s fin d in g th at R elian ce ’s deni al of benefi t s w as no tarbi tra ry and capri ci ou s bec ause the di stri ctcourt im p r o p e r ly f

o u n d th a t R e lia n c e ’s d e c is io n w a s n o t ta in te d b y s e lf - in te r e s t. H ow e ve r , thi s de t e r m i na t i on onl y a f f e c t s the thi r d s t e p of

the f i ve - s t e p a na l y s i s f

or E R I S A c l a i m s . S e e T i ppi tt , 457 F . 3d a t1231–32 ( l a y i ng outthe f i ve s t e ps ) . T he9

d is tr ic t c o u r t f

o u n d th a t T ip p itt’s c la im f a ile d a t th e s e c o n d s te p . I t o n ly w e n t o n to the thi rd t o ann ou nce a n al t ernat i ve ho l di ng . T here fore , even i f T i pp i ttw er e c o rr e c t , i tw o u l d n o ta f

f e c tth e o u t c o me o f

h i s c l a i m. AF F I RME D.