FI LED Unite d St at e s C ourt o f Appe als

Te nt h Ci r c uit 

### S e p t e m b e r 25, 2007 Elisab eth A. Shumaker Clerk of Court PU BL I SH UNI TED S TATES CO URT O F AP PEALS

T E N T H C IR C U IT
RODNEY M I LL ER,

P lain tiff-A p p e llan t, v. M ONU M ENT AL L I F E I NSURANCE C O M PA N Y and N A SR A T PA , I nc. a n d i t s s u c c e s s o r , HCC A D M I N I ST R A T O R S I N C . and/ or G A LLA G H ER BA SSETT SER V I CE S, IN C ., D efen dan t s- A pp el l ees. N o. 05- 2247

A ppeal from t he U ni t ed St at es D i s t ri ct C ourt for t he D i s t ri ct of N ew M exi co ( D. C. No . 2 : 0 4 - c v - 9 7 0 - J B) Ja m e s R a w ley, A lb u q u e rq u e , N M , fo r P lain tiff-A p p e llan t. B e rn ie E . H a u d e r, A d k e rso n , H a u d e r & B e z n e y , D a llas , T X (B ru c e S . M c D o n a ld a n d L u c i n d a S i e mb i e d a , L a w Offi c e s o f Bru c e S . M c Do n a l d , Al b u q u e r q u e , NM , w i t h h i m on t he b ri efs) for D efen dan t s- A pp el l ees. B efor e HENR Y , Mc WI L L I A MS , and TY M KOVI CH , C i rcui tJudg es. HENR Y , C i r cui tJ udge.2

R odneyM i l l erfi l ed s ui ti n the U ni t ed St at es D i s tr i ctC our tforthe D i s tr i ct of N ew M exi co cha l l engi ng M onum ent al L i fe I ns ur ance ’ s ( M onum ent al ’ s ) deni al o f a req u est fo r l o n g -t erm d isab il ityb en efit s. T h e d istri ct co u rtg ran ted s u m m ary ju d g m e n t fo r M o n u m e n tal. B e c a u se th e E m p lo ym e n t R e tirem e n t In c o m e S e c u rity A ct (E R IS A ), 2 9 U . S . C . § § 1 0 0 1 -14 6 1 , g o v ern s the term s o f M o n u m en tal ’s m as t er - gr oup i ns ur ance pol i cy , t he di s tr i ctcour t ’ s j ur i s di ct i on ar os e under28 U . S . C . § 1 33 1. E xerci si ng j uri sdi ct i on pu rs uan tt o 2 8 U . S . C . § 1 29 1, w e revers e a n d re m a n d . I. BA CKGROUND I n Sept emberof 1997, R odneyM i l l erw as i nj ur ed i n an aut om obi l e ac ci dent w hi l e w or ki ng forA y cock Tr ans por t at i on, a Texas corpor at i on. A ft err ece i vi ng 24 m ont hs of Tem por aryD i s abi l i tybenef i t s fr om M onum ent al , A y cock’ s pr ovi der of a mast er - gr oup pol i cy( t he Pl an) , M r . M i l l erappl i ed fort he Pl an’ s C ont i nuous T o tal D isab il ityB en efit(C o n ti n u o u s B en efit ), a lon g -t erm d isab il ityp ay m en t. In o rd e r to q u a lifyfo r th e C o n tin u o u s B e n e fit, a n a p p lica n t m u st b e “ T o tally D isa b led ,” w h ich th e P lan d e fin e s a s “ u n a b le to p e rfo rm e v e ryd u typ e rta in in g to an yo cc u p ati o n fo r w h ich h e is o r m ayb ec o m e q u ali fied b yed u ca ti o n . ” A p lt ’s A pp. at37 ( M onum ent al ’ s M as t erPol i cy , effectuat ed J une 10, 1996) . T he Pl an al s o r equi r es appl i cant s t o pr es entpr oof of a Soci al Secur i tyD i s abi l i tyA w ar d, w hi ch the Pl an def

i nes as “Soci al Secur i tydi s abi l i tybenef i t s forw hi ch the I ns ur ed Per s on has s ubm i t t ed a c l ai m and [ha s ] been appr oved forpaym entbyt he“[Q uar t er s of C over age] ar e us ed i n det erm i ni ng i ns ur ed s t atus [under 1 T i t l e I I ] . I n gener al , y ou ar e cr edi t ed w i th [Q uart er s of C over age] bas ed on the w a g e s y o u a re p a id a n d th e se lf-e m p lo ym e n t in c o m e y o u d e riv e d u rin g c e rta in p e ri o d s .” 2 0 C .F .R . § 4 0 4 .1 0 1 (b ) ( 2 0 0 7 ). 3 Soci al Secur i t yA dm i ni s t r at i on. ” Id. M r . M i l l erappl i ed fordi s abi l i tybenef i t s underT i t l e I I and Ti t l e X V I of the Soci al Secur i t yA ct , 42 U . S. C . § 401 et . s eq . A lth o u g h th e S o c ial S e c u rity A dm i ni s t r at i on ( SSA ) admi ni s t er s both pr ogr ams, the Supr eme C our thas out l i ned t hei rdi s t i nct i ons : “Ti t l e I I i s an i ns ur ance pr ogr am. E nact ed i n 1935, i tpr ovi des ol d- age, s ur vi vorand di s abi l i t ybenef i t s t o i ns ur ed i ndi vi dual s i rr es pect i ve of fi nanci al need. T i t l e X V I i s a w el far e pr ogr am. E nact ed i n 1972, i tpr ovi des [S o cial S ec u ri tyInsu ran ce ] be n efit s to finan ciall yn ee d yind ividu als w h o are b lin d , o r d is a b le d re g a rd le s s o f th e irin s u re d s ta tu s .” B o w e n v . G a lb ra ith , 485 U .S . 7 4 , 7 5 (1 9 8 8 ) ( c ita tio n o m itte d ). T h e S S A d e n ied M r. M ill e r’s c laim fo r T itl e II d isa b ili tyin su ra n c e b e n e fits beca us e he had fai l ed t o acc rue “s uffi ci ent quart er s of cover age t o confe r 1 di s abi l i t yi ns ur ed s t atus . ” A pl t ’ s A pp. at93 ( Soci al Secur i tyA dm i ni s tr at i on O ffice o f H ea ri n g s an d A p p ea ls D ec isi o n , fil ed A u g u st 28 , 2 0 0 3 ) (T it le II De c i s i o n ) . Ne v e r t h e l e s s , t h e S S A g r a n t e d M r . M i l l e r ’ s c l a i m fo rT i t l e XVI s uppl ement al s oci al s ecur i t yi ncome benefi t s beca us e the admi ni s tr at i ve l aw j udge ( A L J ) det erm i ned thathe mett he r egul at or ys t andar d forphy s i cal di s abi l i tyand h a d b a sic a llyn o in c o m e . M r. M ill e r se n t M o n u m e n tal n o tice o f th e S S A ’s T itl e4

X V I D e c isio n , b u t M o n u m e n tal d e n ied p a ym e n t o n th e g ro u n d s th a t itw a s n o t a Soci al Secur i t yD i s abi l i t yA w ar d. M r . M i l l erbr oughts ui tchal l engi ng M o n u m e n ta l’ s c o n c lu s io n . B eca us e M onum ent al had notr et ai ned author i tyt o i nt erpr etthe Pl an, the di s t r i ctcourtr evi ew ed M onum ent al ’ s deni al of cove r age de novo. R eas oni ng t hat “ther e i s l i t t l e di ffe r ence betw een N ew M exi co l aw and Texas l aw , ” Mi l l erv. Monum entalLi

f e Ins . C o. , 376 F. Supp. 2d 1238, 1248 ( D . N . M . 2005) , the d istric t co u rt a p p lied N e w M e x ico law to in terp re t th e ter m S o c ial S e c u rity D isab il ityA w ard . T h e c o u rtg ran ted M o n u m en tal ’s m o ti o n fo r sum m ary j u d g me n to n t h e t h e o r yt h a tt h e P l a n u n a mb i g u o u s l yp r o v i d e d th a ta T i t l e XVI aw ar d w as nota Soci al Secur i t yD i s abi l i tyA w ar d. M or e s peci fi cal l y , the di s tr i ct cour tfound thatt he “phr as e [Soci al Secur i tyD i s abi l i tyA w ar d] has a t echni cal m e a n in g th a t d o e s n o t in c lu d e [ S o c ial S e c u rityIn c o m e ] p a ym e n ts” a n d re f u se d to “go bey ond t he t echni cal m eani ng of Soci al Secur i tyD i s abi l i tyA w ar d. ” Id. at 1250. T he courtemphasi zed “ t hatthe l anguage i n eac h of thes e pl ace s m eans w hatM onum ent al m eanti tt o s ayw hen i tw r ot e [the] defi ni t i on. ” Id. T hi s appea l fol l ow ed. II. DI S CU S S I ON W e begi n byhol di ng t hatt he di s tr i ctcourterr ed i n i nt erpr et i ng the Pl an acc or di ng t o N ew M exi co l aw beca us e ER I SA pr e- empt s s t at e rul es of i ns ur ance c o n tr a c t in te rp re ta tio n . See Bl ai rv. Metr o. Li f e Ins . C o. , 974 F. 2d 1219, 1221- 225

(1 0 th C ir . 1 9 9 2 ) ( a p p lyin g fe d e ra l c o m m o n la w to in te rp re t a n E R IS A p la n ). T hen, appl y i ng fede r al comm on l aw , w e det erm i ne thatthe pr operi nqui ryi s not w hatM onum ent al i nt ended a t erm t o s i gni fy ; r ather , w e cons i derthe “c om m on and or di narym eani ng as a r eas onabl e per s on i n the pos i t i on of the [pl an] par t i ci pant. . . w oul d have unde r s t ood the w or ds t o m ean. ” A dm i n. C om m . of Wal-MartA ssocs. Health & Wel f are P lan v. Wi l lard , 3 9 3 F .3 d 1 1 1 9 , 1 1 2 3 (1 0 th C ir. 2 0 0 4 ) (in ter n a l q u o tatio n m a rk s o m itt e d ). E m p lo y in g th is s tan d a rd , w e h o ld th a t th e P lan is a m b ig u o u s b e c a u se a re a so n a b le p lan p a rticip a n t co u ld e a sily c o n c lu d e th a t a T itl e X V I a w a rd c o u p led w ith a fin d in g o f p h y sic a l d isa b ili ty w oul d cons t i tut e a Soci al Secur i tyD i s abi l i tyA w ar d forthe purpos es of the C ont i nuous B enef

i t . W e then appl ythe doctr i ne of contr a pr of er ent em , w hi ch s tr ic tly c o n s tru e s a m b ig u itie s in in s u ra n c e c o n tr a c ts a g a in s t th e d ra f te r. A . ER I SA P RE - EMP TI ON W e r evi ew de novo the ques t i on of w hatl aw governs ouri nt erpr et at i on of th e P la n . Mow r

y v. Uni t ed Parce lSer v. , 4 1 5 F .3 d 1 1 4 9 , 1 1 5 2 (1 0 th C ir . 2 0 0 5 ). A l t hough t he di s t r i ctcour tappl i ed N ew M exi co l aw t o i nt erpr ett he Pl an, t he par t i es do notdi s put e thatfede r al l aw governs ourdet erm i nat i on of w hethert he P la n is a m b ig u o u s . W e a g re e . C o n g ress e n ac ted E R IS A to en su re n ati o n al un ifo rm ityin fidu ciary s ta n d a rd s fo r t h e a d m in is tr a tio n o f e m p lo y e e b e n e fit p la n s . S e e Sh a w v . D e lta A ir Li nes , Inc. , 463 U . S. 85, 104 ( 1983) . T o thatend, i ti ncl uded a br oad pr ovi s i on6

t hat“pr e- empt s al l s t at e l aw s i ns ofaras theym aynow orher eaf t err el at e t o any empl oy ee be nefi tpl an. ” K y. A s s ’ n of

Heal th P lans , Inc. v. Mi l l er , 538 U . S. 329, 3 3 3 (2 0 0 3 ) (in ter n a l q u o tatio n m a rk s o m itt e d ). N e v e rth e les s, e v e n u n d e r th is e x p a n s iv e p re e m p tio n s c h e m e , “ s ta te ‘l a w [ s ] . . . w h ic h re g u la t[ e ] i n s u ra n c e ’ . . . ar e s aved f

r om pr e- empt i on. ” Id. ( quot i ng 29 U . S. C . § 1144( b) ( 2) ( A ) ) . I n Mi l l er , t he Supr eme C our thel d t hat“fora s t at e l aw t o be dee m ed a ‘ l aw . . . w hi ch re g u la te s in s u ra n c e ’ u n d e r § 1 1 4 4 (b )( 2 )( A ), i t m u s t s a tis f ytw o re q u ir e m e n ts . F ir s t, it m u s t b e s p e c ific a lly d ir e c te d to w a rd e n titie s e n g a g e d in in s u ra n c e . Second . . . t he s t at e l aw m us ts ubs t ant i al l yaffectthe r i s k pool i ng arr angement betw een the i ns ur erand the i ns ur ed. ” Id . a t 3 4 1 -4 2 . L i ke the Seventh C i r cui t , “[w ] e ca nnoti m agi ne anyr at i onal bas i s forthe p ro p o sitio n th a t sta te r u les o f c o n tra c t in terp re tatio n ‘re g u late in su ra n c e ’ w ith in t he meani ng of § 1144( b) ( 2) . ” Ham m ond v. F i d. & G uar . Li f e Ins . C o. , 965 F. 2d 428, 430 ( 7t h C i r . 1992) . I n t he cont extof the s avi ng cl aus e, the Mi l l erC o u rt d e sc rib e d a n in su ra n c e re g u latio n a s a law th a t p lac e d “ c o n d iti o n s o n th e rig h t to engage i n t he bus i nes s of i ns ur ance . ” 538 U . S. at338. R ul es of contr act i nt erpr et at i on “for ce the i ns ur ert o bearthe l egal r i s ks as s oci at ed w i th uncl ear pol i cyl anguage . ” Ham m ond , 965 F. 2d at430. Shi ft i ng l egal r i s k i s , how ever , “a farcryfr om . . . t r ans ferr i ng ors pr eadi ng a pol i cyhol der ’ s r i s k. ” Id. ( i nt ernal quot at i on m arks om i t t ed) . T hus , the rul es of contr acti nt erpr et at i on ati s s ue do nots at i s fyt he fi r s tpr ong of the Mi l l erin q u ir y .7

O u r d e c isio n to a p p lyfe d e ra l co m m o n law is c o n sis ten t w ith o u r p re c e d e n t, a n d th a t o f

th e v a s t m ajo ri ty o f

o th e r c ir c u its . See B la ir , 974 F. 2d at1222 (“M et L i fe urges us t o ap plyfede ral com m on l aw , go verned bypri ncipl es of t rust law . W e d o so .”) ( in ter n a l cita tio n o m itt e d ); see also Thibodea ux v. C on t ’lC as. Ins . C o. , 1 3 8 F .3 d 5 9 3 , 5 9 6 (5 th C ir. 1 9 9 8 ); Ham m ond , 9 6 5 F .2 d a t 4 3 0 ; B r ew er v. Li ncoln Nat ’ lLi

f e Ins . C o. , 9 2 1 F .2 d 1 5 0 , 1 5 3 (8 th C ir. 1 9 9 0 ); E vans v. Saf eco Li f e Ins . C o. , 9 1 6 F .2 d 1 4 3 7 , 1 4 4 0 -4 1 (9 th C ir. 1 9 9 0 ); McMahan v. New E ngland Mut . Li f e Ins . C o. , 8 8 8 F .2 d 4 2 6 , 4 2 9 -3 0 (6 th C ir. 1 9 8 9 ); Sa mp so n v . Mu t. B e n e fit Li f e Ins . C o. , 8 6 3 F .2 d 1 0 8 , 1 1 0 (1 s t C ir . 1 9 8 8 ). B. A MB I GU I TY H avi ng det erm i ned thats t at e l aw i s pr e- empt ed, w e now as s es s w hethert he p la n is a m b ig u o u s . 1 . St andard of R evi ew I n F i r es t one Ti r e & R ubberC o. v. B r uch , 489 U . S. 101 ( 1989) , t he S u p re m e C o u rt o b se rv e d th a t E R IS A im p o se s u p o n p ro v id e rs a fid u c iar yd u ty s im ila r t o th e o n e tru s te e s o w e tru s t b e n e fic ia ri e s . Id. at 11 0 (“E R IS A ’s le g is la tiv e h is to ry c o n fir m s th a t th e A c t’ s fid u c ia ry re s p o n s ib ility p ro v is io n s . . . c o d if ya n d m a k e a p p lica b le to E R IS A fid u c iar ies c e rta in p rin c ip les d e v e lo p e d in t he ev olut i on of the l aw of trust s. ”) ( i nternal quotat i on m arks om i t t ed). Justas a t rus t ee mustconducthi s deal i ngs w i th a bene fi ci aryw i th the utm os tdegr ee of hones t yand tr ans par ency , an ER I SA pr ovi deri s r equi r ed t o cl ear l ydel i neat e the8

s c o p e o f its o b lig a tio n s . T h is fid u c iar yd u tya lso e n a b les E R IS A p ro v id e rs to re tain th e a u th o rityto in terp re t am b ig u o u s p ro v isio n s in a p lan . W h e n a n E R IS A p ro v id e r re tain s th is a u th o ri ty in e x p lic it te rm s , w e e m p lo ya d e fe re n tia l s ta n d a rd o f re v ie w . Id. at111 ( not i ng t hat“[t ] rus tpr i nci pl es m ake a defe r ent i al s t andar d of r evi ew appr opr i at e” w hen an ER I SA pr ovi derhas expl i ci t l yr et ai ned the author i tyt o i nt erpr et ambi guous pl an) . I n t he i ns t antcas e, how ever , M onum ent al di d notr es erve any su ch p o w ers o f in terpretati o n . H en ce , w e re v iew the c o n tr ac t and M o n u m en tal ’s d e n ia l o f

b e n e fits d e n o v o . Id. at115 ( not i ng thatw her e the bene fi tpl an does not gi ve the admi ni s t r at ororanotherfi duci arydi s cr et i on t o det erm i ne el i gi bi l i tyor cons t rue the t erm s of a pl an, “a de ni al of [ER I SA ] benef i t s . . . i s t o be r evi ew ed u n d e r a d e n o v o s ta n d a rd ” ). “In i nterpret i ng an E R ISA plan, [w e] exam i ne[] the p l an d ocu m ents as a w hol e and, i f unambi guous , cons true[] t hem as a m at t erof l aw . ” Wi l lard , 393 F .3 d a t 1 1 2 3 . “A m b ig u itye x ists w h e re a p lan p ro v isio n is re a so n a b lysu sc e p tib le t o m or e than one meani ng, orw her e ther e i s uncert ai ntyas t o the meani ng of the t erm . ” Id . I n or dert o det erm i ne w hethera pl an i s ambi guous , w e cons i dert he “comm on and or di narym eani ng as a r eas onabl e per s on i n the pos i t i on of the [ p lan ] p a rticip a n t, no t th e a c tu a l p a rticip a n t, w o u ld h a v e u n d e rsto o d th e w o rd s to m ean. ” Id . T h u s, w e m u st de term ine w h ethe r a rea so n ab le pe rson in M r. M il ler’s pos i t i on w oul d have be l i eved thatt he Ti t l e X V I aw ar d combi ned w i th a fi ndi ng of9

phy s i cal di s abi l i t yw oul d have s at i s fi ed the r equi r ementthathe r ece i ve a Soci al S e c u ri ty D is a b ility A w a rd . 2 . The Pl an i s ambi guo us T he ER I SA pl an ati s s ue i s an “O ccupa t i onal A cci dentPl an, ” A pl t ’ s A pp. at35, m eantt o pr ovi de t empora ryorperm anentdi s abi l i typaym ent s for e m p lo y e e s w h o s u ffe r d e b ilita tin g o n -t h e -j o b inju ri e s . Id. at40 ( s t at i ng thatt he Pl an pr ovi des i ndemni t yforan empl oy ee w ho s us t ai ns i nj ur i es “w hi l e per form i ng t he dut i es of hi s r egul aroccupa t i on”) . A ft er“exa m i n[i ng] t he pl an document s as a w hol e, ” Wi l l ard , 393 F. 3d at1123, i ti s cl eart hatt he Pl an’ s r equi r ementof a S o c ial S e c u rityD isa b ili tyA w a rd se rv e s a s a d e leg a tio n o f su b sta n tiv e d isa b ili ty det erm i nat i ons t o t he SSA . T he Pl an mandat es t hata bene fi ci arybe i ncapa bl e of engagi ng i n pr oduct i ve l abor . H ow ever , i tpr ovi des no m echa ni s m foras s es s i ng h is p h y sic a l co n d iti o n , o th e r th a n w h e th e r h e h a s re c e iv e d a S o c ial S e c u rity D isa b ili tyA w a rd . A s e v id e n c e d b yth e p ro lo n g e d lit ig a tio n in th is c a se , w h e n it comes t o phy s i cal di s abi l i t y , M onum ent al i s nots i m pl yw i l l i ng t o t ake a b e n e ficia rya t h is w o rd . B yre q u irin g th a t a c laim a n t o b tain a S o c ial S e c u rity D i s abi l i t yA w ar d, M onum ent al pr ovi des a r el i abl e and uni form m echa ni s m for e n su rin g th a t th o se c laim in g d isa b ili tyb e n e fits a re in fa c t u n a b le to e n g a g e in p ro d u c tiv e la b o r. M onum ent al ’ s del egat i on s ugges t s t hata r eas onabl e per s on coul d have expec t ed M r . M i l l er ’ s T i t l e X V I aw ar d and the SSA ’ s fi ndi ng of di s abi l i tyt o have10

sati sfied the S o cial S ec u ri tyA w ard req u ir em en t. T h e A L J w h o ruled that M r. M i l l erm ett he Ti t l e X V I r equi r ement s fordi s abi l i ty , found thatM r . M i l l er su ffe re d f

ro m “ th e fo llo w in g m e d ica llyd e ter m in a b le s e v e re im p a irm e n ts: c h ro n ic back a nd neck pa i n as s oci at ed w i th fac etanthr opathyw i th cervi cal and l um bar r adi cul opathy , carpal tunnel s yndr om e, bi pol araffect i ve di s or derand val vul ar h e a rt d ise a se w ith v a lv e re p lac e m e n t.” A p lt’s A p p . at 8 7 (S o c ial S e c u rity A dm i ni s t r at i on O ffi ce of H ear i ngs and A ppeal s D eci s i on, fi l ed M ar ch 30, 2001) ( T i t l e X V I D eci s i on) . I n l i ghtof hi s phy s i cal i m pai r m ent s , educa t i on, and j ob sk ill s, th e S S A c o n c lu d e d th a t M r. M ill e r w a s “ u n a b le to p e rfo rm e v e ryd u ty per t ai ni ng t o anyoccupa t i on forw hi ch he i s orm aybecome qual i fi ed by educa t i on, t r ai ni ng orexper i ence . . . . ” Id. at88. T hi s fi ndi ng s eems t o s at i s fy th e P lan ’s r e q u ire m e n t th a t a r e c ip ien t o f C o n tin u o u s B e n e fit b e “ u n a b le to per form t he phy s i cal and ment al r equi r ement s of anypas tr el evantw or k. ” Id. at 3 7 . G iven the s im il arityb etw ee n the S S A ruli n g an d the P lan’s re q u ir em en ts, M r. M i l l ercoul d have r eas onabl yexpec t ed thatthe Ti t l e X V I aw ar d w oul d have s a tis fie d th e S o c ia l S e c u ri ty A w a rd p re s c ri p tio n . A n exami nat i on of the pr ogr ams’ r es pect i ve r egul at i ons s tr engthens our concl us i on t hata r eas onabl e pl an part i ci pantcoul d r eas onabl ybel i eve thatei ther a Ti t l e I I ora Ti t l e X V I aw ar d w as a Soci al Secur i tyD i s abi l i tyA w ar d. T o begi n, fort he purpos es of det erm i ni ng phy s i cal di s abi l i ty , ther e i s vi r tual l yno di s t i nct i on betw een the pr ogr ams. A s the di s tr i ctcourtnot ed, “the def i ni t i on for11

‘ t ot al di s abi l i t y ’ i s t he s ame underT i t l e I I and Ti t l e X V I . ” Mi l l er , 376 F. Supp. 2d at1245. B ot h T i t l e I I and Ti t l e X V I us e the s ame fi ve- s t ep eva l uat i on s equenc e t o det erm i ne di s abi l i t y . 20 C . F. R . § 404. 1520 ( T i t l e I I ) , § 416. 920 ( T i t l e X V I ) . I n addi t i on, bot h pr ogr ams us e the s ame L i s t i ng of I m pai r m ent s , 20 C . F. R . § 404. 1525 ( T i t l e I I ) , § 416. 925 ( T i t l e X V I ) , and empl oyi dent i cal M e d ic a l- V o c a tio n a l G u id e lin e s . 2 0 C .F .R . § 4 0 4 .1 5 0 1 (g )( 6 ) ( T itle II ), § 4 1 6 .9 0 1 (j)(6 ) (T itl e X V I). F in a lly , a d e c isio n f ro m th e S S A th a t a c laim a n t is d is a b le d u n d e r e ith e r T itle II o r T itle X V I r e s u lts in a m o n e ya w a rd . In c o n tr ast t o the T it le X V I D ec isi o n , the A L J’s find ing s in the T it le II p ro c e e d in g b o re n o re la tio n to M r. M ille r’ s a b ility to e n g a g e in p ro d u c tiv e la b o r. I n or dert o be el i gi bl e forT i t l e I I benef i t s , “an i ndi vi dual m us tbe both i ns ur ed for di s abi l i t ybenef

i t s and di s abl ed w i thi n the meani ng of the A ct . ” See Har vel lv. C hat er , 8 7 F .3 d 3 7 1 , 3 7 2 (9 th C ir. 1 9 9 6 ); see also 2 0 C . F . R . § 4 0 4 . 1 3 0 . T it le II i nsurance o perat es som ew hat l i ke a typical i nsurance p rogram i n thaton l ytho se w h o h av e p aid in to the sy stem are co v ere d , an d co v era g e d ep en d s u p o n w h ethe r a t axpay erhas acc rued s uffi ci entquar t er s of cove r age. O ne mayobt ai n quart er s of c o v e ra g e b yw o rk in g q u a lifie d jo b a n d re p o rt in g a m in im u m le v e l o f in c o m e . S ee Ha rv e ll , 87 F. 3d at373 ( not i ng t hatan appl i cantw as notcover ed forthe purpos es of Ti t l e I I beca us e he ha d “w or ked i n non- cover ed empl oym ent. . . and pai d no so c ial s e c u ritytax e s d u rin g th a t p e rio d ” ); Un itedS ta tes v . Sm ith , 294 F. Supp. 2d 920, 921 n. 2 ( E . D . M i ch. 2003) ( expl ai ni ng thatT i t l e I I el i gi bi l i tydepends upon12

t he “pa ym entof s oci al s ecur i t yt axes ”) . B eca us e M r . M i l l erhad fa i l ed t o fi l e a l egi t i m at e t ax r etur n s i nce 1997, and perhaps none befor e that , the A L J found that th e las t d a yh e c o u ld h a v e b e e n c o v e re d w a s D e c e m b e r 3 1 , 1 9 9 6 . D u e to h is “l ack of appr opr i at e i ns ur ed s t atus , ” A pl t ’ s A pp. at92 ( T i t l e I I D eci s i on) , he w as n o t el igible fo r be n efit s o n S ep tem b er 1 5 , 1 9 9 7 , the d ate w h en h is disab li n g injury occurr ed. T hus , t he rul i ng w as a r es ul tof M r . M i l l er ’ s fai l ur e t o fi l e t ax r eturns a n d a c c ru e “ su ff

icie n t q u a rte rs o f

c o v e ra g e to m e e t th e c riter ia fo r d isa b ili ty i ns ur ed s t atus . . . . ” Id. a t 9 1 . N evert hel es s , M onum ent al cont ends thatthe Pl an unambi guous l ypr ecl udes M r. M ill e r’s re c o v e ryb e c a u se a T itl e X V I a w a rd “ is not a S o c ial S e c u rity D i s abi l i t yA w ar d. ” A pl t ’ s B r . at18 ( emphasi s i n or i gi nal ) . R el y i ng heavi l yon t he d i stri ctcou rtdecis i on , M on um ental avers, [T it le X V I] b en efit s are n o t d isab il ity b en efit s. [T it le X V I] b en efit s are s uppl ement al i ncome, w hi ch ca n be pai d fora numberof r eas ons that p e o p le lo s e in c o m e , o n lyo n e o f w h ich is a w e lfa re p ro g ra m e n a c ted to pr ovi de bene fi t s t o fi nanci al l yneedyi ndi vi dual s w ho ar e age d, bl i nd, o r d isa b led re g a rd les s o f th e ir in s u re d sta tu s. [ S o c ial S e c u rity D isab il ity ] be n efit s, o n the o ther h an d , are a w ard ed u n d er T it le II, w hi ch i s an “i ns ur ance pr ogr am” t hatC ongr es s enac t ed t o pr ovi de ol dage, s ur vi vor , and di s abi l i ty benef i t s t o i ns ur ed i ndi vi dual s i rr es pect i ve o f fin a n c ia l n e e d . I d. at17- 18 ( quot i ng Mi l l er , 3 7 6 F . S u p p . 2 d a t1 2 5 0 ) . T h i s i s e s s e n t i a l l y a s u mma r yo f

o n e p a r a g r a p h o f

S u p r e me Co u rtd i c t a f r o m B ow en , 4 8 5 U .S . a t 7 5 . U n d e r t h e p ro p e r c ir c u m s ta n c e s , th is a rg u m e n t m ig h t b e m o re p e rs u a s iv e . H ere, t he p robl em i s that M on um ental assum es B ow en ’ s di ct a i s di s pos i t i ve w hen13

i n fac ti ti s i nappl i cabl e. I n B ow en , the C o u rtw as a sk ed to d eterm ine, “w h ethe r, u n d e r T itl e X V I o f

th e S o c ial S e c u rityA c t, a d istric t co u rt h a s th e a u th o rityto or dert he Secr et aryof H eal t h and H um an Servi ces t o w i thhol d a port i on of p ast-du e su p p lem en tal sec u ri tyinco m e b en efit s fo r th e p ay m en t of att o rne y ’s fee s . ” Id. at74. H er e, w e ar e notc a lled u p o n to in terp re t th e S o c ial S e c u rity A ct; rathe r, w e addr es s t he di s cr et e ques t i on of w hetherthe Ti t l e X V I aw ar d at iss u e c o u p led w ith a fin d in g o f d isa b ili tyc o n stitu ted a S o c ial S e c u rityD isa b ili ty A w ar d undert he Pl an. I n or dert o m ake thi s det erm i nat i on, w e l ook nott o the r ol e ea ch pr ogr am pl ay s i n t he gr and s cheme of Soci al Secur i tyent i t l ement s , but to this pa rt icular p lan’s lan g u ag e a n d the S S A ’s de term ination s reg ard ing M r. M ille r’ s c o n d itio n . Fi nal l y , M onum ent al emphasi zes , and M r . M i l l erdoes notcont es t , thatt he T i t l e X V I benef

i t s , w hi ch ar e nee d- bas ed, w oul d cea s e once M onum ent al began p a y in g th e C o n tin u o u s B e n e fit b e c a u s e M r. M ille r w o u ld h a v e to o m u c h in c o m e . H ow ever , he r emai ns el i gi bl e forT i t l e X V I benef i t s as l ong as M onum ent al r efus es t o payC ont i nuous B enef i t . T hus , l i ke O rr , the bomberpi l oti n J os eph H el l er ’ s r enow ned novel , M r . M i l l erappea r s t o be tr apped i n a now - pr overbi al “C atch -22 . ” M o n u m en tal co rrectl yo b serv es th at th is ap p ea rs t o b e a n “a b su rd a n d u n in te n d e d re s u lt,” le n d in g le g itim a c yto th e irin te rp re ta tio n o f th e P la n . A p le’ s B r. at 2 0 . H o w e v e r, th e q u e stio n th a t co n f ro n ts u s is n o t w h e th e r th e ir in terp re tatio n is re a so n a b le, b u t w h e th e r th e re is m o re th a n o n e re a so n a b le14

in te rp re ta tio n o f

th e P la n . I n s um , al t hough M onum ent al ’ s i nt erpr et at i on s eems r eas onabl e i n m any r es pect s , beca us e the SSA deni ed Ti t l e I I benef i t s bas ed on a r at i onal e unr el at ed t o di s abi l i t y , and bec aus e the purpos e of the Pl an i s t o pr ovi de compens at i on for d eb il it ati n g injuries, itis al so rea so n ab le th at a b en efici aryin M r. M il ler’s pos i t i on coul d have e xpect ed the Ti t l e X V I aw ar d ati s s ue t o s at i s fythe Soci al S e c u rityD isa b ili tyA w a rd re q u ire m e n t. H e n c e , w e h o ld th a t th e P lan is a m b ig u o u s b e c a u se th e ter m “ S o c ial S e c u rityA w a rd ” “ is re a so n a b lysu sc e p tib le t o m or e than one meani ng. ” Wi l lard , 393 F. 3d at1123 ( i nt ernal quot at i on o m itte d ). 3. E x t ri nsi c E vi dence M o n u m en tal arg u es th at i f th e P lan’s lan g u ag e is am b igu o u s, this C o u rt sh o u ld re so rt to e x trin sic e v id e n c e to in terp re t th e ter m S o c ial S e c u rityD isa b ili ty A w a rd . W h e re a p lan ’s la n g u a g e is a m b ig u o u s o n its fa c e , co u rts m a y“ tu rn to extr i ns i c evi dence of part i es ’ i nt entt o cr eat e ves t ed i ns ur ance benef i t s . ” D ebo ard v. Suns hi ne Mi n. & Ref
. C o. , 208 F. 3d 1228, 1241 ( 10th C i r . 2000) . I n D eboar d, forexampl e, corr es pondence betw een the part i es expos ed the empl oy er ’ s i nt ent “t o cr eat e ves t ed r i ght s t o l i fet i m e hea l th i ns ur ance cover age. ” Id. B yc o n tra st, th e re c o rd in th is c a se re v e a ls n o e x trin sic e v id e n c e th a t w o u ld il lum inate the p arti es’ inten t. B ec au se th is case w as d ispo sed o f a t sum m ary j udgm ent , t he part i es s houl d have br oughtanyextr i ns i c evi dence t o the di s tr i ct15

cour t ’ s at t ent i on befor e the courtcons i der ed the mot i on. I n fac t , atthe di s tr i ct cour t ’ s hear i ng on t he s um m aryj udgm entm ot i on, the part i es m ade c l earthatthey had no add i t i on al evidence to present . A plt ’s A pp . at56 -57, 82 -83. T hu s, rem an d fo r find ing s o n ex tr insic ev iden ce w o u ld b e f u ti le. M o reo v er, M onum ent al fai l ed t o r ai s e thi s ar gum entbel ow . B eca us e M onum ent al has gi ven n o re a so n w h yw e sh o u ld d e p a rt f ro m “ th e g e n e ra l ru le th a t a fe d e ra l ap p e llate cour tdoes notcons i deran i s s ue notpas s ed upon bel ow , ” Walkerv. Mather , 959 F. 2d 894, 896 ( 10t h C i r . 1992) ( i nt ernal quot at i on m arks om i t t ed) , w e dee m the extr i ns i c evi dence ar gum entw ai ved.

C . I NTE R PR ETING T HE A MBI GUOUS T ERM H avi ng deci ded thatt he Pl an i s ambi guous , and thatw e mustus e fe der al comm on l aw t o i nt erpr eti t , w e mustnow s el ecta mode of contr actual i nterpret at i on . W e ho l d thatt he am biguou s t erm m ustbe co nst rued ag ai nst M onum ent al i n acc or dance w i t h the doctr i ne of contr a pr of er ent em . 1. C ont ra Profere nt em Co n tr a p r o

f e r e n t e m c o n s tru e s a ll a m b ig u itie s a g a in s t th e d ra f te r. Todd v. A IG Li f e Ins . C o. , 475 F. 3d 1448, 1451- 52 ( 5th C i r . 1995) . W e have r ej ect ed c o n tr a p r o

f e r e n t e m i n cas es w her e the pl an admi ni s tr at orr et ai ns di s cr et i on and w her e w e r evi ew onl yt o cons i derw hethert he admi ni s tr at orabus ed di s cr et i on. See Ki m berv. Thi okolC or p. , 196 F. 3d 1092, 1100 ( 10th C i r . 1999) ( hol di ng “that w hen a pl an admi ni s t r at orhas di s cr et i on t o i nt erpr ett he pl an and the s t andar d of16

r evi ew i s arbi t r aryand ca pr i ci ous , the doctr i ne of c o n tr a p r o f e r e n t e m is inap p li ca b le”). N ev erthe less, w e h av e re serv ed the q u esti o n o f w h ethe r th is co u rt w o u l d a p p l y contr a pr of er ent em in re v ie w in g a n a m b ig u o u s E R IS A p la n d e n o v o . S e e B la ir , 974 F. 2d at1222 ( r es ol vi ng ambi gui t i es i n favorof the dr aft er“w i thout r es or tt o t he c o n tr a p r o f e r e n t e m ru le, a n d w ith o u t re so lv in g w h e th e r th a t ru le s houl d be appl i ed t o contr act s governed by E R I SA ”) . T oday , w e ans w ert hat ques t i on i n t he affi r m at i ve. T h e p a r t i e s a c k n o w l e d g e th a tm o s tc i r c u i t s e m p l o y c o n tr a p r o f e r e n t e m to cons t rue ambi guous l anguage i n contr act s governed byE R I SA w her e r evi ew i s de n o v o . I n d e e d , s i n c e t h e m aj o r i t y o f c o u r t s w o u l d a p p l y c o n tr a p r o f e r e n t e m i n a cas e l i ke thi s , empl oy i ng t he doctr i ne compor t s w i th the pr i nci pl e under l y i ng E R IS A p re e m p tio n , u n ifo rm ity. See Per ezv. A etna Li f e Ins . C o. , 150 F. 3d 550, 5 5 7 n . 7 (6th C ir . 1 9 9 8 ); Todd , 4 7 F .3 d a t 1 4 5 1 -5 2 ; L e e v . B lu e C ro ss /B lu e Sh ield of A l ab. , 10 F. 3d 1547, 1551 ( 11th C i r . 1994) ( “H avi ng det erm i ned thatt he pl an is a m b ig u o u s, w e h o ld th a t ap p lica tio n o f th e ru le o f

c o n tra p ro fe re n tem is appr opr i at e i n r es ol vi ng ambi gui t i es i n i ns ur ance contr act s r egul at ed by E R IS A .”); Hughes v. B os t on Mut . Li f e Ins . C o. , 2 6 F . 3 d 2 6 4 , 2 6 8 (1st C ir . 1 9 9 4 ); Heas l ey v . B elden & B l ake Corp. , 2 F . 3 d 1 2 4 9 , 1 2 5 7 -58 (3d C ir . 1 9 9 3 ); D elk v. D ur ham Li

f e Ins . C o. , 9 5 9 F . 2 d 1 0 4 , 1 0 5 -06 (8th C ir . 1 9 9 2 ); Gl o c ke rv . W. R. G r ace & C o. , 9 7 4 F .2 d 5 4 0 , 5 4 4 (4 th C ir. 1 9 9 2 ); P h ill ip s v . L in c o ln Na t’l L ife Ins . C o. , 978 F. 2d 302, 311 ( 7t h C i r . 1992) ( “The adopt i on byt he di s tr i ctcour tof17

t he s t at e l aw rul e of c ont r acti nt erpr et at i on c o n tr a p r o f e r e n t e m as partof the fe d e ra l co m m o n law o f E R IS A w a s p ro p e r.”) ; Mas el la v. B l ue C r os s & Bl ue Shi eld of

C onn. , Inc. , 9 3 6 F . 2 d 9 8 , 1 0 7 (2d C ir . 1 9 9 1 ); Ku n in v . B e n e fitTru st L ife Ins . C o. , 9 1 0 F .2 d 5 3 4 , 5 4 0 (9 th C ir . 1 9 9 0 ). St r i ct l ycons t rui ng ambi gui t i es agai ns tthe dr aft ercomport s w i th our pr ece dent . O urcourthas nevercons trued the ambi gui t i es of an ER I SA pl an a g a in s t a b e n e fic ia ry. See D ebo ard , 208 F. 3d at1243 ( “Even as s um i ng, arguendo , the e v id e n c e w a s e q u iv o c a l re g a rd in g th e p a rties ’ in ten t o n th is p o in t, w e b eli ev e the am b igu itysh o u ld h av e b ee n co n stru ed in fav o r of p lai n ti ffs. ”); C hi l es v. C er i di an C or p. , 95 F. 3d 1505, 1518 ( 10th C i r . 1996) ( “A nybur den of un cert ai ntycreat ed b ycarel ess ori naccu rat e draft i ng . . . m ustbe p l aced o n those w ho do t he dr aft i ng, and w ho ar e mostabl e t o bearthatbur den . . . . ”) ( i nt ernal q u o tatio n m a rk s o m itt e d ); B la ir , 974 F. 2d at1222 ( “H avi ng det erm i ned thatthe pol i cyi s ambi guous w e r es ol ve thatambi gui tyi n [the bene fi ci ary ’ s ] favorbas ed on t he r ecor d i n t hi s cas e. ”) . D oi ng s o w oul d underm i ne the pol i ci es under l y i ng E R IS A , w h ich C o n g re ss e n a c ted “ to p ro m o te th e in ter e sts o f e m p lo y e e s a n d th e ir benef i ci ar i es i n empl oy ee be nefi tpl ans and t o pr ot ectcontr actual l ydefi ned benef i t s . ” F i r es t one Ti r e & R ubberC o. , 489 U . S. at113 ( i nt ernal quot at i on m arks om i t t ed) . E R I SA al s o gi ves s i gni fi cantbenef i t s t o pr ovi der s by p re e m p tin g m a n y“ sta te la w c a u se s o f a c tio n . . . w h ich th re a ten c o n sid e ra b ly gr eat erl i abi l i t yt han thatal l ow ed byE R I SA . ” C hi l es , 95 F. 3d at1518 ( i nt ernal18

quot at i on m arks om i t t ed) . I n l i ghtof the A ct ’ s bal anci ng of i nt er es t s , “[a ] ccur acy [i n dr aft i ng] i s nota l ott o as k. A nd i ti s es peci al l ynota l ott o as k i n r eturn for t he pr ot ect i ons affor ded byE R I SA ’ s pr eempt i on of s t at e l aw caus es of ac t i on. ” Id
. (i n te rn a l q u o ta tio n m a rk s o m itte d ). F a i l u r e t o e m p l o y c o n tr a p r o f e r e n t e m w o u ld “ a ffo rd les s p ro tec tio n to e m p lo y e e s a n d th e irb e n e fic ia ri e s th a n th e ye njo y e d b e fo re E R IS A w a s e n a c te d , a r es ul tt hatw oul d be atodds w i t h the congr es s i onal purpos es of pr om ot i ng the i nt er es t s of empl oy ees and bene fi ci ar i es and pr ot ect i ng contr actual l ydefi ned benef i t s . ” Ma se lla , 936 F. 2d 98 at107 ( i nt ernal quot at i on m arks om i t t ed) . T he N in th C ir c u it p re s e n te d a n illu m in a tin g e x p la n a tio n fo r a p p lyin g th e d o c tr in e . I ns ur ance pol i ci es ar e al m os tal w ay s dr aft ed bys peci al i s t s empl oy ed by t he i nsu rer. I n l i ghtof the dr aft er s ’ expert i s e and e xper i ence , the in su re r sh o u ld b e e x p e c ted to se t fo rth a n ylim itatio n s o n its liab ili ty cl ear l yenough fora comm on l ayper s on t o under s t and; i f i tfai l s t o do t hi s , i ts houl d notbe al l ow ed t o t ake advant age of the ver yambi gui t i es t hati tcoul d have pr event ed w i th gr eat er di l i gence . M or eover , once the pol i cyl anguage has been dr aft ed, i t i s not us ual l y s ubj ectt o amendm ent byt h e i ns ur ed, even i f he s ees ambi gui ty ; an i ns ur er ’ s pr act i ce of for ci ng t he i ns ur ed t o gues s and hope r egar di ng the scope of cove r age r equi r es t hatanydoubt s be r es ol ved i n favor of the party w ho has been p lac e d in su c h a p re d ica m e n t. Ku n in , 9 1 0 F . 2 d a t5 4 0 . S t r i c t l yc o n s tru i n g a mb i g u o u s t e r ms pr e s e nt s ER I SA pr ovi der s w i t h a cl earal t ernat i ve: dr aftpl ans thatr eas onabl e peopl e ca n u n d e rs ta n d o r p a yfo r a m b ig u ity. C onfr ont ed w i t h ambi guous l anguage undera de novo s t andar d of r evi ew and appl y i ng contr a pr of er ent em , w e c o n stru e the P lan’s term s in fav o r of M r.19

M ill e r a n d h o ld th a t h is T itl e X V I a w a rd c o u p led w ith a fin d in g o f d isa b ili ty sa tisfied th e S o c ial S e c u rityD isa b ili tyA w a rd re q u ire m e n t. 2 . Sol e C ausat i on W e not e thatM onum ent al al s o m oved fors um m aryj udgm enton the g ro u n d s th a t M r. M ille r’ s a c c id e n t w a s n o t th e “ s o le c a u s e ” o f h is d is a b ility. A pl t ’ s Supp. A pp. at5 ( D efe ndant ’ s M ot i on forSum m aryJ udgm ent , fi l ed M ay5, 2006) . B eca us e the di s t r i ctcourtdi d notaddr es s t hi s i s s ue, w e mustr emand for f u rt h e r p ro c e e d in g s . III . CO NC L US I ON W e th e re fo re R E V E R S E a n d R E M A N D fo r p ro c e e d in g s c o n sis ten t w ith th is o p in io n .