## In the



# U n ited S ta tes Co urt o f Ap p ea ls

F o rth eS e v e n th C ir cu it

N o. 07

- 2531 A LBERTG . A BE NA, D .D .S., Plai nt i f f

-Appe l l ant, v . M ET R OPOL I T AN L IF E I NS URANC E C OMPAN Ya nd A MERI CAN D EN T AL P ARTN ERS, I NCO RPORATE D , D efend a nts-A pp ellees.

A pp eal from the United S t ates Di strictC our t fo r the E astern Di stricto f Wisc onsin

. No . 06 C495

—Rudo lphT. Rand a, Chief Ju dge
.

A RGUED J AN UA RY 23, 2008

— D ECIDED S EP TE MBE R 16, 2008

Befo re M A NI ON, R OV NERa nd E VANS, C ircu it Judges . R OV NER, Cir cu i tJudg e . A lber t G. A bena work ed as a denti st f orA m er i can D entalPar tner s, I nc. ( “A m er i can De n t a l ” ) fr o m 1 9 9 3 u n t i l he be c a me d i s a b l e d i n 2 0 0 0

. He ap pli ed f orl ong ter m di sabi l i ty benefi ts und era pla n sponsor ed by hi s e m plo yerand adm i ni ste re d by M etr o-2 N o. 07

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“ D isa b ili ty ” is a d efi n ed te rm in th e P la n . 1 pol i tan Li f e Insurance Co. ( “M etLi f e”) , wh i ch w as al so t h e p lan fid u c iar y. M et L ife in itia lly ap p ro ve d th e c laim an d p aid A b en a b en efit s u n d er th e p lan for a p p ro x im at ely tw o yea rs . A fterl ear ni ng tha t Abe n a w as em plo yed ata ne w j o b, M et Li f e r e- ev al ua te d hi s di sabi l i tys ta tu s an d det er m in ed th athe no l o ng erwas di sabl ed unde r the pla n’s defi ni ti on. M et L i f e t er m i nated A bena’ s be nefi ts as ofthe dat e th e com pany deter m i ned he no l onge r w as disabl ed. A fterp u rs uingi nter nal r em edi es to chal l enge th e ter m i nati on, A bena fi l ed sui t i n the dist ri ct court in 2006

. The di str i ct c ourtco ncl ud ed that the sui t was not ti m el y fi l ed and gr anted sum m ar y j ud gm ent in f avo r of t h e d e f e n d a n t s . A b e n a a p p e a l s a n d w e a f fi r m. A m er i can Dentalsponso re d a Long Ter m Dis ab il i ty Ben efi ts Pl an( “P l an ”) f o r e l i g ibl e empl o y ees. Underthe Pl an, em plo yee s w ho becam e di sabl ed w er e pai d benefi ts f o l l ow ing an“ El i m i na ti o n P er i o d” whi chb eg ano n the day the em plo yee bec am e di sabled a nd ended after ni nety c ontinuous days o fdi sabi l i ty. A n em plo yee w i shi ng to cl ai m benefi ts w as re quir ed to supply a “ proo f o fDi sabi l i ty ” wi thin t hree months a fte r the e nd o fthe Eli m i nati on Peri od. The em plo yee s w er e thus r equi re d to 1 fi l e th e pr o o f o f Di sabi l i ty wi th i n th r ee m o nths pl us ni ne t y da y s o fthe o ns e to fthe Di s a b i l i ty, or wi t hi n a pproxi m ate l y s i x m onths. The Pl an al so p ro vid ed l i m i tati o ns f o r l eg ala ct i o ns r el at ed to the Pl an : N o l ega l act i on o fany ki nd m ay be fi l ed aga i nst us:N o. 07

- 2531 3 1. w i thi n the 60 days after proo f of Disabi l i ty has been gi ven; o r 2. m or e than thre e year s af terp ro ofof Disabi l i ty m ust be fi l ed. Thi s w illnotapplyi fthe l aw i n the ar ea w here yo u l i ve al l ows a l onge r pe ri od ofti m e t o fi l e pr oo fo fDis abi l i ty. R. 24 , atD 0319

. A bena work ed f orA m er i can Dental fro m 19 93 thro ugh Decem ber4, 20 00. O n O c tob er23 , 20 00, A bena s ubm i tte d a cl ai m to A m er i can Dentalf orl ong ter m disa b i l i ty benefi ts, as ser ti ng that hi s di sabi l i ty com m enced on M ay 16, 200 0. A m er i can Dentalf or w ar ded the cl ai m to i ts Pl an adm i ni str at o ra nd fi du c i a ry, MetLi f e, o n N ove m ber8, 20 00. O n M arch 1, 2001, after review ing the clai m , M etL ife approv ed A bena’ s cl ai m and gr anted be nefi ts re tr oac ti ve t o Au g u s t1 5 , 2 0 0 0 , the en d o fth e E l i mi n a t i o n P e r i o d

. At som e poi nt, A m er i can Dentall ear ned that A b en a w as ag ain w or kin g a s a d en t i s t
. T h e c om p an y p as se d th is i nfo rm ati on o n to M etLi f e, and on J anuary 15 , 20 02, M et L ife in for m ed A b en a t h at i t int en d ed to rev iew h is con t i nu e d e l i g ib i l i t y f o r b e ne fi t s . Met Li f e r e qu e s t e d tha t A bena s up plyaddit i onali nfo rm ati on ab ou t hi s di sabi l i ty and a l so conducted an i nvest i gat i on i nto A bena’s h ea l th sta tus, w hi ch incl ud ed vi deo survei l l ance and a revi ew o f hi s re cor ds by an i nd ependent physi ci an. A fter the r evi ew pr o ce ss , M et Li f e no ti fi ed Aben a o n A ug us t 8 , 2 00 2 th athe no longe r m et th e P lan ’s definition of D isabil ity. A ben a’s b e ne fi t s we r e th e r e f o r e te r mi na t e d a s o fAugus t9 , 2 0 0 2

. On J anuary 14 , 20 03 , A bena a pp eal ed M etLi f e’ s deci si on thro ugh an i nt er nal appeal s pro cess . M etLi f e o rder ed4 N o. 07

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an o th eri nde pen den t phy si ci anr ev i ew ofA be na ’ s fi l e, a nd on A p ril 16 , 200 3 a ffirm ed its d ec isio n to te rm in at e h is benefi ts. On A pri l 17, 20 06, A bena fi l ed t hi s ERI SA suitag ai nst A m er i can Dentalan d M etLi f e, cl ai m i ng ent i tl em ent t o dis abi l i ty benefi ts afterthe A ugust 9 , 20 02 ter m i nati on dat e. The defe nd ants m ove d fo r sum m ar y j ud gm ent o n tw o grou n ds. Fi rs t, theyas ser ted thatthe deci si on t o te r m i na te b en efi ts was no t arbitr ar y o r c apr i ci o us b ut ra therwas a r eas onabl e dete rm i nati on s u pp or ted by s ub s t a nt i a l e v i de nc e i n t he a dmi ni s t r a t i v e r e c o r d. S e c o nd , th ey arg u ed th at A b en a fa iled t o f i le t h e la w su it w ith in the t i m e lim i tat i on pre scr ibed by the Pl an. The di str i ct co ur t g r an te d s um m ar y j udg m en t i n f av o r o fthe de f en d an ts , agr ee in g t h a t t h e su it w as u n tim ely . Th e c ou rtd id not re ach the m er i ts ofthe dispute. A bena a pp eal s. The di st r i ctc o ur t r el i ed o n o ur de ci si o n i n D oev. Blu e C ross Blue Shie ld U nite d of Wis consin , 112 F.3d 869 ( 7th Cir. 19 97 ) , i n fi ndi ngthe s ui t unt i m el y . I n D oe, th e p lai nt iff so u gh t t re at m en t fo r ob se ss ive co m p u l s i ve d iso rd er in 1989

. H i s e m plo yer - sponsor ed heal th i nsurance pla n i ni ti al l y pai d fo r hi s psyc hi atr i c tr eat m ent b ut l ate r s t o pp e d p a y i nga nd f o r mal l y de ni e d c o v e r a g e . On A ug us t 17, 1990 , Blu e C ross, t h e plan ad m inistrator, n ot ified D oe th at it w ou ld n ot p ay for an y p s y c h iat ric t r e a t me n tr e n d e r e d a ft e r D e c e mb e r 1 , 1 9 8 9

. O n S e p t e mber27, 1994, aft ercom ple ti ng an i nter nal appeal s pro cess , Do e s ue d t o r e c o v e r b e ne fi t s f o r t r e a t men t pr o v i ded t o hi m bet w een Dece m ber 1 989 and M ay 31, 19 91. A s with the Pl an i n A bena’s actio n, Doe’ s pl an l i m i ted the ti m e-N o. 07

- 2531 5

Abena m i s c on str ues the pl an i n D oe, ar gui ng thatthe pe ri od 2 ofl i mi t a t i o n s th e r e d i d n o tb e g i n t o r u n u n t i l c o n t i nui ng b en efits ha d b een d en ied , no t w he n the initial pro o f o f c l aim ha d to b e f i l e d

. O n th e con trar y , the p erio d of lim itation s in Doe’ s p l a n wa s t r i g g e r e d b y th e p r o v i s i o n o f s e r v i c es f or w hich benef it s w ere sought. A clai m ant was requi red to fil e a wri t t enpr oo f of los s withi n n i ne t y days ofthe dat e ofthe s er vi c e, an d was r equi re d t o fi l e s ui tw i t hi n thr ee ye ar s aft er the (co n tin u ed ...) f ra m e i n w hi ch sui ts coul d be fi l ed . D oe’ s pl an pro vi ded that “no l ega l act i on m ay be c om m enced .

. . l ate r than thre e ( 3) year s fr om the ti m e wri tte n proo fo fl oss was re quir ed to be fi l ed. W ri tte n p ro of of l oss m ust be fi l ed wi th i n ni ne ty ( 90 ) day s o f th e dat e o f se r vi ce . Th is m eans that any l ega l act i on m ust be co m m enced w i thi n thi rtyni ne ( 39 ) month s ofthe fi r stda te o fs er vi ce s o n whi chthe acti on i s ba sed. ” D oe, 112 F.3d at 872 -73. Th e d istri ct cou rt re ad thi s pro vi si on t o m ean that, f or D oe to re cove r al l o f th e be nefi ts he was see ki ng, he was r equi re d to sue by M ar ch 199 3, thi rty- nine m onths afterthe Decem ber19 89 psy ch i at r i c servi ce s he r ec ei ve d. The c o ur t al so c o ncl ude d tha t t he l as t dayo n whi chhe c o ul d s ue f o r a ny benefi ts w as A ugust 2 9, 19 94, a d ate thatfel l thi rtyni ne m onths afterM ay 31 , 1 991, the fi nal date on wh i ch ser vi ces w er e r endered. A notherpro vi si on in Doe’ s pl an p ro hibi ted sui ts f ro m being fi l ed unti l the exhausti on o f the c l ai m ant’ s i nter nal r em ed i es. Fo r Doe, thatpro cess l ast ed unti l S eptem ber25 , 19 91, l eavi ng se vente en m ont hs l eft i n th e con tr a c t u al l im itations p eriod before the M ar ch 199 3 cut- offdate to sue f orfullbene fi ts. 26 N o. 07

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(

. . . c on t i nu e d) 2
w ri tt en p ro o f of lo ss w a s re q u ir ed to b e fil ed

. SeeDoe , 1 1 2 F. 3d at 87 2- 73

. Obvious l y, i fbe ne fi t s wer e gr ant ed f or c ertain se rvice s, the re wou ld be no reas on to fil e s uit, a n d w hen b en efits w ere d en ied , the lim itation s pe riod ran fro m nin ety da y s a ft e r t h e t i me p r o o f o f l o s s wa s r e q u i r e d t o b e fi l e d f or thatparti cular s erv ic e. There is no real diff erenc e between t he oper at i on ofthe pl an i n D oeand the Plan under w hich A b en a sou g ht b en efits. W e o bser ved thatERIS A c on ta i ns no sta tute ofl i m i tatio n s, and that the usualprac ti ce in that i nstance i s t o b orro w the l i m i tat i ons peri od ofthe m ostcl ose ly an al o g o us s ta te o r fede r als ta tu te
. W e al so no te d the pr ev ai l i ngr ul e i n c o nt r ac t l aw tha t co nt r ac tu all i m i ta ti o ns p eriods th at are sh orter tha n th e statu tory pe riod are p er m iss ible , p ro vid ed t h ey are rea so n ab le. D oe, 11 2 F

. 3d at 874. W e a dopted that pr evai l i ng r ule and hel d that c ontr actual l i m i tat i ons, i f re aso nabl e, ar e enf or ceabl e i n su i ts u n d e r E R I S A, r e g a r d l e s s o fs t a t e l a w. 1 1 2 F

. 3 d a t8 7 5

. We d ee m e d t h e t h irt y-n in e m on th p er iod rea so n ab le in gener aland und erthe c irc um sta nces ofDoe’ s ca se. Even th o ug h the i nt erna l a ppea l s pr o ce ss was p ro tr ac te d, the empl o y ee , who was r epresente d b y c o uns elthr o ug ho ut the pr oce ss, st i l l had sev entee n m onths i n w hi ch to b rin g t h e s u it b efo re th e p er iod ex p ire d . W e like n ed a su it und erERISA , f ol l owing the c om ple ti on o fan i nter nal appeal s pro cess, t o a s uitto se t a si de an adm i ni str ati ve d ec isio n, an ac tio n th at ty p ica lly m u st be f i l e d w ith in th irt y or six ty d ay s o f t h e d e c i sio n . 112 F.3d at87 5. A seve nt een m ont h p eriod w as th erefore m ore tha n su f-N o. 07

- 2531 7 fi ci ent t o m eetthe sta nd ar d of reaso nabl eness . W e a l so re m ar ke d th at th e d oc tr in e of eq u ita b le est op p e l w o u ld pr o t e c tER I S A c l a i man t s a nd wo ul d d i s c o ur a g e p l an ad m in ist ra to rs from d ra gg in g on th e in te rn al a p p e als p ro c es s in ord er to sh or te n th e t im e le ft fo r filin g s u it. D oe, 112 F. 3d at 876. A pp l yi ng D oeto A ben a’s situation, the d istri ct cou rt f o und tha t th e Pl anr equi r ed a par ti ci pan t to fi l e su i t no l ate r than thr ee yea rs fro m the ti m e pr oo fo fDis abi l i ty w as re quir ed to be fi l ed. T he Plan, in turn, requi re d that pr oo f o fDi sabi l i tymustb e fi l ed no l at ertha n thr ee months afte r the El i m i na ti o n P er i o d. The El i m i na ti o n Pe r i o d i s th e ni nety days ofco nti nuous Dis abi l i ty f ol l owing the o nset of the D isabil ity. T he d istri ct cou rt calcu lated that A ben a’s Eli m i na t i o n Pe r i o d e nd e d o n Aug us t1 5 , 2 0 0 0

. He was re quir ed to subm i t hi s p ro ofof Dis abi l i ty by N ove m ber15 , 2000 , and shoul d have fi l ed any l aw sui t by N ove m ber15 , 2003

. Becau se A bena di d not fi l e the sui t unti l A pri l 17, 2006 , the su it w as not tim ely. Th e cou rt noted that M etL ife d id n ot co m p let e t h e in te rn al a p p ea ls p ro c es s u n til A pri l 16 , 20 03, but A bena sti l l had s eve n m onths i n w hi ch to fi l e s uitbef or e the N ove m b er 1 5, 20 03 contr actual d ead li ne . U nd er D oe, the dist ri ct c ourtr eas oned thatse ven m onths w as a r eas onabl e a m ount o fti m e i n w hi ch to fi l e the sui t, and gr anted sum m ar y j ud gm ent in fa vor o f the defendants. Ou r re vi ew o fthatj ud gm ent i s deno vo . D arstv. Inte rs tate Bran ds Corp. , 5 12 F

. 3d 90 3, 9 07( 7th Ci r . 2 00 8)

. Abe na ar gues that D oei s f ac tu al l y di st i ng ui sh ab l e an d no t co ntr ollin g in h is c as e. A b en a p oin ts ou t t h at h is c laim8 N o. 07

- 2531 initi all y w as ap p roved a n d h e w as p aid for tw o years bef or e the Pl an adm i ni str ato r deci ded to te rm i nate benefi ts. I n that c irc um sta nce, A bena a rgues, a thre e- yea r l i m i tat i ons peri od i s unre aso nabl e. A fteral l, A bena poi nts o ut, a pl a n c o ul d pa y b e ne fi t s f o r t hr e e y e a r s a nd t hen st o p pa y i ngwi th o uta ny re co ur se f o r the em pl o y ee . Abe na al so po i nt s o ut tha t th e co nt r ac tu alpe r i o d o fl i m i ta ti o ns ap p ea rs in a se c tio n tit led “C laim s ” a n d co n te n d s t h at it shoul d app l y o nl y t o the ini ti alcl ai m de c i si on a nd notto subsequ ent t er m i nati ons ofcl ai m s. I nstea d, he m ai ntai ns, t h e Wi s c o n s i n s t a t u t e o fl i mi t a t i o n s f o r c o n t r a c tc l a i ms shoul d app l y. Because the W i sco nsi n sta tute provi des f ora si x-y earper i od, he a rg ues that hi s s uitwas ti m el y. I t is tr ue tha t th e m an ne r i n whi chthe Pl ans et s th e lim ita tio n s p er iod is be tt er su ite d to th e i n i t i a l cla im dec i si o n tha n i t i s to cl ai m s th ata r e i ni ti al l y g r an te d a nd subsequentl y t er m i nate d , but that f act i s no t co ntro l l i ng. A p o o r l y d r a ft e d c o n t r a c tt e r m i s s t i l l a c o n t r a c tt e r m. Thi s co nt r ac t te r m a l l o ws thr ee y ea rs fr o m the t i m e th e p ro of of D isa b ility m u st be su b m itt ed in w h i c h to file su it. U nd er D oe, a c o nt r ac tu all i m i ta ti o ns pe r i o d i s en f or ceabl e i n an ERI SA acti on s o l ong as i t i s r eas onabl e. 11 2 F. 3d at 87 4-7 5. Se eal s o W hi t ev. Su n L i

f eAs s uranc eCo. of Can. , 4 88 F .3d 2 40 , 2 50 (4 th C ir.), cert. denied , 12 8 S

. Ct. 61 9 ( 20 07 ) ( ag r ee i ngwi th D oetha t ERI S A aff o r ds pl an s th e fl ex ibi l i tyt o s etc o nt r ac tu all i m i ta ti o ns pe r i o ds o fv ar y i ng len gt h s); Wi l ki ns v. Har t f or d L i f e& Acc i de ntIns . Co. , 29 9 F. 3d 9 45 , 9 48 ( 8th Ci r. 20 02) ( up hol ding a co ntra ctual l i m i tat i ons p er iod i n an ERI SA p l an so l ong as i t i s no t u n re as on ab ly sh or t); N orthl ake R eg’l M ed. Ctr. v. Waffl e H ous eSy s . Em pl oye eBe ne f i tPla n , 16 0 F

. 3d 1301, 13 03 ( 11thN o. 07

- 2531 9 C ir

. 1 99 8) ( ag r ee i ngwi th D oeth a tc o n t r a c t u a l l i mi t a t i o ns peri ods i n ER I SA acti ons ar e e nfo rce abl e, r ega rdl es s o f st at e la w , p ro vid ed t h ey a re r ea so n ab le). W e c an ce rt ain ly im ag in e c irc u m st an c es in w h ich th e a p p lica tio n of th is pr ovisio n wo ul d no t be r ea so nabl e. F o r e xa m pl e, i fthe em plo yerp aid the cl ai m f orthr ee orm or e y ear s a nd then term i nated paym ents, i t would be unrea sonab l e t o en for c e a lim ita tio n s p er iod th at en d ed be fo re th e c laim coul d have e ven a ccr ued. Or i fthe appeal s pro cess was so p ro tr ac te d th at th e c laim an t w as u n ab le t o file s u it w ith in th e c on tr ac tu a l p e r iod , th e a p p lica tio n of th is provi si on would notb e re as onabl e. But that i s no t what happ ened her e. Even tho ugh the cla i m i ni ti al l y was gr an te d an d th en te rm in at ed tw o ye a r s lat er , A b en a s till had seve n m onths f ol l owing the c oncl usi on o fthe i nter nal appeal s pro cess in w hi ch to fi l e his suit i n the dist ri ct c ourt
. B y h i s o wn admi ss i o n a t o r ala r g um en t, the r e was no r e a s o n he c o ul d n ot f i l e hi s s ui tdu r i ngtha tt i me. I nd e e d, h e w a s rep re se n te d by co u n se l d u rin g t h at tim e. In t h e s e c i r c u ms t a n c e s , a p pl i c a t i o n o fth e c o n t r a c t u a l l i mi tat i ons peri od i s no t unre aso nabl e. N o r a r e we pe r su ade d tha t th e plac emento fthe c o ntr actuall i m ita ti ons peri od i n a s ecti on t i tl ed “Cl ai m s” shoul d change the o utcom e. The prov i si on cl ear l y s tat es th at“ [ n] o l eg alact i o n ofany ki nd m aybe fi l ed ag ai ns t” the Pl an afterthe lim itati ons peri od. Thi s l anguage i s br oad e n o u g h t o c o v e r b o t h i n i t i a l d e n i a l s o fc l a i ms a n d c l a i ms t ha t i ni t i a l l y a r e g r a nt e d a nd t he n l a t e r a re t e r mi na t e d. A gai n, the Pl an l anguage i s no t parti cul ar l y w el l sui ted to c laim s w h ich are ini tia lly gr an te d an d th en lat er te rm ina te d. A l i m i ta ti o ns pe r i o d tha t b eg i ns whenthe10 N o. 07

- 2531 in te rn al a p p ea ls p ro c es s e n d s w ou ld be ea sie r to ap p ly to a l l ki nd s o fc l ai m s, b utwe ar e no t he r e to r ewr i te the Pl an . Ourt as ki s t o det er m i ne whethe r a ppl i ca ti o n o fthe contr actuall i m i tat i ons peri od i s r eas onabl e in thes e ci r cumst an ce s. W e ag r ee wi ththe di st r i ctc o urt’s c o nc l usi on tha t it is. The j ud gm ent o fthe dist ri ct c ourti s there

fore A FFI RMED
.

9- 16- 08