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Sliwa v. Lincoln National Life Insurance Co.

United States District Court, D. Nevada

February 8, 2017

LINDA SLIWA, Plaintiff,
v.
LINCOLN NATIONAL LIFE INSURANCE COMPANY as Claims Administrator for GROUP LONG TERM DISABILITY INSURANCE FOR EMPLOYEES OF ALLIED HOME MORTGAGE CAPITAL CORPORATION, Defendant.

          ORDER GRANTING DEFENDANT'S MOTION FOR JUDGMENT AND DENYING PLAINTIFF'S MOTION FOR JUDGMENT (ECF NOS. 59, 60)

          ANDREW P. GORDON UNITED STATES DISTRICT JUDGE.

         Plaintiff Linda Sliwa brings a claim for wrongful denial of ERISA benefits arising out of the denial of her claim for long-term disability (LTD) benefits by defendant Lincoln National Life Insurance Company. Lincoln is the claims administrator for a disability benefits plan offered through Sliwa's former employer, Allied Home Mortgage Capital Corporation.[1] Sliwa claims that although the LTD policy's pre-existing condition exclusion applies to her situation, Lincoln was forbidden to enforce it against her because she never received a copy of the policy.

         Lincoln argues the policy was delivered to Sliwa or, at a minimum, she was on notice of the pre-existing condition provision based on a summary of benefits she received and telephone conversations she had with Lincoln representatives. Both parties move for judgment on the paper record. I conclude that Lincoln did not abuse its discretion in determining that Sliwa received a copy of the policy. I therefore grant Lincoln's motion for judgment.

         I. STANDARD OF REVIEW

         The parties bring competing motions for judgment under Federal Rule of Civil Procedure 52, which is the appropriate procedure for an ERISA case. Kearney v. Standard Ins. Co., 175 F.3d 1084, 1094-95 (9th Cir. 1999) (en banc). The trial court in such cases states its findings of fact and conclusions of law. Burke v. Pitney Bowes Inc. Long Term Disability Plan, 640 F.Supp.2d 1160, 1170 (N.D. Cal. 2009).

         II. FINDINGS OF FACT

         Sliwa began working as an underwriter for Allied Home Mortgage Capital Corporation in November 2009. ECF No. 55-1 at 2. Lincoln issued short-term disability (STD) and LTD policies provided under Allied's employee benefit plan. Sliwa enrolled in both plans, effective February 1, 2010. Id. The LTD plan had a pre-existing condition exclusion stating that it:

will not cover any Total or Partial Disability (1) Which is caused or contributed to by, or results from a Pre-Existing Condition; and (2) Which begins in the first 24 months after the Insured Employee's Effective Date; unless such Insured Employee received no Treatment of the condition for 12 consecutive months after the Insured Employee's Effective Date.

ECF No. 55-26 at 67.

         Sliwa claimed disability leave on February 14, 2011, just over 12 months after her initial enrollment date on the two disability policies. ECF No. 55-1 at 2. Lincoln paid her STD claim covering the period February 21, 2011 through May 23, 2011. ECF No. 55-2 at 60. Lincoln subsequently converted Sliwa's STD claim into an LTD claim for consideration of payment of LTD benefits. Lincoln denied the claim on April 2, 2012, finding it precluded by the LTD preexisting condition provision. Id. at 5-8.

         Sliwa appealed, arguing that the exclusion should not be enforced because she never received a copy of the plan. ECF No. 55-1 at 89-91. She also contended a Lincoln representative had led her to believe that so long as she qualified for STD coverage, a later LTD claim would not be subject to additional review for a pre-existing condition exclusion. Id. at 97. Lincoln denied the appeal, citing the policy exclusion. Id. at 76. Sliwa appealed again and Lincoln again denied, exhausting Sliwa's administrative remedies. Id. at 56-58.

         Sliwa then brought this suit, which I remanded in January 2015 for Lincoln to make an administrative determination on a fully developed factual record. See ECF No. 42. In April 2015, Lincoln completed its review of Sliwa's claim and again denied benefits. ECF No. 56-2 at 23-25. With respect to plan delivery, Lincoln wrote:

[D]ocumentation obtain[ed] during our review . . . indicates that certificates were provided to the group for distribution. Our documentation further indicates that a named certificate was generated for Ms. Sliwa on her effective date of 02/01/2010. Ms. Pizana has provided a declaration that a copy of the approval letter and plan documents are kept in employee files as their proof of distribution.
During our oversight review we did consult with Ms. Pizana to confirm the accuracy of her previous declaration. She confirmed that her statement was accurate and that Ms. Sliwa's certificate would have been mailed to her ...

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