United States District Court, D. Utah
MEMORANDUM DECISION AND ORDER
Waddoups, United States District Judge.
the court is Defendant The Prudential Insurance Company of
America's motion for summary judgment of all of Plaintiff
Alan Hendrickson's claims for short-term and long-term
disability benefits under the Employee Retirement Income
Security Act. (Defendant's Motion, ECF No. 40.)
Prudential argues summary judgment is proper because Mr.
Hendrickson failed to exhaust his administrative remedies
and, in the alternative, that Prudential did not abuse its
discretion in denying Mr. Hendrickson's claim for
short-term disability benefits. (Dkt. No. 40.) The court held
oral argument on October 18, 2017. (Dkt. No. 50.) Having
carefully considered the arguments set forth in the briefs
and during oral argument, the court now GRANTS
Prudential's motion and ORDERS summary judgment be
entered in Prudential's favor.
Hendrickson formerly worked as a salesperson for Hilton.
(Plaintiff's Response to Mot. Summ. J. 2, ECF No. 41.)
Through his employment, Mr. Hendrickson participated in The
Hilton Worldwide, Inc., Welfare Benefit Plan, which included
short-term and long-term disability benefits that Prudential
insured under Group Contract No. G-51532-VA (The Plan).
the beneficiary directly, the Plan “provides financial
protection by paying a portion of your income while you are
disabled, ” PRU 124, and states that
“disability” exists if Prudential
“determines that: you are unable to perform the
material and substantial duties of your
regular occupation due to
sickness or injury; you are
under the regular care of a
doctor; and you have a 20% or more loss in
weekly earnings due to the same sickness or
injury.” PRU 133 (emphasis in original). Regular
occupation, which is at issue in this case, is defined as
“the occupation you are routinely performing when your
disability begins” and includes “your occupation
as it is normally performed, ” rather than “how
the work tasks are performed for a specific employer or at a
specific location.” PRU 133.
Plan vests “sole discretion to interpret the terms of
the Group Contract, to make factual findings, and to
determine eligibility for benefits” in “The
Prudential Insurance Company of America as Claims
Administrator.” PRU 119. The Plan also states that a
claimant will receive notice of a claim determination within
forty-five days of the receipt of the claim, with the
possibility of that deadline being extended by thirty days
when necessary. PRU 119. In the case of a denied claim, the
Plan requires written notice detailing the reasons for the
denial, identifying the Plan provision upon which the
determination was made, a description of any materials that
were missing from the original claim, “a description of
Prudential's appeals procedures and applicable time
limits, ” and an explanation of the scientific or
clinical judgment if the adverse determination was based on a
medical necessity or similar exclusion or limit. PRU 119-20.
Regarding the appeal process, the Plan says that upon an
adverse determination, “you or your representative may
appeal your denied claim in writing to Prudential within 180
days of the receipt of the written notice of denial or 180
days from the date such claim is deemed denied.” PRU
120. It also states the form in which appeal may be filed and
authorizes access to records upon request. PRU 120. The
appeal process also includes a second level of appeal, which
the Plan refers to as “a second, voluntary appeal of
your denial” and about which the Plan states,
“[i]f you elect to initiate a lawsuit without
submitting to a second level of appeal, the [P]lan waives any
right to assert that you failed to exhaust administrative
remedies.” PRU 121.
April 7, 2014, Mr. Hendrickson ceased working for Hilton, and
in June 2014, he filed a claim for short-term disability
benefits, asserting that work-related stress, anxiety, and
panic attacks precluded him from working. (Plaintiff's
Response to Mot. Summ. J. 4 & 10-11, ECF No. 41.) Mr.
Hendrickson submitted an Attending Physician Statement
executed on July 1, 2014, by Dr. Robert W. Hamilton, who is a
family practitioner. (Id. at 11.) Dr. Hamilton
opined that Mr. Hendrickson suffered from panic attacks,
stress, and anxiety but that he would be able to return to
work by December 27, 2014. (Id.) Mr. Hendrickson
also submitted an Activities of Daily Living Questionnaire in
which he noted that he had trouble sleeping but that had
improved with medication; that he could dress and groom
himself; that he drives and shops multiple times a week
without assistance; and that he reads, watches TV, walks
between one and three miles per day, uses a computer, and
visits friends. (Id. at 12.) Prudential also
reviewed medical records from Nurse Practioner Renae Lynn
Power and Dr. Hamilton from April to July 2014. (Id.
at 13- 16.) Prudential employee Collette Howe, RN, conducted
an internal medical review and concluded that the medical
documents demonstrated stress, anxiety, and depression
brought on by Mr. Hendrickson's particular work
environment, but also concluded that the record did not
support an inability to work in his regular profession.
(Id. at 16-17.)
25, 2014, Prudential notified Mr. Hendrickson that his
short-term disability claim was denied. (Plaintiff's
Response to Mot. Summ. J. 4-5, ECF No. 41.) The notice
detailed the documents Nurse Howe had reviewed and explained
that the medical documentation on file “does not
support an inability to perform the material and substantial
duties of your regular occupation as a salesperson, but
rather suggest that your stress, anxiety and depression are a
direct result of your work environment, and there is no
evidence to suggest that you are globally impacted.”
notice of denial also conveyed the following regarding Mr.
Hendrickson's ability to appeal: “If you disagree
with this decision you have the right to appeal. We have
enclosed information on our appeal process should you choose
to appeal this decision. The enclosure also lists the
information that should be included with your appeal. If you
wish to appeal, you must follow the process in the enclosure
and submit your written appeal within 180 days of receiving
this letter.” PRU 060. Prudential enclosed a document
named “Appeal Rights” in which the fact that Mr.
Hendrickson “ha[d] a right to appeal [its]
decision” was disclosed and procedures for appeal and
review of the appeal were set out. Id. The enclosure
also noted that “[i]f our decision to deny benefits is
upheld at the first level of appeal, you . . . may file a
voluntary second appeal” but also that “[a]fter
completion of the first level of appeal, you may also file a
lawsuit under the Employment Income Security Act (ERISA). . .
. Your decision on whether to file a second appeal will not
affect your rights to sue under ERISA.” Id.
Finally, the enclosure addressed the timing for long-term
disability claims subsequent to approval of short-term
disability benefits. Id.
after the denial, Prudential received medical records from
Dr. Alteen A. Lee.(Plaintiff's Response to Mot. Summ. J.
4-5, ECF No. 41.) A second Prudential representative, Kaitlin
Hamilton, RN, BSN, reviewed Mr. Hendrickson's file,
including Dr. Lee's records, on August 1, 2014.
(Id.) Based on Ms. Hamilton's review, Prudential
wrote a second letter to Mr. Hendrickson in which it noted
that the records showed Mr. Hendrickson's symptoms
“stem from work related stress” and that,
“[g]iven the available medical, one would not expect
resulting limitations nor medical reasons that would restrict
your functional capacity in regards to the above condition
from Last Day worked through to the present time.” PRU
064. The letter also stated: “You were also advised in
our July 25, 2015 letter that you had 180 days from your
receipt of that letter to appeal the decision. If you choose
to appeal, you must do so within 180 days of your receipt of
the July 25, 2014 letter.” PRU 065.
Hendrickson did not file anything with Prudential after the
August 1, 2014 letter. (Plaintiff's Response to Mot.
Summ. J. 8, ECF No. 41.) Believing he could not submit a
claim for long-term disability until Prudential approved a
claim for short-term disability, Mr. Hendrickson filed no
claim for long-term disability. (Id.) On August 5,
2015, he filed the instant lawsuit for short- and long-term
disability benefits as well as pre- and post-judgment
interest and attorney fees and costs. (Complaint 31, ECF No.
Rule of Civil Procedure 56(a) requires the court to grant
summary judgment “if the movant shows that there is no
genuine dispute as to any material fact and the movant is
entitled to judgment as a matter of law.” When applying
this standard, the court must “view the evidence and
draw reasonable inferences therefrom in a light most
favorable to the nonmoving ...