Bray v. Symetra Life Insurance Company

Background

Vincent Bray sought long-term disability benefits under an employee welfare benefit plan sponsored by WP Holding, Inc. and insured and administered by Symetra Life Insurance Company. Bray worked as a box stacker, a physically demanding job requiring repetitive lifting of more than 50 pounds and occasional lifting of up to 75 pounds. After a 2016 left-shoulder injury, he underwent several surgeries and continued to experience pain, reduced strength, and limited movement.

Symetra began paying Bray long-term disability benefits on March 17, 2018. Under the plan, the first 60 months of benefits used a “regular occupation” standard: whether the claimant could perform the important duties of his regular occupation. After that period, the plan used an “any gainful occupation” standard: whether the claimant could perform any occupation allowed by his training, education, or experience, or one for which he could be trained.

Symetra suspended and then terminated Bray’s benefits during his incarceration after he did not respond to requests for information. After his release, Bray appealed. Symetra obtained medical reviews from Arjun Saxena, M.D., and Jaime Foland, M.D., who concluded that beginning July 17, 2022, Bray could occasionally lift up to 20 pounds. A vocational analysis identified one other light-duty occupation Bray could perform. Symetra upheld the termination under the any-gainful-occupation standard.

Standard of review

The plan gave Symetra discretion to determine eligibility for benefits and interpret the policy. The court therefore reviewed Symetra’s decision for abuse of discretion. That review considers whether the plan interpretation was reasonable and whether the decision was supported by substantial evidence, meaning more than a small amount of evidence but less than a preponderance. The court also considered only the reasons Symetra gave in its final administrative decision, not new explanations offered during the lawsuit.

Benefits through March 16, 2023

The court held that Symetra applied the wrong plan provision when it terminated Bray’s benefits effective July 16, 2022. The regular-occupation period continued through March 16, 2023, but Symetra evaluated Bray under the any-gainful-occupation standard. Symetra’s final decision did not address whether Bray could perform his regular box-stacker occupation.

The court determined that this error was an abuse of discretion. The medical reviewers concluded that Bray was limited to light-duty work, while his regular occupation required substantially heavier lifting. The court therefore concluded that, if Symetra had applied the correct regular-occupation standard, Bray would have remained eligible for benefits during the remaining period. The court rejected Symetra’s additional arguments concerning proof of continuing disability, regular medical care, and incarceration because Symetra had not relied on those grounds in its final appeal decision and could not use them later as post-lawsuit justifications.

The court granted Bray’s motion for judgment on the administrative record to the extent it sought benefits from the termination date through March 16, 2023. It ordered Symetra to pay the benefits due for that period.

Benefits beginning March 17, 2023

For the period beginning March 17, 2023, Bray argued that the claim should be sent back to Symetra for a more thorough review. The court declined to remand the claim. It found that Bray knew or should have known that Symetra would apply the any-gainful-occupation standard and that he had an opportunity to submit additional information after receiving the independent medical reviews. Bray’s counsel instead asked Symetra to decide the appeal based on the existing file, and Bray did not identify what additional evidence he would submit after a remand.

The court also upheld Symetra’s decision for this period. It found the medical reviews reasonably thorough and consistent with much of the medical evidence showing that Bray could work with restrictions. It further found that the vocational analysis reasonably considered Bray’s restrictions, education, work history, and available occupational data, and identified a light-duty occupation matching his medical and vocational profile. The court stated that even independent review without deference to Symetra favored Symetra on this period.

Order

Judge Eric C. Tostrud granted in part and denied in part Bray’s motion for judgment on the administrative record. The motion was granted as to benefits from the termination date through March 16, 2023 and denied in all other respects.

The court also granted in part and denied in part Symetra’s motion for summary judgment. The motion was granted as to Bray’s claim for benefits during the any-gainful-occupation period beginning March 17, 2023 and denied in all other respects. The parties were directed to meet and confer about the amount of benefits, interest, attorney fees and costs, and other issues requiring resolution.