United States District Court, S.D. New York
Attorney for Plaintiff MICHAEL SWAALEY, ATTORNEY AT LAW By:
Michael Swaaley, Esq.
Attorneys for Defendant GOLDBERG SEGALLA, LLP By: Fallyn B.
Cavalieri, Esq. GOLDBERG SEGALLA, LLP By: Alex J. Yastrow,
W. SWEET U.S.D.J.
an action arising from an alleged wrongful denial of
long-term disability benefits under an employee benefits plan
subject to the requirements of the Employee Retirement Income
Security Act of 1974, 29 U.S.C. § 1001, et seq.
("ERISA"). Plaintiff Pasquale Tulino
("Tulino" or the "Plaintiff") has moved
for a judgment on the administrative record and Defendant
United of Omaha Life Insurance Company ("United" or
the "Defendant") has cross-moved for the same.
Based on the facts and conclusions set forth below, the
motion of the Plaintiff is denied, and the cross-motion of
the Defendant is granted.
Prior Proceedings and Facts
facts are set forth in Plaintiff's Statement of Material
Facts Pursuant to Local Civil Rule 56.1, Defendant's
Response and Counter-Statement of Additional Undisputed
Facts, and Plaintiff's Response and Counter-Statement of
Additional Undisputed Facts, and are not in dispute except as
Tulino, the Plaintiff, is a professional engineer who was
employed by HDR, Inc., as a Senior Vice President-Civil
Section Manager. As part of his compensation package,
Tulino's employer provided Long Term Disability (LTD)
insurance. United of Omaha Life Insurance Company, the
Defendant, issued the disability plan to HDR, Inc., under
policy number GLTD-13J8, effective January 1, 2007 (the
"Plan"). See Plaintiff's Statement of
Undisputed Material Facts Pursuant to Local Civil Rule 56.1
("PL's 56.1 Stmt.") ¶¶ 1-2;
Defendant's Response to Defendant's 56.1 Statement
and Counter-Statement of Additional Undisputed Material Facts
Pursuant to Local Civil Rule 56.1 ("Def.'s Resp.
56.1 Stmt.", collectively with PL's 56.1 Stmt., the
"56.1 Stmts.") ¶¶ 1-2, 44. The plan is an
employee welfare benefit plan governed by ERISA. See
Def.'s Resp. 56.1 Stmt. ¶ 45.
plan provides LTD benefits in the event of a covered claim
under the terms and conditions of the plan. Specifically, the
LONG-TERM DISABILITY BENEFITS
If, while insured under this provision, You become Disabled
due to Injury or Sickness, We will pay the Monthly Benefit
shown in the Schedule. Benefits will begin after You satisfy
the Elimination Period shown in the Schedule.
Id. ¶ 46.
plan contains language which confers United with
discretionary authority to determine eligibility for benefits
and to construe and interpret all terms and provisions of the
policy. Specifically, the plan provides:
This rider is made a part of Group Policy GL TD-13J8 This
rider is effective January 1, 2014.
In the event of a conflict between this Rider and any other
provision of the Policy, including the Certificate, this
Rider shall control.
The following is made a part of the Policy.
Authority To Interpret Policy
The Policyholder has delegated to Us the discretion to
determine eligibility for benefits and to construe and
interpret all terms and provisions of the Policy. Benefits
under the Policy will be paid only if We decide, after
exercising Our discretion, that the Insured Person is
entitled to them. In making any decision, We may rely on the
accuracy and completeness of any information furnished by the
Policyholder, an Insured Person or any other third parties.
The Insured Person has the right to request a review of Our
decision. If, after exercising the Policy's review
procedures, the Insured Person's claim for benefits is
denied or ignored, in whole or in part, the Insured Person
may file suit and a court will review the Insured
Person's eligibility or entitlement to benefits under the
* * *
PAYMENT OF CLAIMS
* * *
Authority to Interpret Policy
Policy benefits will be paid only if We determine, in Our
discretion, that the claimant is entitled to benefits under
the terms of the Policy (see the Authority to Interpret
Policy provision in the ERISA Summary Plan Description
information included with the Certificate).
Id. ¶ 47.
plan contains the following relevant definitions:
LONG-TERM DISABILITY DEFINITIONS
* * *
Disability and Disabled means that because of Injury or
Sickness, a significant change in Your mental or physical
functional capacity has occurred in which You are:
a) prevented from performing at least one of the Material
Duties of Your Regular Occupation on a part-time or full-time
basis: and b) unable to generate Current Earnings which
exceed 99% of Your Basic ...