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Marszalek v. Marszalek & Marszalek Plan

June 30, 2008

JOHN E. MARSZALEK, PLAINTIFF,
v.
MARSZALEK & MARSZALEK PLAN, DEFENDANT.



The opinion of the court was delivered by: Mag. Judge Michael T. Mason

MEMORANDUM OPINION AND ORDER

Before the Court are cross motions for summary judgment filed by plaintiff John E. Marszalek ("Marszalek" or "plaintiff") and defendant Long Term Disability Insurance Plan (incorrectly named as the Marszalek & Marszalek Plan, referred to herein as "defendant" or the "Plan"). Plaintiff seeks disability insurance benefits under the Plan pursuant to the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. 1132(a)(1)(B).

The parties do not dispute that Marszalek became disabled under the terms of the Plan on July 23, 2003, and that thereafter Marszalek continued to work on a part-time basis. The Plan contends that the administrator, Northwestern Mutual Life Insurance Company ("Northwestern Mutual"), properly determined Marszalek's disability benefits based on the net income he received in 2002, and that it was reasonable for Northwestern Mutual to determine that plaintiff was eligible to receive the Plan's minimum monthly benefit of $100. The Plan further contends that Northwestern Mutual reasonably terminated Marszalek's disability claim based on his failure to provide updated documentation of his medical condition and income. In contrast, Marszalek alleges that the Plan contains inconsistent and irreconcilable methods of calculating his monthly disability benefit. Plaintiff further contends that the Plan contains ambiguous terms which must be resolved in his favor. Marszalek claims that Northwestern Mutual's determination was arbitrary and capricious, and that he is entitled to the maximum benefit of $6,000 per month. For the reasons stated below, the Plan's motion is granted and plaintiff's motion is denied.

I. BACKGROUND*fn1

Plaintiff is a licensed attorney. At the relevant times, plaintiff practiced law in the same office as his brother, James Marszalek. Plaintiff's brother completed an application for disability insurance under the Plan on May 19, 2000. Northwestern Mutual accepted the application, and coverage under the Plan became effective on June 1, 2000.

The Plan is governed by the: (1) Summary of Insurance issued by Northwestern Mutual with an effective date of June 1, 2000, covering eligible employees and affiliates of the law firm of Marszalek & Marszalek (the "Summary"); and (2) Group Insurance Policy L665000 issued by Northwestern Mutual to Firstar Trust Company, as trustee, with an effective date of October 1, 1996 (the "Policy").*fn2 The Plan states that:

The Policy or Summary . . . may be changed in whole or in part. No change in the Policy will be valid unless it is approved in writing by one of the Company's executive officers and given to the Policyowner for attachment to the Policy. No change in the Summary . . . will be valid unless it is approved in writing by one of the Company's executive officers and given to the Employer. No agent has authority to change the Policy or the Summary . . . or to waive any of its provisions.

Under the Plan, the term "the Company" refers to Northwestern Mutual.

The Plan provides both total (also known as long term) disability coverage and partial disability coverage. In order to qualify for long term disability ("LTD") benefits during the initial twenty-four month "Own Occupation" period, a Plan participant must be unable to perform the duties of their Own Occupation. The Summary states:

You are Disabled from your Own Occupation if, as a result of Sickness, Injury or Pregnancy, you are unable to perform with reasonable continuity the Material Duties of your Own Occupation.

The term Own Occupation "[is] not limited to your specific job with your Employer, or to your specific area of specialization, interest or expertise within the general occupation." Plaintiff contends his own occupation is "trial attorney," however the Plan contends his occupation is that of an "attorney."

After benefits have been paid for 24 months, the definition of total disability changes to the "Any Occupation" definition of disability. Any Occupation is defined as "any gainful occupation for which you are reasonably fitted by education, training, and experience."

The Plan also provides partial disability benefits. In order to qualify for partial disability benefits during the Own Occupation period, a Plan participant must be working at their Own Occupation "but, as a result of Sickness, Injury or Pregnancy . . . [be] unable to earn more than the Own Occupation Income Level." Similarly, in order to qualify during the Any Occupation period, the participant must be working in "an occupation but, as a result of Sickness, Injury or Pregnancy . . . [be] unable to earn more than the Any Occupation Income Level in that occupation and all other occupations for which [the participant is] reasonably suited" by education, training, and experience. The Summary states that a Plan participant will receive LTD benefits if they satisfy the partial disability definition but have no part-time work earnings: "LTD Benefit. The LTD Benefit will be paid if you do not have Work Earnings. Your LTD Benefit is shown in the Specifications." The Specifications section is not defined in the Summary. However, the "guide to summary of insurance benefits provisions" identifies the Specifications as starting on page one of the Summary and continuing through page five.

The maximum LTD benefit available under the Plan is 60% of the participant's "Predisability Earnings," not to exceed $6,000 per month. The minimum monthly benefit is $100, reduced by "other income." For sole proprietors, partnerships and S-corporation shareholders, Predisability Earnings is defined as follows:

Predisability Earnings means your average monthly compensation from your Employer during the Employer's prior tax year. Your average monthly compensation is determined by adding the following amounts as reported on Schedule C, Schedule K-1, Form W-2, or S-Corporation federal income tax return, and dividing by 12:

C Your ordinary income from trade or business;

C Your guaranteed payments, if you are a partner; and C Your compensation (as an officer), salary, and wages if you are an S-corporation shareholder.

The Plan further states that Predisability Earnings for each uninterrupted period of Disability "will be the Predisability Earnings in effect on the date shown in the Specifications. Any change in your earnings after that date will not affect your Predisability Earnings."

Plaintiff contends that the date shown in the Specifications is June 1, 2000 - the Plan's effective date as identified on page one of the Summary. In contrast, defendant relies on page three of the Summary which states:

Predisability Earnings: Based on your last full day of Active Work Earnings Period: The preceding 12 calendar months.

Thus, defendant contends that Marszalek's Predisability Earnings are based on 2002, the year preceding his last day of Active Work.

The Summary also notifies Plan participants of their obligation to submit information required to support a claim to "the Company," Northwestern Mutual:

7.3 Documentation

At your expense, you must submit completed claims statements, your signed authorization for the Company to obtain information, and any other items the Company may reasonably require in support of your claim. If you do not provide the documentation within 60 days after the Company mails you a request, your claim may be denied.

Marszalek alleges that on July 23, 2003, his nephrologist placed him on hemodialysis to treat end stage renal disease, and he received hemodialysis three times per week thereafter until November 29, 2004.*fn3 Marszalek continued to work on a part-time basis after July 23, 2003.

On or about August 29, 2003, Marszalek requested a disability claim form. In September or October of that year, plaintiff completed the claim form, which was received by Northwestern Mutual on October 23, 2003.*fn4 Marszalek also authorized Northwestern Mutual, on behalf of the Plan, to obtain medical records to be used to determine his eligibility for disability benefits under the Plan.

On November 4, 2003, a Northwestern Mutual employee reviewed plaintiff's claim and completed a new case worksheet (the "Worksheet"). The Plan contends that Northwestern Mutual prepared the Worksheet based on information supplied by Marszalek in the claim form. Among other things, the Worksheet states that Marszalek " . . . is TD." Marszalek claims that this notation evidences Northwestern Mutual's determination that he was totally disabled. The Plan disputes plaintiff's interpretation of the notation. The Worksheet also states "PDE = $12,900." Marszalek claims this establishes that Northwestern Mutual determined that his Predisability Earnings were $12,900. In contrast, the Plan contends that the notation reflects Marszalek's own report, on his disability claim form, of monthly earnings of $12,900. The Plan also relies on the comments section of the Worksheet in which the Northwestern Mutual employee states: "Although claimant['s] medical condition appears to meet definition of disability, we do not have sufficient evidence of predisability earnings or current part-time earnings. I recommend claim remain pending until earnings info is obtained."

On November 4, 2003, Northwestern Mutual sent a letter to Marszalek stating that the initial review of his LTD benefits claim was complete, and requesting copies of his 2002 income tax returns. Specifically, the letter states:

Your group policy defines Predisability Earnings as your average monthly compensation from your employer during the [e]mployer's prior tax year. Your average monthly compensation is determined by adding the following amounts as reported on Schedule C, Schedule K-1, Form ...


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