United States District Court, N.D. Oklahoma
OPINION AND ORDER
TERENCE C. KERN UNITED STATES DISTRICT JUDGE
the Court are (1) Plaintiff's Motion for Judgment on the
Administrative Record (Doc. 28); (2) Defendant's Response
to Plaintiff's Motion for Judgment on the Administrative
Record and Cross-Motion (Doc. 31); and (3) Plaintiff's
Response to Defendant's Cross-Motion for Judgment on the
Administrative Record and Reply to Defendant's Response
to Plaintiff's Cross Motion for Judgment. (Doc. 32).
facts of this case are largely undisputed. On April 2, 2012,
Plaintiff Jennifer Coats was hired as a staff nurse with
Cottage Health Care (“Cottage”), and became a
participant in Cottage's employee welfare benefit plan
(the “Plan”), which is governed by the Employee
Retirement Income Security Act of 1974 (“ERISA”).
The Plan includes long-term disability (“LTD”)
benefits funded by Defendant Reliance Standard Life Insurance
Company (“Reliance”) through Group Policy No. LSC
97, 200. The Plan provides that Reliance “shall serve
as the claims review fiduciary with respect to the insurance
policy and the Plan”; shall “determine
eligibility for benefits”; and shall make
“complete, final and binding decisions on all
parties.” (AR 18.)
MONTHLY BENEFIT: The Monthly Benefit is an amount equal to:
CORE: 50% of Covered Monthly earnings, payable in accordance
with the section entitled Benefit Amount.
BUY-UP: 60% of Covered Monthly earnings, payable in
accordance with the section entitled Benefit Amount.
ELIGIBLE CLASSES: each employee of Cottage Health system . .
. . according to the following classifications:
CLASS 1: active, Full-time and Part-time
employees except an employee included in any other
class and a Traveling Nurse.
CLASS 2: active, Full-time Director or above employee CLASS
1: “Part-time” means working for you for a
minimum of 18 hours during a person's regular
work week, or a minimum of 36 hours bi-weekly but
less than 72 hours bi-weekly.
(emphasis added). The Plan Policy contains the following
CLASS 1: “Covered Monthly Earnings” means the
Insured's monthly salary received from you on the first
of the Policy month just before the date of Total disability.
Covered Monthly earnings does not include
commissions, overtime pay, bonuses or any other special
compensation not received as Covered Monthly
If hourly paid employees are insured, the number of hours
worked during a regular work week, not to
exceed forty (40) hours per week, times 4.333, will be used
to determine Covered Monthly Earnings.
(emphasis added). The term “regular work week” is
uses a standardized form titled “Integrated Disability
Benefit Initial Statement of Claim, RS-1971-A, ” to
initiate and process disability claims. AR 195-201. RSL
claims personnel refer to it as the “EE App.”
See AR 122. Submission of a completed EE App
formally initiates a disability claim. The EE App has five
sections, some to be completed by the employee, some by the
employer and some by a treating physician. AR
October 19, 2013, Plaintiff suffered an on-the-job back
injury, and she has not worked for Cottage since then.
Reliance fixed that date as the “date of loss”
(“DOL”). AR122. On March 24, 2015, Plaintiff
submitted to Reliance an EE App for long term disability
(“LTD”) benefits. AR 195-201, supra.
text fields in the EE App, as completed by Cottage, are
pertinent to this dispute. The first asks the method of
Claimant's' compensation. Cottage stated that
Plaintiff was “Hourly.” AR197. The second
requires the employer to state “Weekly earnings (as
defined in policy)” (emphasis in original).
Id. Cottage inserted the figure “1,
287.49.” Id. The third asks for “Work
schedule at time of disability ___ day/week ___ hrs/day.
Cottage indicated that Plaintiff worked 2 days a week for 12
hours a day.” Id.
5, 2015, RSL's claims examiner, Spencer Wright, requested
that Cottage provide “payroll for the period of
07/01/2013 - 01/15/2014 and timecards for the period of
10/01/2013-01/15/2014.” AR 308. Cottage supplied these
records. AR 311-347. On May 21, 2015, Wright made an extended
entry into the claim log, in which he concluded, based on
Plaintiff's payroll records and timecards, that she
averaged 23.70 hours of work per week in the last 12 weeks
(three months) before she became disabled (July 22,
2013-October 13, 2013),  and was therefore eligible for
benefits. AR 122.
4, 2015, Wright sent an email to Kreuger, asking six
questions. On June 5, 2015, Kreuger responded to the
questions, as follows:
a. Is Ms. Coats an hourly or salaried employee?
Hourly b. If hourly, please provide rate per hour on
10/01/13. $52.7361 hourly, plus a separate night shift
differential rate of $5.00 hourly for hours ...