Insurer prevails in dispute over migraine coverage

Where a disability insurer determined that a beneficiary’s migraine headaches were subject to a limitation in the plan documents, and that determination was supported by the plan documents, the administrative record and medical providers, the insurer was granted summary judgment.

Background

Linda Paulson sued Guardian Life Insurance Company of America for: (1) denial of ERISA benefits and (2) a penalty claim based on Guardian’s alleged failure to comply with requests for information. Both parties have moved for summary judgment.

Notice

Paulson argues that she was not given proper notice that Guardian considered her migraine headaches to be subject to a 24-month limitation period or that Guardian did not consider her cervical radiculopathy to be disabling. The court finds that Paulson was on notice that Guardian was denying her continuing benefits based on her migraines because of the application of the headache limitation in the limited benefit provision, or LBP.

The same cannot be said for Guardian’s handling of Paulson’s disability claim related to her cervical radiculopathy. With respect to that diagnosis and claimed disability, Guardian offers a shifting explanation for the denial of benefits. This “shift” in Guardian’s decision-making violates ERISA’s notice requirements because Paulson did not have an opportunity to appeal the denial on that basis.

The remedy for this notice violation with respect to Paulson’s cervical radiculopathy, however, is not a grant of summary judgment in favor of Paulson, but rather a remand of this issue for Guardian to provide the full and fair review to which Paulson is entitled.

Migraines

Having determined that Paulson had notice that Guardian viewed her migraines claim as subject to the LBP, it is necessary to determine whether that decision was unreasonable. Under the LBP, benefits for “headaches” are limited to 24 months.

The plain meaning of the broad term “headaches,” includes the more specific “migraine headaches.” Guardian acted reasonably when it classified migraine headaches as part of the general category of headaches. Moreover, given the administrative record in this case, it was not unreasonable for Guardian to determine that Paulson’s chronic migraines fell within the general category of “headaches” and thus were subject to the LBP. The purpose of the plan also supports Guardian’s interpretation.

Guardian reviewed the materials submitted by Paulson from her nurses and doctors, reviewed the documentation provided and sought out a second opinion from a board-certified neurologist. Paulson argues that the materials reviewed were not adequate because Guardian’s doctor, Dr. Lorne Label, a board-certified neurologist, did not respond to questions from Paulson. But most of the questions that Paulson sought to ask Dr. Label were related to the extent of her disability or to her cervical radiculopathy, and not to whether migraine headaches are included in the umbrella of headaches more generally.

Guardian’s determination that Paulson’s migraine headaches were subject to the LBP was fully consistent with ERISA’s procedural and substantive requirements. In this regard, Paulson presents no persuasive evidence that Guardian’s determination violated the requirements of ERISA. Thus, the court will grant Guardian’s motion for summary judgment as it pertains to the denial of benefits related to migraine headaches and deny Paulson’s motion to the extent it is based on the same.

Penalties

Although both parties seek summary judgment with respect to the ERISA penalties claim, neither party has submitted sufficient argument or evidence now to resolve those issues. Accordingly, the court directs the parties to submit supplemental briefing that: (i) sets forth each parties alleged undisputed material facts related to the penalty issue, including whether and when Guardian sent a paper and/or CD-rom copy of the claim file and whether and when Paulson (or her counsel) received either a paper or CD-Rom copy of the claim file; (ii) addresses whether Guardian qualifies as a plan administrator under the plan and (iii) otherwise addresses any arguments pertinent to the penalty claim. After the court has decided the final penalties issue, a motion for attorney’s fees and costs may be made, if warranted.

Plaintiff’s motion for partial summary judgment granted in part, denied in part and deferred in part. Defendant’s motion for summary judgment granted in part, denied in part and deferred in part.

Paulson v. Guardian Life Insurance Company of America, Case No. 1:22-cv-877, Feb. 5, 2024. EDVA at Alexandria (Alston). VLW 024-3-061. 23 pp.