Surgeon's Disability Not Sufficient for Long Term Disability Benefits

a. eligibility for insurance; standard may bring its counterclaim under 29 u.s.c. did not reach a meeting of the minds. the court granted disability benefits from standard for two years. at that their respective complaint and counterclaim." the court claim under it; refused to sign. standard's decisions and whether it correctly rejected v. life ins. co. of north america, 317 f.3d 773, 775 (7th group insurance plan, or an agent of any one of the many members of the group receive individual policies." hall and that he had some administrative experience in hospi- language of the standard plan gives the administrator by reference to what the parties expressed to each other he received from his ama policy are not subject to stan- 29 u.s.c. � 1132(a)(3). id. at 1873. the question before erisa fiduciaries. see generally reliance standard life for the administration of the group policy and any equitable lien sought as a matter of restitution"), strict payors who might trigger an offset. thus, the benefits for summary judgment. the reservation of discretion must be communicated employee adequate notice" that standard has the "latitude a judgment within the confines of pre-set standards, or within the offset provision. after doing likewise, we agree. convey the same meaning. see supra ("full and exclusive with the threshold question whether the district court no. 06-3708 3 erly be viewed as seeking "equitable relief" under 29 u.s.c. from standard, and so we too will look to that body of following conditions: type i diabetes, macular degenera- sources when it is approved." that can mean only that s. ct. at 1872. here, too, there is an "equitable lien by as follows: mum ltd [long term disability] benefit will be � 1132(a)(3) even if the benefits it paid gutta are not finally, gutta also asked the district court to enforce cir. 1996). monthly period . . . ." as the parties note, the relevant is conclusive and binding"). this is a far cry from the d. sufficiency and the amount of information we may spare language "when prudential determines" and "satis- gutta possessed was not an individual plan, but merely signal discretion in diaz, 424 f.3d at 638, 640. the standard ins. co., 205 f.3d 327, 331 (7th cir. 2000). indeed, "the given the language in the email exchange and the fact for the seventh circuit to light-level work. it also observed that he had 10 � years' refers to "[t]he amount you receive or are eligible to receive i in their writings, not by their actual mental processes. contracts generally. here, we look to illinois contract mother and it would be up to standard to investigate husband were injured in a car accident, and her employer working as a surgeon, but it found that he had never argued september 11, 2007--decided june 26, 2008 id. at 802 (citations omitted). if a potential jury could reach ____________ gutta's assertion that the parties had concluded an en- "discretion," it uses a variety of equivalent terms that and capricious" standard, the plan's determination was come into being is one of law. see echo, inc. v. whitson co., v. use any particular magic words. see herzberger v. standard notify standard of the amount of the income from other the court was whether the relief mid atlantic sought standard has full and exclusive authority to control and construction and enforcement of settlement agreements tained through his membership in the american medical no. 06-3708 13 ____________ insurance plans. gutta acknowledged receiving benefits ____________ the minds here, and therefore no enforceable settlement overpayment." ment. he first argued for a favorable standard of review, tals. all this added up, in its view, to the conclusion gutta v. standard select trust ins., 2006 wl 2644955, at *27 the minds as to an agreement whereby the parties would, of recovery. leipzig v. aig life ins. co., 362 f.3d 406, offered persuasive evidence showing that he could not made "with full knowledge of the facts." the district blind spot, dislocation of the left thumb, degenerative terms of the policy and otherwise. in our case, standard's plan provides for an offset for 93 f.3d 397, 401 (7th cir. 1996). the district court adjudi- forceable settlement agreement. the facts bearing on discretion in determining benefits. firestone tire & rubber substantive law. from a procedural standpoint, how- paid by standard could not properly have been character- no. 06-3708 9 terms of the agreement." . . . illinois follows the objec- and so it is governed by ordinary principles. gutta relies reasonably require to determine a., b., or c., above. owned and operated a medical practice for over 20 years, `receives benefits' under the plan for such injuries to the benefits paid by standard were "voluntary payments" standard's reimbursement provision is indistinguish- the case of sereboff v. mid atl. med. servs., 126 s. ct. 1869 "thus easily satisfies the `arbitrary and capricious' standard surgeon, suffers from a variety of physical ailments. in focuses on an exchange of emails that took place on june 1, "group insurance coverage." in his view, the ama policy repeated here. see gutta v. standard select trust ins., no. 04 gutta's second defense is that because standard did perform any gainful occupation for which he is suited by c. amount of benefits payable; convertible to an individual plan upon the occurrence of insurance is a variation on group insurance, in which all the one we face here: interpreted the statement to mean "precisely what it tive theory of intent. as a result, whether [the parties] on the merits, this case largely turns on whether the critical question is whether the plan gives the employee certain events. after examining the various indicia of plan and therefore was not subject to the offset provision. says it is: an agreement to come to the table to talk about turning to standard's counterclaim, we must begin adequate notice that the plan administrator is to make subject to the review procedures of the group policy the current posture of the case, your `offer' is accepted." on took note of the fact that a number of experts believed court found, to the contrary, that the "record does not exhaust administrative review, and gutta has not make against it, gutta's position is contrary to the plain no. 04 c 5988--blanche m. manning, judge. the district court found that the statement in the case progressed there was some talk of settlement. gutta cretion but instead merely establishes that standard cated the counterclaim despite standard's failure to we provide here the facts pertinent to the questions viewed under a de novo standard unless the benefit plan requirement that applies to beneficiaries also applies to ultimately decided that gutta was ineligible for contin- would, at this time, entertain resolution of all disputes benefits to gutta for a third year while it investigated part of the definition of "income from other sources" for the northern district of illinois, eastern division. gutta's discussion on this point revolves around the claimed that even using the more deferential "arbitrary irrelevant, because the burden was on standard to investi- is better characterized as franchise insurance. "franchise gutta's group policy with standard contains a section � 1132(a)(3), then jurisdiction is secure, because in that the testimony of no less than twelve doctors, as well as a what he claimed to be a binding settlement agreement, id. at 1877. for the latter kind of lien (in contrast to "an no. 06-3708 11 the district court may consider only evidence that was the judgment of the district court is affirmed. enforceable agreement. on that day, standard sent gutta "income from other sources": "each month your maxi- 2644955, at *23. 6 no. 06-3708 ized as voluntary. effect to the intent of the parties as expressed by the a lien is asserted need not be in existence when the con- of the district court. wilczynski v. lumbermens mut. cas. co., ties' " provision, which "require[d] a beneficiary who as is true in most litigation, from time to time as this the counterclaim. as standard points out and as the filed suit in district court and moved for summary judg- in the amount of $73,996.75, hence, standard's motion authority to control and manage, . . . to administer, . . . and iv coverage was not an individual policy. the policy was perform his own occupation, but that he was unable to other side some amount of money." id. it found no genu- guage "standard has authority . . ." does not confer dis- recoveries from a third party (whether by lawsuit, settle- on illinois law to support his argument, without objection of erisa. ii point, in order to be eligible for continuing benefits under aside from a number of policy arguments one could from another plan, but he claimed that it was not a group facts, fed. r. civ. p. 56 governs the question whether we need not decide whether the same exhaustion united states court of appeals not been entitled to that sum, because its policy contains august of 2000, he came to the conclusion that he could noted that it was denying discovery only with respect to the minds between gutta and standard, then the district to prevail based on several defenses to the counterclaim. discretion. gutta argues unconvincingly that the lan- ment, or otherwise).' " id. (altered by the court). the on the cross-motions for summary judgment with re- whether the district court was correct to apply the deferen- but the court declined to do so, finding that the parties notify standard of the amount of the income from other had jurisdiction over it. erisa preempts state-law theories show that standard select knew that the ama plan was ity is conclusive and binding. without more, dismiss their claims." id. are governed by principles of local law applicable to (joint apx., ex. a, group policy, amendment 8, p. 2) to file its counterclaim. in other words, standard's issued to the ama (the "holder") under group policy 2. the right to establish and enforce rules and procedures gutta attacks these findings, and it is possible that a proper disclosure would also disclose that a given the administrator. his eligibility under the latter, more stringent, criterion. it been requested; the plan further provides that the beneficiary "must party, and mid atlantic pursued reimbursement of the as well as on standard's counterclaim, and gutta now ment of an exhaustion requirement is left to the discretion wood, circuit judge. dr. gandhi gutta, a laparoscopic tial "arbitrary and capricious" standard of review to except for those functions which the group policy c 5988, 2006 wl 2644955, at *1-12 (n.d. ill. sept. 14, 2006). summary adjudication is permissible or if a trial is neces- of $73,996.75, nearly all the disability benefits that it had disability benefits under a group policy with standard imposes on contract formation in a situation similar to 12 no. 06-3708 hand, rotator cuff injury in the left shoulder, and degenera- cir. 2003). our own review of the ama insurance certi- factory to prudential" that this court found inadequate to we review de novo the grant of summary judgment in standard select trust insurance plans, shown that this was an abuse of discretion. to interpret and to resolve all questions arising in its ducting de novo review. but we are not. the district court, although standard's plan does not use the word first, he claims that because he disclosed to standard thority to determine eligibility for benefits or to construe claiming that the policy does not grant the plan administra- because of your disability under any group insurance ment agreement containing additional terms, which gutta record reflects, however, the district court specifically gutta's medical conditions and standard's assessment of gutta's final argument is that the disability payments even if all this is correct, gutta maintains that he ought decision was "based upon substantial evidence because it is appeal from the united states district court plan's language unambiguously communicates the mes- ine dispute over the fact that there was "no meeting of * * * reduced by the income from other sources for the same summary judgment in standard's favor on gutta's claim review standard's determination deferentially, to ensure passes muster. trombetta v. cragin fed. bank for sav. em- favor of standard on the counterclaim. adjudication of titled "allocation of authority," which reads solves any disputed issues. mayer v. gary partners and co., mingled with his other assets or dissipated, tracing is 1. the right to resolve all matters when a review has amount of the overpayment" and the beneficiary "must ficate leaves us confident that gutta's ama insurance email that standard "would `entertain' the idea of a `walk- ment gutta rejected) contained three full pages of new operates the plan rather than some other actor. but that is music co. v. 3m, 477 f.3d 910, 914 (7th cir. 2007). similarly, before the administrator in deciding whether her decision cussed in the district court's opinion and need not be at 1875. the court noted also that "the fund over which language of the plan, which states that "[gutta] must these claims, however, was proper only if the parties a legally binding settlement agreement is a contract, select trust insurance plans (standard). gutta received did not have an enforceable settlement agreement. the fact these problems left gutta unable to continue and so he was entitled to the de novo standard. he further enter into a settlement agreement containing no terms (e.d. tenn. oct. 18, 2006) (holding that an erisa fiduciary 3. the right to determine: `reimburse [mid atlantic]' for those benefits from `[a]ll ever, federal law governs whether a judge or jury re- gate further. not exhaust administrative procedures before filing a of benefits challenged under � 1132(a)(1)(b) is to be re- review of the district court's rulings on the motions specifically reserves to the policyowner or employer, sary. director or assistant medical director. whether his grandmother was an administrator of a june 5, 2005, standard then submitted a draft settle- contract came into being. we may thus proceed to the gutta's lawyer sent an email in response stating, "given fair review. standard's failure to exhaust, according to overpaid, standard will notify [the beneficiary] of the agreement" between standard and gutta, and that lien is to a material dispute of fact. there was no meeting of tors enough discretion to warrant deferential review, dard's offset provision because the ama policy is not right to determine [e]ligibility [and] entitlement"; "any evidence that was before the administrator. it summarized policy favoring exhaustion. sion in the plan created an "equitable lien by agreement." was truly "equitable" for purposes of � 1132(a)(3). the able from the reimbursement provision in sereboff, 126 arthritis in both wrists, ulnar palsy of the left arms and gives the administrator or fiduciary discretionary au- not consider evidence outside the record that was before that the draft settlement agreement of june 5 (an agree- disclose to standard that he got a check from his grand- ployee stock ownership plan, 102 f.3d 1435, 1438 n.1 (7th and content of the rules in each case." diaz v. prudential ins. co. not the only language in the plan. reading it as a whole, because the benefits standard paid him have been com- plaintiff-appellant, the original claim and not the counterclaim. the rest of 8 no. 06-3708 version privilege," which shows that the ama policy 2 no. 06-3708 4 no. 06-3708 benefits it paid the sereboffs, bringing an action under mortgage disability insurance." (emphasis added). on appeal, gutta does not contest this law for guidance. in interpreting a contract under in the defendants-appellees. the plan, he had to show not just that he was unable to consistent with the medical evidence in the record" and b. entitlement to benefits; court held that it was and that the reimbursement provi- few other people. gutta had been diagnosed with the 2005, to support his claim that the parties reached an id. at 1872. the plan contained an " `act of third par- standard likewise moved for summary judgment on of review." see gutta v. standard select trust ins., 2006 wl uing benefits because he was capable of working as a sources when it is approved." if the beneficiary "ha[s] been counterclaim against gutta, gutta was denied a full and unreasonable, and therefore arbitrary and capricious. now just a state-law claim for damages, outside the scope no. 06-3708 the rules in each case." see id at 639-40. thus, we will sage that payment of benefits is subject to standard's court found that the ama policy was a group policy manage the group policy, to administer claims, and to paid to gutta. standard took the position that gutta had commingling or dissipation. 121 f.3d 1099, 1102 (7th cir. 1997). if there are disputed (2006), controls our analysis. marlene sereboff and her 14 no. 06-3708 ins. co. v. smith, no. 3:05-cv-467, 2006 wl 2993054, at *3 other than a mutual promise for the parties to dismiss experience in administrative positions, that he had had a "meeting of the minds" as to security for the are not in dispute, the question whether a contract has gutta's claim; it also filed a counterclaim for restitution tive arthritis in the right ac joint. standard accepted medical director. education and experience. standard continued to pay immediately reimburse standard for the amount of the ____________ administration, interpretation, and application"; "[t]he only one conclusion about the existence of a meeting of no. 90-10613-47. part v of the certificate contains a "con- tracing of the funds to be recovered was not required. id. that he was receiving benefits from a policy that he ob- specifically traceable to gutta's current assets because of payment was indeed from a group plan, i.e., that it was sereboffs did in fact recover tort damages from a third usca-02-c-0072--6-26-08 his eligibility for disability benefits are thoroughly dis- illinois law, "the paramount objective is to give sides walking away as opposed to one side paying the the terms of the plan." when discretionary power is the parameters of an agreement which is premised on both paid their medical expenses pursuant to an erisa plan. bringing an action to recover an overpayment). enforce- federal question jurisdiction. gutta, however, argues that decision standard makes in the exercise of our authority 29 f.3d 330, 332-33 (7th cir. 1994). when the basic facts conferred on the administrator, her decision is reviewed spect to gutta's claim, appellate review is de novo. sound of after exhausting his administrative appeals, gutta as we must, we conclude that standard's plan "gives the we might have found more to criticize if we were con- "walk-away" whereby each party foregoes prosecu- before ripple, manion, and wood, circuit judges. means, in his view, that the counterclaim in substance is no longer work in his chosen profession and filed for rather than a franchise policy, and that it therefore fell no. 06-3708 7 standard's authority includes, but is not limited to: 410 (7th cir. 2004). if standard's counterclaim can prop- terms, id. at 53-55, we too see nothing that might give rise coverage, other than group credit insurance or group clearly in the language of the plan, but the plan need not an offset provision for benefits received from other group of am., 424 f.3d 635, 639 (7th cir. 2005) (emphasis added). appeals both adverse decisions. court had no reason to explore the issue further. group insurance and voluntarily chose to pay benefits." tion, retina artery aneurism in the left eye with a residual income from other sources. otherwise, gutta could that gutta was capable of performing full-time sedentary existing between it and dr. gutta on the basis of a we conclude, reasonably concluded that standard's interpret the group policy and resolve all questions association (ama) with sentry life insurance company, any decision standard makes in the exercise of our author- "response" is that it declines dr. gutta's offer to settle for its payment to him of $25,000, but standard finding. instead, he argues that standard's ignorance is the district court exhaustively reviewed the medical tract containing the lien provision is executed." id. at 1876. to shape the application, interpretation, and content of gutta, also had the effect of impeding his discovery on (emphasis added). that the ultimate decision was not arbitrary, and we will tion of any further claim against the other under the not dependent on the ability to trace particular funds. case it would arise under erisa and would fall within gandhi gutta, group policies found in the ama certificate, the district arising in its administration, interpretation, and application. in laserage technology corp. v. laserage labs., 972 f.2d 799 no. 06-3708 5 purchase of mr. byrum's laserage shares is determined impossible, and thus equitable relief is unavailable. this that gutta had the essential skills to become a medical if it has the latitude to shape the application, interpretation, under the arbitrary and capricious standard, id. at 111, and an email stating: a settlement agreement is a contract and as such, the standard's position is that dr. gutta is indebted to it co. v. bruch, 489 u.s. 101, 115 (1989), held that "a denial away' type of settlement [was] not a binding agreement to iii is not required to exhaust administrative review before perform other activities in the medical field. standard (7th cir. 1992), we reviewed the requirements that illinois 10 no. 06-3708