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Owings v. United of Omaha Life Insurance Co.

United States Court of Appeals, Tenth Circuit

October 17, 2017

GREGGORY B. OWINGS, Plaintiff - Appellant,
v.
UNITED OF OMAHA LIFE INSURANCE COMPANY, Defendant-Appellee.

         APPEAL FROM THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF KANSAS (D.C. No. 6:15-CV-01108-EFM)

          Donald N. Peterson, II (Sean M. McGivern, with him on the briefs), Graybill & Hazlewood, LLC, Wichita, Kansas, appearing for Appellant.

          William E. Hanna (Christopher J. Leopold, with him on the brief), Stinson Leonard Street, LLP, Kansas City, Missouri, appearing for Appellee.

          Before BRISCOE, MATHESON, and PHILLIPS, Circuit Judges.

          BRISCOE, Circuit Judge.

         Plaintiff Greggory Owings sustained a disabling injury on the job and was afforded long-term disability benefits by defendant United of Omaha Life Insurance Company (United), under the terms of a group insurance policy issued by United to Owings' employer. Owings disagreed with, and attempted without success to administratively challenge, the amount of his disability benefits. He then filed suit against United in Kansas state court, but United removed the action to federal district court, asserting that the federal courts had original jurisdiction over the action because the policy was governed by the Employee Retirement Income Security Act of 1974 (ERISA). The district court ultimately granted summary judgment in favor of United. Owings now appeals. Exercising jurisdiction pursuant to 28 U.S.C. § 1291, we conclude that United was arbitrary and capricious in determining the date that Owings became disabled and, in turn, in calculating the amount of his disability benefits. Consequently, we reverse the district court's grant of summary judgment in favor of United and remand with directions to enter summary judgment in favor of Owings.

         I

         The Policy and Plan

         Owings worked for Grene Vision Group in Wichita, Kansas, from 2001 until October 8, 2013. At all times relevant to this case, Grene was covered by a group insurance policy (Policy) issued by United. Aplt. App., Vol. I at 80. The Policy funded a welfare benefit plan (the Plan) that provided long-term disability benefits to qualifying employees of Grene.

         The Policy incorporates by reference the terms of the Certificates[1] and the Summary of Coverage that were provided to Plan participants, such as Owings. Together, these documents serve as the summary plan description and plan document for the Plan. The Plan is governed by the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001, et seq.

         The Policy defines the terms "Disability" and "Disabled" in the following manner:

Disability and Disabled mean that because of an Injury or Sickness, a significant change in Your mental or physical functional capacity has occurred, as a result of which:
a)during the Elimination Period, You are prevented from performing at least one of the Material Duties of Your Regular Occupation on a part-time or full-time basis; and
b) after the Elimination Period, You are:
1. prevented from performing at least one of the Material Duties of Your Regular Occupation on a part-time or full-time basis; and
2. unable to generate Current Earnings which exceed 99% of Your Basic Monthly Earnings due to that same Injury or Sickness.
After a Monthly Benefit has been paid for 3 years, Disability and Disabled mean You are unable to perform all of the Material Duties of any Gainful Occupation.

Id., Vol. II at 359.

         The Policy defines the terms "Material Duties, " "Regular Occupation, " and "Basic Monthly Earnings, " in the following manner:

Material Duties means the essential tasks, functions, and operations relating to an occupation that cannot be reasonably omitted or modified. In no event will We consider working an average of more than the required Full-Time hours per week in itself to be a part of material duties. One of the material duties of Your Regular Occupation is the ability to work for an employer on a full-time basis.

Id. at 360.

Regular Occupation means the occupation You are routinely performing when Your Disability begins. Your regular occupation is not limited to Your specific position held with the Policyholder, but will instead be considered to be a similar position or activity based on job descriptions included in the most current edition of the U.S. Department of Labor Dictionary of Occupational Titles (DOT). We have the right to substitute or replace the DOT with another service or other information that We determine to be of comparable purpose, with or without notice. To determine Your regular occupation, We will look at Your occupation as it is normally performed in the national economy, instead of how work tasks are performed for a specific employer, at a specific location, or in a specific area or region.

Id. at 361.

Basic Monthly Earnings for salaried Employees means Your gross annual salary from the Policyholder in effect on the day immediately prior to the date on which Your ...

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