Stephen Wilkinson v. Sun Life and Health Insurance Company

UNPUBLISHED

UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT

No. 15-2105

STEPHEN WILKINSON,

Plaintiff - Appellee,

v.

SUN LIFE AND HEALTH INSURANCE COMPANY, d/b/a Sun Life
Financial,

Defendant - Appellant,

and

DOLAN & TRAYNOR, INC. EMPLOYEE HEALTH AND WELFARE BENEFIT
PLAN,

Defendant.

Appeal from the United States District Court for the Western
District of North Carolina, at Statesville. Richard L.
Voorhees, District Judge. (5:13-cv-00087-RLV-DCK)

Argued: October 27, 2016 Decided: January 5, 2017

Before MOTZ and DIAZ, Circuit Judges, and Gerald Bruce LEE,
United States District Judge for the Eastern District of
Virginia, sitting by designation.

Affirmed by unpublished opinion. Judge Lee wrote the opinion,
in which Judge Motz and Judge Diaz joined.
ARGUED: Joshua Bachrach, WILSON ELSER MOSKOWITZ EDELMAN & DICKER
LLP, Philadelphia, Pennsylvania, for Appellant. Norris Arden
Adams, II, ESSEX & RICHARDS, P.A., Charlotte, North Carolina,
for Appellee. ON BRIEF: Hannah Gray Styron Symonds, WILSON
ELSER MOSKOWITZ EDELMAN & DICKER LLP, Philadelphia,
Pennsylvania, for Appellant. Frank N. Darras, Susan B.
Grabarsky, Phillip S. Bather, DARRASLAW, Ontario, California,
for Appellee.

Unpublished opinions are not binding precedent in this circuit.

2
LEE, District Judge:

Stephen Wilkinson (“Wilkinson”) brought this action against

Sun Life and Health Insurance Company (U.S.) (“Sun Life”) to

seek long-term disability benefits pursuant to the Employee

Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§

1001 et seq. After approving the benefits claim under a policy

that Sun Life issued to Wilkinson’s former employer, Sun Life

terminated benefits on the grounds that Wilkinson was not an

active full-time employee when the policy took effect.

On cross-motions for summary judgment, the district court

granted judgment in favor of Wilkinson. The key issue presented

is whether the district court erred in holding that Sun Life,

the administrator of an employee welfare benefit plan governed

by ERISA, abused its discretion when it terminated Wilkinson’s

benefits. We hold that Sun Life abused its discretion when it

terminated Wilkinson’s benefits because he provided sufficient

evidence to support his eligibility for coverage, and because

Sun Life’s decision to terminate benefits was not the result of

a principled reasoning process and not supported by substantial

evidence. We therefore affirm the district court’s decision.

3
 I.

A.

The facts relevant to this appeal are those probative of

whether Wilkinson worked at least 30 hours per week as an active

employee on May 1, 2004, when the policy at issue took effect.

In 1973, Wilkinson began working as the vice president of

sales, operations, and distribution for Dolan & Traynor, Inc.

(“D&T”). J.A. 10, 23. 1 D&T is a closely-held corporation based

in New Jersey that distributes building products and plumbing

specialties. J.A. 10, 23, 1110–15. Wilkinson earned an annual

compensation of $434,300, and at some point prior to his

disability, worked approximately 60 hours per week. J.A. 276,

1315-16. He also owned approximately 22% of D&T’s stock. J.A.

91. Wilkinson has represented that his position at D&T was due

to marrying the daughter of one of D&T’s owners. J.A. 521. In

August 2003, Wilkinson’s wife passed away. J.A. 998. In the

months that followed, Wilkinson began to struggle emotionally

and physically, and he eventually developed a heart condition

known as cardiomyopathy. Id.

At a D&T partner meeting in March 2004, Wilkinson and his

business partners discussed his decline in health, his ongoing

1Citations to the “J.A.” refer to the Joint Appendix filed
by the parties in this appeal.

4
role with the company, and the possibility of him taking leave.

J.A. 372–74. Subsequent to this meeting, Wilkinson wrote an

email to his partners stating that over the preceding seven

months, he typically worked from 9 a.m. to 5 p.m., aside from

six weeks of paid time off. J.A. 373. Wilkinson also wrote, “I

would like to feel better and will continue to try to return to

being more productive working no more than 40 hour weeks. This

all depends on my ability based on my current predicament.”

J.A. 373.

A second partner meeting occurred on April 13, 2004. J.A.

375. The partners discussed how D&T was in the midst of a

critical time and needed all the partners to work diligently.

Id. The next day, Wilkinson summarized the meeting in an email

as follows: “My expressed desire to work 30-40 hours a week does

not cut it with [the partners]. They are putting in extra hours,

evenings/weekends and it is not fair.” Id.

A third partner meeting occurred on April 21, 2004. J.A.

999. Wilkinson and his partners again discussed the possibility

of Wilkinson taking leave. Id. According to court filings that

Wilkinson filed in a separate 2007 lawsuit, “Timothy Dolan asked

that [Wilkinson] take the leave now and [D&T] would continue to

pay [his] salary until a written agreement was reached laying

out the terms of [his] leave.” Id. Wilkinson further claimed,

“[b]ased on [D&T’s] promise to work out an agreement within a

5
few weeks, I began a medical leave for an undetermined period of

time, beginning May 7, 2004.” Id.

On May 5, 2004, D&T’s human resources department sent

Wilkinson a document entitled “Response to Employee Request for

Family or Medical Leave and Employee Acknowledgements of

Obligations” (the “FMLA Form”). J.A. 201-03. The FMLA Form

states, “[w]e are aware that you need this leave beginning on or

about May 10, 2004 . . . .” J.A. 201. The record reflects that

Wilkinson took unpaid FMLA leave from May 7, 2004 until August

2004. J.A. 1466. In July 2004, Wilkinson informed D&T that he

would be unable to return to work. J.A. 376.

B.

Eligible employees of D&T were covered under its Employee

Health and Welfare Benefit Plan. J.A. 7, 22. Prior to May 1,

2004, the plan was insured by a different company, Unum. J.A.

1284-1312. Effective May 1, 2004, Sun Life issued a group

benefits policy (the “Policy”) to D&T to insure eligible

participants and beneficiaries of its plan. J.A. 260, 1352–81.

Sun Life served in the dual role of evaluating benefit claims

and paying approved claims. J.A. 9, 23. Wilkinson submitted a

benefits claim to Sun Life on August 18, 2004, which Sun Life

approved. J.A. 927, 1449-53. Sun Life paid Wilkinson

disability benefits for approximately four years from August

6
2004 until July 2008. J.A. 248. Sun Life also performed

periodic reviews to determine whether Wilkinson remained

eligible for long-term disability benefits. J.A. 262.

In November 2007, Wilkinson filed an employment-related

action in New Jersey state court against D&T, as well as his

business partners Timothy Traynor, Michael Dolan, and Timothy

Dolan (the “New Jersey Lawsuit”). J.A. 81–23. Wilkinson

alleged that he was fraudulently induced into resigning as an

officer of D&T and signing a modification of his buyout

agreement. Id. The parties eventually settled the suit under a

confidential agreement. J.A. 312. At the time, the New Jersey

Lawsuit had nothing to do with Wilkinson’s benefits claim. Id.

Sun Life sent Wilkinson the first denial letter on July 29,

2008, stating that he no longer qualified for long-term

disability benefits. J.A. 125–29. This denial letter noted

that Sun Life had recently learned of the New Jersey Lawsuit,

and that Sun Life believed Wilkinson may have resigned from D&T

because of disagreements with the partners, rather than medical

reasons. J.A. 128. Regardless, Sun Life justified the first

denial because it “concluded that there was no medical evidence

to continue to support [Wilkinson’s] claimed restrictions and

limitations.” Id. Importantly, Sun Life’s “assessment of total

disability [was] based on one’s occupation [as a vice president]

in the national economy, not by the job requirements of a

7
particular employer.” J.A. 126. Sun Life claimed that although

D&T described Wilkinson’s “job as heavy duty,” a vice president

in the national economy fits “closer to the light physical

demand level.” Id. In January 2009, Wilkinson challenged the

termination of benefits and provided evidence to rebut Sun

Life’s determination. J.A. 519–640. Wilkinson also challenged

Sun Life’s reliance on what duties a vice president performs in

the national economy, as opposed to what duties he performed at

D&T. See J.A. 521.

Sun Life sent Wilkinson a second denial letter on May 13,

2009. J.A. 61–69. This letter noted that a physician described

Wilkinson’s “cardiac status as causing only slight limitation in

physical activity.” J.A. 63. The letter also stated a

functional capacity evaluation revealed that Wilkinson “had the

capacity to perform his occupation as it is typically performed

in the national economy.” J.A. 63. Nevertheless, Sun Life

expressly stated that it was “not addressing any question of

Disability at this time,” and that it was denying coverage on

different grounds. J.A. 69. Sun Life found Wilkinson

ineligible for coverage under the Policy because, in its view,

two declarations filed in the New Jersey Lawsuit indicated

Wilkinson “was not meeting the requirements of an Active Full-

time Employee at the time coverage became effective . . . on May

1, 2004.” J.A. 68. Thus, five years after Wilkinson left D&T,

8
Sun Life asserted a new theory for why Wilkinson did not qualify

for coverage.

In January 2010, Wilkinson appealed the termination of his

disability benefits a second time. J.A. 346–64. As part of

Wilkinson’s administrative appeal, a physician hired by Sun Life

provided medical findings indicating that “Wilkinson would be

precluded from the duties of his ‘Regular Occupation’ and was

‘Totally Disabled.’” J.A. 45. This finding essentially

foreclosed Sun Life’s denial of benefits based on medical

grounds.

Sun Life sent Wilkinson a third denial letter on July 12,

2010. J.A. 39–50. The sole issue at that point involved

whether Wilkinson was “[p]erforming all the duties of [his] job

on a Full-time Basis and working on a regular work schedule of

at least 30 hours per week” when the Policy took effect. See

id. To prove that he was an active full-time employee,

Wilkinson provided Sun Life with a statement, emails regarding

partnership meetings leading up to his leave of absence, a

declaration from his CPA, applications that Wilkinson submitted

to insurers for other purposes, and Social Security information.

J.A. 44, 50. Sun Life rejected this information because it

believed the evidence did not substantiate whether Wilkinson was

an active full-time employee. See J.A. 45–46, 50. Instead, Sun

Life relied upon two declarations filed in the 2007 New Jersey

9
Lawsuit as evidence of Wilkinson’s ineligibility for coverage.

See J.A. 48–49.

C.

Wilkinson brought this case pursuant to section

502(a)(1)(B) of ERISA, 29 U.S.C. § 1132(a)(1)(B), to determine

his entitlement to long-term disability benefits under the

Policy. J.A. 7–21. Having exhausted his administrative

remedies, on June 18, 2013, Wilkinson filed suit against Sun

Life in the United States District Court for the Western

District of North Carolina. Id. Sun Life responded with a

Counterclaim seeking repayment of $386,539.37, the amount of

benefits Sun Life paid to Wilkinson prior to terminating

benefits. J.A. 22–29. Wilkinson moved to dismiss Sun Life’s

Counterclaim, and later the parties filed cross-Motions for

Summary Judgment. J.A. 30–35, 204–40.

On September 1, 2015, the district court published an

opinion granting Wilkinson’s Motion for Summary Judgment and

awarding him benefits under the Policy. Wilkinson v. Sun Life &

Health Ins. Co., 127 F. Supp. 3d 545, 568 (W.D.N.C. 2015). The

district also denied Sun Life’s Motion for Summary Judgment, and

dismissed its Counterclaim as moot. Id. First, the district

court determined that the ERISA abuse of discretion standard

applied. Id. at 556–58. Next, under that standard, the

10
district court weighed the relevant factors to determine whether

Sun Life’s denial of benefits was reasonable. Id. at 562–68.

In doing so, the court considered the FMLA Form even though it

was not part of the administrative record. Id. at 560–62.

Ultimately, the district court found that Wilkinson met his

burden to show that he was covered under the Policy, and that

Sun Life abused its discretion by denying benefits. Id. at 562.

Sun Life filed this appeal.

II.

As a threshold issue, we first consider the appropriate

judicial standard of review. A participant or beneficiary of a

plan covered under ERISA may bring a civil action to recover

benefits due to him or her under the plan’s terms. See 29

U.S.C. § 1132(a)(1)(B). The scope of judicial review in an

action challenging an administrator’s coverage determination

under section 1132(a)(1)(B) turns on whether the benefit plan

vests the administrator with discretionary authority. Firestone

Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989); Helton v.

AT & T Inc., 709 F.3d 343, 351 (4th Cir. 2013). When a plan

does not vest the administrator with discretionary authority, a

district court reviews the administrator’s coverage

determination de novo. Helton, 709 F.3d at 351 (citing Williams

v. Metro. Life Ins. Co., 609 F.3d 622, 629 (4th Cir. 2010)). In

11
contrast, when a plan vests the administrator with discretionary

authority to make eligibility determinations, a district court

reviews the administrator’s decision under the abuse of

discretion standard. See Helton, 709 F.3d at 351.

Here, the district court applied the abuse of discretion

standard because a document attached to and delivered with the

benefits plan contained discretionary language. J.A. 223. The

parties agree that if this document, referred to as the

“Statement of ERISA Rights,” is considered part of the plan,

then the document clearly grants Sun Life discretionary

authority. While Sun Life contends that the abuse of discretion

standard applies, Wilkinson contends that de novo review applies

because the Statement of ERISA Rights was not part of the

benefits plan. We need not reach the issue of whether the

district court appropriately considered the document part of the

plan because the standard of review is not outcome

determinative. Even under the abuse of discretion standard,

which is more favorable to Sun Life, we conclude that the

district court properly granted judgment in Wilkinson’s favor.

Accordingly, we review the district court’s grant of

summary judgment to Wilkinson de novo, applying the same abuse

of discretion standard employed by the district court. See

Harrison v. Wells Fargo Bank, N.A., 773 F.3d 15, 20 (4th Cir.

2014); Williams, 609 F.3d at 629. Under the abuse of discretion

12
standard, this circuit will uphold the decision of a plan

administrator if the decision is reasonable, even if this court

would have reached a contrary conclusion upon an independent

review. See Fortier v. Principal Life Ins. Co., 66 F.3d 231,

235 (4th Cir. 2012). A decision is reasonable when the decision

“is the result of a deliberate, principled reasoning process,

and is supported by substantial evidence . . . .” Helton, 709

F.3d at 351 (internal quotation marks and citation omitted). In

evaluating whether a plan administrator abused its discretion,

this circuit has identified the following eight nonexclusive

“Booth factors”:

(1) the language of the plan; (2) the purposes and
goals of the plan; (3) the adequacy of the materials
considered to make the decision and the degree to
which they support it; (4) whether the fiduciary’s
interpretation was consistent with other provisions in
the plan and with earlier interpretations of the plan;
(5) whether the decisionmaking process was reasoned
and principled; (6) whether the decision was
consistent with the procedural and substantive
requirements of ERISA; (7) any external standard
relevant to the exercise of discretion; and (8) the
fiduciary’s motives and any conflict of interest it
may have.

Booth v. Wal–Mart Stores, Inc. Assocs. Health and Welfare Plan,

201 F.3d 335, 342–43 (4th Cir. 2000).

III.

We next consider Sun Life’s three primary contentions

concerning whether the district court: (1) improperly considered

13
evidence outside the administrative record; (2) erroneously

shifted the burden to prove coverage eligibility from the

claimant to the plan administrator; and (3) erroneously held

that Sun Life abused its discretion. Each contention is

addressed in turn.

A.

Sun Life contends that the district court improperly

considered evidence outside the administrative record by relying

upon Wilkinson’s FMLA Form as evidence of when he ceased

working.

When a court reviews a coverage determination under the

abuse of discretion standard, generally, consideration of

evidence outside of the administrative record is inappropriate.

Helton, 709 F.3d at 352 (citing Sheppard & Enoch Pratt Hosp. v.

Travelers Ins. Co., 32 F.3d 120, 125 (4th Cir. 1994)). However,

in Helton, this circuit stated that courts reviewing ERISA cases

should take “a more nuanced approach to consideration of

extrinsic evidence on deferential review, rather than embracing

an absolute bar.” 709 F.3d at 352. Under Helton, “a district

court may consider evidence outside of the administrative record

on abuse of discretion review in an ERISA case when [1] such

evidence is necessary to adequately assess the Booth factors and

[2] the evidence was known to the plan administrator when it

14
rendered its benefits determination.” Id. at 356. By focusing

on what evidence was known to the plan administrator at the

time, courts within this circuit maintain their ability to

review coverage determinations and prevent administrators from

omitting unfavorable evidence from the administrative record.

See Helton, 709 F.3d at 353.

On appeal, as in the district court, both prongs of this

two-part test are satisfied. The first prong is met because

evidence of the FMLA Form is necessary to adequately assess at

least three Booth factors. The third Booth factor instructs

courts to assess the “adequacy of the materials considered to

make the decision,” 201 F.3d at 342, and here the FMLA Form is

probative of what Wilkinson told his employer and when, J.A.

201. The fifth Booth factor instructs courts to assess “whether

the decisionmaking process was reasoned and principled,” 201

F.3d at 342, and here Sun Life’s process consisted of granting

benefits, denying benefits for medical reasons, reversing the

medical determination, and then denying benefits for purportedly

not being an active full-time employee. The eighth Booth factor

instructs courts to assess “any conflict of interest [the

fiduciary] may have,” 201 F.3d at 343, and here Sun Life’s

motives are at issue because of its dual role of evaluating and

15
paying benefits claims, see Metro. Life Ins. Co. v. Glenn, 554

U.S. 105, 112 (2008). 2

The second prong required to consider an FMLA Form that is

not part of the administrative record is met because Wilkinson’s

request to take FMLA leave was known to Sun Life when it

rendered its benefits determination. First, Sun Life’s May 2009

denial letter acknowledged that it received in 2004 a letter

from Wilkinson indicating that he took FMLA leave. See J.A.

445. Second, the May 2009 denial letter acknowledges Wilkinson

had “assert[ed] that his [FMLA] leave of absence commenced on

May 7, 2004.” J.A. 451. Third, Wilkinson provided to Sun Life

a declaration in January 2010 stating that D&T “prepared a

memorandum confirming” his request to take FMLA leave, J.A. 311,

and Sun Life acknowledged receipt of the declaration in its July

2010 denial letter, J.A. 265.

Because the FMLA Form is necessary to adequately assess the

Booth factors and the evidence was known to Sun Life, the

district court properly considered that evidence. As discussed

2
Applying the Supreme Court’s precedent in Glenn, this
circuit has held that a plan administrator’s conflict of
interest does not change the judicial standard of review, and
instead is viewed as “one factor among the many identified in
Booth for reviewing the reasonableness of a plan administrator's
discretionary decision.” Williams, 609 F.3d at 631.

16
further below, we too will consider such evidence in evaluating

whether Sun Life abused its discretion.

B.

Next Sun Life contends that the district court erroneously

shifted the burden to establish coverage eligibility from the

claimant to the plan administrator.

“ERISA represents a careful balancing between ensuring fair

and prompt enforcement of rights under a plan and the

encouragement of the creation of such plans.” Conkright v.

Frommert, 559 U.S. 506, 507 (2010) (internal quotation marks and

citation omitted). Plan administrators have a fiduciary duty to

balance “the obligation to guard the assets of the trust from

improper claims, as well as the obligation to pay legitimate

claims.” Harrison, 773 F.3d at 20 (internal quotation marks and

citation omitted). Further, under ERISA, plan administrators

must set forth “the specific reasons” for denial and must

“afford a reasonable opportunity . . . for a full and fair

review . . . .” Id. (quoting 29 U.S.C. § 1133).

On the one hand, this circuit has consistently stated, “the

primary responsibility for providing medical evidence to support

a claimant's theory rests with the claimant.” Harrison, 773

F.3d at 24 (citing Berry v. Ciba–Geigy Corp., 761 F.2d 1003,

1008 (4th Cir. 1985)). Claimants are more familiar with their

17
medical and work history. See Harrison, 773 F.3d at 24.

Additionally, claimants, their physicians, and their employers

are typically better suited to provide the evidence necessary to

support a claim. See id. This circuit has “recognize[d] that

plan administrators possess limited resources,” and has never

required them “to scour the countryside in search of evidence to

bolster” a claim. Id. at 22. On the other hand, this circuit

has also stated that “once a plan administrator is on notice

that readily-available evidence exists that might confirm

claimant's theory of disability, it cannot shut its eyes to such

evidence where there is little in the record to suggest the

claim [is] deficient.” Id. at 24.

Here, the district court stated that in its view, Wilkinson

satisfied his burden of showing that he was covered under the

Policy. Wilkinson, 127 F. Supp. 3d at 562. Then pursuant to

relevant Booth factors, the district court concluded that Sun

Life abused its discretion because its decision-making was not

reasoned and principled and was not supported by substantial

evidence. Id. at 562–68. We challenge Sun Life’s contention

that the district court’s decision should be construed as

demanding an investigation that “leave[s] no stone unturned.”

Compare id. at 567, with Appellant’s Br. at 31. The point is

not that Sun Life failed to be an archeologist digging up

evidence underneath a rock; quite the contrary here, Sun Life

18
shut its eyes to evidence in plain sight. For the reasons that

follow, we agree that Wilkinson satisfied his burden to show he

qualified for coverage, and that Sun Life abused its discretion

by denying benefits.

C.

We next turn to the terms of the Policy, the evidence that

Wilkinson provided to establish his entitlement to coverage, and

the evidence that Sun Life relied upon to deny coverage.

The terms of the Policy limit coverage to “ACTIVE FULL-TIME

EMPLOYEES WHO SATISFY THE COVERAGE ELIBILITY REQUIREMENTS.”

J.A. 1354. The Policy further provides: “You are an Active

Full-time Employee actively at work on any day if on that day

you are: . . . [p]erforming all of the duties of your job on a

Full-time Basis and working on a regular work schedule of at

least 30 hours per week . . . .” J.A. 1356.

Sun Life frames Wilkinson’s evidence as relevant to the

time period when he received compensation, not when he actually

worked. Nevertheless, Wilkinson met his burden to provide

sufficient evidence of his eligibility for coverage when the

Policy took effect on May 1, 2004 (i.e., by providing evidence

that he worked at least 30 hours per week). First, the FMLA

Form indicates that D&T expected Wilkinson to take leave

beginning “on or about May 10, 2004.” J.A. 201-03. Second, a

19
Sun Life letter acknowledges: “[D&T] indicated May 7, 2004 as

the last day that Mr. Wilkinson worked and that his work

schedule at the time of the disability was 5 days per week, 8

hours per day.” J.A. 261, 1487. Third, notes dated August 2004

from Wilkinson’s physician lists May 7, 2004 as the “Date

patient-ceased work because of disability.” J.A. 1544. Fourth,

an April 2004 email from Wilkinson to his business partners

“expressed [his] desire to work 30–40 hours a week,” J.A. 352,

which at least implies his business partners wanted him to work

more than 30 hours. Fifth, Wilkinson filed an unrelated

insurance application with Security Mutual listing May 7, 2004

as the “Date [he] stopped work.” J.A. 366. 3

In contrast, Sun Life relies almost entirely upon two court

filings in an unrelated New Jersey Lawsuit to establish that

Wilkinson ceased working prior to May 1, 2004. First, Sun Life

relies upon Wilkinson’s declaration, which states:

At that April 21st meeting, Timothy Dolan asked that I
take the leave now and they would continue to pay my
salary until a written agreement was reached laying
out the terms of my leave. I agreed to take the leave
of absence with Tim Traynor’s agreement that, in a few
weeks, they would have a written agreement prepared

3
We are mindful that five years prior to today, in 2011, a
typical vice president would likely have more electronic records
evidencing his or her work. However in 2004, five years prior
to Sun Life challenging Wilkinson’s full-time status,
expectations on what records might be available are different.
Further, D&T explained to Sun Life that it did not keep
attendance records for executives such as Wilkinson. J.A. 47.

20
 for me and that my health insurance would continue.
. . . Based on their promise to work out an agreement
within a few weeks, I began a medical leave for an
undetermined period of time, beginning May 7, 2004.

J.A. 115, 999 (emphasis added). Second, Sun Life relies upon a

declaration from Wilkinson’s former business partner, which

states:

Wilkinson spent very little time working from August
18, 2003 through May 7, 2004 because of emotional and
physical problems. Despite a drastic reduction in his
attendance and production, D&T voluntarily paid
Wilkinson $451,300 from August 22, 2003 until he
ceased working completely on May 7, 2004.

J.A. 917. 4

In both instances, Sun Life hones in on the first

underlined phrase (which favors its interest in denying

benefits) and completely ignores the second phrase (which favors

Wilkinson). Simply because the first phrase in Wilkinson’s

4 In its Reply Brief and during oral argument, Sun Life
posited a new argument for denying benefits that was not raised
in its denial letters, in the district court, or in its Opening
Brief. Sun Life now argues that because a cardiologist
diagnosed Wilkinson with serious health problems, he was
incapable of “occasionally lift[ing] up to 100 pounds” as part
of his job duties overseeing distribution operations.
Appellant’s Reply at 12 (quoting J.A. 499). This argument is
unpersuasive for two reasons. First, ERISA requires plan
administrators to “provide adequate notice . . . setting forth
the specific reasons” for denial, and Sun Life did not deny
coverage on this basis. See 29 U.S.C. § 1133(1). Second, Sun
Life waived this argument on appeal. See Helton, 709 F.3d at
360 (“[B]ecause [defendant] failed to raise this argument before
the district court, it is waived on appeal.”).

21
declaration indicates someone “asked” Wilkinson to take leave

“now” does not mean that he did in fact take leave that same

day. It is not even clear if “now” means today, tomorrow, or

next week, especially when the second phrase indicates that

Wilkinson “began medical leave . . . beginning May 7, 2004.” In

addition, the first phrase in the other declaration referencing

a “drastic reduction” in work schedule is ambiguous because a

reduction for someone working 60 hours per week, as Wilkinson

did at one point, could be reduced to 40 hours, 30 hours, or 5

hours. Sun Life also conveniently ignores that the second

phrase clearly states Wilkinson “ceased working completely on

May 7, 2004.”

In sum, several Booth factors show that Sun Life abused its

discretion, including: (1) the “language of the plan”; (2) the

“adequacy of the materials considered”; (3) Sun Life’s

“decision-making process”; and (4) the indicators that Sun

Life’s conflict of interest played a role in its review process.

See Booth, 201 F.3d at 342–43. Because Sun Life’s coverage

determination was not reasoned and principled and not supported

by substantial evidence, the Court holds that Sun Life abused

its discretion.

22
 IV.

For the foregoing reasons, we affirm the district court’s

decision to grant Wilkinson’s Motion for Summary Judgment, to

deny Sun Life’s Motion for Summary Judgment, and to dismiss as

moot Sun Life’s Counterclaim.

AFFIRMED

23