20-1281
Mayer v. Ringler Associates Inc. and Af.
In the
United States Court of Appeals
FOR THE SECOND CIRCUIT
AUGUST TERM 2020
No. 20-1281
GREGORY MAYER,
Plaintiff-Appellant,
v.
RINGLER ASSOCIATES INC. AND AFFILIATES LONG TERM DISABILITY
PLAN, HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY,
Defendants-Appellees.
On Appeal from the United States District Court
for the Southern District of New York
ARGUED: FEBRUARY 3, 2021
DECIDED: AUGUST 12, 2021
Before: WALKER, SACK, and MENASHI, Circuit Judges.
Plaintiff-Appellant Gregory Mayer appeals from a judgment of
the district court (Briccetti, J.) sustaining the final determination of
Defendant-Appellee Hartford Life and Accident Insurance Company
(“Hartford Life”) with respect to Mayer’s disability benefits under the
terms of Defendant-Appellee Ringler Associates Inc. and Affiliates
Long Term Disability Plan (the “Plan”). Mayer argues that the district
court erred by reviewing Hartford Life’s final determination under
the arbitrary-and-capricious standard of review. He further argues
that even under that standard of review, Hartford Life’s
determination was incorrect.
The Plan invests broad discretionary authority in Hartford Life
as the claims administrator. Mayer argues that (1) California
Insurance Code § 10110.6(a) voids this grant of discretionary
authority, and (2) his claim did not receive the “full and fair review”
that the claims-procedure regulations of the Employee Retirement
Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001 et seq.,
require because Hartford Life failed to produce certain documents
developed and considered during the appeal from the initial
determination while Mayer’s claim was still under review. For that
reason, Mayer argues, Hartford Life’s determination must be
reviewed de novo.
We disagree and hold that California Insurance Code
§ 10110.6(a) applies only to the claims of California residents. It does
not apply to Mayer because he was a New York resident at all relevant
times. We further hold that “full and fair review” under ERISA’s
claims-procedure regulations does not require the claims
administrator to produce documents developed or considered during
the appeal from the initial determination while the claim is still under
review and before a final benefits determination. Mayer therefore
cannot establish that Hartford Life did not provide his claim a “full
and fair review.” The district court correctly reviewed Hartford Life’s
determination under the arbitrary-and-capricious standard and
correctly concluded that the final determination was reasonable and
2
supported by substantial evidence in the record. We AFFIRM the
judgment of the district court.
MICHAEL CONFUSIONE, Hegge & Confusione, LLC,
Mullica Hill, NJ, for Plaintiff-Appellant.
PATRICK W. BEGOS, Gregory J. Bennici, on the brief,
Robinson & Cole LLP, Stamford, CT, for Defendants-
Appellees.
MENASHI, Circuit Judge:
Plaintiff-Appellant Gregory Mayer appeals from a judgment of
the district court (Briccetti, J.) sustaining the final determination of
Defendant-Appellee Hartford Life and Accident Insurance Company
(“Hartford Life”) with respect to Mayer’s disability benefits under the
terms of Defendant-Appellee Ringler Associates Inc. and Affiliates
Long Term Disability Plan (the “Plan”). The primary issue on appeal
is whether Hartford Life’s determination should receive deference.
Resolving this issue depends on the answers to two questions:
(1) whether the Plan grants discretion to Hartford Life as the claims
administrator, and (2) whether Hartford Life complied with the
claims-procedure regulations promulgated under the Employee
Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001
et seq., and set forth in 29 C.F.R. § 2560.503-1.
Mayer urges us to answer both questions in the negative. First,
although it is undisputed that the Plan expressly grants broad
discretionary authority to Hartford Life, Mayer argues that California
Insurance Code § 10110.6(a) voids the grant of discretion. We disagree
3
and hold that § 10110.6(a) applies only to the claims of California
residents. It does not affect the grant of discretion to Hartford Life
here because Mayer is not a California resident.
Second, Mayer argues that Hartford Life did not satisfy its
obligation to provide him “reasonable access to, and copies of, all
documents, records, and other information relevant to the claimant’s
claim for benefits,” 29 C.F.R. § 2560.503-1(h)(2)(iii), because Hartford
Life did not produce certain email communications that were
considered during the administrative appeal until after Hartford Life
made its final determination. We disagree again and hold that the
regulations in effect at the time of Mayer’s claim did not require
claims administrators to produce documents developed or
considered during the administrative appeal before a final
determination had been rendered.
For these reasons, we affirm the judgment of the district court.
BACKGROUND
I
Mayer was the owner, operator, and sole employee of Ringler
Associates Scarsdale, Inc. (“RAI-Scarsdale”), an affiliate of Ringler
Associates Inc. (“RAI”). From 2001 to 2015, Mayer sold annuities to
fund structured personal injury settlements. In September 2015,
Mayer underwent multiple surgeries to his knees and spine. From
October to December 2015, he attempted intermittent work. On
December 16, 2015, unable to continue working, Mayer applied for
long-term disability benefits under the Plan.
The Plan is a group policy issued by Hartford Life and
“administered by the Plan Administrator with benefits provided in
4
accordance with the provisions of the applicable group plan.” App’x
69. The Plan defines “Employer,” “Policyholder,” and “Plan
Administrator” as “Ringler Associates Incorporated and Affiliates,”
located at 27422 Aliso Creek Road, Aliso Viejo, California. App’x at
45, 58, 68. The Plan designates Hartford Life as the claims
administrator and grants Hartford Life “full discretion and authority
to determine eligibility for benefits and to construe and interpret all
terms and provisions of the Policy.” App’x at 31, 68, 105.
The Plan incorporates several booklets that describe the terms
of coverage for different classes of employees. Because Mayer is a
“producer” under the terms of the Plan, only Booklet 4.5 1 and
Booklet 1.32 2 relate to Mayer’s claim. App’x 45, 82. Both booklets
have identical definitions regarding disability and identical
provisions for calculating benefits. The booklets calculate benefits
based on the insured’s pre-disability earnings—defined as the
insured’s average monthly rate of pay, including bonuses and
commissions, paid by the Employer for the two calendar years before
the insured became disabled. The two booklets differ only with
respect to tax consequences, which depend on whether the insured
pays his own premiums.
II
After Mayer applied for long-term disability benefits, RAI’s
operations manager sent Mayer’s claim forms to Hartford Life. The
1Booklet 4.5 applies to “All Active Full-time Employees who are producers
… not paying their premium who receive a W2.” App’x 45.
2 Booklet 1.32 applies to “All Active Full-time Producers … who are
choosing to pay their premium who receive a W2.” App’x 82.
5
forms included an employer statement that the operations manager
completed and signed, Mayer’s job description, and Mayer’s most
recent W-2, which reported wages of $100,000.16 for 2014.
On December 21, 2015, Mayer faxed additional claim
information directly to Hartford Life. He included a Form 1099-MISC,
which showed additional wages of $125,000 paid by RAI-Scarsdale in
2014 and several Simplified Employee Pension (“SEP-IRA”)
contributions made by RAI-Scarsdale in 2014 and 2015. Mayer told
Hartford Life that RAI-Scarsdale rather than RAI was his Employer
under Plan, and accordingly RAI could not provide all of his financial
information. He argued that the additional income should be
considered in calculating his pre-disability earnings. According to
Mayer, therefore, his “total payment from Ringler Associates Inc. in
2013 was $200,000.00 and for 2014[, $]277,000.” App’x 1529.
Hartford Life sought clarification from RAI about the disparity
between Mayer’s earnings as reported by RAI and those reported by
Mayer himself, noting that “Mr. Mayer indicated that he received
additional bonuses that aren’t indicated on the information you sent.
He indicated another $100,000 in bonuses and $50,000 in SEP plan
contributions.” App’x 1507. RAI replied that its records “do not show
any contributions to a SEP account or pension contributions. If
[Mayer] has made any of these contributions it was not through his
Ringler business.” App’x 1506-07. When Hartford Life provided RAI
with the Form 1099-MISC for 2014 that Mayer had submitted, RAI
confirmed that it did not issue that document. RAI’s operations
manager explained that benefits calculations are based on gross
salaries and that this additional income should not be considered.
6
On January 28, 2016, Mayer wrote to Hartford Life, insisting
again that RAI-Scarsdale was his Employer for purposes of
adjudicating his disability claim and that RAI-Scarsdale’s records
demonstrated that he had received $463,256 in commissions in 2013
and $448,491 in commissions in 2014. RAI’s operations manager
wrote back to Mayer that “Ringler Associates, Inc. (the home office)
is the plan administrator of the Hartford Long Term Disability Policy”
and “[t]he premium payments are [RAI’s] responsibility and the
calculations are based on payroll activity through our ADP payroll
system which we keep for all Associates.” App’x 1404-05. The
operations manager also disputed Mayer’s report of 2014 earnings:
[Y]our application included a copy of a 2014 1099 issued
to you for $125,000 from Ringler Associates, Inc.
According to our files, the home office did not create a
1099 in that amount. In addition, I have reviewed all the
financial records we maintain for your corporation and
am unable to substantiate or determine how Ringler
Associates Scarsdale was able to provide you an
additional $125,000 in 2014 as income.
App’x 1405. Mayer responded that he had earned this additional
income from rent and other sources that did not involve RAI and
which RAI could not substantiate.
On May 13, 2016, Hartford Life denied Mayer’s claim on the
ground that he did not meet the Plan’s definition of “Disability.”
App’x 269. Along with the denial letter, Hartford Life sent Mayer a
copy of Booklet 1.32. Mayer appealed this determination to Hartford
Life’s Claim Appeal Unit. App’x 963.
7
On January 4, 2017, Hartford Life reversed its initial
determination and approved Mayer’s claim. Hartford Life calculated
Mayer’s monthly pre-disability earnings based on the pay statements
provided by RAI rather than RAI-Scarsdale. Mayer’s attorney
requested copies of documents relevant to the administration of
Mayer’s claim from Hartford Life. On February 10, 2017, Hartford
Life provided Mayer’s attorney a copy of its claim file, which included
Booklet 4.5 rather than Booklet 1.32.
III
On July 5, 2017, Mayer’s attorney notified Hartford Life’s Claim
Appeal Unit of Mayer’s intent to appeal the claim determination. On
July 13, 2017, Mayer’s attorney submitted materials in support of
Mayer’s appeal.
In his appeal submission, Mayer again asserted that
RAI-Scarsdale, not RAI, should be considered his Employer for
purposes of claim determination. He argued that his benefits should
be calculated based on the “corrected” RAI-Scarsdale W-2s that he
included in his appeal submission. According to the corrected W-2s,
Mayer earned $151,842.01 in 2013 and $399,614.01 in 2014, and he also
received SEP contributions of $50,000 in each year, for total earnings
in those two years of $651,456.02—a higher total than was reflected in
his initial claim submissions. Mayer did not include in the corrected
materials the $125,000 “nonemployee compensation” that he had
identified as earnings from 2014 in his initial claim submissions.
On November 9, 2017, Hartford Life affirmed its initial claim
determination, concluding again that Mayer’s disability benefits
should be based on the earnings documentation provided by RAI, not
RAI-Scarsdale. Hartford Life explained that RAI is the
8
“Employer/Plan Administrator” and as such is “responsible for
keeping all documents related to employee’s eligibility, enrollment
and cost to be paid by the employee with respect to the [long-term
disability] coverage under the Policy.” App’x 235. Hartford Life
observed that the documentation provided by RAI confirmed that
Mayer’s annual salary in both 2013 and 2014 was $100,000, plus a
$50,000 bonus in 2013, and that Mayer’s SEP-IRA contributions were
not included in the pre-disability earnings calculation because a “SEP-
IRA is considered a 408(k) plan” and is not a salary-reduction
agreement that would affect the “Monthly Rate of Basic Earnings”
under the Plan. App’x 236-37. Hartford Life also noted that RAI-
Scarsdale’s general ledger report did not show that RAI paid any
commissions to Mayer.
Finally, Hartford Life determined that Booklet 4.5 rather than
Booklet 1.32 governed Mayer’s claim because Booklet 4.5 provides
coverage for producers who do not pay their own premiums under
the Plan. Accordingly, Hartford Life concluded that Mayer’s claim
benefit was fully taxable because Mayer did not pay the premiums for
his disability benefits coverage.
IV
Mayer filed an ERISA claim against Hartford Life and the Plan
in federal district court, alleging that Hartford Life incorrectly
calculated his long-term disability benefits and determined that his
benefits are fully taxable.
After a bench trial on a stipulated record, the district court
entered judgment for the defendants. The district court concluded
that the Plan grants Hartford Life discretion and that California
Insurance Code § 10110.6(a) did not void the grant of discretion; the
9
district court also rejected Mayer’s arguments that Hartford Life
violated ERISA’s claims-procedure regulations. The district court
therefore held that Hartford Life’s benefits determination should be
reviewed under the arbitrary-and-capricious standard.
Applying that standard, the district court concluded that
Hartford Life’s final determination—including its reliance on
earnings documentation provided by RAI—was reasonable and
supported by substantial evidence in the record. Accordingly, the
district court sustained Hartford Life’s determination as consistent
with ERISA. Mayer timely appealed.
DISCUSSION
Mayer argues that the district court erred by reviewing
Hartford Life’s final determination under the arbitrary-and-
capricious standard and by holding Hartford Life’s determination to
be consistent with ERISA even under that standard of review. “On
appeal from a judgment after a bench trial, we review the district
court’s findings of fact for clear error and its conclusions of law de
novo.” Hartford Roman Catholic Diocesan Corp. v. Interstate Fire & Cas.
Co., 905 F.3d 84, 88 (2d Cir. 2018). We hold that the district court did
not err in applying the arbitrary-and-capricious standard or in
sustaining Hartford Life’s determination.
I
While “ERISA does not itself prescribe the standard of review
by district courts for challenges to benefit eligibility determinations,
… plans investing the administrator with broad discretionary
authority to determine eligibility are reviewed under the arbitrary
and capricious standard.” Novella v. Westchester Cnty., 661 F.3d 128,
10
140 (2d Cir. 2011) (internal quotation marks and alterations omitted);
see also Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 111 (2008); Firestone
Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). In the absence of a
delegation of discretionary authority, the determination of the claims
administrator is reviewed de novo. Novella, 661 F.3d at 140.
Mayer does not dispute that the Plan confers broad
discretionary authority on Hartford Life. As the Plan documents note,
“[t]he Plan has granted the Insurance Company full discretion and
authority to determine eligibility for benefits and to construe and
interpret all terms and provisions of the Policy.” App’x 31. Yet Mayer
argues that because the Plan was delivered in California, and because
California law governs the Plan, California Insurance Code
§ 10110.6(a) voids the Plan’s grant of discretion to Hartford Life. For
that reason, he maintains that the Plan does not delegate discretion
and Hartford Life’s determination should be reviewed de novo. We
disagree. California Insurance Code § 10110.6(a) does not apply to
Mayer’s insurance policy because Mayer is not a resident of
California.
California Insurance Code § 10110.6(a) states in pertinent part:
If a policy, contract, certificate, or agreement offered,
issued, delivered, or renewed, whether or not in
California, that provides or funds … disability insurance
coverage for any California resident contains a provision
that reserves discretionary authority to the insurer, or an
agent of the insurer, to determine eligibility for benefits
or coverage, to interpret the terms of the policy, contract,
certificate, or agreement, or to provide standards of
interpretation or review that are inconsistent with the
laws of this state, that provision is void and
unenforceable.
11
Cal. Ins. Code § 10110.6(a) (emphasis added). Section 10110.6(c) in
turn defines a provision that reserves “discretionary authority” as “a
policy provision that has the effect of conferring discretion on an
insurer or other claim administrator to determine entitlement to
benefits or interpret policy language that, in turn, could lead to a
deferential standard of review by any reviewing court.” Id.
§ 10110.6(c).
While § 10110.6(a) seems focused on “California resident[s],” it
is possible to read the provision to void all grants of discretion in any
group policy, such as the one at issue here, that provides benefits to
even one California resident, even if the claimant himself is not a
California resident and not otherwise connected to California. Such
an interpretation, however, would raise concerns under the
Commerce Clause of the U.S. Constitution because it would allow for
“the application of a state statute to commerce that takes place wholly
outside of the State’s borders, whether or not the commerce has effects
within the State.” Healy v. Beer Inst., Inc., 491 U.S. 324, 336 (1989); see
U.S. Const. art. I, § 8, cl. 3 (granting Congress the power “[t]o regulate
commerce ... among the several States”). In this case, it is undisputed
that Mayer was a resident of New York at all relevant times. He sold
annuities, became disabled, and applied for long-term disability
benefits in New York. To void the grant of discretionary authority to
the claims administrator with respect to a New York resident’s
disability claim arising from activity in New York would have the
impermissible “effect of requiring out-of-state commerce to be
conducted at the regulating state’s direction.” Am. Booksellers Found.
v. Dean, 342 F.3d 96, 102 (2d Cir. 2003).
That the policy here was issued in California does not appear
to solve this problem because § 10110.6(a) expressly provides that its
12
applicability does not depend on “whether or not” the policy was
issued “in California.” Rather, we must determine the scope of the
statute’s application to policies that provide benefits “for any
California resident.” Cal. Ins. Code § 10110.6(a).
To the best of our knowledge, no court has interpreted that
statutory language to extend to claimants who are not California
residents. Our sister circuits have not addressed this issue, but district
courts that have considered it, including those in the Ninth Circuit,
have concluded that § 10110.6 applies when the claimant is a resident
of California, not when the policy potentially insures some other
beneficiary who resides in California. See, e.g., Campbell v. Hartford Life
& Accident Ins. Co., No. 17-80193-CIV, 2018 WL 4963118, at *8 n.8 (S.D.
Fla. Oct. 15, 2018) (“[B]y its own express terms, [California Insurance
Code § 10110.6(a)] applies only to California residents.”); Pfenning v.
Liberty Life Assurance Co., No. 3:14-CV-471, 2015 WL 9460578, at *8
(S.D. Ohio Dec. 28, 2015) (“Liberty further argues that this
discretionary clause is valid because [California Insurance Code
§ 10110.6] only applies to California residents. The Court agrees.”),
vacated and remanded by agreement, No. 16-3068, 2016 WL 11618609, at
*1 (6th Cir. Aug. 2, 2016); Cox v. Allin Corp. Plan, No. 16-4675, 2018 WL
9543021, at *6 (N.D. Cal. Sept. 28, 2018) (explaining that § 10110.6
“applies, regardless of where the policy was offered, issued, delivered,
or renewed” if the plaintiff “was a California resident when he filed
his claim … notwithstanding the [policy’s] choice of law clause”),
remanded for further development of the record, 848 F. App’x 343 (9th Cir.
2021); see also Snyder v. Unum Life Ins. Co. of Am., No. CV-13-07522,
2014 WL 7734715, at *10 (C.D. Cal. Oct. 28, 2014) (holding that
§ 10110.6 applies because “the parties do not dispute that Plaintiff is
a California resident” regardless of “where the policy was offered,
13
issued, delivered, or renewed” and “regardless of the choice of law
provision”). 3
In addition to the constitutional concerns it would raise and the
tension it would create with prior case law, we note that Mayer’s
expansive interpretation of § 10110.6 would also “undermine the
significant ERISA policy interests of minimizing costs of claim
disputes and ensuring prompt claims-resolution procedures” because
the standard of review applicable to a given claimant would depend
on the residence of any other person insured under the policy,
assuming one might be from California. Locher v. Unum Life Ins. Co. of
Am., 389 F.3d 288, 295 (2d Cir. 2004); see also Varity Corp. v. Howe, 516
U.S. 489, 497 (1996).
Because Mayer is not a California resident, we conclude that
the Plan’s grant of discretionary authority to Hartford Life is not void
under California Insurance Code § 10110.6.
II
Next, Mayer argues that his claim should be reviewed de novo
because Hartford Life did not provide a “full and fair review” of his
benefits claim as required by ERISA’s claims-procedure regulations.
29 C.F.R. § 2560.503-1(h)(4). He argues that § 2560.503-1(h)(4)
3 We disagree with Mayer that Orzechowski v. Boeing Co. Non-Union Long-
Term Disability Plan, Plan No. 625, 856 F.3d 686 (9th Cir. 2017), stands for the
proposition that § 10110.6 applies to an insurance policy that covers a
California resident regardless of the claimant’s residence. In Orzechowski,
the Ninth Circuit applied § 10110.6 to an insurance policy issued to a
California resident. See id. at 692-95; Complaint at 3, Orzechowski v. Boeing
Co. Non-Union Long-Term Disability Plan, No. CV-12-1905, 2014 WL 979191
(C.D. Cal. Mar. 12, 2014), ECF No. 1. The court did not address whether
§ 10110.6 applies to claimants who are not California residents.
14
required Hartford Life to provide him with documents considered for
the first time during the administrative appeal—in particular, email
communications between an underwriter and broker for the Plan—
and to provide those documents while the appeal was still under
review in advance of the final determination. We disagree.
ERISA provides that every claim for benefits must receive a
“full and fair review” by the claims administrator. 29 U.S.C. § 1133(2).
When Mayer submitted his claim, the regulation governing claims
procedures—29 C.F.R. § 2560.503-1—provided that claims
procedures “will not … be deemed to provide a claimant with a
reasonable opportunity for a full and fair review of a claim and
adverse benefit determination unless the claims procedures comply
with the requirements of paragraphs (h)(2)(ii) through (iv) and
(h)(3)(i) through (v) of this section.” 29 C.F.R. § 2560.503-1(h)(4)
(effective until Jan. 18, 2017). 4 As relevant to this case, paragraph
(h)(2)(iii) directs that the administrator must, “upon request,” provide
the claimant “reasonable access to, and copies of, all documents,
records, and other information relevant to the claimant’s claim for
benefits.” Id. § 2560.503-1(h)(2)(iii). A document is “relevant” to a
claim if, inter alia, the document “was relied upon in,” or “submitted,
considered, or generated in the course of,” making the final benefits
determination. Id. § 2560.503-1(m)(8)(i)-(ii). If a claims administrator
does not comply with the claims-procedure regulations, the resulting
4 While this paragraph was later amended, see infra note 5, the standard
provided by this version of the paragraph continued to apply to all claims
for disability benefits filed on or before April 1, 2018. See 29 C.F.R.
§ 2560.503-1(p)(4)(ii) (2020); Claims Procedure for Plans Providing
Disability Benefits, 81 Fed. Reg. 92,316, 92,316. (Dec. 19, 2016).
15
benefits determination will usually be reviewed de novo in federal
court. Halo v. Yale Health Plan, 819 F.3d 42, 60-61 (2d Cir. 2016).
We have not addressed whether providing a “full and fair
review” pursuant to the version of § 2560.503-1(h)(4) applicable to
Mayer’s claim requires the claims administrator to provide the
claimant with documents developed or considered during the
administrative appeal in advance of the final determination.
However, those circuits that have considered this question have
uniformly concluded that it does not. Pettaway v. Teachers Ins. &
Annuity Ass’n of Am., 644 F.3d 427, 436-37 (D.C. Cir. 2011); Midgett v.
Wash. Grp. Int’l Long Term Disability Plan, 561 F.3d 887, 895-96 (8th Cir.
2009); Glazer v. Reliance Standard Life Ins. Co., 524 F.3d 1241, 1245-46,
(11th Cir. 2008); Metzger v. UNUM Life Ins. Co. of Am., 476 F.3d 1161,
1166-67 (10th Cir. 2007); see also Killen v. Reliance Standard Life Ins. Co.,
776 F.3d 303, 310-11 (5th Cir. 2015); Balmert v. Reliance Standard Life
Ins. Co., 601 F.3d 497, 502 (6th Cir. 2010); Morningred v. Delta Family-
Care & Survivorship Plan, 526 F. App’x 217, 221 n.9 (3d Cir. 2013).
In Glazer, the Eleventh Circuit concluded that under the claims-
procedure regulations, the claims administrator is “not required to
produce the documents it relied upon while it reviewed the initial
denial of benefits; the production occurs after a final decision is
reached.” 524 F.3d at 1245. The court reasoned that a claims
administrator has not “relied upon” or “used [a document] ‘in the
course of making the benefit determination’ until the determination
ha[s] been made.” Id. (quoting 29 C.F.R. § 2560.503-1(m)(8)(i)-(ii)). The
court noted that § 2560.503-1(i)(5) requires all relevant documents
generated during the appellate review and initial claim determination
to be produced to the claimant after the final determination—a
requirement that “would be superfluous if the claimant had a right to
16
the documents during the pendency of the review.” Glazer, 524 F.3d
at 1245.
The Tenth and Eleventh Circuits have also “agreed with the
Department of Labor that the purpose of the production of these
documents is to enable a claimant to evaluate whether to appeal an
adverse determination.” Id. at 1246 (citing Metzger, 476 F.3d at 1167).
Giving claimants “pre-decision access to relevant documents
generated during the administrative appeal … would nullify the
Department’s explanation” that § 2560.503-1(m)(8) “serve[s] the
interests of both claimants and plans by providing clarity as to plans’
disclosure obligations, while providing claimants with adequate access to
the information necessary to determine whether to pursue further appeal.”
Metzger, 476 F.3d at 1167 (quoting ERISA Claims Procedure, 65 Fed.
Reg. 70,246, 70,252 (Nov. 21, 2000)) (emphasis in original). Providing
access to documents while the claim is still under review “would not
aid claimants in determining ‘whether to pursue further appeal,’
because claimants would not yet know if they faced an adverse
decision.” Id.
These courts have further explained that “‘subsection (h)(2)(iii)
does not require a plan administrator to provide a claimant with
access to … reports of appeal-level reviewers prior to a final decision
on appeal’” because “requiring these documents to be produced
earlier would create ‘an unnecessary cycle of submission, review, re-
submission, and re-review.’” Glazer, 524 F.3d at 1245-46 (quoting
Metzger, 476 F.3d at 1166, 1167). “Such a cycle ‘would undoubtedly
prolong the appeal process, which, under the regulations, should
normally be completed within 45 days.’” Midgett, 561 F.3d at 895
(quoting Metzger, 476 F.3d at 1166); see also Pettaway, 644 F.3d at 436
(“[E]ven though new medical reports were generated during TIAA’s
17
administrative review, the regulations provide for the ‘opportunity to
appeal an adverse benefit determination’ and not for the opportunity
to engage in a continuous cycle of appeals from appeals.”) (internal
citation omitted) (quoting 29 C.F.R. § 2560.503-1(h)(1)).
We join these circuits and hold that the version of
§ 2560.503-1(h)(4) in effect at the time of Mayer’s claim does not
require the claims administrator to produce documents developed or
considered during the administrative appeal before rendering its final
determination. Therefore, providing Mayer’s claim a “full and fair
review” did not require Hartford Life to produce documents
developed or considered while Mayer’s claim was under review prior
to a final determination. 5 Accordingly, Mayer has failed to
5 The 2018 amendment to § 2560.503-1(h)(4) does not change our
conclusion. The amended subsection provides that a “full and fair review”
requires the claims administrator, “before the plan can issue an adverse
benefit determination on review on a disability benefit claim,” to “provide
the claimant … with any new or additional evidence considered, relied
upon, or generated by the plan, insurer, or other person making the benefit
determination.” 29 C.F.R. § 2560.503-1(h)(4)(i) (2020). However, the
amended language does not dictate the proper interpretation of the
regulatory text applicable to Mayer’s claim. If the prior regulation had
already required all plans to disclose documents developed or relied on
before a final determination on appeal, then it would not have been
necessary to amend § 2560.503-1(h)(4) to expressly include an obligation for
plans providing disability benefits to disclose documents developed or
relied on during the appeal before a final determination. Indeed, when
amending the regulation, the Department of Labor explained that it was
providing “additional protections,” including “the right of claimants to
respond to new and additional evidence,” in order to make “improvements
to the claims process for disability claims.” Claims Procedure for Plans
Providing Disability Benefits, 81 Fed. Reg. 92,316, 92,316-17 (Dec. 19, 2016).
The Department explained that it had determined “updates and
modifications” and “enhancements in procedural safeguards” were needed
18
demonstrate that the district court erred in reviewing Hartford Life’s
final benefits determination under the arbitrary-and-capricious
standard. 6
for the claims process for disability benefits in order to incorporate
“protections similar to those required for group health plans under the
Affordable Care Act.” Id. at 92,317. That the Department adopted these
changes indicates that the prior version of § 2560.503-1(h)(4)—which is
applicable to Mayer’s claim—did not already include those procedural
requirements.
6 Mayer alleges other violations of ERISA’s claims-procedure regulations.
He first argues that Hartford Life violated 29 C.F.R. § 2560.503-1(i)(1), (3) by
failing to “notify” him of his “benefit determination on review” within “45
days” of Hartford Life’s “receipt of the [his] request for review.” Hartford
Life, however, provided timely notice with an updated expected benefit
determination date and an explanation that it would need more than 45
days to process Mayer’s claim because it was “still awaiting information
from the Employer needed to fully investigate [Mayer’s] claim.” App’x 239;
see 29 C.F.R. § 2560.503-1(i)(1), (3) (allowing the plan administrator to
extend the deadline by 45 days if it “determines that an extension of time
for processing is required” and provides “written notice ... indicat[ing] the
special circumstances requiring an extension of time and the date by which
the plan expects to render the determination on review”). Mayer
acknowledges in his brief that this notice was timely. Appellant’s Br. 24.
Mayer also lists a series of allegedly “missed deadlines” during the initial
benefits determination, which he did not present to the district court and
which the district court did not consider. Appellant’s Br. 22-23. We decline
to consider this argument now. See Sczepanski v. Saul, 946 F.3d 152, 161 (2d
Cir. 2020) (declining to consider arguments that “were available to the
parties below” and the parties “proffer no reason for their failure to raise
the arguments below”). Finally, Mayer argues that Hartford Life violated
29 C.F.R. § 2560.503-1 (h)(2)(iv) by “ignoring” documents that showed that
Mayer was employed by RAI-Scarsdale rather than RAI for the purpose of
plan administration. The record does not support the claim that Hartford
Life ignored relevant documentation by concluding that RAI was Mayer’s
Employer under the Plan.
19
III
We now turn to Hartford Life’s final benefits determination. As
noted, after a bench trial in an ERISA case, we review the district
court’s conclusions of law de novo and its findings of fact for clear
error. Hartford Roman, 905 F.3d at 88. “We review de novo the district
court’s application of [its factual] findings to draw the legal
conclusion that the defendant’s decision to deny benefits was not
arbitrary or capricious.” Zuckerbrod v. Phoenix Mut. Life Ins. Co., 78
F.3d 46, 49 (2d Cir. 1996).
A district court reviewing a final benefits determination under
the arbitrary-and-capricious standard may disturb that determination
only if the determination “was without reason, unsupported by
substantial evidence, or erroneous as a matter of law.” Novella, 661
F.3d at 140 (alteration omitted). The district court may not deem a
final benefits determination to be arbitrary and capricious merely
because the record contains evidence supporting an alternative
determination. Pulvers v. First UNUM Life Ins. Co., 210 F.3d 89, 94 (2d
Cir. 2000), abrogation on other grounds recognized by McCauley v. First
Unum Life Ins. Co., 551 F.3d 126 (2d Cir. 2008). The determination need
only be supported by substantial evidence—meaning “more than a
scintilla but less than a preponderance” of “such evidence that a
reasonable mind might accept as adequate to support the conclusion
reached by the administrator.” Celardo v. GNY Auto. Dealers Health &
Welfare Trust, 318 F.3d 142, 146 (2d Cir. 2003) (alteration omitted).
The district court did not err in applying this standard to
conclude that Hartford Life’s determination was reasonable and
supported by substantial evidence. There is no clear error in the
findings on which the district court relied to reach this conclusion.
20
The Plan expressly defines RAI as the “Employer” and
“Policyholder” for purposes of Plan administration. The record also
indicates that RAI managed Plan enrollment, administrated the Plan,
kept all documents related to employees’ eligibility, and paid Plan
premiums based on records of employee earnings that were in RAI’s
possession. From this evidence, it was reasonable for Hartford Life to
calculate Mayer’s disability benefits from earnings information
provided by RAI—and not RAI-Scarsdale—because RAI was Mayer’s
Employer for the purposes of the Plan.
Mayer additionally argues that Hartford Life erred both by
disregarding Mayer’s SEP-IRA contributions when calculating
Mayer’s pre-disability earnings and by concluding that his disability
benefits are fully taxable. We do not think the district court erred in
finding these determinations to be reasonable and supported by
substantial evidence in the record.
First, the district court did not clearly err in concluding that a
SEP-IRA is not a salary-reduction agreement under the Plan’s terms
and therefore should not be included in calculating pre-disability
earnings. According to the Plan, the only qualifying contributions are
those made pursuant to a salary-reduction agreement, which the Plan
defines as “an Internal Revenue Code (IRC) Section 401(k), 403(b) or
457 deferred compensation arrangement,” “an executive non
qualified deferred compensation arrangement,” or “a salary
reduction arrangement under an IRC Section 125 plan.” App’x 59.
This definition does not include a SEP-IRA, which is an Internal
Revenue Code Section 408(k) plan. As RAI confirmed to Hartford
Life, Mayer’s paystubs did not show that Mayer had made “any
contributions … through a salary reduction agreement with the
Employer to an Internal Revenue Code (IRC) Section 401(k), 403(b) or
21
457 deferred compensation arrangement; an executive non-qualified
deferred compensation arrangement; or a salary reduction
arrangement under an IRC Section 125 plan.” App’x 236; see also
App’x 1506-08.
Mayer contends that his SEP-IRA contributions were payments
into an executive non-qualified deferred compensation plan. But
Mayer’s corrected W-2’s do not reflect contributions to any
“Nonqualified Plans.” App’x 937-38. And SEP-IRAs, which are
governed by Internal Revenue Code § 408(k), are distinct from non-
qualified deferred compensation plans, which are governed by
Internal Revenue Code § 409A. The district court did not clearly err
in concluding that Hartford Life’s determination with respect to the
SEP-IRA contributions was supported by substantial evidence.
Second, the district court did not err in concluding that the
record contains substantial evidence that RAI paid the Plan’s
premiums on Mayer’s behalf. RAI confirmed that Mayer did not pay
these premiums directly, and Mayer does not dispute that fact.
Rather, Mayer argues that RAI collected the funds to pay the
premium from RAI-Scarsdale. Yet the Plan provides that “[t]he
Employer pays the premium for the insurance” and “determines the
portion of the cost,” if any, “to be paid by the employee,” as Hartford
Life noted in its final determination on appeal. App’x 69; App’x 234.
Because the Employer determines employee eligibility and
enrollment and is responsible for keeping documentation related to
eligibility and enrollment, Hartford Life reasonably relied on
documentation provided by the Employer, which reflected that RAI
paid the premiums. Hartford Life further concluded that an
arrangement in which RAI-Scarsdale reimbursed the premiums
would not affect the benefits determination because “employees do
22
not have the option to pay premiums back to their Employer in order
to make a noncontributory benefit a contributory benefit.” App’x 237.
Thus, such an arrangement “would need to be resolved between the
Employer and … Mayer, regarding any type of refund for premium
payment.” App’x 237. The district court did not err in concluding that
Harford Life’s determination—that Mayer did not pay his own
premiums and therefore his benefits are taxable—was supported by
substantial evidence and was neither arbitrary nor capricious.
***
In sum, we hold that (1) California Insurance Code § 10110.6(a)
applies only to the claims of California residents and (2) ERISA’s
claims-procedure regulations applicable to Mayer’s claim did not
require the claims administrator to produce documents developed or
considered during the administrative appeal before rendering a final
determination. Accordingly, we conclude that the district court
correctly reviewed Hartford Life’s determination under the arbitrary-
and-capricious standard. We also conclude that the district court did
not err in holding that Hartford Life’s determination was reasonable
and supported by substantial evidence in the record. We therefore
AFFIRM the judgment of the district court.
23
Mayer v. Ringler Associates Inc. and Af.
Combined Opinion