United States District Court, N.D. Georgia, Atlanta Division
STEPHANIE D. VAUGHN, Plaintiff,
AETNA LIFE INSURANCE COMPANY, Defendant.
OPINION AND ORDER
WILLIAM S. DUFFEY, JR. UNITED STATES DISTRICT JUDGE
matter is before the Court on Defendant Aetna Life Insurance
Company's (“Aetna”) Motion for Judgment on
the Administrative Record  and Plaintiff Stephanie D.
Vaughn's (“Ms. Vaughn” or
“Plaintiff”) Motion for Summary Judgment .
Also before the Court is Aetna's Motion for Leave to File
Under Seal  and Aetna's Motion for Oral Argument
regarding its Motion for Judgment on the Administrative
Stephanie Vaughn is the daughter of Mr. James Sheffield,
deceased, and the named beneficiary of his life insurance
policy. Mr. Sheffield was an employee of Lafarge North
America Inc. (“Lafarge”) from 1980 until February
5, 2010, when he left his employment due to a disability. Mr.
Sheffield, while employed, participated in an employee
welfare benefit plan (the “Plan”) sponsored by
Lafarge. The Plan includes long term disability
(“LTD”) benefits and death benefits under a basic
and supplemental life insurance program. Mr. Sheffield died
on October 24, 2012. This action is a dispute regarding
Aetna's denial of benefits to Plaintiff for supplemental
life insurance coverage (“Supplemental Life”)
under the Plan. There is no dispute regarding Mr.
Sheffield's LTD and basic life insurance benefits. Aetna
was the Plan administrator for Supplemental Life coverage
under the Plan.
The Plan and Death Benefits
Plan provided Basic and Supplemental Life to Mr. Sheffield,
funded by the Group Life and Accident and Health Insurance
Policy No. GP-885600, issued by Aetna to Lafarge.
(Administrative Record  (“AR”) at 000297).
The Basic Life insurance (“Basic Life”) provided
benefits equal to 200% of the employee's basic annual
earnings at the time of death, rounded up to the next $1,
000. (AR000250). The Plan provided that benefits generally
terminate on the last day of the month during which the
employee ceases active work. (AR000236). The Plan allowed
Basic Life coverage to continue after the employee ceased
active work if Lafarge determined that the employee became
“totally and permanently disabled” while insured
and Lafarge continued premium payments. Mr. Sheffield
qualified for this extension, and Aetna paid the $130, 000
Basic Life benefit to Plaintiff when he died. Benefits under
the Basic Life coverage are not at issue in this
Plan also provided Supplemental Life coverage.
(AR000250). It is this coverage that is at issue in
this case. Under the Supplemental Life coverage provisions,
Supplemental Life coverage premium payments are waived if the
employee is determined to be totally and permanently
disabled, as that term is defined in the Plan (the
“Waiver of Premium”). Whether an employee is
“totally and permanently disabled” is a decision
required to be made by Aetna. The Waiver of Premium provision
If you are not able to work due to disease or injury, your
insurance may be extended if Aetna determines you are
permanently and totally disabled. If a determination of
permanent and total disability is made, you will not have to
make any further contributions for your coverage and no
premium payments will be required from your Employer.
You are permanently and totally disabled only if disease or
injury stops you from working at your own job; or any other
job for pay or profit; and it must continue to stop you from
working any reasonable job.
A “reasonable job” is any job for pay or profit
which you are, or may reasonably become fitted for by
education, training, or experience.
The Supplemental Life Coverage Request
August 10, 2010, Mr. Sheffield submitted to Aetna a
“Group Claim Form - Permanent and Total Disability -
Life Insurance.” (AR000205). Mr. Sheffield claimed
Supplemental Life coverage and sought a waiver of premium on
the grounds he was permanently and totally disabled. On March
29, 2012, Aetna sent a letter (the “March 29, 2012,
Denial Letter”) to Mr. Sheffield denying his
Supplemental Life insurance claim. (AR000341-344). Aetna
We have completed our review of your claim for the Waiver of
Premium benefit and have determined that the information
received in support of this claim has not established that
this loss falls within the Permanent and Total Disability
coverage requirements of the Policy. Accordingly, the Waiver
of Premium benefit in the amount of $200, 000.00 has not been
approved for you under the terms of the Policy.
. . . .
Based on our review of the clinical documentation in your
file, we have determined that there was insufficient medical
evidence to support a permanent and total disability, one
that will preclude you working at any occupation, and
therefore, you do not qualify for an extension of your Life
Insurance benefit. For these reasons, we are unable to
approve your request.
(AR000342-43). The letter cited two physicians'
statements that did not support Mr. Sheffield's
disability including because there was no information to
support that he was unable to participate in vocational
March 29, 2012, Denial Letter explained to Mr. Sheffield that
he had a right to appeal the decision not to provide
Supplemental Life benefits. It also informed him that he had
a right to bring a claim under ERISA if the denial of the
insurance benefit was upheld on appeal. He was told:
If you disagree with this determination of benefits, you have
a right to a review of the decision and to bring a civil
action under Section 502(a) of [ERISA] if your denial is
upheld on appeal. [Aetna] will review any additional evidence
you submit, including but not limited to:
. The specific information listed above,
. Any other claim information or
documentation you believe would assist us in reviewing your
To obtain a review, you or your representative should submit
a request in writing to this office. Your request should
include the group name (e.g., employer), name of the insured,
the insured's social security number and the issues and
comments and any documents, records or other information that
you would like to have considered, whether or not submitted
in connection with the initial claim. You may also receive,
upon request free of charge, documents, records and other
information relevant to your claim. The written request for
review must be mailed or delivered within
180 days following receipt of this
explanation. Ordinarily, you will receive notification of the
final determination within 45 days following your receipt of
(AR000343 (emphasis in original)). On March 29, 2012, Aetna
sent a similar letter to Lafarge, notifying Lafarge of
Aetna's denial, and Lafarge ceased paying premiums for
Mr. Sheffield's Supplemental Life benefits. (AR000345).
Sheffield did not seek review of the denial of his Waiver of
Premium benefits within the 180-day period required in the
March 29, 2012, Denial Letter. He died on October 24, 2012.
The January 21, 2015, Denial of Plaintiff's Claim for
the Supplemental Life Benefit
November 24, 2014, over two years after Mr. Sheffield's
death, Ms. Vaughn sent a letter to Aetna demanding that Aetna
pay Ms. Vaughn Supplemental Life benefits in the amount of
$200, 000, plus interest. (AR000500).
January 21, 2015, Aetna responded to Ms. Vaughn's letter
(the “January 21, 2015, Denial Letter”), denying
her demand. (AR000507-510). The January 21, 2015, Denial
Letter explained that “[i]n order for the
[Supplemental] Life Insurance Benefit to be payable under
this Policy, Mr. Sheffield must have had [Supplemental] Life
Insurance coverage in force at the time of his death.”
(AR000509). The letter explained further that because Aetna
had determined that Mr. Sheffield was not totally and
permanently disabled and Lafarge discontinued Supplemental
Life insurance premiums, Mr. Sheffield's Supplemental
Life coverage terminated on or about March 29, 2012. The
letter also explained the distinction between the Basic Life
coverage that was extended due to illness after Mr. Sheffield
ceased working, and the Supplemental Life Insurance coverage
that was not:
[T]he requirements for payment of additional benefits under
the Supplemental Life Insurance are different from the
requirements for Long Term Disability and Basic Life
Insurance coverage. Even though Mr. Sheffield met the
eligibility for Long Term Disability Benefit and extension
for Basic Life Insurance determined by [Lafarge], we have
determined that there was insufficient medical evidence to
support a permanent and total disability under the Permanent
and Total Disability Feature for his Supplemental Life
Insurance coverage. Our denial letter was sent to Mr.
Sheffield and [Lafarge] on March 29, 2012. According to
[Lafarge], Mr. Sheffield's premium payment(s) ...