Gross v. Sun Life Assur. Co. of Can.

In this 2013 ERISA case, the longer-term disability benefits provided by an employer were subject to ERISA where the documents associated with the employee benefits program established all five constituent elements of an ERISA plan. ERISA’s safe harbor provision did not apply as the employer did not provide multiple, independent plans. The plan administrator’s rejection of the employee’s claim for benefits was subject to de novo review as the “satisfactory to us” language in the policy did not state with sufficient clarity that the administrator was to make a judgment largely insulated from judicial review by reason of being discretionary. Applying the de novo standard, the court could not determine whether the employee’s disability claim was justifiably rejected on the basis of the surveillance video and the likelihood of symptom embellishment, particularly relating to her right arm.

Judgment vacated; case remanded with directions.

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