Bertha Campos v. Reliance Standard Life Insurance Company, 2:15-cv-08304

Campos was employed by WHM, LLC as a banquet server and was covered under WHM’s group long-term disability (LTD) policy issued by Reliance Standard Life Insurance (the Plan).
The Plan requires an employee to be "Full-time" (defined as a minimum of 30 hours per regular work week) to be eligible for LTD benefits; the Plan does not define "regular work week."
Campos injured herself on April 11, 2013, and submitted an LTD claim on November 21, 2013; Reliance denied coverage solely on the ground that she did not meet the Plan’s 30-hour "full-time" requirement.
Reliance determined eligibility by reviewing eight pay periods (16 weeks) before the injury and concluded Campos only met the 30-hour threshold in three pay periods; Campos argued she averaged 31 hours/week over the six pay periods before the injury.
The parties stipulated to de novo review; the district court found the term "regular work week" ambiguous and adopted Campos’s averaging method (six pay periods) to conclude she met the 30-hour requirement.
The court dismissed WHM (not the plan administrator/insurer), rejected Reliance’s late-raised "regular occupation" disability defense as waived, and remanded issues concerning the "Any Occupation" period and the Plan’s 24-month musculoskeletal limitation to the administrator.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether Campos met the Plan’s "Full-time" (30 hrs/regular work week) requirement	Campos averaged 31 hours/week over six pay periods before injury, which shows a regular work week ≥30 hrs	Reliance used eight pay periods and argued Campos did not consistently work ≥30 hrs/week	Court: "regular work week" ambiguous; averaging over six pay periods is reasonable → Campos meets 30-hr requirement
Whether Reliance may assert that Campos could perform her "Regular Occupation" (so not disabled)	N/A (primary contention was eligibility)	Reliance argued she could perform her regular occupation, so benefits unavailable during elimination/24-month period	Court: Reliance waived this defense by not raising it in the administrative process; cannot raise it in litigation
Whether Reliance can contest disability under the "Any Occupation" standard or apply the 24-month musculoskeletal pay limit	N/A at administrative denial stage	Reliance preserved these arguments; they were not addressed in the admin record	Court: Remanded to plan administrator to decide "Any Occupation" disability and applicability of 24-month musculoskeletal limitation
Whether WHM is a proper defendant	Campos alternatively argued waiver/estoppel because premiums were deducted by WHM	WHM had no role in benefits decision or payment; employer provided payroll data only	Court: WHM not a proper defendant and is dismissed without prejudice

Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (establishes de novo review unless plan gives discretionary authority to administrator)
Evans v. Safeco Life Ins. Co., 916 F.2d 1437 (9th Cir. 1990) (plan terms interpreted in ordinary, popular sense under de novo review)
Patterson v. Hughes Aircraft Co., 11 F.3d 948 (9th Cir. 1993) (ambiguities in ERISA plans resolved in participant's favor)
Kunin v. Benefit Trust Life Ins. Co., 910 F.2d 534 (9th Cir. 1990) (same rule on ambiguities and construction in participant’s favor)
Mitchell v. CB Richard Ellis Long Term Disability Plan, 611 F.3d 1192 (9th Cir. 2010) (failure to raise a coverage defense administratively bars the insurer from raising it in subsequent litigation)
Harlick v. Blue Shield of Cal., 686 F.3d 699 (9th Cir. 2012) (same principle regarding administrative exhaustion/waiver of defenses)
Cyr v. Reliance Standard Life Ins. Co., 642 F.3d 1202 (9th Cir. 2011) (employer not a proper ERISA defendant where it did not deny the claim or pay benefits)