Sizemore v. Northwestern Mutual Life Insurance Company, 2:17-cv-00789

Plaintiff Vaughn T. Sizemore claimed long‑term disability benefits under a group policy issued by Northwestern Mutual after a significant drop in billable hours; benefits were approved in April 2012 and paid until June 22, 2015.
Plaintiff resigned from his law firm and began full‑time salaried employment as a state government attorney on January 20, 2015.
Northwestern Mutual investigated, obtained updated treating records and independent physician and vocational reviews, and on June 22, 2015 concluded Plaintiff could perform his own‑occupation duties full time and terminated benefits.
Plaintiff appealed, arguing he remained partially disabled because his post‑change earnings were below 80% of predisability income; Northwestern Mutual upheld the termination on December 15, 2015 and denied a further administrative review in February 2016.
Plaintiff sued under ERISA challenging the termination; cross‑motions for summary judgment were filed and the court applied the abuse‑of‑discretion standard because the plan clearly conferred discretionary authority on the administrator.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Standard of review	Plan procedures weren’t followed; entitles de novo review	Plan grants administrator discretionary authority; abuse‑of‑discretion review applies	Abuse‑of‑discretion review applies (plan grants clear discretion)
Adequacy of administrative review	Denial of a second appeal after Dec. 15, 2015 deprived Plaintiff of a full and fair review	Single administrative appeal complied with plan and ERISA regulations; no further review required	No requirement for additional appeal; administrator provided fair review
Termination under Own‑Occupation definition	Sizemore contends he still qualifies as partially disabled (loss of earnings)	Northwestern concluded medical evidence showed ability to perform own‑occupation full time; income drop resulted from job change to salaried position, not medical limits	Termination was reasonable; Sizemore did not qualify under own‑occupation and was not shown to meet partial‑disability criteria
Evaluation of evidence and process	Claim file and treating‑provider notes support continued limitations (fatigue, kidney issues)	Defendant relied on treating records, two physician consultants, vocational review, interview, and gave claimant opportunity to submit evidence	Decision was supported by substantial evidence and reasoned process; no abuse of discretion

Helton v. AT&T Inc., 709 F.3d 343 (4th Cir. 2013) (standard for reviewing ERISA benefit denials depends on plan discretion)
Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (U.S. 1989) (discusses de novo vs. deferential review for ERISA benefit denials)
Williams v. Metro. Life Ins. Co., 609 F.3d 622 (4th Cir. 2010) (abuse‑of‑discretion standard requires decision be reasonable and supported by substantial evidence)
Griffin v. Hartford Life & Accident Ins. Co., 898 F.3d 371 (4th Cir. 2018) (review limited to whether administrator exceeded authority or abused discretion)
Booth v. Wal‑Mart Stores, Inc. Assocs. Health & Welfare Plan, 201 F.3d 335 (4th Cir. 2000) (factors guiding reasonableness under abuse‑of‑discretion review)
Gagliano v. Reliance Standard Life Ins. Co., 547 F.3d 230 (4th Cir. 2008) (full and fair review requirement and when a new ground may trigger further review)
Evans v. Eaton Corp. Long Term Disability Plan, 514 F.3d 315 (4th Cir. 2008) (administrator’s denial upheld where supported by substantial evidence and reasoned analysis)
Harrison v. Wells Fargo Bank, N.A., 773 F.3d 15 (4th Cir. 2014) (ERISA’s full and fair review requirement explained)