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Anthony J. Scibelli, Executor of the Estate of Walter Jajuga; Estate v. Prudential Insurance Company of America

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Before Lynch, Chief Judge, Stahl and Lipez, Circuit Judges.

This is one of those rare ERISA denial of benefits cases in which the plan administrator, The Prudential Life Insurance Company of America, did not reserve to itself discretion as to interpretation and administration of its plan. The benefits at issue are the proceeds of a group life insurance policy (Group Policy) in the sum of $300,000, claimed by the estate of Walter Jajuga, who died on December 31, 2008. Whether the estate gets those benefits turns on whether Jajuga was “totally disabled” on May 6, 1997, when he stopped working for Mercedes-Benz USA (MBUSA). If he was so disabled, then he was entitled to continuing coverage under the policy even though he was no longer working for MBUSA.

After a series of mishaps by Prudential in its administration of the claim, and despite Prudential’s having agreed Jajuga was totally disabled for purposes of a separate individual life insurance policy (Individual Policy) Jajuga held and Prudential administered, Prudential denied Jajuga’s claim under the Group Policy initially and throughout his administrative appeals.

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