United States District Court, E.D. Michigan, Southern Division
ORDER GRANTING PLAINTIFF'S MOTION FOR SUMMARY
JUDGMENT [Doc. #17] AND GRANTING IN PART AND DENYING IN PART
DEFENDANT'S MOTION FOR SUMMARY JUDGMENT [DOC.
VICTORIA A. ROBERTS, UNITED STATES DISTRICT JUDGE
Sun (“Sun”) filed suit against United Omaha Life
Insurance Company (“United”) to enforce her
long-term disability insurance policy. Sun says United
violated the Employee Retirement Income Security Act of 1975
(“ERISA”) by wrongfully terminating her long-term
disability (“LTD”) benefits. United says Sun has
not established by a preponderance of the evidence that she
is “disabled.” The parties filed cross-motions
for summary judgment.
requests that the Court: 1) reverse United's decision to
terminate her benefits; and (2) declare her disabled under
asks the Court to affirm the administrator's decision and
require Sun to reimburse it $25, 476.67 for Social Security
benefits she received from 2011 to 2013.
Court GRANTS Sun's motion for summary judgment and DENIES
IN PART AND GRANTS IN PART United's motion for summary
2002 until December 28, 2010, Sun worked for HR Staffing Team
as a registered nurse who cared for quadriplegic patients.
Her position held a strength demand of “medium”
(i.e. 50 pounds maximum lifting with frequent lift/carry up
to 25 pounds). Her major job duties included caring, bathing,
feeding, dressing, administering medication, and assessing
patients' condition/illness. Sun used a hoyer lift to
move patients, which required pushing, pulling, and lifting
approximately 30 pounds. She also drove on a daily basis and
took patients to various appointments and on personal
errands. [Doc. #15-5, Pg ID 698-701].
her employment, Sun participated in HR Staffing's ERISA
qualified benefit plan. United issued the Group Long Term
Disability Insurance Policy (“Policy”) to HR
Staffing. Under the Policy, United agreed to pay LTD benefits
subject to the terms and conditions of the Policy. HR
Staffing self-insured a short-term disability
(“STD”) benefits program for eligible employees;
it retained United to review claims under the Policy.
of her employment, Sun agreed to:
repay the Company [i.e., United], in a lump sum, all monthly
and/or weekly benefits that have been paid to me, and which
exceed the amount I was entitled to under the terms of the
Policy, as a result of receipt of Other Benefits. I will
make\ this repayment within 30 days from the date on which
Other Benefits are received.
[Doc. #15-5, Pg ID 599].
event of Disability, the Policy required Sun to apply for
“other income” benefits for which she may be
eligible, such as Social Security Disability
(“SSD”) benefits. The Social Security
Administration (“SSA”) awarded Sun SSD full
benefits in June 2013 and back-pay from June 2011 through May
2013. That award is the subject of United's counterclaim
against Sun to recoup SSD benefits awarded to Sun during the
same time she received LTD benefits from United.
injured her foot in December 2010. Because of her injury, Sun
could not perform her job duties as a registered nurse, and
HR Staffing said it could not modify Sun's job duties.
[Doc. #15-6, Pg ID 847].
doctor's recommendation, Sun took time off work. However,
her foot never healed properly, and she did not return to
work. Sun's last day of employment was December 28, 2010.
United provided Sun STD benefits from January 2011-April
the terms of the Policy, a participant is entitled to receive
monthly disability benefits if she is “disabled.”
The Policy defines disabled:
Disability and Disabled means that because of an Injury or
Sickness, a significant change in Your mental or physical
functional capacity has occurred in which You are:
(a) prevented from performing at least one of the Material
Duties of Your Regular Occupation on a part-time or full-time
(b) unable to generate Current Earnings which exceed 80% of
Your Basic Monthly Earnings due to that same Injury or
After a Monthly Benefit has been paid for 2 years, Disability
and Disabled mean You are unable to perform all of the
Material Duties of any Gainful Occupation. Disability is
determined relative to Your ability or inability to work. It
is not determined by the availability of a suitable position
with Your employer.
[Doc. #15-1, Pg ID 119-20 emphasis omitted)]. The Policy
defines “Gainful Occupation” as:
an occupation, for which You are reasonably fitted by
training, education, or experience, is or can be expected to
provide You with Current Earnings at least equal to 60% of
Basic Monthly Earnings within 12 months of Your return to
[Id., Pg ID 120].
January 18, 2011, Dr. Anthony Benenati, D.P.M, a podiatrist,
diagnosed Sun with “Plantar Fasciitis and possible
Peroneal Longus tear, ” with the symptom of pain and
first appearing on December 28, 2010. He found Sun could
return to work full-time in 1-3 months. [Doc. #15-6, Pg ID
848-49]. Dr. Benenati sent United medical records to confirm
April 2011, United spoke with Sun. On the call “she
indicated disability due to a diagnosis of plantar fasciitis;
the wearing of a walking cast; the abstention from surgery
due to having lupus and the medication that she takes for the
lupus; the exacerbation of the plantar fasciitis symptoms if
she walks without the walking cast; her belief she will have
to live with pain for the rest of her life; her ability to do
the activities of daily life (“ADL's”); her
continuing to drive on a daily basis; her hope to return to
work April 24, 2011.” [Doc. #20, Pg ID 1047, citing
Doc. #15-5, Pg ID 698-701].
April 6, 2011, Sun began to receive LTD benefits. Supporting
her claim for LTD benefits were medical reports from Dr.
Benenati's July 12, 2011 report concluded Sun had not
achieved maximum medical improvement; he said fundamental
changes in her medical condition were expected in 1-2 months.
[Id., Pg ID 637]. In a November 2011 report, Dr.
Benenati indicated that Sun had not achieved maximum medical
improvement, but noted that fundamental changes in her
condition could be expected in 5-6 months, with the medical
prognosis for recovery being “good.”
[Id., Pg ID 607].
December 5, 2011, Dr. Benenati evaluated Sun's Peroneus
Brevis Tendonitis - rupture or tear in the ankle - and found
“improvement gained w/ infiltration of corticosteroid,
85% improvement, just a residual ache over the area. [Sun]
states she has good and bad days and this is a bad
day.” [Doc. #15-4, Pg ID 544]. Sun told Dr. Benenati
she took an experimental drug for lupus [Id.]. Dr.
Benenati examined Sun and found no apparent distress,
cardiovascular problem, or skin problems except for a 4 cm
hyperkeratotic fissure on the left heel. He found normal
lymphatic findings; good coordination and normal touch, pin,
vibratory, and proprioception sensations; stable, normal
gait; muscle strength 5/5 for all groups tested and normal
muscle tone; and inspection and palpation of bones, joints,
and muscles unremarkable other than a pain on palpation over
the left peroneus brevis tendon. [Id.].
February 1, 2012, Sun mailed an Education, Training and Work
Experience form to United. [Id., Pg ID 584-86]. In
response to the last question on the form, “What is
your employment goal, ” Sun wrote, “to Return to
work as an RN in a non-patient care role.”
[Id., Pg ID 585].
9, 2012, United concluded Sun was not disabled and denied LTD
benefits. Sun appealed United's decision and submitted
additional evidence of disability.
August 13, 2012, United reinstated Sun's LTD benefits.
United decided to reinstate Sun's LTD benefits because it
received a July 13, 2012, report and phone call from Dr.
Benenati. From this information, United documented this:
“[Sun has] a new medication (Benlysata) in an attempt
to treat her Lupus, and from the information, and phone
conversation she is unable to have surgery ...