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Sun v. United of Omaha Life Insurance Co.

United States District Court, E.D. Michigan, Southern Division

July 19, 2017

JULIE SUN Plaintiff/Counter-Defendant,
v.
UNITED OF OMAHA LIFE INSURANCE COMPANY Defendant/Counter-Plaintiff.

          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. #18]

          VICTORIA A. ROBERTS, UNITED STATES DISTRICT JUDGE

         I. INTRODUCTION

         Julia 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.

         Sun requests that the Court: 1) reverse United's decision to terminate her benefits; and (2) declare her disabled under the policy.

         United 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.

         The Court GRANTS Sun's motion for summary judgment and DENIES IN PART AND GRANTS IN PART United's motion for summary judgment.

         II. BACKGROUND

         a. Administrative Record

         From 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].

         During 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.

         As part 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].

         In the 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.

         Sun 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].

         At her 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 2011.

         Under 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 basis; and
(b) unable to generate Current Earnings which exceed 80% of Your Basic Monthly Earnings due to that same Injury or Sickness.
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 work.

[Id., Pg ID 120].

         On 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 his diagnosis.

         In 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].

         On April 6, 2011, Sun began to receive LTD benefits. Supporting her claim for LTD benefits were medical reports from Dr. Benenati.

         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].

         On 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.].

         On 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].

         On July 9, 2012, United concluded Sun was not disabled and denied LTD benefits. Sun appealed United's decision and submitted additional evidence of disability.

         On 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 ...


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