United States District Court, E.D. Michigan, Southern Division
OPINION AND ORDER GRANTING DEFENDANT'S MOTION FOR
JUDGMENT AFFIRMING ERISA BENEFITS DETERMINATION (DOC. 15) AND
DENYING PLAINTIFF'S CROSS MOTION FOR JUDGMENT (DOC.
CARAM STEEH, UNITED STATES DISTRICT JUDGE
case involves a claim by plaintiff Lyle Pransch for
short-term disability benefits under an employee welfare
benefit plan (the Plan) governed by the Employee Retirement
Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001,
et seq. Defendant the Guardian Life Insurance
Company of America, claims administrator of the Plan, denied
coverage for plaintiff after he failed to provide requested
medical documentation of his disability. Defendant also
determined that plaintiff was not covered by the Plan because
his injury occurred at work. Plaintiff brings this lawsuit
claiming that defendant's decision to deny benefits fails
de novo review and is arbitrary and capricious.
is a former employee of Valeo North America, Inc.. Valeo
sponsors and directly funds a short-term disability insurance
plan through defendant. (Doc. 12 at PageID 773-806). The Plan
defines disabled as “a current sickness or injury
[that] causes physical or mental impairment to such a degree
that you are: (a) not able to perform, on a full-time basis,
the major duties of your own job and (b) not able to earn
more than this plan's maximum allowed disability
earnings.” (Doc.12 at PageID 793). The Plan requires
claimants to prove written proof of loss. (Doc. 12 at PageID
791). The Plan expressly excludes coverage for disabilities
“caused by, or related to. . . job related or
on-the-job injury.” (Doc. 12 at PageID 791).
disability is back pain. He first noticed this pain while
lifting boxes at work on July 2, 2014. Plaintiff submitted a
handwritten statement on July 3, 2014 as well as numerous
medical records regarding his injury.
submitted a claim for short-term disability benefits in July
2014. He received benefits for five days and returned to
work. (Doc. 12 at PageID 627, 632-33). He submitted a second
short-term disability claim in September 2014. Approval was
updated periodically following the submission of forms from
plaintiff's physicians indicating continued restrictions.
(Doc. 12 at PageID 662). Defendant reviewed plaintiff's
claim file in January 2015. It thereafter denied
plaintiff's benefits, asserting that he had not provided
medical evidence supporting his disability beyond January 5,
2015. (Doc. 12 at PageID 672). Plaintiff submitted additional
information. Defendant conducted a second review in May 2015
but came to the same conclusion. (Doc. 12 at PageID 701).
Plaintiff submitted an ERISA Administrative Appeal in August
2015. Defendant requested that plaintiff submit additional
information for its reconsideration review. (Doc. 11 at
PageID 367-373). The parties dispute the corresponding
exchange of information. Defendant's reconsideration
review concluded that its prior decision to deny ongoing
benefits was proper because plaintiff had not provided all of
the requested medical records and his injury occurred at
work. (Doc. 14 at PageID 937 - 943). Plaintiff thereafter
filed this lawsuit.
Standard of Review
district court reviewing a decision regarding benefits under
ERISA shall “conduct a . . . review based solely upon
the administrative record, and render findings of fact and
conclusions of law accordingly.” Wilkins v. Baptist
Healthcare Systems, Inc., 150 F.3d 609, 619
(6th Cir. 1998). A denial of benefits is subject
to the arbitrary and capricious standard of review if the
benefit plan accords discretionary authority to the claims
administrator to “determine eligibility for benefits or
to construe the terms of the plan.” Firestone Tire
& Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989).
Language requiring a participant to submit “written
proof of loss” is a clear grant of discretionary
authority warranting arbitrary and capricious review.
Leeal v. Continental Casualty Co., 17 F. App'x
341, 343 (6th Cir. 2001). “When it is
possible to offer a reasoned explanation, based on the
evidence, for a particular outcome, that outcome is not
arbitrary or capricious.” Williams v. International
Paper Co., 227 F.3d 706, 712 (6th Cir. 2000)
(internal citations omitted).
denial of benefits at issue here shall be reviewed under the
arbitrary and capricious standard because the Plan vests
defendant with discretion to make benefit determinations.
See (Doc. 12 at PageID 791) (requiring claimants to
provide defendant with written proof of loss).
asserts that, as the claims administrator, not the plan
administrator, it has no liability for the payment of Plan
benefits. Defendant also argues that plaintiff failed to
provide all of the requested medical information necessary to
demonstrate continued short-term disability. Plaintiff
counters that he provided everything that was within his
ability to produce. The Court finds it unnecessary to rule on
these issues because even if defendant has liability and
plaintiff fulfilled his obligation to furnish medical
information, judgment for defendant is appropriate based on
its determination excluding coverage of work related injuries
under the Plan.
denied plaintiff benefits after determining that his
disability was caused by a work-related injury. The Plan
“does not pay benefits for disability caused by, or
related to. . . job related or on-the-job injury.”
(Doc. 12 at PageID 791). Plaintiff provided defendant with
medical records that repeatedly illustrate that he was
injured at work while lifting boxes. Progress notes from Dr.
Balbir Gandhi reflect that plaintiff stated that “he
was at work loading boxes onto a truck” and
“developed a sharp pain” that
“progressively worsened” as “he continued
to load the boxes.” (Doc. 11 at PageID 132). Dr. Rahman
stated that plaintiff “injured [his] back at
work.” (Doc. 11 at PageID 180). Dr. Surindar Kaura
wrote that plaintiff has suffered a pain problem “since
2014” when he “was loading boxes on a rack for
work.” (Doc. 11 at PageID 190, 203, 212). Dr. Tyra
McKinney noted that plaintiff “was injured at work
lifting boxes.” (Doc. 11 at PageID 290). Plaintiff told
her “that he repeatedly lifted boxes and developed sore
aching pain.” (Id.). Dr. Jai Duck Liem noted
that, “according to Mr. Pransch. . . he was allegedly
injured at work. . . on July 2, 2014, when he lifted boxes
weighing [ ] between 40-60 pounds and then started having the
severe pain.” (Doc. 11 at PageID 333). Finally,
plaintiff's own hand written statement, composed the day
after his injury, states that he “had a pain on [his]
right side” after finishing loading the 74 wire
harnesses and beginning to load the 72 wire harnesses. (Doc.
11 at PageID 100). Plaintiff wrote that the pain began around
5pm, worsened around 7pm, and by 8pm, became so severe that
he alerted a co-worker and stated that he needed to go to the
evidence is sufficient “to offer a reasoned
explanation” for defendant's determination that,
because plaintiff's disability was caused by or related
to an on-the-job injury to deny benefits, it was not covered
by the Plan. Williams, 227 F.2d at 712.
Defendant's decision to deny benefits is, therefore,
neither arbitrary nor capricious. Id.