United States District Court, E.D. Michigan, Southern Division
OPINION AND ORDER GRANTING IN PART AND DENYING IN
PART PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT , AND
GRANTING IN PART AND DENYING IN PART DEFENDANT'S MOTION
FOR JUDGMENT ON THE ADMINISTRATIVE RECORD 
G. Edmunds United States District Judge
Dr. Alba Rodriguez filed this action against Defendant Life
Insurance Company of North America (“LINA”)
seeking long-term disability (“LTD”) income
benefits under Section 502(a)(1)(b) of the Employee
Retirement Income Security Act ("ERISA"). Currently
before the Court is Plaintiff's motion for summary
judgment and Defendant's cross motion for judgment on the
administrative record. For the reasons set forth below, the
Court GRANTS IN PART and DENIES IN PART Plaintiff's
motion, and GRANTS IN PART and DENIES IN PART Defendant's
FINDINGS OF FACT
1986, Plaintiff was involved in a motor vehicle accident, and
she sustained fractures to her spine, left hip, left
acetabulum, and pelvis. She underwent pelvic reconstruction
surgery with hardware implants. In 1987, Plaintiff underwent
a total left hip arthroplasty. She was diagnosed with a
cervical herniation in 2004. Years later, on January 28,
2012, Plaintiff slipped and fell, allegedly in the course of
her work. Worker's compensation benefits were denied, and
the claim remains pending. As a result of this slip and fall,
Plaintiff re-injured her left hip and back. Plaintiff was 45
years old on her alleged disability onset date of May 24,
is an eligible participant in the Long Term Disability Plan
for employees of the Henry Ford Health Service, for which
Defendant LINA is the insurer. Under the LTD Plan, the
claimant must provide LINA with “satisfactory proof of
Disability before benefits will be paid, ” and LINA
requires “continued proof of the Employee's
Disability for benefits to continue.” (Dkt. # 10-3, Pg
ID 540). In relevant part, a claimant must provide LINA
satisfactory proof that she was continuously disabled
throughout the entire “Elimination Period, ”
which for Plaintiff was 180 days. See Id. at Pg ID
Plan defines “Disability/Disabled” during the
first 24 months (the “own occupation” period) as
Employee is considered Disabled if, solely because of Injury
or Sickness, he or she is:
1. unable to perform the material duties of his or her
Regular Occupation; and
2. unable to earn 80% or more of his or her Indexed Earnings
from working in his or her Regular Occupation.
Id. at Pg ID 526.
Plan defines “Disability/Disabled” after 24
months (the “any occupation” period) as follows.
Disability Benefits have been payable for 24 months, the
Employee is considered Disabled if, solely due to Injury or
Sickness, he or she is:
1. unable to perform the material duties of any occupation
for which he or she is, or may reasonably become, qualified
based on education, training or experience; and
2. unable to earn 60% or more of his or her Indexed Earnings.
the LTD Plan, LINA may reduce the amount of LTD benefits
payable by the amount of “Other Income Benefits,
” which include any amounts received or assumed to be
received by the employee under social security and/or
worker's compensation. Id. at Pg ID 540-41.
alleged disability onset date, Plaintiff had been employed by
Henry Ford Health Service as Associate Director of the Center
for Integrative Wellness. Her job was considered a Program
Manager skilled job. According to the Program Manager job
description, Plaintiff's duties included leading group
wellness programs with 100 attendees, traveling to corporate
offices and conference centers, developing and implementing
all operational aspects of the group wellness programs,
overseeing activities and training of support personnel and
group program leaders, serving on internal and external
committees, and writing publications. (Dkt. # 10-2 at Pg ID
406-07). The job required a doctorate degree. Id. at
Pg ID 407. According to the Dictionary of Occupational Titles
(“DOT”), the job of Program Manager has a
Specific Vocational Preparation of four to ten years (level 8
out of a possible 9 levels). It requires the ability to apply
principles of logical or scientific thinking to define
problems, collect data, establish facts, and draw valid
conclusions; interpret an extensive variety of technical
instructions in mathematical or diagrammatic form; and deal
with several abstract and concrete variables (Reasoning
Development level 5). The Program Manager job also requires
Mathematical Development at a level 5 and Language
Development at a level 5 (out of a possible 6 levels).
16, 2012, approximately five months after her slip and fall
accident, Plaintiff underwent an invasive and long revision
surgery of the total left hip arthroplasty. Id. at
Pg ID 449-51. Dr. Robb Weir, Plaintiff's orthopedic
surgeon, initially estimated that Plaintiff would be able to
return to work without restrictions on September 10, 2012.
Id. at Pg ID 463. Plaintiff had a follow up visit
with Dr. Weir on October 24, 2012. Id. at Pg ID 434.
Dr. Weir noted that Plaintiff was continuing to improve, was
participating in physical therapy and water therapy, and
denied any pain with weightbearing in the leg. Dr. Weir
further noted that Plaintiff was somewhat limited due to her
back, and he referred her to Dr. Shlomo Mandel to address her
back pain. Dr. Weir recommended another 4-6 weeks off work.
He delayed her work release date to December 10, 2012.
Id. at Pg ID 427.
collected short-term disability (“STD”) benefits
from June 25, 2012 through December 9, 2012, at which point
continued STD benefits were denied. (Dkt. # 10-1 at Pg ID
272, 305). Plaintiff's STD claim is not at issue in this
first denied Plaintiff's claim for LTD benefits on
November 30, 2012, explaining that Plaintiff had failed to
provide satisfactory proof that she was
“Disabled” throughout the entire Elimination
Period: “Your first day of disability was June 18,
2012. You would not have satisfied the elimination period
until December 24, 2012. According to the information on
file, you were released to work on December 10, 2012.”
Id. at Pg ID 258.
LINA received additional medical records from Dr. Mandel and
Dr. Weir. These, along with all other records in the file,
were reviewed by a Claim Manager and a Nurse Claim Manager.
Id. at Pg ID 233. On December 7, 2012, Dr. Mandel
saw Plaintiff and noted that an MRI conducted on November 23,
2012 showed disk bulging at the L5-S1 level. (Dkt. # 10-2, Pg
ID 401). Dr. Mandel noted that Plaintiff has limited flexion
and extension and pain with straight leg rising. Dr. Mandel
further noted that Plaintiff complained of numbness and
paresthesias. On December 12, 2012, Dr. Weir again delayed
Plaintiff's work release date until January 2, 2013.
Id. at Pg ID 394. On December 18, 2012, the Nurse
Case Manager reached out to Dr. Weir to clarify
Plaintiff's restrictions, and Dr. Weir indicated that
Plaintiff could return to work on January 2, 2013. Dr. Weir
did not place any activity restrictions at that time. (Dkt. #
10 at Pg ID 86). On December 19, 2012, Dr. Mandel completed a
Physical Abilities Assessment form, and noted that
Plaintiff's restrictions were limited sitting and no
repetitive lifting, stooping, bending, or twisting. (Dkt. #
10-2 at Pg ID 389-90). On December 21, 2012, the Nurse Claim
Manger spoke with Dr. Mandel's office to clarify
Plaintiff's restrictions. According to the nurse's
notes, Dr. Mandel's staff indicated that Plaintiff was
capable of sitting frequently with position changes and
capable of sedentary work. (Dkt. # 10 at Pg ID 86).
December 28, 2012, LINA again denied Plaintiff's claim
for LTD benefits. (Dkt. # 10-1 at Pg ID 232-34). The denial
letter notes that Plaintiff's treating providers do not
give any measurable exam findings to support a functional
impairment that would preclude her from performing her own
occupation as a Program Manager, a sedentary occupation under
filed her first administrative appeal on June 27, 2013. (Dkt.
# 10-2 at Pg ID 374). Plaintiff submitted additional medical
documentation, including a Work/School Letter from Dr.
Mandel, a letter from Dr. Ramon Nunez, an office visit note
from Dr. Steven Fried, and a Medical Questionnaire from Dr.
Work/School Letter, dated April 26, 2013, Dr. Mandel wrote
that he examined Plaintiff on April 8, 2013. He recommended
that Plaintiff may return to work with the following
restrictions: no repetitive squatting, bending, or lifting;
no lifting in excess of ten pounds; and ...