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Rodriguez v. Life Insurance Company of North America

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

January 12, 2018

ALBA RODRIGUEZ, Plaintiff,
v.
LIFE INSURANCE COMPANY OF NORTH AMERICA, Defendant.

          OPINION AND ORDER GRANTING IN PART AND DENYING IN PART PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT [25], AND GRANTING IN PART AND DENYING IN PART DEFENDANT'S MOTION FOR JUDGMENT ON THE ADMINISTRATIVE RECORD [27]

          Nancy G. Edmunds United States District Judge

         Plaintiff 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 motion.

         I. FINDINGS OF FACT

         In 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, 2012.

         Plaintiff 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 527, 540.

         The LTD Plan defines “Disability/Disabled” during the first 24 months (the “own occupation” period) as follows.

         The 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.

         The LTD Plan defines “Disability/Disabled” after 24 months (the “any occupation” period) as follows.

         After 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.

Id.

         Under 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.

         At the 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).

         On June 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.

         Plaintiff 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 case.

         LINA 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.

         Subsequently, 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).

         On 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 the DOT.

         Plaintiff 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. Fried.

         In a 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 ...


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