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Wilson v. Reliance Standard Life Insurance Co.

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

February 21, 2018

James Wilson, Plaintiff,
v.
Reliance Standard Life Insurance Company, Defendant.

          Mona K. Majzoub, U.S. Magistrate Judge

          ORDER GRANTING DEFENDANT'S MOTION FOR SUMMARY JUDGMENT [10]; DENYING PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT [11]

          Arthur J. Tarnow, Senior United States District Judge

         Plaintiff James Wilson is a 55-year-old resident of Ann Arbor, Michigan. He suffers from a malignant cancer (lymphoma) of the spine, HIV, gastroesophageal reflux disease, and hypertension. He challenges the decision by Defendant Reliance Standard Life Insurance Company to deny his claim for Long Term Disability (“LTD”) benefits issued under an ERISA-governed employee benefit plan (“the Plan”) to his employer, RCF Information Systems. Plaintiff's claim falls under 502(a)(1)(B) of ERISA, 29 U.S.C. § 1132(a)(1)(B).

         For the reasons stated below, Defendant's Motion for Summary Judgment [10] is GRANTED. Plaintiff's Motion for Summary Judgment [11] is DENIED.

         Factual Background

         I. Terms of the Insurance Policy

         In 2011, Defendant issued to RCF a group LTD policy that provides coverage to active, full time RCF employees. Under that policy, “Totally Disabled” and “Total Disability” mean, that as a result of an Injury or Sickness:

(1) during the Elimination Period and for the first 24 months for which a Monthly Benefit is payable, an Insured cannot perform the material duties of his/her Regular Occupation;
(a) “Partially Disabled” and “Partial Disability” mean that as a result of an Injury or Sickness an Insured is capable of performing the material duties of his/her Regular Occupation on a part-time basis or some of the material duties on a full-time basis. An Insured who is Partially Disabled will be considered Totally Disabled except during the Elimination Period;
(b) “Residual Disability” means being Partially Disabled during the Elimination Period. Residual Disability will be considered Total Disability; and
(2) after a Monthly Benefit has been paid for 24 months, an Insured cannot perform the material duties of Any Occupation. We consider the Insured Totally Disabled if due to an Injury or Sickness he or she is capable of only performing the material duties on a part-time basis or part of the material duties on a Full-time basis.

(AR10).

         II. Plaintiff's Medical and Claims History

         A. Pre-Termination

         Plaintiff was in the U.S. Air Force from 1981 through 1991. From July 1, 2011 through December 13, 2014, Plaintiff worked as an IT Programmer/Systems Analyst[1] (a sedentary occupation) for RCF Information System, a defense contractor. Plaintiff was living in Ohio at this time. RCF purchased group disability coverage from Defendant effective June 1, 2011. (AR001).

         In November 2014, Plaintiff was briefly hospitalized at Wright Patterson Air Force Base Hospital, where he was diagnosed with malignant cancer (lymphoma) of the spine. (AR215). Plaintiff applied for Short Term Disability (“STD”) benefits in December 2014. (AR211). Dr. Nicholas Conger, M.D. completed an Attending Physician's Statement in which he diagnosed Plaintiff with “inflammatory mass of the lumbar spine” and indicated that Plaintiff was unable to perform his job. (AR209). On December 28, 2014, Dr. Borislav Hristov, Chief of Radiation Oncology, recommended that Plaintiff “be off of work” while he received intensive radiation therapy. (AR215). Defendant promptly approved Plaintiff's STD benefits claim. (AR53-76).

         Plaintiff received radiation therapy from December 30, 2014 through January 2, 2015. Shortly thereafter, he began chemotherapy. He received his final chemotherapy on April 20, 2015. (AR269). Shortly thereafter, Lieutenant Colonel Roger A. Wood, Chief of Hematology/Oncology, indicated that Plaintiff cares for himself, but was “[u]nable to carry on normal activity or to do active work.” (AR266). Wood also stated that Plaintiff “[r]equires occasional assistance but is able to care for most personal needs.” Id. Plaintiff also “[r]equires considerable assistance and frequent medical care.” Id.

         It appears that Defendant approved Plaintiff's claim for Long Term Disability (“LTD”) benefits in May 2015. (AR124-26). Wood twice extended Plaintiff's leave until approximately August or November 2015. (AR265, 266).

         Plaintiff treated with a number of doctors throughout the summer and fall of 2015. He saw Dr. Niklas Mackler, M.D. on June 16, 2015. Dr. Mackler noted that Plaintiff was “steadily improving his strength” and that there was “no clinical evidence to suggest relapse” of Burkitt's lymphoma. (AR 349-50). A few days later, Dr. Roger Chen, M.D. evaluated Plaintiff. Plaintiff told Dr. Chen that “his coughing has improved.” (AR469). Plaintiff denied chest pain or wheezing and had no fever or chills. Id.

         On July 1, 2015, Plaintiff returned to Dr. Mackler, who found that Plaintiff was “making a steady recovery with improving appetite and energy.” (AR343). Plaintiff had “established care with an infectious disease doctor” and had started antiviral therapy. Id. Dr. Mackler again noted that Plaintiff presented with “no evidence to suggest relapse” of Burkitt's lymphoma. Id.

         Plaintiff saw Dr. Neelay Kothari, M.D. on July 16, 2015. At this point, Plaintiff was taking Triumeq for his HIV, which he tolerated well. (AR420). Plaintiff suffered no adverse side effects from the Triumeq. Id. Plaintiff felt “well overall” and told Dr. Kothari that his energy level had improved. Id.

         On July 29, 2015, Plaintiff returned to Dr. Mackler, who said that Plaintiff had “[n]o new complaints” and was “[f]eeling well.” (AR504). On that same date, Liz Kirshner, NP, and Dr. Mark Weiner, M.D. evaluated Plaintiff for his leg, knee, and back pain, substance abuse, and suspected mood disorder. Plaintiff reported that his leg pain was “4-5/10.” (AR527).

         Plaintiff treated with Nurse Kirshner and Dr. Weiner several times throughout the summer of 2015. Their notes indicate that Plaintiff's level of pain continued to decrease. On August 5, 2015, for example, Plaintiff reported “suboptimal pain management at 4-5/10.” (AR526). On September 9, 2015, Plaintiff rated his pain level at ¶ 4/10 and at ¶ 2-3/10. (AR523). Finally, on September 17, 2015, Plaintiff reported no side effects from the pain medication and stated that his pain “has gone from a 5/10 down to 2/10.” (AR522). He was also sleeping better. Id.

         Plaintiff followed up with Dr. Kothari on September 3, 2015. Plaintiff continued feeling better overall, including “improvement in energy levels and overall strength.” (AR410). Plaintiff had no “recent fever or chills, ” nor did he suffer from “cough or respiratory symptoms.” Id. Plaintiff continued to tolerate the Triumeq and did not notice any “significant side effects.” Plaintiff returned to Dr. Mackler on ...


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