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Davis v. Northwestern Mutual Life Insurance Co.

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

February 26, 2018



          ELLEN S. CARMODY United States Magistrate Judge

         This matter is before the Court on Plaintiff's challenge to Defendant's decision denying his application for disability benefits pursuant to a group long term disability policy. The parties have consented to proceed in this Court for all further proceedings, including trial and an order of final judgment. 28 U.S.C. § 636(c)(1). By Order of Reference, the Honorable Janet T. Neff referred this case to the undersigned. The Court has determined that oral argument is unnecessary in this matter. For the reasons discussed herein, Plaintiff's appeal is denied and this matter terminated.


         As detailed herein, in January 2012, Plaintiff began to implement a plan to gradually, over the course of no more than twelve months, completely discontinue his medical practice and transition into other related employment. In July 2012, prior to the completion of this transition plan, Plaintiff underwent a surgical procedure subsequent to which he experienced complications which Plaintiff asserts rendered him disabled from practicing medicine.

         On January 3, 2013, Plaintiff submitted disability claims pursuant to several individual disability policies. Plaintiff's claims were denied after which Plaintiff initiated legal action. Plaintiff subsequently settled these claims and the action was dismissed. Davis v. Northwestern Mutual Life Ins. Co., 1:14-cv-912 (W.D. Mich.). On February 5, 2015, Plaintiff submitted a disability claim pursuant to a group long term disability policy obtained through his employer, Michigan Pain Consultants, P.C., and administered by Defendant Northwestern Mutual (hereinafter, “the Policy”). (ECF No. 17-2 at PageID.425-28). Plaintiff's claim was denied, (ECF No. 1-3 at PageID.47-56; ECF No. 1-4 at PageID.58-67), prompting the present action.


         The parties have stipulated that the de novo standard of review applies in this matter, pursuant to which the Court's role “is to determine whether the administrator. . .made a correct decision.” Ross v. Reliance Standard Life Ins. Co., 112 F.Supp.3d 620, 622 (W.D. Mich. 2015) (citations omitted). The Court's review is limited to the record that was before the administrator whose decision is accorded neither deference nor presumption of correctness. In sum, the Court “must determine whether the administrator properly interpreted the plan and whether the insured was entitled to benefits under the plan.” Ibid (citations omitted).


         I. Relevant Policy Language

         With respect to the definition of disability, the Policy provides, in relevant part, that “[y]ou are Disabled if you meet one of the following definitions during the period it applies”: (1) Own Occupation Definition of Disability; (2) Any Occupation Definition of Disability; or (3) Partial Disability Definition. (ECF No. 1-2 at PageID.22). Plaintiff argues that he satisfied the Own Occupation Definition of Disability. Before addressing the parties' dispute over the meaning of the term Own Occupation, certain other relevant portions of the Policy must be noted.

         As discussed below, Plaintiff terminated his employment with Michigan Pain Consultants on September 9, 2012. (ECF No. 17-7 at PageID.1726, 2017). The Policy provides that Plaintiff's insurance under the Policy ended on that date. (ECF No. 1-2 at PageID.30). Thus, to be covered by the Policy's disability provisions, Plaintiff must demonstrate that his disability began prior to September 9, 2012. Plaintiff must further establish that he was disabled continuously through his benefit Beginning Date, which is defined as the “181st day of Disability in the first 210 days after the date you became Disabled.” (ECF No. 1-2 at PageID.15).[1]

         The Policy also requires that Plaintiff have been under the care of a physician or practitioner during the time period of any alleged period of disability. (ECF No. 1-2 at PageID.30). Specifically, the Policy states, “[n]o benefits will be paid for any period of Disability when you are not under the ongoing care of a Physician or Practitioner.” (ECF No. 1-2 at PageID.30). In sum, to be covered by the Policy's disability provisions, Plaintiff must demonstrate that he was unable to perform his Own Occupation prior to September 9, 2012, and that such disability continued for 180 days. Plaintiff must also have been under the ongoing care of a physician or practitioner during any claimed period of disability.

         II. Own Occupation

         Plaintiff argues that he is disabled because he was rendered unable to perform his Own Occupation. The parties dispute how Plaintiff's occupation is properly defined for purposes of his disability claim. The relevant Policy language provides as follows:

Own Occupation Definition of Disability.
During the period preceding your Beginning Date and during the Own Occupation Period[2] you are required to be Disabled only from your Own Occupation.
You are Disabled from your Own Occupation if, as a result of Sickness, Injury, or Pregnancy, you are unable to perform with reasonable continuity the Material Duties of your Own Occupation.
You may meet the Own Occupation Definition of Disability while working in another occupation.

(ECF No. 1-2 at PageID.22).

The Policy defines Own Occupation and Material Duties as follows:
Own Occupation. This is any employment, business, trade, profession, calling or vocation that involves Material Duties of the same general character as your regular and ordinary employment with your Employer. Your Own Occupation is not limited to your specific job with your Employer or to your specific area of specialization, interest or expertise within the general occupation.
Material Duties. These are the essential tasks, functions and operations and the skills, abilities, knowledge, training and experience, generally required by employers from those engaged in a particular occupation.

(ECF No. 1-2 at PageID.23).

         While there is no dispute that Plaintiff is a medical doctor licensed as an anesthesiologist, the parties nevertheless cannot agree as to the proper characterization of Plaintiff's Own Occupation. The parties' dispute can be generalized thusly: Plaintiff seeks a characterization which focuses on the actual job duties he performed for Michigan Pain Consultants whereas Defendant seeks to characterize Plaintiff's occupation by reference to generic definitions of anesthesiologist. Despite being presented with information regarding Plaintiff's actual job duties, Defendant nevertheless defined Plaintiff's occupation by reference to two generalized definitions of anesthesiologist, one provided by the American Medical Group Association Compensation and Financial Survey and the other articulated by the United States Department of Labor. (ECF No. 1-3 at PageID.48-50; ECF No. 1-4 at PageID.61-62).

         While there appears to be significant overlap between the parties' competing definitions, the fundamental shortcoming of Defendant's interpretation is that, by apparently disregarding the Material Duties that Plaintiff actually performed, Defendant largely ignores the first sentence of the definition of Own Occupation. Granted, Defendant's position is not completely unjustifiable in light of the relevant Policy language; however, Plaintiff's interpretation enjoys at least equal support in the Policy language. In the Court's estimation, the relevant language is ambiguous and confusing in which case such is construed in Plaintiff's favor. See English v. Blue Cross Blue Shield of Michigan, 688 N.W.2d 523 537 (Mich. Ct. App. 2004) (an insurance policy is a contract); Auto Club Ins. Assoc. v. DeLaGarza, 444 N.W.2d 803, 805-06 (Mich. 1989) (ambiguous contract terms are interpreted against the drafter).

         Accordingly, the Court finds that the better reading of the relevant Policy language is that Plaintiff's Own Occupation is defined by reference to the Material Duties of Plaintiff's employment with Michigan Pain Consultants as of the date of Plaintiff's alleged disability, to the extent such are not inconsistent with or incompatible with the tasks an anesthesiologist might generally perform. This does not terminate the inquiry, however, as there exists a legitimate question as to the precise nature of Plaintiff's job duties as of July 2012.

         Dr. Mark Gostine, President of Michigan Pain Consultants, submitted a letter in which he articulated the job description of an interventional pain management physician working for Michigan Pain Consultants. (ECF No. 17-2 at PageID.578). According to Gostine, an interventional pain management physician treats patients experiencing chronic pain by performing various interventional procedures and also participates in medical group governance, professional advocacy, and various teaching and continuing education activities. (ECF No. 17-2 at PageID.578). Dr. Gostine described the physical and mental activity requirements of this position as: (1) the ability to treat an average of twenty-two (22) patients daily; (2) the ability to work 9-10 hours daily, five days weekly; and (3) the ability to daily perform twenty (20) highly technical interventional procedures all while standing and frequently wearing a ten pound x-ray resistant apron. (ECF No. 17-2 at PageID.578).

         The Court notes, however, that Dr. Gostine did not describe Plaintiff's actual job duties, but instead described the general requirements of the position which Plaintiff held. Generally, this distinction would be without significance as, absent evidence to the contrary, it is not unreasonable to conclude that an employee performs duties consistent with the employer's job description. Here, however, there is compelling evidence, from Plaintiff himself, that his job duties, as of July 2012, were not nearly as extensive and demanding as Dr. Gostine suggests.

         On July 15, 2011, Plaintiff moved in state court for a reduction of his court ordered spousal support obligations. (ECF No. 17-7 at PageID.2024). On February 10, 2012, the state court conducted an evidentiary hearing on the matter. (ECF No. 17-7 at PageID.2022-88). At this hearing, Plaintiff testified, under oath to the following. Plaintiff described his medical practice as performing nerve block procedures. (ECF No. 17-7 at PageID.2078-79). Plaintiff reported that he previously performed “about” 22 such procedures daily. (ECF No. 17-7 at PageID.2078-79). Plaintiff further reported, however, that he had “substantially reduced [his] clinical activities” and was “working in a different capacity now.”[3] (ECF No. 17-7 at PageID.2058).

         Plaintiff, then aged 62, testified that he wanted to retire from the practice of medicine, but because “there is no replacement for me in my practice, ” he had “to take a strategy of gradually reducing my patient care by attrition so that the patients are not abandoned.” (ECF No. 17-7 at PageID.2058-59, 2062). Plaintiff reported that beginning on January 1, 2012, he officially began his transition to retirement from the practice of medicine. (ECF No. 17-7 at PageID.2062-65). Specifically, Plaintiff testified that he was presently working “about 12 days a month, ” down from “16 to 18 a month” the previous year. (ECF No. 17-7 at PageID.2065). According to Plaintiff, working 18 days monthly was considered full-time. (ECF No. 17-7 at PageID.2067). Plaintiff continued that his plan going forward was to locate a physician to whom he could immediately transfer his practice. (ECF No. 17-7 at PageID.2065-66). However, in the event no such replacement could be located, Plaintiff would nonetheless “fully retire” from the practice of medicine no later than December 31, 2012.[4] (ECF No. 17-7 at PageID.2066).

         The Court cannot discern from Plaintiff's testimony or anything else in the record the precise nature of Plaintiff's job duties as of July 2012. However, it is clear from Plaintiff's state court testimony that as of February 2012, he was working significantly fewer days each month. Specifically, Plaintiff testified that he was working twelve days monthly or approximately three days each week. There is nothing in the record to suggest that between February 2012 and July 2012, Plaintiff increased his workload. Thus, the Court finds that Plaintiff's Own Occupation consists of the general duties described by Dr. Gostine, except that Plaintiff was not working full-time, but instead was working only three (3) days weekly.[5]

III. Examination of the Relevant Medical Evidence

         On July 16, 2012, Plaintiff underwent a laser surgical procedure to treat: (1) obstructive benign prostatic hypertrophy [BPH] with a very large prostate, and (2) left renal calculus. (ECF No. 32-1 at PageID.2756-58). While this procedure “went smoothly and quickly, ” Plaintiff experienced “significant continued bleeding following the procedure.” (ECF No. 32-1 at PageID.2781-82). Plaintiff thereafter underwent a procedure which confirmed “a clot present in the prostatic fossa and bladder.” (ECF No. 32-1 at PageID.2781-82). The clot was removed and the area coagulated with a laser. (ECF No. 32-1 at PageID.2781-82). Plaintiff was subsequently diagnosed as having experienced an episode of disseminated intravascular coagulation (DIC). (ECF No. 32-1 at PageID.2829-40).

         Treatment notes dated July 18, 2012, indicate that Plaintiff's condition was “much improved.” (ECF No. 32-1 at PageID.2876). It was determined, based upon clinical assessment and laboratory testing, that the most likely cause of Plaintiff's DIC episode was that such was simply a side effect of his prostate surgery rather than some other underlying pathology or cause. (ECF No. 32-1 at PageID.2904-06). Treatment notes dated July 19, 2012, indicate that ...

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