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O'Neill v. Unum Life Insurance Company of America

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

March 19, 2018

TIMOTHY O'NEILL, Plaintiff,
v.
UNUM LIFE INSURANCE COMPANY OF AMERICA, Defendant.

          OPINION

          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. For the reasons discussed herein, Plaintiff's appeal is denied and this matter terminated.

         BACKGROUND[1]

         As of April 2013, Plaintiff had “an extensive past medical history of alcoholism and depression with previous suicide attempts.” (ECF No. 17-8 at PageID.1807; ECF No. 17-10 at PageID.2165). On April 15, 2013, Plaintiff, after having “a few drinks, ” fell and suffered a head injury which required hospitalization. (ECF No. 17-4 at PageID.608-12). Plaintiff subsequently returned to work, but again attempted suicide on September 15, 2013. Shortly thereafter, Plaintiff submitted a disability claim pursuant to a group long term disability policy issued by Defendant (hereinafter “the Policy”). Plaintiff alleged that due to a hearing-related injury suffered as a result of his April 15, 2013 injury, he was no longer able to perform his duties as an anesthesiologist. Defendant paid Plaintiff disability benefits for a period of time after which it terminated Plaintiff's benefits pursuant to a policy provision that limits disability benefits “due to mental illness” to twenty-four (24) months. Plaintiff's appeal of this determination was rejected by Defendant prompting the present action.

         LEGAL STANDARD

         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).

         ANALYSIS

         I. Relevant Policy Language

         The Policy provides that a claimant is disabled if Unum determines that: (1) you are “limited from performing the material and substantial duties of your regular occupation due to your sickness or injury” and (2) you experience “a 20% or more loss in your indexed monthly earnings due to the same sickness or injury.” (ECF No. 17-2 at PageID.123). The Policy defines “regular occupation” as follows:

REGULAR OCCUPATION means the occupation you are routinely performing when your disability begins. Unum will look at your occupation as it is normally performed in the national economy, instead of how the work tasks are performed for a specific employer or at a specific location.
For physicians, “regular occupation” means your specialty in the practice of medicine which you are routinely performing when your disability begins. Unum will look at your occupation as it is normally performed in the national economy, instead of how the work tasks are performed for a specific employer or at a specific location.

         (ECF No. 17-2 at PageID.141).

         The Policy also provides that “[t]he lifetime cumulative maximum benefit period for all disabilities due to mental illness is 24 months.” (ECF No. 17-2 at PageID.130). The Policy defines “mental illness” as follows:

MENTAL ILLNESS means a psychiatric or psychological condition classified in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM), published by the American Psychiatric Association, most current as of the start of a disability. Such disorders include, but are not limited to, psychotic, emotional or behavioral disorders, or disorders relatable to stress. If the DSM is discontinued or replaced, these disorders will be those classified in the diagnostic manual then used by the American Psychiatric Association as of the start of a disability.

         ECF No. 17-2 at PageID.140).

         II. Examination of the Administrative Record

         On April 15, 2013, Plaintiff, after having “a few drinks, ” “fell, struck his head, [but] did not lose consciousness.” (ECF No. 17-4 at PageID.608-12). Plaintiff “did not think too much of it, ” but awoke the following morning with “a severe headache, [which] seemed to get worse.” (ECF No. 17-4 at PageID.608). When Plaintiff later spoke with his girlfriend, “she thought [Plaintiff] could have some suicidal ideation, ” at which point the “authorities were called” who “insisted that [Plaintiff] come to the Emergency Department.” (ECF No. 17-4 at PageID.608).

         A CT scan of Plaintiff's head revealed the presence of a “fairly sizeable acute subdural hematoma on the left side.” (ECF No. 17-4 at PageID.608). Dr. Christopher Marquart thereafter performed “an uncomplicated craniotomy with coagulation of a torn bridging vein at the temporal tip [which] was the source of the subdural [hematoma].” (ECF No. 17-4 at PageID.606). A postoperative CT scan of Plaintiff's head revealed “excellent postoperative result without evidence of acute complicating process.” (ECF No. 17-4 at PageID.613). Following this procedure, Plaintiff “gradually seemed to improve without any significant difficulties or problems.” (ECF No. 17-4 at PageID.606). Plaintiff was discharged from the hospital on April 21, 2013. (ECF No. 17-4 at PageID.606).

         On April 25, 2013, Plaintiff was examined by Dr. Marquart. (ECF No. 17-4 at PageID.604). The doctor reported that Plaintiff was “doing fairly well, ” should “slowly increase his activities, ” and would be able to return to work on May 21, 2013, with “no restrictions.” (ECF No. 17-4 at PageID.604; ECF No. 17-11 at PageID.2396).

         On May 30, 2013, Plaintiff was examined by Dr. A. James Potter. (ECF No. 17-12 at PageID.2575). Plaintiff reported that he was experiencing “hearing loss in the left ear.” (ECF No. 17-12 at PageID.2575). An audiogram examination revealed “normal hearing on the right and a moderate sloping to severe mixed loss on the left.” (ECF No. 17-12 at PageID.2575). Plaintiff's left side hearing loss was “primarily high frequency hearing loss.” (ECF No. 17-4 at PageID.602; ECF No. 17-12 at PageID.2575). The doctor also reported that Plaintiff “has excellent speech recognition bilaterally” and, moreover, that his “acoustic reflexes are intact.” (ECF No. 17-12 at PageID.2575). A subsequent MRI examination of Plaintiff's auditory canal was “entirely normal.” (ECF No. 17-4 at PageID.602-03; ECF No. 17-12 at PageID.2574-75).

         On June 6, 2013, Plaintiff was examined by Dr. Marquart. (ECF No. 17-4 at PageID.602-03). The results of the examination were unremarkable and Plaintiff reported that “his biggest complaint is his hearing loss is bothering him.” (ECF No. 17-4 at PageID.602-03). Dr. Marquart concluded that Plaintiff was “doing very well” and further noted that he was “back to work full time without any problems.” (ECF No. 17-4 at PageID.602-03).

         On June 18, 2013, Plaintiff began treating with Dr. Eric Sergent with the Michigan Ear Institute. (ECF No. 17-10 at PageID.2247-50). Plaintiff reported that he was experiencing hearing loss, tinnitus, “left aural fullness, ” and occasional sound distortion. (ECF No. 17-10 at PageID.2247). Plaintiff also reported that “he had some left hearing loss which preceded [his April 15, 2013] accident.” (ECF No. 17-10 at PageID.2247). Plaintiff denied experiencing otalgia or otorrhea. (ECF No. 17-10 at PageID.2247). Plaintiff reported experiencing “some imbalance but no true vertigo, lightheadedness, or dizziness.” (ECF No. 17-10 at PageID.2247).

         The results of an audiogram examination revealed that the hearing in Plaintiff's right ear was within normal limits. (ECF No. 17-10 at PageID.2249). With respect to Plaintiff's left ear, the audiogram revealed CHL (conductive hearing loss) at low frequencies and SNHL (sensorineural hearing loss) at higher frequencies. (ECF No. 17-10 at PageID.2249).

         Following examination and an exploratory surgery of Plaintiff's left middle ear canal, Dr. Sergent diagnosed Plaintiff with left superior semicircular canal dehiscence (SSCD). (ECF No. 17-10 at PageID.2235-38, 2245-46, 2247-50). Dr. Sargent discussed with Plaintiff treatment options, including the use of hearing aids and surgical intervention. (ECF No. 17-10 at PageID.2249-50). Treatment notes dated August 5, 2013, indicate that Plaintiff was experiencing “imbalance, ” but “does not have true vertigo or lightheadedness.” (ECF No. 17-10 at PageID.2235).

         On August 19, 2013, Dr. Sergent performed surgery to repair Plaintiff's SSCD. (ECF No. 17-10 at PageID.2232-34). Treatment notes dated September 3, 2013, indicate that Plaintiff was still experiencing “severe symptoms of left ear recruitment and autophony, but no dizziness.” (ECF No. 17-10 at PageID.2230-31). The doctor also reported that while Plaintiff reported that “he is very sensitive to noises, such as a shoe dropped, ” Plaintiff was “not bothered by his motorcycle.” (ECF No. 17-10 at PageID.2230-31).

         On September 15, 2013, Plaintiff texted his girlfriend, “I do not want to be here anymore, today is the day[.] I am done taking care of the dogs and I am gone.” (ECF No. 17-10 at PageID.2165). Plaintiff's girlfriend contacted paramedics who subsequently discovered Plaintiff sitting in a corner of his closed garage with three vehicles running. (ECF No. 17-10 at PageID.2165). Plaintiff was transported to an emergency room where he denied drinking or “trying to hurt himself.” (ECF No. 17-10 at PageID.2165). Blood testing revealed Plaintiff's blood alcohol level to be .180 and, based upon statements Plaintiff made to his girlfriend after arriving at the hospital, the emergency room doctor concluded that Plaintiff was “clearly very suicidal at this time” and “needs to be admitted” to a psychiatric facility. (ECF No. 17-10 at PageID.2166). Plaintiff was subsequently transferred to Forest View Psychiatric Hospital where he was treated until September 26, 2013. (ECF No. 17-7 at PageID.1393-1556; ECF No. 17-10 at PageID.2165-66). Plaintiff was diagnosed as suffering from bi-polar disorder and alcohol dependence, both of which are identified in the DSM as mental illnesses. (ECF No. 17-7 at PageID.1394).

         On September 30, 2013, Plaintiff submitted a disability claim with Defendant alleging that he had been disabled since July 15, 2013. (ECD No. 17-6 at PageID.1153-58). On November 21, 2013, Defendant approved Plaintiff's disability claim, stating:

We approved your benefits because you are unable to perform the duties required of an Anesthesiologist at this time based on the surgical procedures performed on April 16, 2013, July 15, 2013 and August 19, 2013, as well as your ...

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