Evans v. Unumprovident Corp.
| Citation | 434 F.3d 866 |
| Decision Date | 20 January 2006 |
| Docket Number | No. 05-5154.,05-5154. |
| Parties | Mona EVANS, Plaintiff-Appellee, v. UNUMPROVIDENT CORPORATION, Defendant-Appellant. |
| Court | United States Courts of Appeals. United States Court of Appeals (6th Circuit) |
ARGUED: Tony R. Dalton, Woolf, McClane, Bright, Allen & Carpenter, Knoxville, Tennessee, for Appellant. Charlton R. DeVault, Jr., Kingsport, Tennessee, for Appellee. ON BRIEF: Tony R. Dalton, Woolf, McClane, Bright, Allen & Carpenter, Knoxville, Tennessee, for Appellant. Charlton R. DeVault, Jr., Kingsport, Tennessee, for Appellee.
Before: SILER and GRIFFIN, Circuit Judges; KATZ, District Judge.*
In this action under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. §§ 1001-1461, plaintiff Mona Evans claims that her long-term disability ("LTD") benefits were wrongfully terminated by defendant UnumProvident Corporation ("UnumProvident"). The parties filed cross-motions for judgment on the administrative record. Determining that defendant's decision to terminate plaintiff's LTD benefits was arbitrary and capricious, the district court granted plaintiff's motion for judgment on the administrative record and denied defendant's motion. The district court ordered defendant to reinstate plaintiff as a participant and beneficiary under its LTD and life insurance policies and to pay to her past due benefits, plus accrued interest. The district court also awarded plaintiff reasonable attorney fees. UnumProvident's timely appeal followed. We affirm.
The present case arises from a complaint originally filed by plaintiff on February 13, 2004, in the district court against her employer, Sunbridge HealthCare, Inc. ("Sunbridge"),1 and her long-term disability insurer, defendant UnumProvident,2 seeking damages resulting from the termination of her LTD benefits and reinstatement of those benefits.
The policy defines disability, with regard to the class of employees that includes plaintiff, as follows:
You are disabled when UNUM determines that:
you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and
you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury; and
during the elimination period, you are unable to perform any of the material and substantial duties of your regular occupation.
The LTD policy further states that disability benefits will cease upon the occurrence of certain events, including "when you are able to work in your regular occupation on a part-time basis but choose not to . . . ." Finally, certain disabilities have a limited pay period under the policy. For example, "[d]isabilities, due to sickness or injury, which are primarily based on self-reported systems, and disabilities due to mental illness have a limited pay period up to 12 months."
Plaintiff is a forty-two-year-old single mother who suffers from complex intractable seizures, a form of epilepsy. According to her affidavit filed in conjunction with the administrative appeal, plaintiff worked as a nursing home administrator at various facilities in Alabama and Tennessee before beginning her work in 1996 with Sunbridge in Greeneville, Tennessee, as a nursing home administrator. As the senior administrator, plaintiff traveled between three nursing homes in Greeneville and Kingsport on a daily basis in order to oversee their operations. Her managerial and administrative duties included top-level decision-making on resident care, financial, budgetary, and personnel issues.
In 1994, plaintiff's family began noticing that she exhibited periods of unresponsiveness and, in January 1995, she suffered a grand mal seizure. In August 1995, Dr. John Dengler, a neurologist, diagnosed plaintiff as suffering from complex partial epilepsy and began medicating her. The seizure medication was ineffective, however, and plaintiff's condition deteriorated. Her seizure episodes began interfering with her work for Sunbridge. Plaintiff's seizures became more frequent, typically lasting three to five minutes, and unexpectedly occurred during and after work. Plaintiff suffered seizures during staff meetings and employee conferences, and a particularly severe seizure during an awards ceremony presentation required that plaintiff recuperate at home for more than two days. From February 1997 forward, plaintiff relied on friends, employees, and family to drive her back and forth to the nursing homes each workday. Even as a passenger, she continued to suffer seizures during her commute.
Dr. Dengler referred plaintiff to Dr. Bassel Abou-Khalil, a Vanderbilt University Medical Center neurologist and director of the University's Epilepsy Laboratory. In February 1999, Dr. Abou-Khalil hospitalized plaintiff and monitored her for seizure activities. A total of six seizures were recorded by video and electroencephalograph ("EEG") during the three-day hospitalization. Plaintiff was diagnosed as suffering from partial epilepsy with the epileptogenic focus in the left anterior-basal temporal region of her brain. Surgery was not considered to be an option.
Despite new medications, plaintiff's seizures continued to increase in number and severity. Plaintiff suffered on-the-job seizures that were debilitating. After each seizure, she was unable to remember what had happened in the recent past and could not recall what she had to do in the near future. By June 1999, Dr. Dengler and Dr. Abou-Khalil advised plaintiff that she should take an extended medical leave of absence. Both physicians opined that the stress associated with her administrative duties was responsible for the severity and frequency of the seizure episodes. Plaintiff applied for and received short-term disability benefits from September 1999 through February 2000. She then applied for LTD benefits under the group LTD policy provided by Sunbridge.
In support of her claim for benefits, plaintiff submitted attending physician statements from Dr. Dengler and Dr. Abou-Khalil and the neuro-diagnostic report from Dr. Abou-Khalil based on his three-day hospitalization study. Dr. Dengler opined that plaintiff was unable to drive or work in stressful situations and that her prognosis for recovery was "fair." Dr. Abou-Khalil indicated that plaintiff had frequent seizures with altered awareness which impaired her ability to work. He restricted plaintiff from activities such as using the stove or oven, driving, and operating heavy machinery. Dr. Abou-Khalil opined that plaintiff had not reached maximum medical improvement and that he expected it to be more than six months before there would be any fundamental changes in her medical condition.
Defendant determined that plaintiff met the definition of disability under the LTD policy and approved her receipt of benefits from March 2000 through May 2003. Because plaintiff's employee welfare benefit plan also provided a waiver of her group life insurance premium if she was disabled, she also received defendant's life insurance benefit with a waiver of premium guarantee. Plaintiff was awarded, and continues to draw, social security disability benefits.
Defendant thereafter continued to monitor plaintiff's medical condition with periodic updates. The following information was collected as part of defendant's monitoring process and is included in the administrative record considered by the district court.
An office note dated October 31, 2000, from Dr. Abou-Khalil indicated that plaintiff had not suffered any complex partial seizures since her last visit on July 31, 2000, although she still experienced auras (indications of the onset of a seizure) and difficulty with her memory. An examination revealed that she had no nystagmus, no tremor, no dysmetria, and no ataxia. Dr. Abou-Khalil was pleased with her seizure control.
A form completed by Dr. Abou-Khalil on January 4, 2001, indicated that plaintiff should not work in any situation where seizures could cause harm to herself or others, and she should not drive, handle hot items, operate moving machinery, or be in high, unprotected places. In an office note dated April 23, 2001, Dr. Abou-Khalil reported that plaintiff had not experienced any seizures since her visit in October 2000, and, in light of her excellent seizure control, he would not need to see her again for a year.
On April 20, 2001, defendant's disability consultant, Rick Yi, recommended that defendant conduct a vocational review and obtain further information from Dr. Abou-Khalil regarding his restrictions and how they would apply to plaintiff's occupation. On May 4, 2001, Lilia Rascon, a certified rehabilitation consultant, reviewed plaintiff's file and determined that her light duty occupation as an administrator of a health care facility fit well within Dr. Abou-Khalil's restrictions; thus, according to Ms. Rascon, plaintiff should be able to perform the material requirements of her position.
On August 8, 2001, defendant sent a letter to Dr. Abou-Khalil advising him that it believed plaintiff could perform her occupation within the restrictions and limitations he had provided. Dr. Abou-Khalil was asked whether or not he agreed with this assessment. He responded as follows:
Increased levels of stress can be a precipitant to seizure activity. Since Ms. Evans has been away from her work environment, the seizures have improved tremendously. The position of Nursing Home Administrator requires an enormous amount of responsibility along with very important decision-making skills. The stress level is very high. During and after a seizure, Ms. Evans is unaware of her surroundings, and is unable to make any rational decisions. It would be in Ms. Evans['] best interest not to return to work at this time.
On August 24, 2001, at a roundtable discussion of plaintiff's case, Dr. Michael Randall, a staff physician for defendant, who is board-certified in preventive medicine...
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