763 F.3d 598 (6th Cir. 2014), 13-6319, Hayden v. Martin Marietta Materials, Inc.
|Citation:||763 F.3d 598|
|Opinion Judge:||JULIA SMITH GIBBONS, Circuit Judge.|
|Party Name:||GAYLON HAYDEN, Plaintiff-Appellant, v. MARTIN MARIETTA MATERIALS, INC. FLEXIBLE BENEFITS PROGRAM, Defendant-Appellee|
|Attorney:||Geordi Garatt, Paducah, Kentucky, for Appellant. Robert L. Steinmetz, Rebecca A. Wood, GWIN STEINMETZ & BAIRD, PLLC, Louisville, Kentucky, for Appellee.|
|Judge Panel:||Before: GILMAN, GIBBONS, and STRANCH, Circuit Judges. GIBBONS, J., delivered the opinion of the court, in which GILMAN, J., joined, and STRANCH, J., joined in part. STRANCH, J., delivered a separate opinion concurring in part and dissenting in part. JANE B. STRANCH, Circuit Judge, concurring in p...|
|Case Date:||August 18, 2014|
|Court:||United States Courts of Appeals, Court of Appeals for the Sixth Circuit|
Appeal from the United States District Court for the Western District of Kentucky at Paducah. No. 5:11-cv-00116--Thomas B. Russell, District Judge.
Gaylon Hayden, a participant in Martin Marietta Materials, Inc.'s long-term disability plan (" the Plan" ), appeals from two adverse judgments in her suit for long-term disability benefits under the Employee Retirement Income Security Act (" ERISA" ), 29 U.S.C. § 1001 et seq. In the district court's first order, it affirmed the plan administrator's denial of benefits on Hayden's physical-disability claim but remanded her mental-disability claim because
the plan administrator failed to consider medical evidence from three doctors. On remand, the plan administrator again rejected Hayden's claim, and the district court affirmed. For the reasons set forth below, we affirm with respect to Hayden's physical-disability claim but reverse with respect to her mental-disability claim. We further instruct the district court to award Hayden mental-health benefits consistent with the terms of the Plan.
Hayden was employed as an office manager at Martin Marietta beginning in 1997. She was covered by Martin Marietta's long-term disability plan, which was insured and administered by Liberty Life Assurance Company of Boston (" Liberty" ). She stopped working as an office manager on January 4, 2010, and applied for benefits under the Plan the next day.
Martin Marietta employees who provide proof that they are disabled due to injury or sickness are entitled to monthly disability payments under the Plan. The Plan defines " disability" and " disabled" :
1. For persons other than pilots, co-pilots, and crewmembers of an aircraft:
i. if the Covered Person is eligible for the 24 Month Own Occupation benefit, " Disability" or " Disabled" means that during the Elimination Period and the next 24 months of Disability the Covered Person, as a result of Injury or Sickness, is unable to perform the Material and Substantial Duties of his Own Occupation; and ii. thereafter, the Covered Person is unable to perform, with reasonable continuity, the Material and Substantial Duties of Any Occupation.
In turn, the Plan defines " Any Occupation," " Own Occupation," and " Elimination Period" :
" Any Occupation" means any occupation that the Covered Person is or becomes reasonably fitted by training, education, experience, age, physical and mental capacity.
" Own Occupation" means the Covered Person's occupation that he was performing when his Disability or Partial Disability began. For the purposes of determining Disability under this policy, Liberty will consider the Covered Person's occupation as it is normally performed in the national economy. " Elimination Period" means a period of consecutive days of Disability or Partial Disability for which no benefit is payable. The Elimination Period is shown in the Schedule of Benefits and begins on the first day of Disability.
Employees disabled by mental illness are entitled to recover " a combined period of 24 months of Monthly Benefit payments while the Covered person is insured."
" Mental Illness" means a psychiatric or psychological condition classified as such in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) regardless of the underlying cause of the Mental Illness. If the DSM is discontinued, Liberty will use the replacement chosen or published by the American Psychiatric Association.
An employee is thus entitled to benefits for a period of 24 months if she cannot perform the duties of her own occupation from the first day of claimed disability through the next 180 days (the Elimination Period) and subsequent 24 months, and, thereafter is entitled to benefits if the employee cannot perform the material and
substantial duties of any occupation. Hayden claims that she was disabled within the meaning of the Plan by virtue of both physical and mental ailments.
Hayden suffers from a litany of physical ailments, including, among others: chronic hepatitis C; pancreatitis; fibrocystic breast disease with breast implants; degenerative arthritis; breast carcinoma; hypothyroidism; hypotension; hypertension; and crepitation1 and decreased range of motion around her shoulders, cervical spine, hips, and knees.
Dr. Joseph Bassi is Hayden's primary treating physician. As early as 2003, Dr. Bassi suggested that Hayden consider applying for disability benefits. In his notes from April of that year, he wrote: " I spoke with the patient regarding her overall situation. She is slowly declining, has lost weight . . . . I think it is time Gaylon consider total permanent disability." On January 6, 2010, two days after Hayden left Martin Marietta, Dr. Bassi noted: " Her symptoms have been going on for an extended period of time, months; mild to moderate severity, now more severe in the context of advancing generalized medical illness." Hayden continued to visit Dr. Bassi during the Elimination Period. By September 2010, Dr. Bassi had become concerned that Hayden suffered from syncope2 or presyncope, and in November 2010, Hayden was hospitalized for presyncope. She was eventually sent to Vanderbilt University Medical Center, where a Q-SWEAT showed abnormal results as to whether Hayden suffered from syncope.
In January 2011, Dr. Bassi gave a sworn statement in connection with Hayden's claim for Social Security disability benefits. Dr. Bassi explained that by the time of his consultation in January 2010, " the multiple symptoms from her comorbities3 had gotten to a point where . . . she just couldn't continue any further." Dr. Bassi also explained that Hayden suffered from serious dysfunction of her autonomic nervous system and that while she was on a medication called Midodrine, the FDA had discontinued the drug and there was no replacement. Without the Midodrine, Dr. Bassi opined that Hayden would be prevented from performing even basic functions such as standing for moderate periods of time. Hayden was eventually awarded Social Security disability benefits.
Dr. Kest also saw Hayden from June 2008 through 2010. In December 2009, he noted that her left vocal cord showed signs of paralysis but believed that her right vocal cord was compensating for the problem. In September 2010, he found an edema of the laryngeal structures which affected her ability to speak.
Hayden submitted evidence from four doctors detailing her serious psychiatric conditions. She saw Dr. Ronald Kelley from December 2006 to February 2007. Dr. Kelley diagnosed her with general anxiety disorder, major depression, and insomnia. Thereafter, Hayden's oncologist referred her to Dr. Roger Lyons for treatment of extreme anxiety with consequential depression. She saw Dr. Lyons throughout 2008. Dr. Lyons observed that her " thought content was dysphoric and fear-based (appears to be a manic defense)," that her psychomotor skills " appeared
leaden suggesting malaise," that she had " annoying preoccupations with fears that produce ritualistic/prophylactic behaviors," and that her emotional tone was dulled and numb. Hayden did not continue treatment with Dr. Lyons because her insurance company erroneously advised her that she would not be covered.
In his January 6, 2010, consultation with Hayden, Dr. Bassi noted that Hayden suffered from anxiety with depression that had become worse with her deteriorating health. He stated that she suffered from " disability, weakness, and inability to care about her day to day life" and that she had significant weight loss because she was " just not eating." Dr. Bassi explained that she had previously " forced herself to work, but now she just can't continue on." In February, he observed in connection with his diagnosis of anxiety and depression that " [h]er life is overwhelmed by symptoms at this time" and that " [i]t is obvious this patient is no longer able to function effectively with ongoing symptoms." Dr. Bassi's notes from July 2010 recount that she was " totally disabled, if nothing else, from her nerves, dealing with multiple issues at this time." In his sworn statement in connection with Hayden's claim for Social Security disability benefits, Dr. Bassi explained that by January 6, 2010, " she was basically overwhelmed with her day-to-day life chores, activity of daily living, stresses and just plain physical work she was doing" and that she was at " a point where she just...
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