Anderson v. Nationwide Mut. Ins. Co.
| Decision Date | 12 January 2009 |
| Docket Number | No. 3:07-cv-00097 RP-RAW.,3:07-cv-00097 RP-RAW. |
| Parties | Christine ANDERSON, Plaintiff, v. NATIONWIDE MUTUAL INSURANCE COMPANY, Defendant. |
| Court | U.S. District Court — Southern District of Iowa |
Mark R. Fowler, Gomez May Cartee & Schutte, Davenport, IA, for Plaintiff.
Elizabeth A. Coonan, Michael A. Dee, Brown Winick Graves Gross Baskerville & Schoenebaum PLC, Des Moines, IA, for Defendant.
ORDER ON DEFENDANT'S MOTION FOR SUMMARY JUDGMENT
Before the Court is Defendant's, Nationwide Mutual Insurance Company ("Nationwide"), Motion for Summary Judgment, filed on August 27, 2008. Clerk's No. 16. Plaintiff, Christine Anderson ("Anderson"), filed Plaintiff's Memorandum in Opposition to Defendant's Motion for Summary Judgment on October 7, 2008. Clerk's No. 22. Nationwide filed its Reply Brief in Support of its Motion for Summary Judgment on October 20, 2008. Clerk's No. 23. The matter is fully submitted.
Anderson was hired by Nationwide in 1997 as a Multiline Special Claims Representative I. Def.'s Statement of Undisputed Facts in Supp. of its Mot. for Summ. J. (hereinafter "Def.'s Facts") ¶ 1. Anderson was eligible for coverage under the Nationwide Insurance Companies and Affiliates Disability Income Benefit Plan (hereinafter "Benefit Plan"). See Def.'s App. at 54. The Benefit Plan is an "employee benefit plan" covered by the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001, et seq. See Clerk's No. 9. "Disability" is defined within the Benefit Plan as:
"Disability" or "Disabled" means a disability or disablement that results from a substantial change in medical or physical condition as a result of Injury or Sickness and is prevented from engaging in Substantial Gainful Employment for which she is, or may become, qualified. Continuation of an existing medical or physical condition will generally not constitute a substantial change in medical or physical condition if Claimant has been able to engage in Substantial Gainful Employment, or such medical or physical condition could be or has been accommodated. A substantial change in medical or physical condition may be evidenced by the change or loss of at least one of the Activities of Daily Living.
Def.'s Facts ¶ 47. "Substantial Gainful Employment" is defined as:
(a) For Active, Associates who are not Eligible Statutory Employees, any occupation or employment from which an individual may receive an income equal to or greater than one-half of such individual's Covered Compensation as of her Date of Disability.
(b) For Active Associates who are not Eligible Statutory Employees, any occupation or employment from which an individual may receive an income equal to or greater than one-half of such individual's pre-disability income. Pre-disability income is equal to all income earned in the calendar year prior to the Date of Disability, regardless of source, i.e., including non-Nationwide employers, income reported on a W-2, on a 1099, etc. Upon request, the Plan Administrator will use the Eligible Statutory Employee's adjusted gross income as reported on Eligible Statutory Employee's Form 1040 for the calendar year prior to the Date of Disability.
Id. ¶ 48. The named plan administrator for the Benefit Plan is the Benefits Administration Committee (hereinafter "the Committee") and, as such, it is responsible for the payment of all benefits. Def.'s Facts ¶ 51; Def.'s App. at 74. The Committee is "established by the Board of Directors of the Plan Sponsor," and members are "appointed by the Board of Directors of the Plan Sponsor." Def.'s App. at 46. The Committee has the "powers and duties, . . . (a) To exercise discretion and authority to construe and interpret the provisions of the Plan, ..., and enforce rules and regulations under the Plan ... (b) To decide all questions as to the rights of Participants under the Plan and such other questions as may arise under the plan." Id. at 74. The Committee may delegate administrative duties and an initial claim determination to another party, but an appeal from an adverse benefit determination will be considered by the Committee. Id. at 47.
As a Multiline Special Claims Representative I, Anderson was required to drive and sit at a computer with intermittent walking and standing. Def.'s Facts ¶ 1. It is unclear from the record when Anderson's back pain began, but documentation of medical care for Anderson's back starts following a back surgery, "a laminectomy at L4-5," performed by Dr. Roski in September 2002. Id. ¶ 3; Def.'s App. at 130. Following the surgery, on November 20, 2003, Anderson was referred to Dr. Timothy Millea ("Dr. Millea") and reported that she was experiencing pain across her low back that was radiating into her lower extremity. Def.'s Facts ¶ 4. On December 11, 2003, Anderson applied for and was granted disability benefits due to "persistent lower back pain" following the L4-5 laminectomy. Id. ¶ 7; Def.'s App. at 2. On December 23, 2003, an MRI of Anderson revealed a "small disc protrusion at L5-S1." Def.'s Facts ¶¶ 11-13; Def.'s App. at 127. Dr. Millea subsequently completed an Attending Physician's Statement reporting Anderson's back pain and concluding both that Anderson was totally disabled from performing her job and that it was undetermined when she could return to work. Def.'s App. at 1-3.
Anderson subsequently underwent physical therapy and acupuncture but developed other radicular symptoms and heel pain. Def.'s Facts ¶¶ 8-10. Anderson continued to consult with Dr. Millea as her symptoms increased and, in March 2004, she reported that she found it "quite difficult to sit." Def.'s App. at 125. On June 1, 2004, she consulted Dr. Dudley Davis ("Dr. Davis") at the Mayo Clinic who diagnosed Anderson with Arachnoiditis and stated that her prognosis was uncertain. Def.'s Facts ¶ 20; Def.'s App. at 93, 95, 97, 99. In June 2004, Dr. Millea stated in response to the diagnosis of Arachnoiditis in her lumbar spine that he "certainly did not have this opinion but certainly the possibility is a consideration since we have not made any further headway in her treatment otherwise." Def.'s App. at 124.
A disability case manager with GatesMcDonald Disability Management Solutions ("GatesMcDonald") arranged for an Independent Medical Examination ("IME") of Anderson. Id. at 88-93. GatesMcDonald, according to its letters to Anderson, provided case management and claims administrative services for the Benefit Plan but foreswore any role in benefit determinations, which it stated were made at the discretion of Nationwide Insurance. Id. at 87, 90, 92. On June 10, 2004, Dr. Thomas Hughes ("Dr. Hughes") conducted the IME and diagnosed Anderson with "post lumbar discectomy" and "laminectomy at L4-5 left sciatica secondary to apparent disc herniation at L5-S1 with some residual S1 radiculopathy associated with an absent ankle jerk on the left side," "chronic arachnoiditis (non-surgical)," and "chronic pain syndrome." Def.'s Facts ¶¶ 21-22. Dr. Hughes wrote in his evaluation:
At this point in time, it does not appear to be a practical consideration to attempt to direct Ms. Anderson return to work or substantial employment in virtually any capacity. She is simply not able to sustain any position for [a] long enough period of time to accomplish any kind of productive task. Travel, sitting at a desk, operating a computer, talking on the telephone and obtaining information and similar office duties seem to be beyond her work capacity at this time. She appears to be chronically sleep deprived and experiencing chronic pain that would preclude her from performing useful tasks for which she could be paid. This assessment might be subject to revision with a different line of treatment.
Id. ¶ 22. Dr. Hughes also noted that Anderson "seem[ed] to have some flattening of the affect and [he thought] there [were] some subtle mood changes, which [were] suggestive of some evidence of depression." Def.'s App. at 110.
Anderson was referred from the Mayo Clinic to the University of Iowa Hospitals and Clinics where, on July 1, 2004, Dr. Naeem Haider ("Dr. Haider") determined that Anderson had chronic low back pain and possible Arachnoiditis. Id. at 132, 134. On September 3, 2004, during a follow-up visit, Anderson reported improvements in her condition, though her back pain would "increase[] with periods of increased standing or sitting for long periods of time," and when her pain became extreme, she would "lay[] down with her leg pain, usually 2-3 times a day." Id. at 137. When she returned on January 7, 2005, Dr. Haider reported that she continued to experience these pain symptoms and also noted a concern that her medications were interfering with her concentration. Id. at 145.
Anderson consulted with Dr. Mark Lucas ("Dr. Lucas") about her foot pain on September 16, 2004. Id. at 121. An X-ray examination revealed "infracalcaneal spurs" and "joint-space narrowing about the talonavicular joints" on each foot. Id. Dr. Lucas diagnosed Anderson with heel spurs and plantar fascitis. Id. at 123. Anderson also consulted with Dr. Charles Saltzman ("Dr. Saltzman") of the University of Iowa Hospitals and Clinics regarding her foot pain between November 2004 and March 2005. Def.'s App. at 139, 144. She reported that she believed that her health was somewhat better than it had been a year previously, but continued to report pain that increased when she sat for "very long." Id. During her initial visit, Dr. Saltzman observed "bilateral heel pain," "midfoot arthritis at the talonavicular joint," a "possible injury to her gastroc at the musculotendinous junction," and the need for "greater rehab on her right ankle." Id. at 143. In her follow-up visits with Dr. Saltzman, Anderson continued to show signs of foot and back pain, especially in her central heel. Id. at...
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