Atkins v. Guardian Life Ins. Co. of Am.

• Citation: 969 F.Supp.2d 788
• Decision Date: 26 August 2013
• Docket Number: Civil Action No. 12–70–HRW.
• Parties: Frances ATKINS, Plaintiff, v. GUARDIAN LIFE INSURANCE COMPANY OF AMERICA, Defendant.
• Court: U.S. District Court — Eastern District of Kentucky

969 F.Supp.2d 788

Frances ATKINS, Plaintiff,

v.GUARDIAN LIFE INSURANCE COMPANY OF AMERICA, Defendant.

Civil Action No. 12–70–HRW.

United States District Court,

E.D. Kentucky,

Northern Division,

Ashland.

Aug. 26, 2013.

Dwight O. Bailey, Flatwoods, KY, for Plaintiff.

David Eric Lycan, Steptoe & Johnson, PLLC, Lexington, KY, Sara E. Hauptfuehrer, Steptoe & Johnson PLLC, Bridgeport, WV, for Defendant.

MEMORANDUM OPINION AND ORDER

HENRY R. WILHOIT, JR., District Judge.

This matter is before the Court upon the parties' cross Motions for Judgment as a Matter of Law [Docket No. 19 and 20]. The motions have been fully briefed by the parties [Docket Nos. 21, 22, 23, 24, 25 and 26]. The Court having reviewed the parties' briefs as well as the Administrative Record [Docket No. 15] finds that the Defendant is entitled to judgment as a matter of law.

I. FACTUAL AND PROCEDURAL BACKGROUND

This lawsuit arises from Defendant Guardian Life Insurance Company of America's (hereinafter “GLIC”) termination of Plaintiff's Frances Atkins' long-term disability benefits. Plaintiff seeks reinstatement of her benefits under § 502(a)(1)(B) of ERISA, 29 U.S.C. § 1132. In addition to a reinstatement of her benefits, Plaintiff seeks an award of attorneys' fees and costs.

A. The Plan

Plaintiff began working as a Family Youth Specialist at Specialized Alternatives for Family and Youth (hereinafter “SAFY”) in July of 2004. As a benefit of her employment, she obtained long-term disability insurance coverage under a Guardian Group Insurance Plan sponsored by SAFY (“the Plan”). The Plan is insured and administered for purposes of claims adjudication by GLIC. The Plan expressly designates GLIC as the “Claims Fiduciary with discretionary authority to determine eligibility for benefits and to construe the terms of the plan with respect to claims.” [ See Administrative Record (hereinafter “AR”), Docket No. 15 at 43]. The Plan also provides, “[w]e [GLIC] decide: (a) if you are eligible for this insurance; (b) if you meet the requirements for benefits to be paid; and (c) what benefits are to be paid by this plan.” [AR 24].

The Plan offers monthly disability benefits equal to 60 percent of a participant's “insured earnings,” as defined by the Plan. [AR 29]. A participant is “disabled” if she has “physical, mental or emotional limits caused by a current sickness or injury” and as a result of those limits she “[is] not able to perform the major duties of [her] own occupation or any gainful work.” [AR 37]. The “own occupation” definition of disability applies during the first twenty-four months of benefit payments; thereafter, the “any gainful work” or “any occupation” standard applies. Id. Upon a determination of disability by GLIC, benefits are payable following a ninety-day elimination period. [AR 23]. Plan benefits are offset by certain kinds of other income, such as workers' compensation benefits and Social Security disability benefits. [AR 101].

Generally, “any occupation” benefits are payable for as long as the disability continues, up to age 65. Id. Benefits terminate prior to age 65, if, among other things, the participant is no longer disabled or fails to provide “required current proof of loss.” [AR 27].

“Special limitations” can also affect the maximum period for which benefits are payable. For a disability due to mental or emotional conditions, the maximum payment period is twenty-four months. [AR 28]. A twelve-month lifetime payment limit applies to “subjective disorders,” defined as “a condition that cannot be proved using current clinical standards.” Id.

The Plan also excludes disabilities due to a pre-existing condition until the participant has been actively employed by the plan sponsor for twenty-four months. [AR 105]. Pre-existing conditions are those for which the participant was treated during the six-month period immediately preceding the effective date of the participant's coverage under the Plan. Id.

B. The Accident

On December 10, 2004, Plaintiff was working on a case near Vanceburg, Kentucky. She left the foster home and was on her way to pick up some clothing for the child when she was struck, nearly head-on, by another vehicle. Her head struck the steering wheel and she was briefly rendered unconscious. She was transported by ambulance from the scene of the accident to Meadowview Medical Center and was released that day. That evening she experienced dizziness and nausea as well as neck and back pain. The next day she went to the Emergency Room at Kings Daughters Medical Center. X-rays revealed “mild frontal scalp soft tissue swelling.” [AR 322]. She was released that day. On December 16, 2004, Plaintiff returned to King's Daughters for a CT examination of her cervical spine, which revealed “[n]o evidence of post traumatic injury.” [AR 321].

C. Plaintiffs Application for Disability

GLIC received Plaintiff's application for long-term disability benefits and supporting documentation on May 17, 2005. [AR 292–337]. According to the attending physician's statement Plaintiff's diagnoses were “Displaced Cervical & lumbar Disc”; “Vestibulopathy”; and “Brain Concussion.” [AR 300]. Her complaints were “severe neck & low back pain.” Id.

GLIC requested medical records from Plaintiff's physicians. [AR 344–52]. GLIC also requested additional information from the Plaintiff, including a copy of an Independent Medical Evaluation (“IME”) report relating to her workers' compensation claim. [AR 398]. In addition, in June 2005 GLIC's claims specialist referred the file to Karen Walczer, R.N. for follow-up and further investigation with respect to the Plaintiff's medical issues. [AR 128].

On July 19, 2005, GLIC paid Plaintiff four months worth of benefits ($5,968.00) “on an administrative basis to assist [her] during [GLIC's continued] investigation” of her claim. [AR 584]. The payment was made under a reservation of rights and was based on Plaintiff's conditions of displaced cervical and lumbar disc and concussion, which were not pre-existing conditions under the terms of the Plan. [AR 585]. GLIC referred the matter to its Special Investigation Unit to follow up on reports that Plaintiff was working at her husband's health food store instead of reporting for work at SAFY. [AR 580–82]. Monthly benefit payments were made to Plaintiff during GLIC's investigation.

Plaintiff continued to see Dr. Bansal for various complaints of back, neck, and knee pain, along with problems with concentration, memory, and dizziness, during the remaining months of 2005 and into 2006. [E.g., AR 662, 661, 660, 658–59, 656–57]. Dr. Bansal performed a nerve conduction study and electromyography on May 19,2005. The report states: “[e]ssentially normal study; [t]here was no indication of any cervical radiculopathy or lumbosacral radiculopathy and there was no evidence of any myopathy or neuropathy from this study.” [AR 654–55]. On November 22, 2005, Plaintiff was evaluated at Tri–State Otolaryngology for problems walking due to poor balance. [AR 527–28]. The evaluator found “no significant evidence” to support a conclusion that Plaintiff's disequilibrium was due to “vestibular insult” and recommended physical therapy. [AR 528]. Plaintiff underwent an extensive neuropsychological examination which entailed visits on July 20, September 27, October 30, 2005, and January 17, 2006. [AR 608–31]. As this evaluation was conducted over an extended period of time, Plaintiff requested and GLIC gave her an extension of time for submitting information needed to complete the review of her claim. [AR 136–40]. Meanwhile, in December 2005 GLIC learned that the Plaintiff had been awarded Social Security disability benefits in January 2004 for depression, anxiety, and panic attacks. [AR 536].

By letter dated June 1, 2006, GLIC notified Plaintiff that she was eligible for Plan benefits. AR 669–70. Such benefits were payable under the Plan's “own occupation” definition of disability. GLIC also determined that the Social Security disability benefits Plaintiff had been receiving since January 2004 were properly offset against benefits under the Plan and requested repayment of $2,970.82 in overpayments. [AR 676–77]. Plaintiff was not able to satisfy the overpayment in a lump sum, so GLIC began withholding installments from her monthly benefits. [AR 683].

D. GLIC's Determination of Non–Eligibility for “Any Occupation” Benefits

GLIC continued to monitor Plaintiff's condition, seeking information concerning her ongoing medical care and her own assessment of the effect of her symptoms on daily activities. [AR 698–70]. On October 31, 2006 and again on February 12, 2007, GLIC notified Plaintiff that effective March 11, 2007, the Plan's “any occupation” definition of disability would apply, such that benefits would continue if Plaintiff was “unable to perform the duties of any occupation for which [she was] suited by education, training, or experience.” [AR 714, 715]. It was not until September of 2007 that GLIC received the information necessary to complete its review; benefit payments continued in the meantime.

In connection with GLIC's review, Kevin Duncan, an independent functional capabilities therapist retained through United Review Services, Inc., the evaluated Plaintiff on August 2, 2007. He noted that her participation was self-limiting in seventeen out of twenty-one tasks. [AR 769]. Such performance indicates that it is likely that “psychosocial and/or motivational factors may be influencing physical performance.” [AR 770]. Still, the functional capabilities evaluation (“FCE”) report concluded that the Plaintiffs results “indicate the ability to function at the sedentary level of work at this time,” which conclusion was consistent with a Physical Capabilities Evaluation completed by Dr. Bansal on April 26, 2007. [AR 769; AR 737–39]. GLIC forwarded a copy of the Mr. Duncan's FCE report to Dr. Bansal for comment on August 23, 2007, and telephoned his office twice, but did not receive a...