Bombassei v. The Lincoln Nat'l Life Ins. Co.
| Decision Date | 23 May 2023 |
| Docket Number | 22-10593 |
| Parties | CHERYL BOMBASSEI, Plaintiff, v. THE LINCOLN NATIONAL LIFE INSURANCE COMPANY, Defendant. |
| Court | U.S. District Court — Eastern District of Michigan |
ORDER GRANTING PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT [#17] AND DENYING DEFENDANT'S MOTION FOR JUDGMENT ON THE ADMINISTRATIVE RECORD [#18]
On March 21, 2022, Plaintiff Cheryl Bombassei brought suit against Defendant The Lincoln National Life Insurance Company. Plaintiff is seeking long term disability benefits after Defendant determined that she did not suffer from a disability under the terms of her policy. On January 17 2023, Plaintiff filed a Motion for Summary Judgment, ECF No 17, and Defendant filed a Motion for Judgment on the Administrative Record. ECF No. 18. Both motions have been fully briefed. For the reasons that follow, Plaintiff's motion is granted and Defendant's motion is denied.
Plaintiff, who worked for more than 20 years as a nurse and a nurse practitioner, was covered by an employer disability plan. She stopped working on September 4, 2018, and she has never returned to work. Plaintiff stopped working due to a shoulder injury, rheumatoid arthritis, and extreme daytime sleepiness that was diagnosed in 2014 as narcolepsy. Her treating neurologist, Dr. Trock, opined that she was incapable of work.
When Plaintiff stopped working, she applied for and ultimately was approved for a 26-week short-term disability leave. Plaintiff then transitioned to the long-term disability plan, where she was considered “disabled” because she was unable to perform the main duties of her “Own Occupation,” as defined below. Plaintiff received long-term disability benefits for a 24-month period that ended on March 5, 2021.
One condition of receiving the long-term benefits was that Plaintiff had to seek other available benefits, including Social Security Disability. Plaintiff applied for Social Security Disability, and she was found to have severe impairments consisting of rheumatoid arthritis, left shoulder disorder, narcolepsy, and depression. The Social Security Administrative Law Judge (“ALJ”), who consulted impartial vocational expert Harry Cynowa, concluded that Plaintiff had a less-than- sedentary functional capacity, namely because she must lay down 20% (2 hours) of the workday. The ALJ ruled in relevant part:
[...]The claimant has the residual functional capacity to perform sedentary work as defined in 20 CFR 404.1567(a) except claimant requires the ability to lay down for up to 2 hours during the workday. [.] Considering the claimant's age, education, work experience and residual functional capacity, there are no jobs that exist in significant numbers in the national economy that claimant can perform [.] Even if the claimant had the residual functional capacity for the full range of sedentary work, a finding of “disabled” would be directed by Medical-Vocational Rule 201.14. [.].
Id. On March 24, 2020, the Administrative Law Judge found Plaintiff unable to perform any other job in the economy.
On June 18, 2020, Defendant notified Plaintiff that it was reviewing her long-term disability claim because she was approaching 24 months of being qualified under the policy. The policy definition of “disabled” changes after 24 months of coverage from inability to perform main duties of “Own Occupation” to “Any Occupation.” On December 30, 2020, Defendant informed Plaintiff that it was terminating coverage beyond March 5, 2021, the end of her Own Occupation period. Defendant denied Plaintiff's (and Plaintiff counsel's subsequent) appeal of Defendant's determination to terminate coverage.
Under the policy, certain relevant terms have the following definitions:
Section 1132 is the civil enforcement provision of ERISA which states:
A civil action may be brought ... by a participant or beneficiary ... to recover benefits due to [her] under the terms of [the] plan, to enforce [her] rights under the terms of the plan, or to clarify [her] rights to future benefits under the terms of the plan.
29 U.S.C. § 1132(a)(1)(B). A denial of benefits “is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan.” Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 103, 115 (1989). In this case, the parties agree that the Court's review of Defendant's denial of disability benefits is to be reviewed de novo.
Under a de novo review, “the role of the court reviewing a denial of benefits is to determine whether the plan administrator made the correct decision.” Hoover v. Provident Life and Acc. Ins., 290 F.3d 801, 808 (6th Cir.2002) (internal quotations omitted). First, the Court must decide whether the administrator properly interpreted the Plan. Id. at 809. Applying general principles of contract law, the Court must read the Plan provisions “according to their plain meaning in an ordinary and popular sense” and construe any ambiguities in the Plan against the drafter. Williams v. Int'l Paper Co., 227 F.3d 706, 710 (6th Cir. 2000).
Second, relying only on the record before the plan administrator at the time of its decision, the Court must decide whether the insured was entitled to benefits under the proper interpretation of the Plan provisions. Hoover, 290 F.3d at 809.
Plaintiff contends that, as of March 5, 2021 and continuing to today, she has not been able to perform each of the Main Duties of any occupation which her training, education or experience will reasonably allow. For this reason, she maintains that she is “totally disabled” as defined by the policy. There are two steps of this analysis - first, what, if any, ability to perform does Plaintiff have in light of her medical conditions. Second, do her residual abilities, training, education and experience align with the main duties of any potential occupation in the economy. Plaintiff claims she has no occupational functional capacity because her residual abilities are less than required for any job in the economy, such that she satisfies the policy's definition of total disability. The parties have two different views of Plaintiff's physical limitations.
Plaintiff argues that she has a long medical history of uncontrolled rheumatoid arthritis and severe narcolepsy, all of which is supported by objective evidence. It is undisputed that, in 2014, Plaintiff was diagnosed with excessive daytime sleepiness and narcolepsy without cataplexy (type 2 narcolepsy). See ECF No. 17, Ex. A . Plaintiff states that narcolepsy is incurable, so there is no reason to test for it again after a diagnosis. Plaintiff also notes that Defendant's final reviewer (Dr. Reilly) agrees there is a diagnosis of narcolepsy.
Imad M. Obeid, MD opined that daytime naps are necessary for Plaintiff to function, AR, LIN000293-298; 687-690 (see also and Gary L. Trock, MD, at 504). A psychologist, Robin Billing, PhD, indicated on October 1, 2019 that Plaintiff would be expected to be absent four or more days a month and be off task 20% of the workday. AR, LIN000207-08. Plaintiff also has a Social Security functional restriction that she must have the ability to lay down for up to two hours during the workday, AR, LIN000339, which renders her disabled for purposes of the Social Security Administration. Id. at LIN000343. Plaintiff contends this restriction would render her disabled from “any occupation” under the policy, including a sedentary clerical occupation.
Defendant questions the validity of the Social Security determination because it was made in March 2020, a year before the claimed current disability period commenced, and was based on an October 1, 2019 letter from a psychologist (who the ALJ believed to be a neurologist) who had not seen Plaintiff since November 2018.
Plaintiff's self-reports, and reports of her daughter and a co-worker indicate that since 2018 she has falling asleep at work, with patients, and at home, and that she has been “controlling” her narcolepsy with multiple daytimes naps daily. Defendant argues, however, that the reports of her daughter and co-worker were written in 2018, yet her fatigue, arthritis...
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