Caskey v. Prudential Ins. Co. of Am., CIVIL ACTION NO. 18-694-JWD-RLB

• Decision Date: 20 July 2020
• Docket Number: CIVIL ACTION NO. 18-694-JWD-RLB
• Citation: 473 F.Supp.3d 644
• Parties: Steven W. CASKEY v. The PRUDENTIAL INSURANCE COMPANY OF AMERICA
• Court: U.S. District Court — Middle District of Louisiana

473 F.Supp.3d 644

Steven W. CASKEY

v.The PRUDENTIAL INSURANCE COMPANY OF AMERICA

CIVIL ACTION NO. 18-694-JWD-RLB

United States District Court, M.D. Louisiana.

Signed July 20, 2020

Reagan Levert Toledano, James Frederick Willeford, Willeford & Toledano, New Orleans, LA, for Steven W. Caskey.

Patricia Schuster LeBlanc, LeBlanc Butler, LLC, Metairie, LA, Amanda A. Sonneborn, Pro Hac Vice, Megan E. Troy, Pro Hac Vice, Seyfarth Shaw LLP, Chicago, IL, for Prudential Insurance Company of America.

RULING AND ORDER

JOHN W. deGRAVELLES, JUDGE

This matter is before the Court on cross motions for summary judgment. (Docs. 37 & 38.) The parties have filed responses and replies. The Court held oral argument on the cross motions on June 25, 2020. (Doc. 67.) The Court has considered the facts in the administrative record, the arguments of the parties, and the applicable law. For the reasons expressed, the Court will grant The Prudential Insurance Company of America's Motion for Summary Judgment. (Doc. 37.)

RELEVANT FACTS

a. Factual Background

Steven W. Caskey ("Plaintiff" or "Mr. Caskey") is 49 years old. (Doc. 20-1 at 229.) Mr. Caskey worked at Occidental Chemical Corporation ("Oxy") from 1996 to October 22, 2014. (Id. at 224.) His final job title was Shift Supervisor. (Id. at 229) Mr. Caskey filed this suit seeking judicial review of the decision by The Prudential Insurance Company of America ("Prudential") to terminate his long-term disability benefits. (Doc. 1.)

b. The Plan

1. General provisions in the Plan and Plan Documents

Oxy is the plan sponsor and plan administrator for the Occidental Petroleum Corporation Welfare Plan ("Plan") that provided, among other benefits, long term disability benefits to eligible participants in the Plan. (Doc. 20-1 at 1-21; 206.) The Plan is governed by the Employment Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq. (Doc. 20-1 at 206-211.)

The Plan consists of the Occidental Petroleum Corporation Welfare Plan ("Oxy Wrap"), the Oxy Long-Term Disability Summary Plan Description ("Oxy SPD"), the Oxy, Inc. Group Contract G-50262-TX, including applicable amendments ("Group Contract"), and the Long-Term Disability Booklet Certificate, including applicable rider, ("LTD Booklet Certificate"). (See Doc. 20-1 at 4 (Oxy Wrap at Section 1.2).) Section 1.2, Governing Documents of the Oxy Wrap states:

(a) The following documents are hereby incorporated by reference into and shall be part of the document governing this Plan: (1) The Plan documents governing each Benefit Program. These documents shell provide, among other things, rules relating to the Coverage Options available under each such Benefit Program, the benefits available under each Coverage Option, and the rules governing eligibility for such benefits.

(Doc. 20-1 at 4.)

Section 8.2(d) of the Oxy Wrap, Powers of the Plan Administrator, states:

The Plan Administrator shall have the exclusive right to interpret the terms and provisions of the Plan and to resolve all questions arising thereunder, including without limitation the right to resolve and remedy ambiguities, inconsistencies, or omissions in the Plan.... All findings of fact, interpretations, determinations, and decisions of the Plan Administrator with respect to any matter or question arising under the Plan, shall be final, conclusive, and binding upon all persons having or claiming to have any interest in or right under the Plan, and shall be given the maximum possible deference allowed by law.

(Doc. 20-1 at 13.) The Oxy Wrap also states, "Additional named fiduciaries may be designated, and their respective functions delineated in the applicable summary plan descriptions." (Id. )

The Oxy SPD states, under the heading, The Claims Administrator, "Prudential, as the Claims Administrator, will decide your claims and appeals. Prudential has exclusive discretionary authority to interpret LTD Plan provisions as well as to determine facts and other information related to claims and appeals. Prudential's decisions are conclusive and binding." (Doc. 20-1 at 56.) The Supplement SPD attached to the LTD Booklet Certificate further states: "The Prudential Insurance Company of America as Claims Administrator has the sole discretion to interpret the terms of the Group Contact, to make factual findings, and to determine eligibility for benefits. The decision of the Claims Administrator shall not be overturned unless arbitrary and capricious." (Id. at 207.)

As designated, Prudential is the claims fiduciary and claims administrator for long term disability benefit claims brought pursuant to the terms and conditions of the Plan. (Id. at 56 and 207.) Prudential also insures long term disability benefits payable under the Plan. (Id. at 151 and 207.)

Section 10.9 of the Plan entitled Governing Law, states, "The Plan shall be construed, administered and governed in all respects under the applicable laws of the State of Delaware, except to the extent preempted by federal law, or governed by the applicable insurance law." (Doc. 20-1 at 19.) The Group Contract states, "The Group Contract is delivered in and is governed by the laws of the Governing Jurisdiction." (Doc. 20-1 at 151.) The Group Contract defines that the Governing Jurisdiction is the "State of Texas." (Id. at 152.) The Oxy SPD states, "If a conflict exists between a statement in this summary and the provisions of the Plan document or any applicable contract, the Plan document will govern." (Doc. 20-1 at 57.)

2. The Plan's Definitions

The terms of the Plan provide the following definitions.

A. Disability:

You are disabled when Prudential determines that: you are unable to perform 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 monthly earnings due to that sickness or injury. After 24 months of payments, you are disabled when Prudential determines that due to the same sickness or injury: • you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience; and • you are under the regular care of a doctor.

(Doc. 20-1 at 178 (emphasis in original).)

B. Regular Occupation:

[T]he occupation you are routinely performing when your disability begins. Prudential will look at your occupation as it is normally performed instead of how the work tasks are performed for a specific employer or at a specific location.

(Id. )

C. Material and Substantial Duties:

Duties that: are normally required for the performance of your regular occupation; and cannot be reasonably omitted or modified.

(Id. )

1. Terms under the Plan

The Plan provides that:

We will stop sending you payments and your claim will end on the earliest of the following: 1. During the first 24 months of payments, when you are able to work in your regular occupation on a part-time basis but you choose not to; after 24 months of payments, when you are able to work in any gainful occupation on a part-time basis but you choose not to.

...

3. The date you are no longer disabled under the terms of the plan.

(Id. at 186.) If an individual is disabled and not working, the Plan details that Prudential will determine that individual's payment by following:

this process to figure out your monthly payment: 1. If you are enrolled for Option 1, multiply your monthly earnings by 50%. But, if you are enrolled for Option 2, multiply your monthly earnings by 60%. 2. The maximum monthly benefit is $15,000. 3. Compare the answer in item 1 with the maximum monthly benefit. The lesser of these two amounts is your gross disability payment. 4. Subtract from your gross disability payment any deductible sources of income.

(Id. at 180-181.) The Plan also provides with respect to deductible sources of income that:

Prudential will deduct from your gross disability payment the following deductible sources of income:

...

(3) The gross amount that you, your spouse and children receive or are entitled to receive as loss of time disability payments because of your disability under: (a) the United States Social Security Act; ...

(Id. at 182-183.) Regarding overpayments, the Plan further states:

What Happens If Prudential Overpays Your Claim? Prudential has the right to recover any overpayments due to: • fraud; • any error Prudential makes in processing a claim; and • your receipt of deductible sources of income. You must reimburse us in full. We will determine the method by which the repayment is to be made.

(Id. at 197-198.)

c. Mr. Caskey's Claim

1. The onset of Mr. Caskey's hearing loss, tinnitus, depression/anxiety

On September 20, 2012, Mr. Caskey saw otolaryngologist Stanley E. Peters, Jr., MD, ("Dr. Peters") with complaints of tinnitus, and sensorineural hearing loss. (Doc. 20-1 at 486.) Dr. Peters recommended that he wear ear protection around any excessive noise and avoid all tobacco products. (Id. at 490.) On October 14, 2014, saw Vicki Muhovich, PA at the NeuroMedical Center Clinic who notes in the history of present illness:

44 year old male here for FU OV, last seen 9/30/14 Dr Acosta, with complaint of poor memory, poor sleep due to shift work, and episodes of confusion, anxiety, depression. History of tinnitus. He is very emotional and crying at OV. Reviewed MRI Brain which noted to be negative. EEG preliminary is within normal limits. [L]abs as available in system all noted to be normal.

He reports that this started around 2010 after he had shingles involving his left side of his face. He recovered from the face pain but now he has constant chirping in his hearing. He hears it equally out of both ears. He doesn't have any vertigo. He has some light headedness. but he does feel tired all the time. He does shift work and has irregular hours of sleep. He has about two or three hours of sleep at night. He does 12 hour shifts from 4 pm to 4 am.

He will go to work and feels like a zombie. He will go through the motions and has to really concentrate to complete his tasks. He has had to lead

...