Crider v. Highmark Life Ins. Co.
| Decision Date | 14 September 2006 |
| Docket Number | No. 1:05-cv-660.,1:05-cv-660. |
| Citation | 458 F.Supp.2d 487 |
| Parties | Scott CRIDER, Plaintiff, v. HIGHMARK LIFE INSURANCE CO., Defendant. |
| Court | U.S. District Court — Western District of Michigan |
Troy W. Haney, Dilleyhaney PC, Grand Rapids, MI, for Plaintiff.
Andrew T. Blum, Miller Canfield Paddock & Stone PLC, Grand Rapids, MI, David Faulkner Schmidt, Chittenden Murday & Novotny LLC, Chicago, IL, for Defendant.
This is an action for benefits brought pursuant to the Employment Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. §§ 1001-1461. This court has jurisdiction pursuant to 28 U.S.C. § 1331 and 29 U.S.C. § 1132(a)(1)(B). Plaintiff seeks reinstatement of long-term disability (LTD) benefits under a policy of insurance provided by his former employer, Wickes Lumber Company. The policy was written by Trans-General Life Insurance Company, now known as Highmark Life Insurance Company. The insurance policy (AR 345-367)1 contains all of the operative provisions regarding payment of LTD benefits and for all intents and purposes is the ERISA plan. Highmark paid LTD benefits under the plan from February 23, 2000, until October 31, 2004, when Broadspire Services, Inc., the third-party claims administrator, found that plaintiff was no longer entitled to benefits under the plan. After Highmark rejected plaintiffs appeal, plaintiff initiated this action on September 26, 2005.
On November 17, 2005, the parties submitted a stipulation and a proposed order (docket # 6) dismissing Broadspire Services, Inc. as a defendant. The parties also stipulated to dismissal of count II of plaintiffs complaint with prejudice. On November 17, 2005, Chief Judge Robert Holmes Bell entered an order granting the stipulated motion, (docket # 8). Plaintiffs remaining claim is his claim in count I against Highmark pursuant to 29 U.S.C. § 1132(a)(1)(B).
Pursuant to the requirements of the case management order (docket # 13), the parties have now filed the administrative record and their briefs, addressed to the procedural and substantive issues involved in this case. Under Wilkins v. Baptist Healthcare System, Inc., 150 F.3d 609 (6th Cir.1998), the court's review of plaintiffs claim under ERISA must be based upon the administrative record alone. The parties have consented to the dispositive jurisdiction of a magistrate judge. (See Consent and Order of Reference, docket # 14). Upon review of the administrative record, the court finds that the decision to terminate plaintiffs LTD benefits does not withstand de novo review.
1. The LTD plan was embodied in a policy of group insurance issued by the Trans-General Life Insurance Company, effective October 1, 1995 (AR 345-367) (hereinafter "Group Policy"). The Group Policy covered the officers and employees of Wickes Lumber Company. The Group Policy provided for the payment of longterm disability benefits after a 180-day elimination period. (Group Policy, Part 3, AR 352).
2. The Group Policy contains the following provisions relevant to the definition of disability:
You will be considered DISABLED during the Elimination Period if you are Totally Disabled as defined below, and you are not working at all. You will be considered Disabled during the Maximum Benefit Period if you are either Totally Disabled or Residually Disabled, as defined below:
TOTALLY DISABLED:
1. You are only required to be Totally Disabled from your own occupation during the Elimination Period and the first 24 months of the Maximum Benefit Period.
You are Totally Disabled from your own occupation if you are currently unable, as a result of your sickness, accidental bodily injury, or pregnancy, to perform the substantial and material duties of your own occupation, and you are not working at all.
2. You must be Totally Disabled from all occupations after the first 24 months of the Maximum Benefit Period.
You are Totally Disabled from all occupations if you are currently unable, as a result of your sickness, accidental bodily injury, or pregnancy, to perform the substantial and material duties of any occupation for which you are reasonably fitted by education, training, and experience, and you are not working at all.
RESIDUALLY DISABLED:
1. You are Residually Disabled during the first 24 months of the Maximum Benefit Period if you are currently unable, as a result of your sickness, accidental bodily injury, or pregnancy, to perform the substantial and material duties of your own occupation, and you satisfy one of the following conditions:
a. You are working in your own occupation, and you are currently unable, as a result of your sickness, accidental bodily injury, or pregnancy, to earn more than 80% of your Indexed Predisability Earnings.
b. You are working in another occupation or specialty, and your actual work earnings do not exceed 80% of your Indexed Predisability Earnings.
2. You are Residually Disabled after the first 24 months of the Maximum Benefit Period if you are working in your own occupation or any other occupation or specialty, and you are currently unable, as a result of your sickness, accidental bodily injury, or pregnancy, to earn more than 80% of your Indexed Predisability Earnings from work in that occupation or any other occupation for which you are reasonably fitted by education, training, and experience.
(Group Policy, Part 5, AR 355-56).
3. Plaintiff, Scott Crider, began working for Wickes Lumber Company as a truck driver on May 4, 1998. One month later, he was promoted to Yard Supervisor, a position he held until August 25, 1999. On that day, plaintiff suffered a back injury on the job while lifting 100-pound bundles of shingles. AR 415).2 Plaintiff began to treat with Dr. Roger Holman, D.O., a family practice physician. An MRI taken shortly after the accident revealed disc material impinging on the L3-L4 nerve root, with spinal canal narrowing at the L4-L5 level arising from the disc bulge and bilateral severe facet disease. A myelogram taken four months after the accident showed bulging discs at L2-L3, L3-L4, L4-L5, and L5-S1. In addition, it showed spinal stenosis consistent with disc herniation. (Id.). Plaintiff applied for LTD benefits under the Group Policy.
4. During the 180-day elimination period, plaintiff underwent a physical therapy program and treated with Dr. Randy Russo. He continued to complain of back pain with some radiation into the right leg. By December 21, 1999, Dr. Russo did not believe that any further aggressive medical evaluation was warranted. The doctor also concluded that no further diagnostic studies or injection therapy were necessary and that surgery was not indicated. (AR 416). The insurance company sent plaintiff for a functional capacity evaluation on December 29, 1999, by Mark DeKraker and Mark Scharich. The evaluation revealed that plaintiff was performing at a level between sedentary and light physical demands. (AR 417). In January 2000, plaintiff saw Dr. Ken Eason, who diagnosed mild spinal stenosis and probable irritation of the right side nerve roots. He suggested epidural injections and physical therapy. In February 2000, Dr. Stephen Winston administered a transforaminal L5 epidural steroid injection. (Id.).
5. Trans-General Life Insurance approved plaintiffs claim for LTD benefits and made its first payment as of February 23, 2000, the expiration of the 180-day elimination period. The insurance company paid benefits for twenty-four months, under the provisions of the Group Policy that deemed a beneficiary to be totally disabled if he was unable, as a result of sickness or bodily injury, "to perform the substantial and material duties of your own occupation," the test under the policy for the first twenty-four months of disability. (Group Policy, Part 5, AR 355).
6. After certifying plaintiff for LTD benefits, the insurance company required him to submit to physical examinations and employability reviews. Highmark retained Brian P. Giersch, M.D., a rehabilitation medicine specialist, to perform a medical evaluation. Dr. Giersch submitted to Highmark a nine-page medical report dated November 9, 2000. (AR 415-23). The report indicates that Dr. Giersch reviewed all previous medical and vocational records and conducted a physical examination. Dr. Giersch diagnosed chronic low back pain, caused by degenerative disc disease with positive discogram at L5-S 1, facet hypertrophy and spinal stenosis at the L3-L4 and L4-L5 levels. (AR 421). The doctor also noted sleep and mood disturbances and hypertension. Dr. Giersch identified as the "first option" symptomatic treatment with anti-inflammatories, work restrictions, anti-depressants, intermittent physical therapy and a home exercise program; he identified spinal fusion as "a last resort." (AR 422). Dr. Giersch opined as follows concerning plaintiffs employability:
Most importantly, I believe that Mr. Crider is capable of gainful employment. It is also a very important part of his overall rehabilitation reestablishing for him a role and sense of purpose. I have again reviewed his functional capacity evaluations and he is felt to be able to work at the light duty level3 as defined by the Dictionary of Occupational Titles, U.S. Department of Labor. I would add to this, however, the option to sit/stand every hour as needed.
(AR 423).
7. Contemporaneously with the medical examination by Dr. Giersch, the insurance company had plaintiff undergo a functional capacity evaluation at the Healthsouth Sports Medicine and Rehabilitation Center of Paw Paw. The evaluation, conducted by a physical therapist, is summarized in a five-page report. (AR 410-14). The examiner found that plaintiff had deficits in his musculoskeletal system, including antalgic ambulation, impaired posture,...
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