Green v. Union Sec. Ins. Co.

• Decision Date: 31 March 2010
• Docket Number: No. 4:08-CV-0186-DGK.,4:08-CV-0186-DGK.
• Citation: Green v. Union Sec. Ins. Co., 700 F.Supp.2d 1116 (W.D. Mo. 2010)
• Parties: Charles GREEN, Plaintiff,v.UNION SECURITY INSURANCE COMPANY, Defendant.
• Court: U.S. District Court — Western District of Missouri

700 F.Supp.2d 1116

Charles GREEN, Plaintiff,v.UNION SECURITY INSURANCE COMPANY, Defendant.

No. 4:08-CV-0186-DGK.

United States District Court,

W.D. Missouri,

Western Division.

March 31, 2010.

COPYRIGHT MATERIAL OMITTED

Talia Ravis, Leawood, KS, Yvonne Marie Ernzen, Overland Park, KS, for Plaintiff.

Richard N. Bien, Robyn L. Anderson, Lathrop & Gage LLP, Kansas City, MO, for Defendant.

SUMMARY JUDGMENT ORDER

GREG KAYS, District Judge.

Plaintiff Charles Green (“Green”) brings this action pursuant to the Employee Retirement Income and Security Act (“ERISA”) following Defendant Union Security Insurance Company's (“Union”) denial of his application for long-term disability benefits. Now pending are the parties' cross motions for summary judgment. After review of the entire record Union's motion (Doc. 58) is DENIED and Green's motion (Doc. 60) is GRANTED.

Summary Judgment Standard

A moving party is entitled to summary judgment “if the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to judgment as a matter of law.” Fed.R.Civ.P. 56(c). A party who moves for summary judgment bears the burden of showing that there is no genuine issue of material fact. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 256, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986). When considering a motion for summary judgment, a court must scrutinize the evidence in the light most favorable to the nonmoving party, and the nonmoving party “must be given the benefit of all reasonable inferences.” Mirax Chem. Prods. Corp. v. First Interstate Commercial Corp., 950 F.2d 566, 569 (8th Cir.1991) (citation omitted).

To establish a genuine issue of fact sufficient to warrant trial, the nonmoving party “must do more than simply show that there is some metaphysical doubt as to the material facts.” Matsushita Elec. Indus. Co., Ltd. v. Zenith Radio Corp., 475 U.S. 574, 586, 106 S.Ct. 1348, 89 L.Ed.2d 538 (1986). The nonmoving party must set forth specific facts showing there is a genuine issue for trial. Anderson, 477 U.S. at 248, 106 S.Ct. 2505. But the nonmoving party “cannot create sham issues of fact in an effort to defeat summary judgment.” RSBI Aerospace, Inc. v. Affiliated FM Ins. Co., 49 F.3d 399, 402 (8th Cir.1995) (citation omitted).

ERISA Standard of Review

Where the ERISA plan grants the administrator discretionary authority to determine eligibility for benefits or to construe the terms of the plan, this Court reviews the denial of benefits under an abuse of discretion standard. Groves v. Metro. Life Ins. Co., 438 F.3d 872, 874 (8th Cir.2006) (citing Ortlieb v. United HealthCare Choice Plans, 387 F.3d 778, 781 (8th Cir.2004)); accord Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). The decision of the plan administrator should be reversed only if it is arbitrary and capricious. Groves, 438 F.3d at 874 (citing Hebert v. SBC Pension Benefit Plan, 354 F.3d 796, 799 (8th Cir.2004)); cf. Schatz v. Mut. of Omaha Ins. Co., 220 F.3d 944, 946 n. 4 (8th Cir.2000) (holding that the level of review “for an ‘abuse of discretion’ or for being ‘arbitrary and capricious' is a distinction without a difference,” and that the terms are generally interchangeable). “When a plan administrator offers a reasonable explanation for its decision, supported by substantial evidence, it should not be disturbed.” Ratliff v. Jefferson Pilot Fin. Ins. Co., 489 F.3d 343, 348 (8th Cir.2007). Substantial evidence is “more than a scintilla but less than a preponderance.” Wakkinen v. UNUM Life Ins. Co. of Am., 531 F.3d 575, 583 (8th Cir.2008) (citation omitted).

In this case the parties agree that the plan grants discretionary authority to the administrator, so the abuse of discretion standard of review applies. The Court's review under this “deferential standard is limited ‘to evidence that was before’ the [administrator].” Cash v. Wal-Mart Group Health Plan, 107 F.3d 637, 641 (8th Cir.1997) (quoting Collins v. Cent. States S.E. & S.W. Areas Health & Welfare Fund, 18 F.3d 556, 560 (8th Cir.1994)); accord Ravenscraft v. Hy-Vee Employee Ben. Plan & Trust, 85 F.3d 398, 402 (8th Cir.1996) (“In conducting judicial review under the deferential [abuse of discretion] standard, the reviewing court looks to the evidence before the Plan administrators when they denied the claim.”) (citation omitted). “The purpose of this caveat is to ‘ensure expeditious judicial review of ERISA benefit decisions and to keep district courts from becoming substitute plan administrators.’ ” Cash, 107 F.3d at 641-42 (quoting Donatelli v. Home Ins. Co., 992 F.2d 763, 765 (8th Cir.1993)). “A district court may admit additional evidence in an ERISA benefit-denial case, however, if the plaintiff shows good cause for the district court to do so.” Brown v. Seitz Foods, Inc., Disability Ben. Plan, 140 F.3d 1198, 1200 (8th Cir.1998) (citing Ravenscraft, 85 F.3d at 402).

Where the plan administrator both evaluates claims for benefits and pays benefits claims it approves, the administrator is operating under a conflict of interest that must be weighed as a factor in the Court's determination whether the denial of benefits was an abuse of discretion. Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 128 S.Ct. 2343, 2350, 171 L.Ed.2d 299 (2008). The conflict of interest is weighed as one of several factors and “serves ‘as a tiebreaker when the other factors are closely balanced’ and is ‘more important ... where circumstances suggest a higher likelihood that it affected the benefits decision’ and ‘less important ... where the administrator has taken active steps to reduce potential bias and to promote accuracy.’ ” Hackett v. Standard Ins. Co., 559 F.3d 825, 830 (8th Cir.2009) (quoting Glenn, 128 S.Ct. at 2351).

Procedural and Factual Background

Green's employment and the Plan

Plaintiff Green is forty-four years old, holds a GED, and has sixteen years of work experience as a light industrial and warehouse worker. Green worked for Andersen Distributions, Inc. (“Anderson”) as a warehouse worker from November 13, 2000 until February 20, 2001, earning $1,960.00 a month.

Andersen provides long-term disability benefits to its employees pursuant to The Anderson Long-Term Disability Insurance Plan (“the Plan”). Union insured the Plan under a group insurance policy (“the Policy”). The Plan and the Policy are governed by ERISA, 29 U.S.C. § 1001 et seq.

Green participated in the Plan. Under the Policy, as a full-time hourly employee, Green was classified as a Class II employee. The Policy states,

Disability or disabled means that in a particular month, you satisfy either the Occupation Test or the Earnings Test, as described below. You may satisfy both the Occupation Test and Earnings Test, but you need only satisfy one Test to be considered disabled.”

Occupation Test

* * *

For covered persons in Class II, III, and IV:

during the first 24 months a period of disability (including the qualifying period), an injury, or sickness, or pregnancy requires that you be under the regular care and attendance of a doctor, and prevents you from performing at least one of the material duties of your regular occupation; and

after 24 months of disability, an injury, sickness, or pregnancy prevents you from performing at least one of the material duties of each gainful occupation for which your education, training, and experience qualifies you.

(Emphasis in original). The Policy defines the italicized words as follows: “ 'Material duties ' means the sets of tasks or skills required generally by employers from those engaged in a particular occupation; and ‘ gainful occupation ’ means an occupation in which you could reasonably be expected to earn at least as much as your Schedule Amount.” (Emphasis in original). The Policy provides that the Schedule Amount for “Class II covered persons” is “66 2/3% of monthly pay subject to a maximum Schedule Amount of $10,000 per month.” (Emphasis in original).

Under the Plan and Policy, Union had “sole discretionary authority to determine eligibility for participation or benefits and to interpret the terms of the Policy. All determination and interpretations made by [Union] are conclusive and binding on all parties.” The Policy requires the participant to “furnish whatever items we decide are necessary as proof of loss or to decide our liability.... If you do not furnish any required information or authorize its release, we will not pay benefits.”

Claim History

Union approves benefits under the “regular occupation” test.

Green stopped working in February of 2001, due to the combined disabling effect of several conditions, including fibromyalgia, migraines, chronic back pain, and chronic neck pain.

On November 12, 2001, Green applied to Union for long-term disability (“LTD”) benefits, claiming that he was unable to perform his job duties of lifting over ten pounds and standing for a long period. He reported his injury as cervical and lumbar pain. Green submitted an “Attending Physician's Initial Statement of Disability” (“Initial Statement”) which had been completed on November 9, 2001 by his primary care physician, Steven D. Rettinger, M.D, a family practice doctor. Dr. Rettinger concluded that Green's primary diagnosis was chronic back pain, chronic neck pain, fibromyalgia, and tremor, with subjective symptoms of neck and back pain and tremor, and objective findings of a “central disc bulge at C-3-4, C4-5, and C5-6 without evidence of herniated nucleus pulpous nor spinal stenosis.” At this time Dr. Rettinger believed that Green had a “moderate limitation of functional capacity” and that Green was “capable of clerical/administrative (sedentary) activity.”

Around this time Green began experiencing the symptoms of fibromyalgia. On May 23, 2001, Dr. David Cooley, M.D., F.A.C.P., rheumatologist, wrote Green “has symptoms highly...