Hoover v. Provident Life and Acc. Ins. Co.
| Decision Date | 21 May 2002 |
| Docket Number | No. 00-5796.,00-5796. |
| Citation | 290 F.3d 801 |
| Parties | Mary Moore HOOVER, Plaintiff-Appellee, v. PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY, Defendant-Appellant. |
| Court | U.S. Court of Appeals — Sixth Circuit |
Kathryn E. Barnett (briefed), Donald Capparella (briefed), John A. Day (argued and briefed), Branham & Day, Brentwood, TN, for Plaintiff-Appellee.
Steven A. Riley (briefed), Katharine R. Cloud (argued and briefed), Jennifer A. Lawson, Bowen, Riley, Warnock & Jacobson, Nashville, TN, for Defendant-Appellant.
Before: MERRITT, SILER and DAUGHTREY, Circuit Judges.
Defendant Provident Life and Accident Insurance Company ("Provident") appeals two orders of the district court which reversed Provident's decision to terminate plaintiff Mary Moore Hoover's ("Hoover") residual disability benefits and awarded her attorneys' fees as well as prejudgment interest under the Employee Retirement Income Act ("ERISA"), 29 U.S.C. § 1132(e). For the reasons stated below, we affirm.
Hoover was a psychologist employed by Maury County Regional Hospital in Columbia, Tennessee. In 1988 and 1989, Hoover obtained disability insurance policies from Provident. These policies provided benefits for the insured should she become totally or partially disabled under the terms of the policies.
With respect to "residual disability" benefits, the type of coverage that is at issue in this case, both policies provided benefits to compensate for such a disability if she:
1. was not able to do one or more of her substantial and material daily business duties or she was not able to do her usual daily business duties for as much time as it would normally take her to do them;
2. lost 20 percent of her monthly income in her occupation; and
3. was receiving care by a Physician which is appropriate for the condition causing disability.
After the sixty-day elimination period was satisfied, she was required to satisfy only the first and second elements set forth above and was no longer required to have a loss of duties or time in order to qualify for benefits.
In July 1992, Hoover underwent emergency coronary bypass surgery. As a result of this medical procedure, she submitted a claim for residual disability benefits since she was able to return to her job only on a part-time basis. From 1992 until May 1998, Provident paid Hoover benefits pursuant to the terms of the disability policies for what was determined to be a residually disabling condition of coronary artery disease with stress-induced angina.
During 1993 and 1994, Hoover made multiple visits to her primary cardiologist physician, Dr. Janice M. Vinson. At many of these visits, Hoover complained of intermittent episodes of chest discomfort, which Dr. Vinson attributed mostly to stress rather than physical exertion.
In May 1996, Dr. Vinson again saw Hoover for complaints of chest pain. In her notes concerning Hoover's visit, Dr. Vinson noted that there is "some disease in a septal perforator, and certainly, that is enough to give her some anginal type pain, but unfortunately, with a septal perforator you really can't do anything about [sic] with regard to bypass or angioplasty because of the angle of take-off from its AD." In addition, Dr. Vinson reported:
Mary Moore has had some increase in her chest pain. At this time, I think medical therapy is really all this is indicated. Her cath showed that her IMA graft was patent, but she still does have some septal disease. It seems that most of her chest pain is stress-related and most of her stress is related to work, and so she has had to cut back quite significantly on that. She is continuing to do everything she can from a standpoint of taking care of herself, most specifically, she has done a good job in trying to continue her exercise program. I think at this time the main thing we are talking about is lifestyle changes and continuing to be real careful about her cholesterol and exercise program.
In her report dated July 27, 1996, to Provident, Dr. Vinson opined: "Given that the perforator can't really be treated with angioplasty or bypass and she is continuing to have chest discomfort, albeit though it is mostly stress-related, I do consider that she is disabled, and particularly since her job is very stressful, I have recommended that she retire from her counseling profession."
On referral from Dr. Vinson, Hoover sought a second opinion from Dr. Jan Turner in January 1997. Dr. Turner concluded that Hoover continued to suffer from coronary artery disease and "certainly the septal perforator disease would explain the intermittent angina which [Hoover] has."
Hoover was also examined by Dr. Joseph H. Levine, a New York cardiac arrhythmia and pacemaker specialist, in February 1997. Dr. Levine stated in his letter to Dr. Vinson that:
[Hoover] is somewhat concerned that the critical lesion that she has remaining in the septal perforator, and someone told her that this may be associated with heart block if it were to progress further. I have reassured her that there is no large amount of ischemia that is present at this time and, furthermore, that there is no evidence for any type of conduction abnormality noted on exercise stress testing. Thus, exercise stress testing can be used as a assay for conduction abnormality, which in turn may be a function of the critical lesion in this artery. If she continues to pass stress testing without bundle branch block, heart block, etc., we wouldn't really be that concerned that she would develop a high degree of A-V block, with an occlusion of this vessel, a permanent pacemaker could be easily placed and would totally control the situation.
In October 1997, Hoover was hospitalized for prolonged chest pain. In her report dated November 11, 1997 to Provident, Dr. Vinson stated that
[Hoover] has a septal perforated which has a 70% lesion and does still have angina from that. Her angina seems to be more frequently induced by stress when she's emotional than by physical exertion. As far as limiting her duties, I have felt that there was direct correlation between her stress at work and the frequency and intensity of her chest pain and so I have asked her to restrict herself based on her symptomatology.... Objectively, she does have this lesion on a cardiac cath, which was done approximately two years ago and subjectively certainly her history is compatible with angina, which is incurred when she is under a great deal of stress.
In December 1997, one of Provident's claim representatives asked Dr. William O'Connell, also employed by Provident, to review Hoover's medical records to determine if there was any objective evidence supporting restrictions that would prevent Hoover from performing her occupational duties on a full-time basis. Dr. O'Connell concluded that because of the normal stress test and ejection fraction, there was no reason Hoover could not do her full-time occupation. He suggested Hoover submit to an independent medical exam ("IME").
Hoover submitted to an IME and was examined by Dr. Hal Michael Roseman in February 1998. After reviewing all of Hoover's past medical history and conducting his own examination, Dr. Roseman summarized his findings as follows:
This 55 year old psychologist is alleging disability on the basis of emotional induced angina. Her professional function does not involve any exertional activity, but involves significant emotional stress. Certainly, in the medical literature, angina is only [sic] has been reported to be triggered by emotional stress and not by exercise and not be demonstrated with exercise physiologic stress testing. However, Ms. Hoover's situation is quite unusual, especially in light of her successful bypass surgery performed in 1992. Her primary cardiologist has implicated the septal perforator stenosis as a cause for her chest discomfort. I am certainly not able to deny this as a possibility. But given the probable small caliber of her septal perforator, I doubt whether the chest pain source can be legitimately related to this vessel.
There are several historical facts that would argue against ischemia. The prolonged nature of the chest discomfort is quite unusual for coronary ischemia. She reports having chest pain lasting as long as seven hours without amelioration despite treatments with morphine sulphate and IV nitrates. During these chest pain episodes, the records do not indicate any EKG changes, including conduction abnormalities (if the septal perforator was significant enough to cause ischemia, I would suspect that it would be significant enough to cause conduction or ST abnormalities as well). In addition, the patient has experienced tingling paresthesias. Although the symptoms have not been effected by any medication, the patient does report improvement of her symptoms since being on her present psychotropic medications which include Wellbutrin, Prozac and Xanax. The patient's angina is present only with emotional stress. However, it would be unusual to have induced angina at such a disabling magnitude without any demonstrative ischemia. The patient has certainly been evaluated on numerous occasions with numerous modalities without uncovering any provokable ischemia.
Based upon physical examination, the patient's description of her symptoms do not appear to be manufactured. However, the real question still persists whether the symptoms are indeed caused by disabling coronary insufficiency.
* * * * * *
In essence, since the patient's symptoms are emotionally triggered, then the patient would have a difficult time in dealing with emotionally stressful situations. However, as a psychologist, I believe, occupational situations can be present as to minimize those emotional triggers. More importantly is the question of whether the symptoms are cardiac in origin. Coronary artery disease has been invoked as a cause for her symptoms,...
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