Jalali v. Unum Life Ins. Co. of Am.

• Docket Number: 2:20-cv-5071
• Decision Date: 28 March 2022
• Parties: SEPANTA JALALI, Plaintiff, v. UNUM LIFE INSURANCE COMPANY OF AMERICA, Defendant.
• Court: U.S. District Court — Southern District of Ohio

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SEPANTA JALALI, Plaintiff, v. UNUM LIFE INSURANCE COMPANY OF AMERICA, Defendant.

No. 2:20-cv-5071

United States District Court, S.D. Ohio, Eastern Division

March 28, 2022

Deavers Magistrate Judge

OPINION & ORDER

ALGENON L. MARBLEY CHIEF UNITED STATES DISTRICT JUDGE

This matter is before the Court on the parties' cross Motions for Judgment on the Administrative Record. (ECF Nos. 16, 19). Having reviewed this matter and concluding that these motions are appropriate for resolution without oral argument and for the reasons set forth below, Defendant's Motion for Judgment on the Administrative Record (ECF No. 19) is DENIED and Plaintiffs Motion (ECF No. 16) is GRANTED IN PART.

I. BACKGROUND

A. Factual Background

Plaintiff Sepanta Jalali worked as a family practice resident physician with Mount Carmel until November 2008. (ECF No. 16 at 7; ECF No. 19 at 8)). She participated in Trinity Health's, via Mount Carmel, long-term disability plan. (ECF No. 1 at 1; ECF No. 16 at 6; ECF No. 19 at 8). Defendant, Unum Life Insurance Company of America (“Unum”), serves as the insurer of the long-term disability plan for Mount Carmel employees. (See ECF No. 19 at 1.). A year prior, while Plaintiff was still in medical school, she suffered severe injury in a car accident. (ECF No. 16 at 7). That accident, in addition to the subsequent required surgeries, is the underlying basis for her inability to work. (Id.).

Moreover, the litigants here are no strangers to this Court. Indeed, over the past decade Plaintiff and Defendant have had three separate actions, including the case sub judice, in this Court.

Jalali I. Following Unum's termination of Plaintiff's Long-term Disability benefits in 2012, Plaintiff brought suit in this Court for the first time, seeking judicial review of Unum's decision. (ECF No. 16 at 6). On March 24, 2014, this Court granted Jalali's Motion for Judgment on the Administrative Record and Denied Unum's, holding that Unum's decision was arbitrary and capricious. (Id.) (citing Jalali v. Unum Life Ins. Co. of Am., No. 2:12- CV-00828, 2014 WL 1212708 (S.D. Ohio Mar. 24, 2014) (Marbley, J.), appeal dismissed (July 9, 2014) (“Jalali I”).

Jalali II. Two years later, Plaintiff filed another Complaint in this Court against Unum. This time, she sought equitable relief under 29 U.S.C. § 1132(a)(3) with respect to a settlement she secured in connection to the 2007 car accident. (ECF No. 19 at 11) (citing Jalali v. Unum Life Ins. Co. of Am., No. 2:16-CV-512, 2018 WL 4468207, at *1 (S.D. Ohio Sept. 18, 2018) (Marbley, J.) (“Jalali II”). Instead of disputing whether Plaintiff was disabled, the litigants argued over a different aspect of Unum's Long-term disability Plan: whether Unum was entitled to the proceeds of the settlement Plaintiff received. (See id.). Because Unum believed that it was entitled to such monies, it reduced Plaintiff's monthly benefit in kind. (Id.). In response, Plaintiff filed suit. Ultimately, this Court found that the Plan did not conclusively demonstrate that Unum was entitled to the proceeds of the settlement; denied both parties Motions for Summary Judgment; and remanded the matter to Unum for additional fact-finding. Jalali II, 2018 WL 4468207, at *7. The parties subsequently settled. (ECF No. 19 at 11).

Jalali III. On February 14, 2018, Unum again decided to terminate Plaintiff's long-term disability benefits. (ECF No. 19 at 6; ECF No. 13-7 at 444). This time, the litigants argue over whether Plaintiff is totally disabled under the Plan. (See ECF No. 13-7 at 445). Unum asserts that “Dr. Jalali is able to perform the duties of other gainful occupations … [and is therefore] not disabled under the policy.” (Id.). This decision, although made in early 2018, is based upon information Unum began gathering approximately a year before. (See ECF No. 13-6 at 498).

As a part of its continuing benefit review, Unum requested certain information from Jalali in late 2016. (Id. at 478). Because of, at least in part, some miscommunication, Jalali did not disclose the requested information until March of 2017. At that time, Jalali faxed a completed Disability Status Update form to Unum. (Id. at 498). Among other things, she noted she had received an online degree since she stopped working and that her treating physician was Dr. James Natalie. (Id.). Later that same month, Dr. Natalie also provided information pursuant to Unum's Disability Status Update request. (ECF No. 13-7 at 7).

There, Dr. Natalie noted under the Functional Capacity section of the form, that Jalali had several restrictions. (Id. at 8). He noted that Jalali could seemingly, at most: frequently sit, occasionally stand and/or walk, and that she should only, if at all, lift or carry items in the 10 to 15lb range occasionally. (Id.). Unum followed up with Dr. Natalie in late May of 2017, sending him an additional form; the relevant portion is excerpted below:

At this time, we need clarification regarding Sepanta Jatali's work capacity within the following occupational demands:

• Exerting up to 10 pounds force occasionally and/or negligible amount force frequently to lift, carry, push or otherwise move objects, including the human body,

• Sedentary work involves sitting most of the time, but may involve walking, standing for brief periods of lime. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. Ability to change positions as needed throughout the work day.

Please answer the following:

• Is Sepanta Jalali able to perform the above occupational demands on a full-time basis?

Yes___ No.___ If yes, as of what date? ___

If no, please explain.

On May 31, 2017, Dr. Natalie responded by filling out, signing, and returning the form to Unum. This completed form is excerpted below:

At this time-, we need clarification regarding Sepanta Jalali's work capacity within the following occupational demands:

• Exerting up to 10 pounds force occasionally and/or negligible amount of force frequently to lift, carry, push or otherwise move objects, including the human body.

• Sedentary work involves sitting most of (he time, but may involve walking, standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. Ability to change positions as needed throughout the work day.

Please answer the following;

• Is Sepanta Jalali able to perform the above occupational demands on a full-tune basis?

Yes_√__ No.___ If yes, as of what date? ___

If no, please explain.

(ECF No. 13-7 at 52). Notably, when asked if Jalali could perform the above-detailed tasks on a full-time basis, Dr. Natalie answered in the affirmative.

In July of 2017, Unum reached out to Jalali's other treating physician: neurologist Dr. Barfield. (ECF No. 13-7 at 212). There, Unum requested records detailing the treatment Dr. Barfield rendered. (See Id. at 215). The records showed that Dr. Barfield treated Jalali with Botox injections for refracting headaches following a second car accident in 2015. (See Id. at 231). Following her April 7, 2017 office visit, Plaintiff reported significant improvement regarding the “reduction in her headache frequency, severity, and duration.” (Id. at 217, 241, 271).

In February of 2018, Unum contacted both Drs. Barfield and Natalie. Dr. Barfield informed Unum that Jalali was receiving treatment, but apparently provided no restrictions or limitations. (See Id. at 428). Dr. Natalie, when asked about his prior statement that Jalali could perform sedentary work, stood by his previous conclusion. (Id. at 429). Following the receipt of this information, Unum communicated to Jalali that it was terminating her LTD benefits. (Id. at 444). Jalali, through counsel, filed an appeal of Unum's decision in October 2018. (ECF No. 13-9 at 110). Little more than a month later, on November 29, 2020, Unum upheld its termination of benefits. (Id. at 103).

As a part of the appeal process, Jalali submitted the results of a Functional Capacity Evaluation (FCE), an independent medical exam (IME), and a vocational report. Additional relevant portions of the administrative records are as follows:

• Defendant's File Review (Dr Fox): On October 4, 2017, Dr. Fox completed his file review. There, he asserted that in his opinion, restrictions and limitations were not supported. (ECF No. 13-7 at 294). Dr. Fox opined that although “the imaging findings include the potential for neural compromise, recent examinations have not” been consistent with this conclusion. (See Id. at 295). Moreover, he based in decision, in part, on his finding that no attending physician was “supporting R&L [restrictions and limitations] precluding work capacity.” (See id). Finally, Dr. Fox found that if Plaintiff is provided a job “with the ability to change positions as needed throughout the workday, ” she would not be precluded from such work. (See Id. at 297).

• Independent Medical Exam (IME) at Defendant's request: On January 2, 2018, Dr. Eugene Lin performed an Independent Medical Exam at Defendant's request. Specifically, Dr. Lin opined he believed the IME demonstrated that “the claimant would be able to perform work withing the expectations of exertion up to 10 pounds constantly, sitting most of the time with brief periods of standing and walking with ability to change positions as needed throughout the workday.” (ECF No. 13-7 at 409). Dr. Lin reached this conclusion because he “found no physical findings consistent with Dr. Jalali's reported radicular symptoms and documents negative lumbar provocative tests.” (ECF No. 13-9 at 105). Put differently, Dr. Lin concluded that Jalali “would be able to return to work in a sedentary full time fashion within the

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