Joyce v. Life Ins. Co. of N. Am., Civil Action No. 2:18-cv-1293

• Decision Date: 10 February 2021
• Docket Number: Civil Action No. 2:18-cv-1293
• Parties: MICHAEL JOYCE, Plaintiff, v. LIFE INSURANCE COMPANY OF NORTH AMERICA, Defendant.
• Court: U.S. District Court — Western District of Pennsylvania

MICHAEL JOYCE, Plaintiff, v. LIFE INSURANCE COMPANY OF NORTH AMERICA, Defendant.

Civil Action No. 2:18-cv-1293

UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF PENNSYLVANIA

February 10, 2021

Hon. William S. Stickman IV

MEMORANDUM OPINION

WILLIAM S. STICKMAN IV, United States District Judge

Plaintiff, Michael Joyce ("Joyce"), sued Defendant, Life Insurance Company of North America ("LINA"), under § 502(a)(1)(B) of the Employee Retirement Income Security Act of 1974 ("ERISA"), codified at 29 U.S.C. § 1132(a)(1)(B). Joyce alleges that LINA wrongfully denied his claim for long-term disability ("LTD") benefits under the employee plan sponsored by his employer, Waste Management, Inc. ("Waste Management"). (ECF No. 43, ¶ 4). Joyce's regular job occupation was "Garbage-Collection Supervisor." (ECF No. 56-1). The issue at hand arises out of a denial of LTD benefits starting with an incident in August 2016.

Both parties moved for Summary Judgment (ECF Nos. 54 and 58). Briefing is complete, and oral argument occurred on October 28, 2020. Ultimately, the Court must determine whether LINA abused its discretion as the benefit plan administrator when it determined that Joyce was not "disabled" from his "Regular Occupation" under the plan and denied his claim for LTD benefits. For the reasons set forth herein, the Court grants Joyce's Motion for Summary Judgment (ECF No. 58) and denies LINA's Motion for Summary Judgment (ECF No. 54) as moot.

FACTUAL HISTORY

Waste Management, a waste management and environmental services company, employed Joyce as a Garbage-Collection Supervisor or Route Manager. (ECF No. 56-1, p. 2). His duties included supervising and coordinating the activities of workers, assigning routes and trucks to workers and other supervisory roles. (Id.).

As a benefit of his employment, Joyce participated in Waste Management's employee welfare plan, which included LTD benefits issued by LINA. (ECF No. 70, pp. 2-3). LINA evaluated LTD claims under the Policy. (ECF No. 56-2). The Policy contained a two-tiered definition of disability, which changed from an initial "Regular Occupation" definition of disability to a heightened "Any Occupation" definition of disability "after disability benefits have been payable for twenty-four months." (Id. at 7). The Policy language states:

Definition of Disability/Disabled

The Employee is considered Disabled if, solely because of Injury or Sickness, he or she is:

1. unable to perform the material duties of his or her Regular Occupation. For drivers only, this includes being unable to meet the driving requirements as outlined under the Department of Transportation regulations; and

2. unable to earn 80% or more of his or her Indexed Earnings from working in his or her Regular Occupation.

After Disability Benefits have been payable for 24 months, the Employee is considered Disabled if, solely due to Injury or Sickness, he or she is:

1. unable to perform the material duties of any occupation for which he or she is, or may reasonably become, qualified based on education, training or experience; and

2. unable to earn 60% of more of his or her Indexed Earnings.

(ECF No. 56-2, p. 7). "Regular Occupation" is defined as

[t]he occupation the Employee routinely performs at the time the Disability begins. In evaluating the Disability, the Insurance Company will consider the duties of theoccupation as it is normally performed in the general labor market in the national economy. It is not work tasks that are performed for a specific employer or at a specific location.

(Id. at 26). The Policy also contained a limited twelve-month benefit period for certain illnesses.

The Insurance Company will pay Disability Benefits on a limited basis during an Employee's lifetime for a Disability caused by, or contributed to by, any one or more of the following conditions. Once 12 monthly Disability Benefits have been paid, no further benefits will be payable for any of the following conditions:

1) Alcoholism

2) Anxiety disorders

3) Delusional (paranoid) disorders

4) Depressive disorders

5) Drug addiction or abuse

6) Eating disorders

7) Mental illness

8) Somatoform disorders (psychosomatic illness)

(Id. at 18).

Under the Policy, the claimant must first establish, then prove on an ongoing basis, his disability to remain eligible for LTD benefits. (Id. at 10). The Policy contains an Elimination Period of 180 days, which is "the period of time an Employee must be continuously Disabled before Disability Benefits are payable." (Id. at 8, 15). "If you are still disabled after 26 weeks and are eligible for LTD benefits, your LTD benefits pick up where your [short-term disability ("STD")] benefits leave off." (ECF No. 62, p. 9). Had Joyce's STD benefits not been terminated, his Elimination Period would have ended February 25, 2017, at which point he would have been allowed to apply for LTD benefits. (ECF No. 66, ¶¶ 15-16); (ECF No. 55, ¶ 16).¹

A. The Incident

On the night of August 28, 2016, a tree struck Joyce in the back of the head during a storm. (ECF No. 70, ¶ 3). He lost consciousness but crawled to his driveway where he called a friend and 911. (Id.). Medical records showed that Joyce did not remember making the calls and could not remember the accident. (Id.). He was admitted to Weirton Medical Center for two days. (Id.). The staff at Weirton found Joyce "in and out of consciousness" and that he had a "sluggish pupillary response, [was] alert to self only, [was] unsure of [his date of birth] and social security number" and that "he was perseverating . . . for most of the ER stay." (ECF No. 56-5, pp. 2, 8). At the time of the incident, Joyce was forty-nine years old. (ECF No. 55, ¶ 6); (ECF No. 66, ¶ 6).

The day following his release from the hospital, Joyce sought treatment from Dr. David M. Lobas, MD, a neurologist. Dr. Lobas concluded that Joyce suffered from a concussion and recommended further testing, including an electroencephalogram (EEG) and magnetic resonance imaging scan (MRI) of his brain. Dr. Lobas confirmed that Joyce's computed tomography (CT) scans were unremarkable on the date of the incident. At the visit, Joyce was alert and his neurologic status was stable. (ECF No. 56-6, p. 2).

On August 31, 2016, Joyce saw his family doctor, who referred him to neurologist Dr. Rami Ausi, MD, who first treated Joyce in September 2016. (Id.). On that day, Dr. Ausi noted, "patient has a constellation of symptoms, including cognitive dysfunction, headaches, frustration, visual problems, and visuospatial difficulties most consistent with post-concussive syndrome . . . ." (ECF No. 56-7, p. 5). Dr. Ausi diagnosed Joyce with post-concussive syndrome and stressed the importance of resting the brain, minimizing mental activities and reducing visual stimulation to accelerate recovery. (Id.). He also notated that Joyce "certainly should not go back to work or drive at this point." (Id.).

B. Joyce's STD and LTD Claims

Following the August 2016 incident, Joyce applied for STD benefits under Waste Management's employee welfare benefit plan. (ECF No. 70, ¶ 4); (ECF No. 61, ¶ 4). LINA was appointed as Claim Fiduciary and, within the scope of that appointment, had the discretion to review, evaluate and determine claims for both STD and LTD benefits. (ECF No. 56-3). LINA acknowledged receipt of Joyce's STD claim by letter dated September 9, 2016 and established Joyce's STD claim with coverage for Joyce's pre-disability earnings of $80,000 per year. (Id.).

LINA issued a February 17, 2017 decision by Ahmed G., Disability Claim Manager, terminating Joyce's STD benefits on December 21, 2016. (ECF No. 43, ¶¶ 8-9); (ECF No. 55, ¶ 21). LINA explained, "[w]hile we are not disputing your diagnosis or symptoms you are having, we did not receive any medical notes from your provider before the deadline of February 15, 2017." (ECF No. 62, pp. 14-15). LINA's February 17, 2017 decision reversed its earlier STD benefit approval, nine days before the transition from STD to LTD benefits. (ECF No. 70, ¶¶ 12-13).

Before administering the February 17 decision, LINA requested information from Dr. Bruce Wright, MD, Joyce's treating psychiatrist. (ECF No. 70, ¶ 10). In early January 2017, Dr. Wright's office faxed to LINA Dr. Wright's office notes from December 20 and 21, 2016 and a Behavioral Health Questionnaire. (Id.). Under the heading "Return to Work Plan," Dr. Wright recorded, "severe symptoms prohibit any work at this time," and where asked to share the patient's "functional, psychological, and cognitive abilities and limitations," Dr. Wright wrote, "severe depression/anxiety and cognitive problems related to concussion." (ECF No. 56-19). LINA sent a letter in early January 2017 to Dr. Wright acknowledging that it reviewed his letter but asked for clarification. (ECF No. 78, p. 16). Dr. Wright responded that Joyce was unable to complete even basic tasks considering his "severe and debilitating symptoms." (ECF No. 62, pp. 27-31).

Dr. Ausi also sent LINA information in December 2016. Dr. Ausi supplied LINA with copies of medications prescribed to Joyce and a completed Medical Request Form. Dr. Ausi diagnosed Joyce with post-concussive syndrome and "major depressive disorder." He restricted Joyce from "intense mental activity, multitasking, and prolonged driving" and specified that Joyce could not return to work, even if his employer provided accommodations. His best estimate for a return to work without restrictions was "6 months." (ECF No. 62, pp. 31-34). Even so, LINA ended STD coverage December 21, 2016, thereby precluding Joyce from obtaining LTD benefits.

C. Joyce's Treatment, Social Security Disability Benefits and LINA's Denial of LTD Benefits

Following the tree incident, Joyce received treatment from Dr. Ausi; Dr. Bruce A. Wright, MD; and Dr. James Baird, Ph.D. Throughout treatment, Dr. Ausi noted some improvement with Joyce and provided updates to LINA. LINA's medical request form asked, "[c]ould your patient return to work at this time if...