Patton v. Mfs/Sun Life Financial Distributors

Decision Date12 March 2007
Docket NumberNo. 05-4765.,05-4765.
Citation480 F.3d 478
PartiesMichael PATTON, Plaintiff-Appellant, v. MFS/SUN LIFE FINANCIAL DISTRIBUTORS, INC., Defendant-Appellee.
CourtU.S. Court of Appeals — Seventh Circuit
480 F.3d 478
Michael PATTON, Plaintiff-Appellant,
v.
MFS/SUN LIFE FINANCIAL DISTRIBUTORS, INC., Defendant-Appellee.
No. 05-4765.
United States Court of Appeals, Seventh Circuit.
Argued September 21, 2006.
Decided March 12, 2007.

[480 F.3d 479]

William R. Groth (argued), Fillenwarth, Dennerline, Groth & Towe, Indianapolis, IN, for Plaintiff-Appellant.

Mark E. Schmidtke (argued), Schmidtke Hoeppner Consultants, Valparaiso, IN, for Defendant-Appellee.

Before BAUER, CUDAHY, and WOOD, Circuit Judges.

CUDAHY, Circuit Judge.


When Michael Patton seriously injured his knee, his doctors concluded that he was no longer able to perform his job as a truck driver for PacVan, Inc. Patton presented a claim for long-term disability benefits to the administrator of Pac-Van's employee benefits plan, MFS/Sun Life Financial

480 F.3d 480

Distributors, Inc. Sun Life initially approved Patton's benefits, but discontinued them a year later. It found him able to perform his job in light of his training for an even more physically stressful career as a paramedic and a bizarre series of contradictory letters from his orthopedic specialist, first claiming that Patton was unable to work, then indicating he was, then finally reversing course again and indicating that he was unable to work. Patton sued for the discontinued benefits under the Employee Retirement Income Security Act. The district court limited its review to Sun Life's administrative record and denied Patton's motion to permit discovery and the introduction of new evidence. Sun Life moved for summary judgment and the district court granted the motion. Patton now appeals the grant of summary judgment and the denial of his motion for discovery. We reverse.

I. Background

On January 10, 2003, Michael Patton fell from a ladder while removing Christmas decorations at his house, injuring his left knee. He went to his doctor three days later and then, on January 22, made a fateful visit to a specialist who will feature large in this tale, orthopedic surgeon Dr. Thomas Ambrose. An MRI revealed softening of cartilage in the patella and Ambrose prescribed a physical therapy regimen that seemed to improve the knee somewhat. But Patton returned on March 12, complaining of "intermittent locking and sharp pain" in the knee. Ambrose decided to operate and performed a left knee arthroscopy, a partial lateral miniscectomy and an adhesive resection. In an April 9 follow-up examination, Ambrose prescribed a second regimen of rehabilitation.

Patton's injury interfered with his job as a truck driver for Pac-Van, Inc.; he stopped working on Monday, January 13, 2003. Pac-Van provided its employees with a long-term disability insurance plan administered by MFS/Sun Life Financial Distributors, Inc. (Sun Life), and funded by an insurance policy issued by Sun Life. Plan participants are entitled to Long-Term Disability benefits when they provide notice and proof that they are "Totally or Partially Disabled." (R. 24 at 16.) For twenty-four months after an initial ninety-day "Elimination Period," an employee is "Totally Disabled" if injury or illness leaves him "unable to perform Material and Substantial Duties of his Own Occupation." (Id. at 13.) One's "Own Occupation" is one's "usual and customary employment . . . as it is generally recognized in the national economy" (id. at 12); its "Material and Substantial Duties" are the "essential tasks, functions, skills or responsibilities" it requires (id. at 11).

On April 25, 2003, Patton submitted a long-term disability claim statement to Sun Life, alleging that he was totally disabled, that is, unable to work as a truck driver. He attached a Sun Life Attending Physician's Statement form filled out by Dr. Ambrose. Ambrose indicated that Patton could work an eight hour day, but only with certain restrictions. For instance, he could walk for no more than six to ten hours a day, sit for no more than five to ten hours a day (for no more than one hour at a time) and lift no more than twenty-five pounds repeatedly and no more than 180 pounds occasionally. Apparently, he did not believe Patton could drive: a series of check boxes for indicating that Patton could drive one to three hours, three to five hours, and five to ten hours were left blank.1 Overall, Ambrose

480 F.3d 481

found that Patton was capable only of "light work" as defined in the U.S. Department of Labor Dictionary of Occupational Titles. In the prognosis section, Ambrose checked a box indicating that Patton's limitations would apply "[p]ermanently." In the "vocational rehabilitation" section, Ambrose indicated that he had reviewed the duties of Patton's occupation "per patient's report" and recommended vocational counseling and rehabilitation to find a way to "Decrease stress on his Left knee." (Id. at 283-86.)

Patton also included a letter from Ambrose and a fellow practitioner. This letter stated in part:

[Patton] continues to have pain and difficulty with his L knee and for this reason we have recommended activity restrictions in order to decrease the stress on his knee. His current restrictions include no repetitive lifting over 25 pounds, no repetitive climbing or squatting, and no sitting with knees flexed for over one hour at a time.

The natural progression of osteoarthritis is to slowly worsen over time. We hope to prolong the use of his L knee so he does not require total joint arthroplasty for quite some time as joint replacement does not last long in the younger, more active person. Unfortunately, his current job requires him to do many stressful activities including driving with his knees flexed, and also requires him to perform repetitive lifting, climbing, and squatting activities. He is currently in need of vocational rehab training in order to be in a career that would not be so stressful on his knee joint. (Id. at 293.)

On May 7, 2003, while Sun Life was evaluating Patton's claim, Ambrose discontinued treating Patton:

Michael is seen back today for follow up of his left knee. He continues to work on physical therapy and rehabilitation and reports improving strength as well as motion about the knee. . . .

Michael is going to continue his therapy and rehabilitation on his own. He has resumed school and is going back to study paramedic training. I am going to release him from further routine follow up although I will be happy to see him back on an as necessary basis. (Id. at 211.)

Sun Life appears to have received this memo in a medical record request on June 17, 2003.

Sun Life approved Patton's claim on July 21, 2003, but a month later noticed something puzzling: his paramedic training. Patton's claim form indicated that he was a "former fire department volunteer with some first responder training," and that he had considered retraining as a paramedic. Patton visited vocational rehabilitation specialist Michael Blankenship, who reported that Patton wanted to become a "registered nurse or paramedic" and was enrolled at Ivy Tech State College, taking courses in English, mathematics and interpersonal communications.

But providing emergency medical service is generally at least as physically stressful as driving a truck. The Department of Transportation's Occupational Description for "EMT-Paramedic" indicates "[v]ery [h]eavy" strength requirements. Paramedics must be able to stoop and kneel frequently, lift fifty pounds regularly and twenty pounds "constantly." Some requirements exceed Ambrose's restrictions. As a result, paramedic training seems a strange course of action for one

480 F.3d 482

restricted as Patton claims to be. Unless his condition improved—and Ambrose suggested that it would not—Patton could never put his training to use.

Sun Life questioned Dr. Ambrose about this peculiarity. On August 26, 2003, it faxed him the message, "Mr. Patton indicated that you provided him with a release so that he can start paramedic's training next week. Please provide a copy of the release with any restrictions." (Id. at 166.) Ambrose responded by sending another copy of the April 25 material that Patton had included with his claim. On September 30, 2003, Sun Life sent Ambrose a copy of the DOT Occupational Description for "EMT-Paramedic," Patton's job description and a letter, the second page of which is a specially-composed form above a signature block:

On August 26, 2003, we requested that you provide us with a copy of Mr. Patton's release with his updated restrictions. We received the copy of the April 24, 2003 notes instead.

Please provide us with a copy of the recent release allowing Mr. Patton to start his Paramedic training. Please include with that release a copy of his current restrictions.

By sending a copy of the April 24, 2003 notes, was your intent to indicate that the restriction contained in the note were Mr. Patton's current restrictions? Please check one Yes _____ No _____ Please advise if Mr. Patton's restrictions have been revised since April 24, 2003. If so, what are the new restrictions? If you have released Mr. Patton to pursue a career in Paramedics, would this be reasonable given the described restrictions in your April 24, 2003 notes. (Id. at 160.)

Ambrose didn't respond to the letter or a reminder sent December 3, 2003. Neither did he immediately respond to a second copy of the letter sent February 9, 2004. Finally, on March 9, 2004, Ambrose faxed to Sun Life a copy of the form he had received on September 30 and February 9, which he had signed. He had checked the "no" box to say that he had not intended to indicate that the April 25, 2003 restrictions were current, and wrote under the question "Please advise if Mr. Patton's restrictions have been revised ..." the phrase "released without restrictions 05/07/03." The form was otherwise unmarked.

Armed with this letter, Sun Life cut off Patton's benefits on April 28, 2004, explaining to Patton that it had discovered that paramedic work was as demanding as truck driving and that...

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