Rusch v. United Health Grp. Inc.

• Decision Date: 15 July 2013
• Docket Number: CIVIL ACTION NO. 2:12-CV-00128
• Parties: CHRISTI R. RUSCH, Plaintiff, v. UNITED HEALTH GROUP INC., aka/dba United Healthcare Services, Inc., Defendant.
• Court: U.S. District Court — Southern District of Texas

CHRISTI R. RUSCH, Plaintiff,

v.UNITED HEALTH GROUP INC., aka/dba United Healthcare Services, Inc., Defendant.

CIVIL ACTION NO. 2:12-CV-00128

UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF TEXAS CORPUS CHRISTI DIVISION

ORDERED: July 15, 2013

ORDER

Before the Court is Defendant's Motion for Complete Summary Judgment. (D.E. 45.) For the reasons set forth below, Defendant's motion is GRANTED IN PART and DENIED IN PART. Plaintiff's civil claim for statutory non-disclosure penalties under 29 U.S.C. § 1132(c)(1) is RETAINED. Plaintiff's remaining causes of action are DISMISSED WITH PREJUDICE.

INTRODUCTION

This case arises out of a dispute between Plaintiff Christi R. Rusch and Defendant United Health Group Inc. (UHG) over Plaintiff's eligibility for short-term disability (STD) and long-term disability (LTD) benefits under UHG's employer-sponsored disability benefits plans (the STD Plan and LTD Plan) in which Plaintiff participated as an employee. The STD Plan and the LTD Plan are subject to the provisions of the Employee Retirement Income Security Act of 1974 (ERISA), which permits a plan participant or beneficiary to seek redress in federal district court. See 29 U.S.C. § 1132(a)(1). Plaintiff brought suit in this Court alleging the following five causes of action against Defendant:

1. Claim for STD and LTD benefits under 29 U.S.C. § 1132(a)(1)(B);

2. Breach of fiduciary duty under 29 U.S.C. § 1132(a)(3);

3. Claim for monetary non-disclosure penalties under 29 U.S.C. § 1132(c)(1);

4. Claim for criminal penalties under 18 U.S.C. § 1027 for failure to disclose to Plaintiff the STD and LTD Plans and Summary Plans when requested; and

5. Claim for criminal penalties under 29 U.S.C. § 1131(a) for failure to disclose to Plaintiff the STD and LTD Plans and Summary Plans when requested.

(See Plaintiff's First Supplemental Complaint, D.E. 34 ¶¶ 23-41.) Defendant argues that all five causes of action must be dismissed with prejudice because there are no genuine issues of material fact, and Defendant is entitled to judgment as a matter of law. (D.E. 45 at 11-12.)

SUMMARY JUDGMENT EVIDENCE

The majority of the summary judgment evidence comes from the joint administrative record, which was compiled by the parties and submitted to the Court. In the case at hand, a determination of ineligibility under the STD Plan was made by the independent Claims Administrator, SedgwickCMS (Sedgwick), which is responsible for making benefits determinations and reviewing denied claims. The administrative record consists of the Plans and those documents and records submitted to the Claims Administrator for review. The administrative record has been Bates-stamped for ease of identification. All citations to the administrative record herein are preceded by the letters UHG. The Summary Plan Description can be found at UHG 1-22; the LTD Plan can be found at UHG 23-53; the STD Plan can be found at UHG 54-75; and the various medical reports, correspondence, and other documents relating to Plaintiff's STD benefits claim and appeal can be found at UHG 76-414. The facts of the case are, for the most part, undisputed. What follows is a brief summary of the case.

Plaintiff was employed by Defendant as an Employee Assistance Program (EAP) Supervisor. (UHG 146.) This is a home-based, sedentary position. (UHG 146, 307.) The lastday that Plaintiff worked before filing a claim for disability benefits was November 17, 2008. (UHG 270.) Plaintiff made a claim for STD benefits on November 21, 2008. (UHG 85-86.)

Plaintiff applied for STD benefits based on swelling and pain in her leg and a lumbar strain. (UHG 321.) Plaintiff's physician, Dr. Jon Chancellor, initially estimated that Plaintiff would be able to return to work on December 22, 2008. (UHG 173.) Plaintiff's claim for STD benefits was initially approved through December 16, 2008, and then extended through December 21, 2008. (UHG 88-90.)

Plaintiff visited Dr. Chancellor's office again on December 30, 2008. (UHG 191.) Following that visit, Dr. Chancellor diagnosed Plaintiff with the following conditions: (1) stress fracture to her left foot; (2) hypothyroidism with myxedema; (3) moderate, recurrent depression; (4) L5-S1 acute disc herniation with radiculopathy; (5) acute myofascial strain; (6) bilateral carpal tunnel syndrome; and (7) migraine headaches. (UHG 191.) Nonetheless, Dr. Chancellor stated that he optimistically anticipated Plaintiff's return to work on January 5, 2009. (UHG 191.) Plaintiff also provided documentation from Robert R. Vranes, a podiatrist, who treated Plaintiff's foot and placed her in a walking boot. (UHG 196-201.) The Claims Administrator extended Plaintiff's STD benefits through January 5, 2009. (UHG 91-92.)

After another office visit on January 6, 2009, Dr. Chancellor determined that Plaintiff could return to work on a part-time basis. (UHG 203-08.) The Claims Administrator approved part-time STD benefits: Plaintiff would return to work 4 hours per day through January 25, 2009, and then increase her work to 6 hours per day thereafter, until returning to work full-time on February 2, 2009. (UHG 93.) Additional STD benefits were subsequently approved through February 8, 2009 due to a surgery on January 28, 2009. (UHG 94.)

Plaintiff returned to full-time work in her home-based sedentary position on February 9, 2009. (UHG 293.) Plaintiff continued to work full-time for almost a month until March 2, 2009, when she claimed she was no longer able to work full-time due to her disability. (UHG 292.) Plaintiff submitted documentation from Dr. Chancellor indicating that she was only able to work part-time from March 9, 2009 through April 9, 2009. (UHG 210-13.) This new claim for STD benefits was approved through March 27, 2009, and then extended until April 24, 2009. (UHG 98, 101.) No further extensions were granted.

On May 4, 2009, an independent review of Plaintiff's disability claim was performed by Dr. Howard Sturtz, a physician advisor for the Claims Administrator. (UHG 104-06.) Based on the medical documentation provided to him, Dr. Sturtz concluded that there were no objective clinical findings or medical evidence indicating that Plaintiff was disabled. (UHG 105.) Dr. Sturtz concluded that Plaintiff could return to work as an EAP Supervisor in a sedentary position. (UHG 104.) On May 7, 2009, the Claims Administrator notified Plaintiff that her STD benefits claim was denied beginning April 25, 2009 as "the medical information submitted does not demonstrate that you are unable to perform the material duties of your own occupation . . . ." (UHG 107.)

Plaintiff appealed the denial of her STD benefits claim to the Claims Administrator. (UHG 121.) Plaintiff submitted additional medical documentation to the Claims Administrator regarding her disability. (UHG 122-44.) The Claims Administrator forwarded the medical documentation regarding Plaintiff's claim to two independent medical specialists for review—Robert Polsky, M.D. and Jamie Lee Lewis, M.D. (UHG 150-52, 158-60, 165-66.) After reviewing the medical records and the findings and recommendations of the independent medical specialists, the Claims Administrator determined that there was no objective medical evidence tosupport a finding that Plaintiff was disabled under the STD Plan. (UHG 165-66.) The denial letter additionally informed Plaintiff of her right to file a civil action under ERISA. (UHG 166.) Plaintiff filed her claim with this Court on April 30, 2012. (D.E. 1.)

SUMMARY JUDGMENT STANDARD

Summary judgment is appropriate where "the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." FED. R. CIV. P. 56(a). In reaching its decision, the Court must consider the affidavits, depositions, declarations, stipulations, and other documents presented to the Court in the light most favorable to the non-movant. Caboni v. General Motors Corp., 278 F.3d 448, 451 (5th Cir. 2002). The substantive law identifies which facts are material. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986); Ellison v. Software Spectrum, Inc., 85 F.3d 187, 189 (5th Cir. 1996). A dispute about a material fact is genuine only "if the evidence is such that a reasonable jury could return a verdict for the nonmoving party." Anderson, 477 U.S. at 248; Judwin Props., Inc., v. U.S. Fire Ins. Co., 973 F.2d 432, 435 (5th Cir. 1992).

The movant has the initial burden of showing that there is no genuine issue of material fact and that he is entitled to a judgment as a matter of law. Rivera v. Houston Indep. Sch. Dist., 349 F.3d 244, 246 (5th Cir. 2003); see also Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986). The movant's initial burden "may be discharged by 'showing'—that is, pointing out to the district court—that there is an absence of evidence to support the nonmoving party's case." Celotex, 477 U.S. at 325. Once the movant has met its initial burden, the burden then shifts to the non-moving party to demonstrate that summary judgment is not appropriate. Rivera, 349 F.3d at 247.

In meeting its burden, the non-movant must establish that there are material, controverted facts precluding summary judgment. Anderson, 477 U.S. at 248-49. The non-movant's burden is not satisfied by showing "some metaphysical doubt as to the material facts, by conclusory allegations, by unsubstantiated assertions, or by only a scintilla of evidence." Willis v. Roche Biomedical Labs., Inc., 61 F.3d 313, 315 (5th Cir. 1995); see also Brown v. Houston, 337 F.3d 539, 541 (5th Cir. 2003) ("Unsubstantiated assertions, improbable inferences, and unsupported speculation are not sufficient to defeat a motion for summary judgment"). Accordingly, summary judgment must be entered "against a party who fails to make a showing sufficient to establish the existence of an element essential to that party's case, and on which that party will bear the burden of proof at trial." Celotex, 477 U.S. at 322-23.

ANALYSIS

Defendant...