Becky Cooper v. Life Insurance Company of North America, Ace Ina Long Term Disability Plan, and Ace Ina Holdings, Inc.

486 F.3d 157, 40 Employee Benefits Cas. (BNA) 2293, 2007 U.S. App. LEXIS 11408, 2007 WL 1425488
CourtCourt of Appeals for the Sixth Circuit
DecidedMay 16, 2007
Docket06-5735
StatusPublished
Cited by127 cases

This text of 486 F.3d 157 (Becky Cooper v. Life Insurance Company of North America, Ace Ina Long Term Disability Plan, and Ace Ina Holdings, Inc.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Becky Cooper v. Life Insurance Company of North America, Ace Ina Long Term Disability Plan, and Ace Ina Holdings, Inc., 486 F.3d 157, 40 Employee Benefits Cas. (BNA) 2293, 2007 U.S. App. LEXIS 11408, 2007 WL 1425488 (6th Cir. 2007).

Opinions

[159]*159GILMAN, J., delivered the opinion of the court, in which TARNOW, D.J., joined. SUTTON, J. (pp. 173-77), delivered a separate opinion concurring in part and dissenting in part.

OPINION

RONALD LEE GILMAN, Circuit Judge.

Becky Cooper appeals from an adverse judgment in her suit for long-term disability insurance benefits. Her employer’s plan is subject to the provisions of the Employee Retirement and Income Security Act (ERISA). Because we conclude that the decision of Life Insurance Company of North America (LINA), the plan administrator, to deny long-term disability benefits to Cooper was arbitrary and capricious, we REVERSE the judgment of the district court and REMAND the case for entry of an order requiring LINA to award benefits retroactive to the date on which Cooper’s short-term disability benefits ceased, and for such incidental relief as the district court may find appropriate in light of our decision.

I. BACKGROUND

Becky Cooper worked out of her home as an insurance claims adjuster for a subsidiary of ACE Insurance Co. (ACE) for 21 years. At all times relevant to this appeal, she was covered by both short-term and long-term disability insurance plans administered by LINA. Only the long-term disability plan (the Plan) is presently at issue.

The Plan defines the term “disabled” as follows:

The Employee is considered Disabled if, solely because of Injury or Sickness, he or she is either:
1. unable to perform all the material duties of his or her Regular Occupation or a Qualified Alternative, or
2. unable to earn 80% or more of his or her Indexed Covered Earnings.

Under the Plan,

[t]he Insurance Company will pay Disability Benefits if an Employee becomes Disabled while covered under this Policy. The Employee must satisfy the Elimination Period, be under the Appropriate Care of a Physician, and meet all the other terms and conditions of the Policy. He or she must provide the Insurance Company, at his or her own expense, satisfactory proof of Disability before benefits will be paid.

The Plan requires covered employees to satisfy a 180-day elimination period of continuous disability before LINA will pay disability benefits. It further obligates claimants to “provid[e] any information or documents needed to determine whether benefits are payable,” and places the bur-' den on them to provide “satisfactory proof’ of disability. The Plan also grants LINA the right to conduct a physical examination, at its own expense, of a claimant “as often as it may reasonably require.”

In January of 2000, Cooper’s lower back was injured in a work-related incident while she was on a business trip. She was reaching from the driver’s seat of her car into the back seat when she both felt and heard a popping sensation in her lower back, which was followed by lower-back pain that radiated down her right leg. After testing and evaluation, her physician told her that she had scoliosis, spondylolis-thesis, nerve entrapment, and degenerative disc disease. She continued to work until May of 2002, when she had a partial lumbar laminectomy performed. Between [160]*160May and October of 2002, while recuperating, Cooper received short-term disability (STD) benefits from LINA.

Her recuperation progressed more slowly than her neurosurgeon, Dr. Peter Boehm, had anticipated. The patient, he said, “has suffered a prolong [sic] post operative course with residual pain.... ” Cooper attempted to return to work in late September of 2002, but Dr. Boehm would not release her to work for more than two to three hours per day. She reported that even that amount of work caused her great pain. On December 19, 2002, Dr. Boehm noted: “In my opinion, this patient is not capable of working for a full 8 hours.” He directed her to stop working as of the following month. Prior to the termination of her short-term disability benefits on October 30, 2002, Cooper applied for long-term disability (LTD) benefits under the Plan.

In addition to being seen by Dr. Boehm, Cooper has been treated by Dr. R. Sean Brown, a physical medicine and rehabilitation (PMR) specialist; Dr. David Close, her primary care physician; Dr. Dennis ■Ford, a pain-management specialist; Dr. Michael Gallagher, a neurosurgeon in the same practice as Dr. Boehm; and Dr. James Osborn, another neurosurgeon. She was also evaluated by Dr. Edward Johnson in April of 2004 in connection with her application for Social Security disability benefits.

In a letter dated October 23, 2002, LINA acknowledged Cooper’s application for LTD benefits and informed her that it needed additional information to make a determination on her claim: “To fully understand how your condition prevents you from working, we must obtain your physician’s treatment plan, as well as medical information regarding your diagnosis and functional abilities from Dr. Boehm ... by December 6, 2002.” On November 12, 2002, LINA faxed requests to Drs. Boehm, Close, and Ford for “updated medical and office notes from August of 2001 through the present date.” Each fax included a request for “objective findings,” including “laboratory/procedure reports, office notes, [and] Physical Abilities assessment.” The Physical Ability Assessment (PAA) form accompanied these requests.

Dr. Boehm submitted copies of office-treatment notes covering his entire time of seeing Cooper, along with the results of an August 2001 lumbar myelogram. The my-elogram report described “[m]arked in-tradiscal degenerative change,” “protrusion type herniation at L2-3,” “[m]ulti-level spondylotic changes including Grade I spondylolisthesis L5-S1,” and “mild compression to the inferior aspect of the L5 root on the right side.” In addition, the myelogram revealed “more advanced degenerative narrowing of the [L4-L5] disc space with a diffuse spondylotic defect crossing the central and descending into the right and left central canals.” Notes from Dr. Close are not included in the record and are not at issue in this appeal. Dr. Ford faxed a copy of his notes from a September 2002 outpatient visit, describing Cooper’s MRI results and assessing her as having postlaminectomy syndrome, lumbar radiculopathy, degenerative disc disease of her lumbar spine, and lumbar spondylosis. He did not offer any opinion about her functionality or ability to return to work.

LINA sent a second letter to Cooper on November 21, 2002, “advising medica [sic] needed by 12/05/02 or will make claim decision with medical on file.” According to LINA’s records, Cooper called LINA on December 2, 2002 to ask what additional information was needed for the determination of her claim. She was told that “[LINA] needed functionality defined.” After receiving no additional information [161]*161from Cooper or on her behalf, LINA denied Cooper’s application for LTD benefits on December 5, 2002, stating that it had been “unable to determine if [Cooper satisfied] the policy definition of disabled.” According to the denial letter, LINA considered the Plan and all of the documents in Cooper’s claim file, including Dr. Boehm’s medical records for the period of July 2001 to November 2002 and Dr. Ford’s medical records from September of 2002.

Karen Wells, the LINA case manager who denied Cooper’s claim, reported that “Dr. Boehm states in his September 2002 office visit [notes] that your pain has improved but is not well. He advises ...

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486 F.3d 157, 40 Employee Benefits Cas. (BNA) 2293, 2007 U.S. App. LEXIS 11408, 2007 WL 1425488, Counsel Stack Legal Research, https://law.counselstack.com/opinion/becky-cooper-v-life-insurance-company-of-north-america-ace-ina-long-term-ca6-2007.