Clark v. Nationwide Mutual Insurance

933 F. Supp. 2d 862, 2013 WL 1194927, 2013 U.S. Dist. LEXIS 39866
CourtDistrict Court, S.D. West Virginia
DecidedMarch 22, 2013
DocketCase No. 2:12-cv-0045
StatusPublished
Cited by4 cases

This text of 933 F. Supp. 2d 862 (Clark v. Nationwide Mutual Insurance) is published on Counsel Stack Legal Research, covering District Court, S.D. West Virginia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Clark v. Nationwide Mutual Insurance, 933 F. Supp. 2d 862, 2013 WL 1194927, 2013 U.S. Dist. LEXIS 39866 (S.D.W. Va. 2013).

Opinion

MEMORANDUM OPINION AND ORDER

JOHN T. COPENHAVER, JR., District Judge.

Pending are cross motions for summary judgment by plaintiff Anita Clark and defendant Nationwide Mutual Insurance Co. (“Nationwide”), each filed on July 27, 2012.1 For the reasons that follow, the court grants summary judgment in favor of Nationwide.

I. Background

This matter arises from Nationwide’s denial of Clark’s long term disability benefits claim and is before the court pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1132(a)(1)(B). Clark is a West Virginia resident who began working for Nationwide on September 21, 1998. Admin. Record 37. While a Nationwide employee, Clark was covered' under the Nationwide Insurance Companies and Affiliates Plan for Your Time and Disability Income Benefits (“the Plan”). Compl. ¶ 6; Admin. Record 210. Clark contends that Nationwide wrongly denied her claim for disability benefits.

A. Plan Language

Nationwide is the “Plan Sponsor.” Admin. Record 224. Nationwide’s Board of Directors appoints the members of the “Benefits Administrative Committee.” Id. at 217. The Benefits Administrative Committee in turn is the “Plan Administrator.” Id. at 224. The Plan Administrator “has the power to take all actions required to carry out the provisions of the Plan.” Id. at 266. This includes the power and duty “to exercise discretion and authority to construe and interpret the provisions of the Plan,' to determine eligibility to participate in the Plan, and make and enforce rules and regulations under the Plan to the extent deemed advisable.” Id. Further, the Plan Administrator has the power to “decide all questions as to the rights of Participants under the Plan and such other questions as may arise.” Id. As a result of these provisions, the parties agree that the court’s review of the Plan Administrator’s decisions is under the abuse of discretion standard. See PL’s Mem. Supp. Mot. Summ. J. 16.

The Plan provides qualifying employees with long term disability (“LTD”) benefits of 60% of the employee’s covered compensation in effect on the Date of the Disability, less any amount provided by certain other benefit plans, including Social Security. Admin. Record at 246-47. The Date [865]*865of Disability is the date an employee “first misses a day of work due to her disability.” Id. at 219. LTD benefits commence on the first day after 1) Short-Term Disability benefits are exhausted and 2) the claimant then provides written proof of loss and medical evidence that the employee is LTD Disabled. Id. at 245.

Section 4.03.03 of the Plan sets forth the proof of loss and medical evidence requirements:

(a) To commence LTD Disability Income Benefits, an Active Associate must present evidence to the satisfaction of the Plan Administrator of the following:
(1) that the Active Associate’s LTD Disability is the direct and proximate result of an illness,
(2) that, as of the Active Associate’s Date of Disability, there is a demonstrated, substantial change in medical or physical condition as the result of a specific physical injury or the specific onset of a physical or mental illness, demonstrated by new, significantly increased physical or mental impairments such as a significant loss of physical functional capacity, and,
(3) that her LTD Disability is an Eligible Disability.

Id. at 246.

“LTD Disability” is defined in section 1.34 as
a disability or disablement that results from a substantial change in medical or physical condition as a result of Injury or Sickness and that prevents an Active Associate from'engaging in Substantial Gainful Employment for which she is, or may become, qualified.' Continuation of an existing medicál or physical condition will generally not constitute a substantial change in medical or physical condition ’if Claimant previously demonstrated through attendance and/or work that Claimant has been able to engage in Substantial Gainful Employment, or such medical or physical condition could be or has been accommodated. A substantial ■ change in medical or physical condition may be evidenced by the change or loss of at least one of the Activities of Daily Living.

Id. at 221-23. The Plan defines Substantial Gainful Employment as being

any occupation or employment from which an individual may receive an income equal to or greater than one-half of such individual’s Covered Compensation as of her Date of Disability.

Id. at 225. When, as found by the Plan here, a LTD Disability is the result of “mood, anxiety, somatoform or other disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association,” benefits have a maximum duration of 36 months. Id. at 251.

B. Claim History

Clark was 52 years of age when she filed this action, on January 10, 2012. Compl. ¶ 1. She began working at Nationwide on September 21, 1998. PL’s Mem. Supp. Mot. Summ. J. 4. Her initial duty was to assist insurance claims managers; however, she later became an Administrative Service Manager, responsible for building maintenance and supply. Id. As described in a psychiatric evaluation, her duties included “supervising/managing seven buildings in three different states, supervising seven (7) people, performing a considerable amount of driving, monitoring budgeted expenditures and answering customers as well as department of insurance complaints.” Admin. Record 22.

The precise timeframe is unclear from the record, but the demands of Clark’s job began to increase in response to budgetary pressures. Id. .Clark’s supervisor told Clark that she needed to work 12 to 14 hours a day, and on some days Clark [866]*866worked longer. Id. She had to personally move computers and other equipment into buildings on occasion, sometimes with the help of her husband due to her fibromyalgia. Id. Despite the extended hours, she received complaints from managers and was told to spend more time at work or alternatively to improve her time management. Id. She also began having conflicts with other employees. Pl.’s Mem. Supp. Mot. Summ. J. 4.

As a result of the increased work demands, Clark began suffering from anxiety and depression, with which she was diagnosed on June 21, 2005. Id. 4-5. She received psychiatric treatment and therapy in 2005 and 2006, but the psychiatric symptoms did not subside and the problems at work escalated. Id. at 5. She requested assistance from a nurse employed by Nationwide and discussed with the nurse the possibility of modifying her job. Id. By Clark’s account, the nurse reported that Nationwide denied the modification request because the duties were considered an integral part of the job. Id. Clark began on occasion to stutter and to have difficulty articulating herself, and she became increasingly unable to keep up with work demands. Id.

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Cite This Page — Counsel Stack

Bluebook (online)
933 F. Supp. 2d 862, 2013 WL 1194927, 2013 U.S. Dist. LEXIS 39866, Counsel Stack Legal Research, https://law.counselstack.com/opinion/clark-v-nationwide-mutual-insurance-wvsd-2013.