Collins v. Life Insurance Company of North America

CourtDistrict Court, M.D. Florida
DecidedMarch 24, 2023
Docket6:21-cv-01756
StatusUnknown

This text of Collins v. Life Insurance Company of North America (Collins v. Life Insurance Company of North America) is published on Counsel Stack Legal Research, covering District Court, M.D. Florida primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Collins v. Life Insurance Company of North America, (M.D. Fla. 2023).

Opinion

UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF FLORIDA ORLANDO DIVISION

BRANDON COLLINS,

Plaintiff,

v. Case No.: 6:21-cv-1756-WWB-DCI

LIFE INSURANCE COMPANY OF NORTH AMERICA,

Defendant. / ORDER THIS CAUSE is before the Court on the parties’ cross Motions for Summary Judgment (Doc. Nos. 16, 17), and the parties’ respective Responses (Doc. Nos. 22, 23) and Replies (Doc. Nos. 24, 25). I. BACKGROUND Brandon Collins filed the instant action against Life Insurance Company of North America (“LINA”) under the Employee Retirement Security Act (“ERISA”), as amended, 29 U.S.C. § 1001, et seq., seeking review of LINA’s denial of long-term disability (“LTD”) benefits. Collins was employed by Estes Express Lines (“EEL”) in the heavy-duty occupation of Materials Handler, a dock worker. (Doc 14-1 at 9, 14, 32; Doc. 14-7 at 136). Collins’s occupation required him to exert fifty to one-hundred pounds of force occasionally, twenty-five to fifty pounds of force frequently, or ten to twenty pounds of force constantly to move objects. (Doc. 14-7 at 136). Collins stopped working on March 10, 2019, due to a torn rotator cuff and two herniated discs caused by two motor vehicle accidents. (Doc. 14-1 at 9; Doc. 14-6 at 202). Collins was covered by EEL’s short-term disability plan (“STD”) and its LTD plan. (Doc. 14-1 at 87; Doc. 14-5 at 24; Doc. 14-8 at 106–108). Defendant initially provided

LTD coverage under Group Policy No. FLK-980233 (the “Plan”), finding Collins could not perform his occupation as Materials Handler. (Doc. 14-9 at 149–150). After an identified period of time passes, however, benefits are only payable under the Plan if the claimant is unable to work in “any occupation for which [he is], or may reasonably become, qualified based on education, training or experience[.]” (Doc. 14-14 at 425). Accordingly, on April 10, 2020, LINA advised Collins that LINA would review his claim to determine if he continued to qualify for benefits under the “any occupation” standard. (Doc. 14-5 at 91– 92). A. The Plan Documents The Plan provides that after disability benefits have been payable for twelve

months, a claimant is disabled if he is “unable to perform the material duties of any occupation for which he . . . is, or may reasonably become, qualified based on education, training or experience; and . . . unable to earn 60% or more of his . . . Indexed Earnings.” (Doc. 14-14 at 484). The Plan requires: The 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 Disability Benefit is shown in the Schedule of Benefits. (Id. at 495). The Amendatory Rider to the Policy provides that “[t]he Plan Administrator has appointed the Insurance Company as the named fiduciary for deciding claims for benefits under the Plan, and for deciding any appeals of denied claims.” (Id. at 509). The Plan further states that a certificate of insurance (“COI”) is to be provided to

the insureds and that the “certificate will list the benefits, conditions and limits of the Policy.” (Id. at 504). In addition, the Supplemental Information document provides that the Supplemental Information and the Certificate provided to Collins make up the Summary Plan Description (“SPD”) as required by ERISA. (Id. at 428). The SPD, which includes the COI, provides: The Plan Administrator has appointed the Insurance Company as the named fiduciary for adjudicating claims for benefits under the Plan, and for deciding any appeals of denied claims. The Insurance Company shall have the authority, in its discretion, to interpret the terms of the Plan, to decide questions of eligibility for coverage or benefits under the Plan, and to make any related findings of fact. All decisions made by the Insurance Company shall be final and binding on Participants and Beneficiaries to the full extent permitted by law. (Id. at 429). B. The Medical Records Plaintiff underwent an anterior cervical discectomy with arthroplasty on March 14, 2019, to address his neck issues. (Doc. 14-1 at 106). On March 26, 2019, Collins’s treating orthopedic surgeon, Dr. Jason Highsmith, noted Collins’s statement that his symptoms had improved post-procedure, but he had some postoperative pain. (Doc. 14- 7 at 47). Collins was unable to increase his range of motion, but the tingling into the left upper extremity was improving. (Id.). On June 15, 2019, Collins had a procedure with Dr. Francis McCormick to address his left shoulder. (Doc. 14-2 at 11–13). On August 9, 2019, Collins expressed that he had diminished pain and was working on strengthening, range of motion, and returning to recreational activity. (Doc. 14-13 at 87–88). On September 5, 2019, Collins was in a third motor vehicle accident that worsened his neck and shoulder pain. (Doc. 14-5 at 63).

On March 25, 2020, Collins saw Dr. Nicholas Newsum with complaints about a finger deformity; Dr. Newsum concluded that the deformity was very functional and discharged Collins from care. (Doc. 14-10 at 158–160). On March 31, 2020, Plaintiff had a procedure with postoperative diagnosis of lumbar disc disruption at L4-L5. (Doc. 14-5 at 117). Based on the medical records provided by Collins, a reviewing physician conducted a medical director review of the disability file and determined that Collins had no restrictions for sitting, standing, walking and reaching at or above waist level, could occasionally reach below waist/desk level, lift/carry up to twenty pounds, push/pull up to fifty pounds, climb ladders, stoop, crouch, squat, crawl, or kneel, and could frequently

lift/carry up to ten pounds, push/pull up to twenty pounds, and climb stairs. (Doc. 14-6 at 203). A Transferable Skills Analysis (“TSA”) was conducted, and it was determined that Collins could perform the sedentary occupation of Repair-Order Clerk. (Id.). Consequently, on October 29, 2020, LINA informed Plaintiff that he no longer met the Policy’s definition of disabled under the “any occupation” standard. (Id. at 201–204). Collins appealed and provided additional medical records of epidural injections he received in 2020, and an MRI of the lumbar spine. (Doc. 14-6 at 123, 144, 269; Doc. 14- 13 at 21–22). Thereafter, Dr. Alen Nourian, a specialist in orthopedic surgery, performed an External MD Appeals Review. (Doc. 14-7 at 22–32). Dr. Nourian concluded that Collins was “functionally limited to a moderate degree” because he continued to have low back pain. (Id. at 27). Dr. Nourian noted the recent lumbar disc disruption at L3-4 and L5-S1,

and Collins’s flare ups. (Id.). Dr. Nourian’s February 12, 2021 report suggested the following restrictions and limitations: Sitting: unrestricted Standing: occasionally 15 minutes at a time, up to 1 hours total per day Walking: occasionally 15 minutes at a time, up to 1 hours total per day Lifting: occasionally up to 15 lbs. Carrying: occasionally up to 15 lbs. Pushing: occasionally up to 15 lbs. Pulling: occasionally up to 15 lbs. Climbing stairs: occasionally Balancing: never Stooping: occasionally Kneeling: occasionally Crouching: occasionally Crawling: never Reaching: occasionally overhead/below waist; unrestricted desk level Use lower extremities for foot controls: unrestricted BLE Fine manipulation: unrestricted [right upper extremity] and occasionally [left upper extremity] Simple and firm grasping: unrestricted [right upper extremity] and occasionally [left upper extremity]

(Id. at 27–28). Dr.

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Collins v. Life Insurance Company of North America, Counsel Stack Legal Research, https://law.counselstack.com/opinion/collins-v-life-insurance-company-of-north-america-flmd-2023.