DELISLE v. Sun Life Assur. Co. of Canada

636 F. Supp. 2d 561, 2007 U.S. Dist. LEXIS 76000, 2007 WL 3013075
CourtDistrict Court, E.D. Michigan
DecidedOctober 12, 2007
DocketCase 06-11761
StatusPublished
Cited by4 cases

This text of 636 F. Supp. 2d 561 (DELISLE v. Sun Life Assur. Co. of Canada) is published on Counsel Stack Legal Research, covering District Court, E.D. Michigan primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
DELISLE v. Sun Life Assur. Co. of Canada, 636 F. Supp. 2d 561, 2007 U.S. Dist. LEXIS 76000, 2007 WL 3013075 (E.D. Mich. 2007).

Opinion

OPINION AND ORDER

LAWRENCE P. ZATKOFF, District Judge.

I. INTRODUCTION

This matter comes before the Court on cross motions for Judgment on the Administrative Record (Docket # 23, 24). The parties have fully briefed the motions. The Court finds that the parties have adequately set forth the relevant law and facts such that oral argument would not aid in the disposition of the instant motions. E.D. Mich. L.R. 7.1(e)(2). Accordingly, the Court ORDERS that the motions be decided on the briefs submitted. For the reasons set forth below, Plaintiffs motion is GRANTED, and Defendant’s motion is DENIED.

II. BACKGROUND

This action involves long-term disability (“LTD”) benefits under an employee benefits plan that is subject to the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1132(a)(1)(B) (“ERISA”). On January 8, 1996, Plaintiff began working for Sidney Krandall & Sons Jewelers (“Krandall”) in Troy, Michigan, as Director of Operations and Chief Financial Officer. As Krandall’s employee, Plaintiff participated in a group disability insurance plan, which was underwritten and administered by Defendant, Sun Life Assurance Company of Canada. Plaintiff worked without incident until suffering head, neck, and back injuries in a January 1998 automobile accident. Her condition following the accident ultimately necessitated a spinal fusion procedure. A second automobile accident on August 24, 2000, compounded these injuries. As a result of the second accident, Plaintiff also suffered a closed head injury. Plaintiff alleges that the injuries sustained from these accidents caused her health to “spiral downward so that she could no longer function as Director of Operations and led to her total disability.” Plaintiff continued to work following these accidents, however, and did not submit a claim for disability benefits until several months after her termination.

*565 On April 17, 2002, Plaintiff arrived at Krandall’s with the intention of working as she normally would. Krandall, however, terminated Plaintiff’s employment that day “because of poor performance” and because “she was not doing her job.” Krandall offered Plaintiff a severance package, which Plaintiff rejected. Krandall compensated Plaintiff for the entirety of April 17. On the same day as her termination from Krandall, Plaintiff informed her therapist, Diane P. Cushing, M.A., L.P.C., that she was fired “based on personality issues vs. job performance.” At that time, Plaintiff contemplated bringing suit against Krandall, but she did not mention any disability or inability to perform her occupation. Plaintiff filed a claim for unemployment benefits, indicating on her application both that she was ready to work and that Krandall released her on account of “lack of work.” She ultimately received these unemployment benefits and also obtained employment after her termination at Krandall. Plaintiff told Cushing that she wanted to quit her new job because of frustration regarding the number of hours she would have to work. Plaintiff was fired from this position, apparently because of her refusal to work excessive hours.

On March 6, 2003, Plaintiff submitted a claim for LTD benefits under Krandall’s disability plan. Defendant’s policy provides for monthly disability payments when an employee cannot perform the material duties of her “own occupation” on account of “injury or sickness.” Material or substantial duties include “the essential tasks, functions, skills, or responsibilities required by Employer for the performance of the Employee’s Own Occupation,” where “own occupation” references “the usual and customary employment, business, trade, profession, or vocation that the Employee performed as it is generally recognized in the national economy immediately prior to the first date Total or Partial Disability began.” Employees must demonstrate that this inability to perform their own occupations, resulting from total or partial disability, persists for a continuous period of ninety days (called the Elimination Period) during which period no LTD benefit is payable. The disability must also persist throughout the twenty-four months following the Elimination Period. The policy mandates that Plaintiff “provide proof of continuing Total ... Disability.”

In support of her claim, Plaintiff submitted Attending Physician Statements from five individuals, all of whom detailed diagnoses stemming from Plaintiffs automobile accidents. Among other maladies, the doctors diagnosed Plaintiff with cervical and lumbar radiculopathy, major depressive disorder, mood disorder, and acute traumatic cervical subluxation. The doctors also observed serious impairment in problem solving ability, an overall decline in intellectual functioning, suicidal ideation, and cognitive disorder due to her motor vehicle accident. The physician statements yielded a consensus that Plaintiff has a physical and mental “Class 5 Level of Functional Impairment,” signifying severe limitation of functional capacity rendering Plaintiff incapable of minimum sedentary activity and psychological, physiological, personal, and social adjustments. Plaintiff was granted Social Security Disability Insurance Benefits, and the Social Security Administration (“SSA”) concluded that Plaintiff was totally disabled under its rules as of April 17, 2002.

Despite Plaintiffs offering of proof regarding her disability, Defendant denied Plaintiffs claim on March 28, 2003, alleging that Plaintiff lacked coverage on the date of her apparent disability because she had been fired. Plaintiff appealed, complete with 800 pages of medical support and documentation, but was once again denied. After Plaintiff exhausted administrative channels, she brought suit. In De *566 lisle v. Sun Life Assurance Co., No. 04-60163 (E.D.Mich. Sept. 30, 2005), the Court held that although Defendant’s Insurance Policy vested discretion in Defendant, Defendant’s interpretation of the disability plan’s eligibility standards was arbitrary and capricious. The Court further held that Defendant did not waive its ability to contest Plaintiffs claimed date of disability. In making its determinations, the Court explicitly avoided consideration of whether Plaintiff was, in fact, disabled. Accordingly, the Court remanded the case to determine whether Plaintiff was disabled on April 17, 2002.

On remand, Defendant referred Plaintiffs file to three physicians and a rehabilitation consultant. These individuals conducted file reviews of Plaintiffs materials. Although Defendant’s physicians concurred with Plaintiffs physicians regarding evidence of major depressive disorder and anxiety disorder, they discovered no evidence that they believed would have rendered Plaintiff unable to perform her functions as of April 17, 2002. These physicians also uncovered no evidence of complaints regarding cognitive problems until after Plaintiffs termination from Krandall. Plaintiffs medical records, in contrast, indicated that Plaintiffs physicians had previously forbidden Plaintiff from working and that her physical impairments led to restricted motion of the neck and limitations on lifting. These records also indicated a retrogression in Plaintiffs mental competence, intelligence, and memory.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
636 F. Supp. 2d 561, 2007 U.S. Dist. LEXIS 76000, 2007 WL 3013075, Counsel Stack Legal Research, https://law.counselstack.com/opinion/delisle-v-sun-life-assur-co-of-canada-mied-2007.