Gilewski v. Provident Life & Accident Insurance Co.

683 F. App'x 399
CourtCourt of Appeals for the Sixth Circuit
DecidedMarch 22, 2017
DocketCase 16-2028
StatusUnpublished
Cited by9 cases

This text of 683 F. App'x 399 (Gilewski v. Provident Life & Accident Insurance Co.) 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
Gilewski v. Provident Life & Accident Insurance Co., 683 F. App'x 399 (6th Cir. 2017).

Opinion

MERRITT, Circuit Judge.

Plaintiff Les Gilewski brought a declaratory judgment action against defendant Provident Life and Accident Insurance Company pursuant to the Employee Retirement Income Security Act, 29 U.S.C. § 1132(a)(1)(B), alleging wrongful termination of long-term disability benefits and seeking reinstatement of those benefits. Gilewski suffered from depression and, at the age of 41, applied for benefits under two long-term’ disability policies he held with Provident. Provident paid benefits under one policy for the two-year duration of its term and those benefits are not at issue in this appeal. Provident also paid benefits under the second policy, but, after four years, it terminated the benefits after it determined that Gilewski was “able to perform the duties of his occupation” and was no longer disabled under the terms of the policy. After exhausting Provident’s administrative appeals, Gilewski brought this action against Provident. The district court granted judgment on the administrative record to Provident. For the following reasons, we affirm.

I. FACTS AND HISTORY

Gilewski, born in 1968, was the owner and president of Radiance Mold and Engineering, Inc., an auto supplier in Michigan, for 20 years. At one time the business employed as many as 100 people. In 2001, Gilweski’s son was born with cerebral palsy, putting a strain on his family and work *401 life. Gilewski also started experiencing marital difficulties that year. By the mid-2000s, Gilewski was losing customers and sales personnel due to his personal struggles.- Gilewski’s business experienced further downturn during the recession that began in 2008, and the business was put into bankruptcy and liquidated in the spring of 2009. Gilewski began experiencing depression, culminating in his hospitalization for one week in June 2009 when he became suicidal. Gilewski left the hospital under the care of Dr. Dan Guyer, who prescribed medications for Gilewski. Gi-lewski was also under the care of a psychologist, Dr. Fred Roberts, -with whom he had weekly therapy sessions. Gilewski’s doctors determined he could not work, and he filed for long-term disability pursuant to two disability insurance policies he had previously purchased from Provident, citing his medical condition as anxiety and depression. When he applied for benefits, Gilewski included a statement from his treating psychiatrist, Dr. Guyer, which stated that Gilewski suffered from major depression and was unable to work. Dr. Guyer further noted that he expected to see improvement in six to twelve months. Provident began paying benefits effective June 2009 and continued until July 2013 when Provident determined that Gilewski was able to return to his previous occupation.

The first policy, which provided 24 months of disability benefits, is not at issue in this ease. The second policy requires Provident to pay monthly benefits to a participant who satisfies various conditions, including being disabled within the meaning of the term as defined by the policy. The policy states:

Disability, or disabled, means that, due solely to Injuries or Sickness:
1. you have a Loss of Time or Duties in your occupation; and
2. you have a Loss of Earnings of at least 20%.
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Loss of Time or Duties means that:
1. you are not able to perform one or more of the substantial and material duties of your occupation; or
2. you are not able to perform the substantial and material duties of your occupation for -as much time as you regularly performed them before you became disabled.
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Your occupation means the occupation ... in which you are regularly engaged at the time you become disabled.

Policy at 5-7 (emphasis omitted).

2009-2011

Provident paid Gilewski all available benefits under the first policy.' Provident initially denied Gilewski’s claim under the second policy because it determined that Gilewski had negative earnings during the years preceding his disability onset date and therefore had not sustained a 20-per-cent earnings loss as required under the policy. Provident later reconsidered that determination, however, and paid all past due benefits. That dispute was resolved and is not at issue in this appeal.

Provident received periodic updates from Gilewski’s treating health-care professionals. On January 5, 2010, Gilewski’s treating psychologist, Dr. Roberts, submitted documentation to Provident noting that Gilewski’s depression had been severe in June 2009, but had improved to moderate by October 2009. Dr. Roberts estimated that it was likely Gilewski would be ready to work at least part-time by June 2010. In June 2011, Dr. Roberts submitted another report stating that Gilewski was less depressed and feeling more hopeful about the future, but noting that it would *402 continue to be too stressful for Gilewski to run a large company.

2011-2013

In November 2010, Gilewski underwent a forensic psychiatric examination as part of his bankruptcy proceeding. He was examined by Dr. Gerald Shiener, a board certified psychiatrist. Dr. Shiener diagnosed Gilewski with “Major depression, recurrent and chronic,” and concluded that Gilewski’s “current condition is incompatible with any sort of competitive employment.” Because Dr. Shiener was not one of Gilewski’s regular treating physicians at this time, his initial report was not sent to Provident at the time it was created. Gi-lewski, however, began to see Dr. Shiener monthly after November 2010. Dr. Shiener began providing regular attending physician statements to Provident in June 2011. However, the statements were simply photocopies of previous statements with only the date changed, noting Gilewski’s diagnosis of “major depression,” stating that he cannot work and that it “cannot [be] determined” when he will be able to return to work. Gilewski stopped seeing Dr. Roberts in May 2011 and it appears that Dr. Shiener became Gilewski’s sole treating physician for his depressive disorder. Dr. Robert’s last treatment note, dated May 12, 2011, indicated that Gilewski was noticing “more energy” and “was better able to think clearly” after a change in his medications.

In early 2012, Provident began requesting further documentation from Dr. Shiener about Gilewski’s current condition and prognosis. Dr. Shiener had been Gilewski’s treating physician for a year, and he had provided Provident only with photocopies of the same attending physician statement with the date changed each month. Provident sent a letter to Dr. Shiener on June 21, 2012, stating that it had sent him four previous requests for “additional information.” On June 18, 2012, Dr. Shiener responded with a letter stating that it was his policy not to release the requested records because disclosure of sensitive personal information limits a patient’s ability to participate in treatment. Dr.

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683 F. App'x 399, Counsel Stack Legal Research, https://law.counselstack.com/opinion/gilewski-v-provident-life-accident-insurance-co-ca6-2017.