Graham v. Life Insurance Co. of North America

222 F. Supp. 3d 1129, 2016 U.S. Dist. LEXIS 163828, 2016 WL 6958151
CourtDistrict Court, N.D. Georgia
DecidedNovember 28, 2016
Docket1:15-cv-3240-WSD
StatusPublished
Cited by5 cases

This text of 222 F. Supp. 3d 1129 (Graham v. Life Insurance Co. of North America) is published on Counsel Stack Legal Research, covering District Court, N.D. Georgia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Graham v. Life Insurance Co. of North America, 222 F. Supp. 3d 1129, 2016 U.S. Dist. LEXIS 163828, 2016 WL 6958151 (N.D. Ga. 2016).

Opinion

OPINION AND ORDER

WILLIAM S. DUFFEY, JR., UNITED STATES DISTRICT JUDGE

This matter is before the Court on Defendant Life Insurance Company of North America’s (“Defendant”) Motion for Judgment on the Administrative Record [12] (“Motion”).

I. BACKGROUND

Plaintiff in this action seeks review, under the Employee Retirement Income Security Act of 1974 (“ERISA”), of Defendant’s denial of long term disability (“LTD”) benefits. Plaintiff was a registered nurse at DeKalb Regional Health System (“DeKalb Regional”), and was enrolled in the DeKalb Medical Welfare Plan (the “Plan”). On July 9, 2012, Plaintiff had a total abdominal hysterectomy. After the procedure she began to suffer severe pain, causing her, she claims, to be totally disabled. Plaintiff challenges Defendant’s administrative determination that she was not entitled to receive LTD benefits.

A. The LTD Plan

DeKalb Medical is the Plan Administrator, and appointed Defendant as the Plan’s claims administrator and administrator of LTD benefits claims. ([12.1]). LTD Plan benefits are funded by Group Policy Number LK-980121 (“Group Policy”) and are payable under the Plan based on Defendant’s application of the Plan’s terms. (Ad[1132]*1132min. R. [12.3-12.6] (“R”) 6-29). The Appointment of Claim Fiduciary delegates to Defendant responsibility “for adjudicating claims for benefits under the Plan, and for deciding any appeals of adverse claim determinations.” ([12.2]). Defendant has “the authority, in its discretion, to interpret the terms of the Plan, including the Policies; to decide questions of eligibility for coverage or benefits under the Plan; and to make any related findings of fact.” (Id.).

The Group Policy provides:

Disability Benefits
The Insurance Company will pay Disability Benefits if an Employee becomes Disabled while covered under this Policy... .He or she must provide the Insurance Company, at his or her expense, satisfactory proof of Disability before benefits will be paid.

(R. 14). The Group Policy defines “disability” as follows:

The Employee is considered Disabled if, solely because of Injury or Sickness, he or she is:
1. unable to perform the material duties of his or her Regular Occupation and
2. unable to earn 80% or more of his or her Indexed Earnings from working in his or her Regular Occupation.
After Disability Benefits have been payable for 24 months, the Employee is considered Disabled if, solely because of Injury or Sickness, he or she is:
1. unable to perform the material duties of any occupation for which he or she is, or may reasonably become, qualified based on education, training or experience; and
2. unable to earn 60% or more of his or her Indexed Earnings.

(R. 9). The Group Policy defines “Regular Occupation” as:

The occupation the Employee routinely performs at the time the Disability begins. In evaluating the Disability, the Insurance Company will consider the duties of the occupation as it is normally performed in the general labor market in the national economy. It is not work tasks that are performed for a specific employer or at a specific location.

(R. 25).

B. Initial Treatment and Administrative Review

Plaintiff worked as a registered nurse with DeKalb Regional for over eight years. (R. 327). A registered nurse is a medium level occupation that requires exerting up to 20 to 50 pounds of force occasionally, or 10 to 25 pounds of force frequently, or greater than negligible up to 10 pounds of force constantly to move objects. (R. 177).

On July 9, 2012, Plaintiff had a total abdominal hysterectomy. (R. 321-22). On September 6, 2012, during a follow-up visit with her gynecologist, Dr. Pamela J. Brown, Plaintiff did not report any pain. (R. 321-24). Plaintiff returned to work. On September 14, 2012, while walking down a hallway at work, she experienced severe pain in her back, pressure in her pelvis, and weakness to both legs. (R. 325). Plaintiffs last day of work was September 15, 2012. (R. 32).

On September 17, 2012, Plaintiff returned to Dr. Brown, complaining of lower back and abdominal pain. (R. 317-19). On September 27, 2012, Plaintiff had an MRI of the lumbar spine. The MRI images were not clear, because Plaintiff “had a difficult time remaining motionless for th[e] study.” (R. 312). The MRI, however, showed “[v]ery mild degenerative changes ... causing neural foraminal stenosis without [1133]*1133substantial spinal canal stenosis.” (R. 313).1

Plaintiff was referred to a neurosurgeon, Dr. Kaveh Khajavi, for further examination. Dr. Khajavi examined Plaintiff on October 22, 2012, for reported symptoms of lower leg pain and back pain. (R. 309). Dr. Khajavi’s notes state: “MRI of the lumbar spine is completely normal. At this point I do not know the etiology of her back or leg symptoms but they do not have a spinal etiology as again her MRI is completely normal.” (R. 309). Dr. Khajavi noted that Plaintiff’s pain “could be consistent with a hip pathology.” (R. 309). It was recommended that Plaintiff consider seeing an orthopedist. (R. 309).

On October 30, 2012, Plaintiff saw Dr. Fred Koch, an orthopedist. Dr. Koch’s exam noted that Plaintiff complained of pain in her back and legs. (R. 342). Dr. Koch observed that the previous MRI. showed “disk bulging but no major obvious neurologic compressive lesion.” (R. 342). He recommended rehabilitation, medication, and—if the pain did not improve— epidural injections or some other type of pain management. (R. 342). On November 19, 2012, Plaintiff followed up with Dr. Koch, who noted that Plaintiff “is not making a lot of headway” through rehabilitation services. (R. 341). Dr. Koch recommended an evaluation by a pain specialist. (R. 341).

On January 3, 2013, Plaintiff was treated by Dr. David A. Stewart, and received an epidural steroid injection (“ESI”) to treat her pain. (R. 363-64). Dr. Stewart’s impression was lumbar radiculopathy.2 On January 25, 2013, Plaintiff received a second ESI from Dr. Stewart, and she reported the first ESI decreased her pain by 60%. (R. 361-62).

On February 20, 2013, Plaintiff applied for LTD benefits. (R. 126). When she applied, Plaintiff only identified Dr. Stewart as her treating physician. (R. 129). On February 26, 2013, Defendant sent Plaintiff correspondence acknowledging Plaintiffs telephonic report of her claim and stating: “We must obtain eligibility information from your employer and your physician’s treatment plan, as well as medical information regarding your diagnosis and functional abilities.” (R. 196).

On March 4, 2013, Plaintiff returned to Dr. Stewart, explaining that when she stands for long periods of time she experiences pain and discomfort. (R. 359). His impression was that Plaintiff might suffer from lumbar spondylosis and lumbar degenerative disease. (R. 359).3 He recommended Plaintiff see a chiropractor. (R. 359).

On March 22, 2013, Defendant sent a letter to Plaintiff stating: “Please under[1134]*1134stand that we need [medical records from Dr.

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222 F. Supp. 3d 1129, 2016 U.S. Dist. LEXIS 163828, 2016 WL 6958151, Counsel Stack Legal Research, https://law.counselstack.com/opinion/graham-v-life-insurance-co-of-north-america-gand-2016.