Jack Calhoun, Jr. v. Life Ins. Co. of North America

665 F. App'x 485
CourtCourt of Appeals for the Sixth Circuit
DecidedDecember 15, 2016
Docket15-3470
StatusUnpublished
Cited by6 cases

This text of 665 F. App'x 485 (Jack Calhoun, Jr. v. Life Ins. Co. of North America) 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
Jack Calhoun, Jr. v. Life Ins. Co. of North America, 665 F. App'x 485 (6th Cir. 2016).

Opinions

MARTHA CRAIG DAUGHTREY, Circuit Judge.

The plaintiff, Jack Calhoun, Jr., filed this Employee Retirement Income Security Act (ERISA) action against defendant Life Insurance Company of North America (LINA) after the insurance company terminated his long-term disability benefits. In deciding to end Calhoun’s benefits, LINA concluded that Calhoun was no longer “totally disabled,” which was a prerequisite to Calhoun’s receipt of disability benefits under the insurance plan. The district court upheld LINA’s determination, finding that under the deferential arbitrary-and-capricious standard of review, LINA’s termination of benefits was not arbitrary and capricious. For the reasons set out below, we conclude that LINA’s decision to terminate Calhoun’s benefits was not the product of reasoned decision-making and was not supported by substantial evidence. Therefore, we hold that LINA acted arbitrarily and capriciously when it denied Calhoun’s claim, and we reverse the judgment of the district court and remand the case for further proceedings.

FACTUAL AND PROCEDURAL BACKGROUND

As a senior maintenance technician at Mars, Inc., Calhoun “[r]an a team of technicians to repair & maintain factory equip[ment].” Calhoun, however, stopped working in January 2010 due to chronic leg and back pain that was aggravated by sitting, standing, and walking. Dr. Monique Boezi, Calhoun’s primary-care physician, summarized Calhoun’s symptoms:

Any walking hurts [Calhoun’s] back.... If he stands for any leng[th] of time, about 10 minutest,] he has to use a cane o[r] sit down.... His legs go numb when he sits for longer than 20-30 minutes .... All of these symptoms are dai[488]*488ly and really affect his normal living.... [H]e cannot walk, stand, or sit for prolonged periods of time.

Di". Boezi’s treatment notes consistently reflected Calhoun’s inability to sit or stand for prolonged periods of time, leading her to conclude that Calhoun could not work in his job as a maintenance technician because it required “a lot of walking and lifting and bending with prolonged standing,” but also that he could not work at a desk job, which required long periods of sitting. Electromyography confirmed that Calhoun suffered from meralgia paresthe-tica, a compression of a nerve in the thigh, and an MRI revealed degenerative disc disease at L5-S1, a vertebral segment at the base of the spine.

In addition to his primary-care appointments with Dr. Boezi, Calhoun regularly saw Dr. Nancy Vaughan, an orthopedic specialist, for treatment of his condition. Dr. Vaughan reported that Calhoun could not stand for longer than 20 minutes and noted Calhoun’s difficulties with walking, but she declined Calhoun’s request for a power scooter, explaining that “[t]he sedentary lifestyle is more harmful to his health.” Dr. Vaughan wrote in her treatment notes that she thought Calhoun was “limiting his function more than he should be” and that his pain was “out of proportion to objective findings.”' Calhoun also saw several other specialists: Dr. Robert Dixon, a neurosurgeon, who confirmed that Calhoun’s symptoms were consistent with Drs. Boezi and Vaughan’s diagnoses; Dr. Robert Stephenson, a physical medicine and rehabilitation specialist, who opined that it was unlikely that Calhoun’s spine was the cause of pain “so severe that [Calhoun] must use a motorized scooter”; and Dr. James Powers, another physical medicine and rehabilitation specialist, who opined that it was more likely that Calhoun’s pain was musculoskeletal rather than neurological.

After exhausting his short-term disability leave, Calhoun submitted a disability claim under Mars’s long-term disability plan. The plan, administered by LINA, provided monthly benefits payments to employees with a “total disability.” An employee was defined as “totally disabled” if, during an initial 24-month period, he was “unable to perform all the essential duties of his occupation.” After that 24-month period, an employee was “totally disabled” only if “he [was] unable to perform all the essential duties of any occupation” for which he was reasonably qualified and also “remain[ed] unable to earn more than 75% of his Basic Monthly Earnings.” LINA both determined which claims were eligible for benefits under the plan and paid the benefits for eligible claims.

While his claim before LINA was pending, Calhoun applied for Social Security benefits with the assistance of LINA, which arranged and paid for Calhoun’s representation before the Social Security Administration (SSA). The plan stipulated that if the employee refused LINA’s assistance with the SSA claim, then the employee’s monthly payments would be reduced by the amount of benefits that the employee would be “assumed to receive” from the SSA for his disability. If the employee cooperated with LINA’s assistance with the SSA claim, as Calhoun did, then his monthly payments would not be reduced by the assumed receipt of [SSA] benefits.' Under the terms of the plan, if his SSA claim was successful, the employee was required to reimburse LINA for any overpayment in his monthly benefits.

In July 2010, LINA notified Calhoun that he satisfied the plan’s definition of total disability, and LINA approved Calhoun’s claim for long-term disability benefits approximately one month later. LINA informed Calhoun that LINA would con[489]*489tinue to monitor his claim, with subsequent payment of benefits contingent upon “confirmation of [his] continuing disability-status.” Calhoun’s long-term disability benefits commenced on July 26, 2010. To document Calhoun’s level of daily activity, LINA arranged for video surveillance of Calhoun over a three-day period in March 2011. The surveillance company, Photo-Fax, Inc., reported that it had obtained nine minutes of film of Calhoun “walking, talking, driving, entering and exiting his vehicle, pushing a shopping cart, and carrying bags of groceries” and 13 minutes of film of Calhoun “sitting down and pushing a shopping cart through a store.”

After Calhoun had received 15 months of benefits payments, LINA reminded him that, consistent with the benefits plan, he would receive benefits beyond the initial 24-month period only if he was “unable to perform all the material duties of any occupation” for which he reasonably could be qualified. LINA informed Calhoun that it would review his claim to determine his continued eligibility for benefits. In addition to reviewing the medical records from his treating physicians, LINA arranged for Calhoun to be evaluated through a functional-capacity analysis, additional video surveillance, transferrable-skills analysis, and peer review of Calhoun’s medical file.

In March 2012, occupational therapist Scott Secrest conducted a functional-capacity analysis of Calhoun. Secrest observed that Calhoun could lift or carry certain amounts of weight occasionally but that he could not carry even negligible weight frequently. Secrest further observed that Calhoun “exhibit[ed] limited tolerance for sustained sitting or standing” and “limited tolerance for various mobility tasks such as walking, stooping, kneeling and climbing stairs, each of which he [was] able to perform on no more than an occasional basis.” Secrest concluded that Calhoun would “require at least one break every hour for 5-10 minutes from sustained sitting” and that he could not tolerate standing for more than 15-20 minutes without a break.

To supplement the functional-capacity analysis, LINA engaged PhotoFax for a second round of video surveillance of Calhoun.

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665 F. App'x 485, Counsel Stack Legal Research, https://law.counselstack.com/opinion/jack-calhoun-jr-v-life-ins-co-of-north-america-ca6-2016.