James v. Liberty Life Assurance Co.

984 F. Supp. 2d 730, 2013 WL 5740875, 2013 U.S. Dist. LEXIS 151879
CourtDistrict Court, W.D. Michigan
DecidedOctober 23, 2013
DocketCase No. 1:12-CV-1361
StatusPublished
Cited by4 cases

This text of 984 F. Supp. 2d 730 (James v. Liberty Life Assurance Co.) is published on Counsel Stack Legal Research, covering District Court, W.D. Michigan primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
James v. Liberty Life Assurance Co., 984 F. Supp. 2d 730, 2013 WL 5740875, 2013 U.S. Dist. LEXIS 151879 (W.D. Mich. 2013).

Opinion

OPINION

ROBERT J. JONKER, District Judge.

Plaintiff, Ashima James, brings this action for long-term disability benefits against Defendants Liberty Life Assurance Company of Boston (“Liberty”) and DTE Energy Company Welfare Benefit Plan under 29 U.S.C. § 1132(a)(1)(B), a civil enforcement provision of the Employee Retirement Income Security Act (“ERISA”). Liberty has filed a motion for judgment on the record (docket # 25). For the reasons set forth below, the Court will grant James long-term disability benefits under the two-year “regular occupation” coverage retroactive to February 24, 2012. The Court declines to address questions regarding potential qualification under the “any occupation” coverage, and potential application of the “mental health symptoms” rider because these issues will not be ripe before February 24, 2014, and may involve a different, or at least expanded, administrative record.

I. Factual Background

James is an approximately fifty-five-year-old woman who worked as a buyer for DTE Energy until August 2011, when she began disability leave because of injuries from a car accident. (Compl., docket # 1, at 3; docket # 18-2, at 123).1 As a buyer, James’s job naturally required a degree of consistent and focused mental engagement. From a physical point of view, the job consisted of carrying out procurement operations, writing contracts, and negotiating contract terms, and is classified as a “sedentary and light physical demand” occupation. (Docket # 18-2, at 113; # 18-5, at 282.) As a DTE employee, James was insured under the DTE Group Disability Income Policy (“Policy”) issued by Liberty. (See docket # 18-1, at 65-106.)

A. Key Policy Provisions

The Policy has an elimination period during which long-term benefits are not payable under the policy. (Id. at 69.) During the first 24 months following the elimination period, the Policy defines “disability” as the inability to “perform the Material and Substantial Duties of [the Covered Person’s] regular occupation or any other occupation with the company for which the Covered person is qualified and which is offered at not less than [his or her] current rate of pay.” (Id. at 73.) Beyond 24 months, the Policy defines “disability” as the inability “to perform, with [732]*732reasonable continuity, the Material and Substantial Duties of Any Occupation.” (Id.) “Any Occupation” is “any occupation that the Covered Person is or becomes reasonably fitted by training, education, experience, age, physical, and mental capacity” to perform. (Id. at 72.) The Policy requires proof of disability. (Id. at 84.) According to the Policy:

“Proof’ means the evidence in support of a claim for benefits and includes, but is not limited to, the following:
1. a claim form completed and signed (or otherwise formally submitted) by the Covered Person claiming benefits;
2. an attending Physician’s statement completed and signed (or otherwise formally submitted) by the Covered Person’s Physician; and
3. the provision by the attending Physician of standard diagnosis, chart notes, lab findings, test results, x-rays, and/or other forms of objective medical evidence in support of a claim for benefits.

(Id. at 76.)

B. The Car Accident

On August 4, 2011, James was a passenger in a vehicle rear-ended by a truck traveling approximately 40 to 45 miles per hour. (Docket # 18-5, at 300; 19-3, at 373.) She was taken to an emergency room and evaluated. (Docket # 18-5, at 294.) She experienced right arm and back pain and exhibited a limited range of motion. (Docket # 18-4, at 227.) X-rays did not reveal any fractures. (Docket # 18-5, at 298.)

C. Treating Physicians

The following day, James saw her primary care physician, Dr. Robert Chang, board-certified in internal medicine, who advised her to not work for at least two weeks due to “strain of the thoracic spine and chest wall, contusions and strain.” (Docket # 21-3, at 885.) Thoracic spine x-rays were negative. (Id.) Dr. Chang referred James to Dr. Thomas Nabity, board-certified in physical medicine and rehabilitation, who examined James on August 22, 2011. (Docket # 19-3, at 373-74.) Dr. Nabity documented right shoulder pain with limited range of motion and a possible rotator cuff tear, thoracic myofascial pain, and acute anxiety attacks. (Id.) He recommended a physical therapy program with the possibility of future trigger point injections for pain, magnetic resonance imaging (MRI) of the rotator cuff, and a formal neuropsychological evaluation. (Id. at 374.) An MRI taken August 28, 2011 revealed a right shoulder labral tear and supraspinatus tendonitis. (Id. at 377.) An MRI taken October 4, 2011 documented cervical degenerative arthritis “with moderate to severe foraminal steno-sis” and “mass effect on the cord.” (Id.) Drs. Chang and Nabity continued to examine and treat James during her disability leave. James was also referred to various specialists, including Dr. Cheryl Mazzara, a board-certified psychiatrist. (See id. at 392.) Dr. Mazzara diagnosed James with Major Depressive Disorder, Recurrent, Severe Without Psychotic Features (DSM-VI 296.33) and Generalized Anxiety Disorder (DSM-IV 300.02). (Docket # 19-4, at 404, 406.)

D.Independent Medical Examinations

During the elimination period, DTE paid James’s short-term disability benefits without objection. (See Docket # 21-5, at 962.) At DTE’s request, two doctors conducted independent medical examinations (IMEs) of James. First, on October 11, 2011, Dr. Shlomo Mandel, board-certified [733]*733in occupational, internal, and environmental medicine, interviewed and examined James. (Docket # 19-5, at 458-71.) His examination revealed tenderness in the paracervical and trapezius region, “very limited” range of motion of the cervical spine with significant decreases in flexion, extension, rotating, and side bending bilaterally. (Id. at 466.) He noted that the examination was “remarkable for extensive subjective difficulty, with very little range of motion of the shoulder and essentially no grip measured in the right compared to left upper extremity.” (Id. at 468.) Dr. Mandel concluded in his report that while there were “a great deal of subjective findings,” there was “no objective indication of orthopedic pathology or focal neurological deficits.” (Id. at 469.) He opined that James’s prognosis was “fair” and James could return to work without limitation as a DTE buyer. (Id.)

On October 19, and again on December 7, 2011, Dr. Saul Forman, a psychiatrist, interviewed and examined James. (Id. at 473-83.) In his first report, Dr. Forman diagnosed James with Posttraumatic Stress Disorder, Acute, with Depression (DSM-IV 309.81). (Docket #21-1, at 775.) He recorded her self-reports of feeling helpless, hopeless, and worthless with some “disordered thinking,” but noted that she was not suicidal or paranoid. (Id. at 773.) He also observed that she became “preoccupied” when Dr. Forman talked about returning to work. (Id. at 774.) In his first report, Dr.

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984 F. Supp. 2d 730, 2013 WL 5740875, 2013 U.S. Dist. LEXIS 151879, Counsel Stack Legal Research, https://law.counselstack.com/opinion/james-v-liberty-life-assurance-co-miwd-2013.