Jones v. WEA Insurance

60 F. Supp. 3d 1000, 2014 U.S. Dist. LEXIS 143631, 2014 WL 4988384
CourtDistrict Court, W.D. Wisconsin
DecidedOctober 7, 2014
DocketNo. 13-cv-741-wmc
StatusPublished

This text of 60 F. Supp. 3d 1000 (Jones v. WEA Insurance) is published on Counsel Stack Legal Research, covering District Court, W.D. Wisconsin primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Jones v. WEA Insurance, 60 F. Supp. 3d 1000, 2014 U.S. Dist. LEXIS 143631, 2014 WL 4988384 (W.D. Wis. 2014).

Opinion

OPINION & ORDER

WILLIAM M. CONLEY, District Judge.

Plaintiff Stefanie Jones seeks to recover unpaid long-term disability (“LTD”) benefits under the terms of an employee benefits plan established by her former employer, defendant WEA Insurance Corporation (“WEA”). Jones challenges as arbitrary and capricious WEA’s decision to deny her LTD benefits with respect to two particular time periods: (1) August 6, 2009, through September 18, 2009; and (2) November 30, 2009, through March 10, 2010. WEA has moved for summary judgment. (Dkt. # 14.) Under the applicable deferential standard, the court agrees that WEA’s decision to deny Jones benefits was based on a substantial review and, at worst, conflicting evidence. Her challenge, therefore, is unavailing and so the court will grant the motion for summary judgment.

UNDISPUTED FACTS1

A. Background

At all relevant times, WEA sponsored and maintained an employee benefits plan (“the Plan”) for its eligible employees. The Plan is governed by the Employment Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et seq., and arises from a group insurance contract WEA issued to itself as employer. WEA, as insurer, is the Plan’s Administrator for ERISA purposes.2

The principal duty of the Administrator is “to carry out the terms of the Plan for the exclusive benefit of persons entitled to participate in the Plan.” Specifically-enumerated administrative duties include interpreting the Plan, prescribing applicable procedures, determining eligibility for an amount of benefits, authorizing benefit payments and gathering information necessary for Plan administration. The Administrator is also explicitly granted discretionary authority to determine eligibility for benefits:

The Plan Administrator has the authority to interpret the Plan in order to make eligibility and benefit determinations as it may determine in its sole discretion. The Plan Administrator also has the dis[1003]*1003cretionary authority to make factual determinations as to whether any individual is entitled to receive any benefits under the Plan.

(Vaughn Vanee Decl. Ex. 1 (dkt. # 17-1) ECF 10.) By the terms of the Plan, the Administrator’s decisions with respect to benefits eligibility are subject to judicial review under an arbitrary and capricious standard, with the record confined to evidence presented to or considered by the Administrator at the time the challenged decision was made.

All regular WEA employees in secretarial and clerical positions, who are represented by the United Staff Union and typically employed for at least 20 hours per week, are eligible for LTD coverage under the Plan and the LTD Policy. The LTD Policy defines “Disabled and Disability” as “the inability of a Covered Employee to perform adequately the material and substantial duties of his or her Regular Occupation due to his or her own involuntary and medically proven and documented physical or mental impairments.” “Regular Occupation” means “the position held by the Covered Employee with the Employer on the Covered Employee’s Date of Disability.” “Date of Disability,” in turn, is defined as “the date which the Company determines to be the first day on which the Covered employee was Disabled.”

The LTD Policy also establishes criteria employees must meet to qualify for benefits. By its terms, to substantiate a claim for benefits, an employee must provide sufficient proof of a covered loss. The policy states that WEA “will require information from the Employer regarding your inability to perform the duties of your Regular Occupation and objective evidence confirming your Disability from a Physician licensed and qualified to diagnose the impairment(s) causing the claimed Disability, in addition to the information you provide yourself.” (Administrative Record (dkt. # 10) Ex. 18.)3 The Policy also expressly advises that “[a] physician’s declaration that you are Disabled, without accompanying objective medical and/or psychiatric evidence, is not sufficient to substantiate your Disability” and mandates that the employee is responsible for providing proof of loss entitling her to benefits. (Id.; PL’s PFOF (dkt. # 15) ¶ 16.) It also gives WEA the right to require that claimants be examined by a health professional of WEA’s choice and at WEA’s expense, “when and as often as it is reasonable with respect to any claim for benefits.” (Pl.’s PFOF (dkt. # 15) ¶ 17.)

B. Jones’ Illness

Plaintiff Stephanie Jones worked for WEA as a customer service representative from 2005 until her employment was terminated in 2010. In June of 2009, she began having severe gallbladder symptoms, including daily vomiting and pain, and she was diagnosed with gallbladder disease. By June 7, she was in the emergency room due to worsening symptoms, and by June 11, Dr. Kenneth Kudsk had decided to perform gallbladder surgery on her. He recommended that surgery be performed on July 22, 2009, but it was delayed when Jones was diagnosed with MRSA.4

[1004]*1004Jones’ last day of work was August 6, 2009. On that day, she was seen at the ER due to blood in her stool. She went to the ER again on August 25, reporting breathing problems and right upper quadrant pain, and received a diagnosis of anxiety and gastritis.

Jones scheduled gallbladder surgery with Dr. Kudsk for August 19, 2009. Following numerous cancellations, the surgery was rescheduled for September 30. Two weeks before the surgery, on September 16, she was seen in the emergency room, complaining of difficulty breathing and an inability to keep food or liquids down. On September 18, she suffered a gallbladder attack, and went to the emergency room. She was admitted to the hospital, and the next day, September 19, Dr. Mark Meier performed a successful laparoscopic gallbladder removal. There were no complications, and a subsequent biopsy was consistent with mild gallbladder disease. Dr. Kudsk indicated that the normal recovery for a laparoscopic gallbladder removal was a “couple of weeks.”

On October 14, 2009, Jones suffered some symptoms, according to her medical records. Dr. Foss later diagnosed those symptoms as related to mild, nonspecific colitis. . He prescribed a medication to treat the condition and scheduled a followup appointment for November 10, 2009.

C. Jones’ LTD Requests and WEA’s Review

On September 1, 2009, ten days before her surgery took place, Jones submitted a claim form for LTD benefits, alleging disability due to “Anxiety, gall bladder, MRSA.” On October 5, 2009, she submitted a second claim form for LTD benefits, this time alleging disability due to “Severe depression, SAD, PTSD, Anxiety/panic, Withdrawal from meds, Fibro.” On October 26, 2009, she submitted a third claim form for LTD benefits, alleging disability due to “Severe depression, SAD, PTSD, Anxiety/panic, Withdrawal from meds, Fibro, Colitis.” She provided several claim forms in support, including those completed by Dr. Kudsk, Dr. Meier, Dr. Moore, and Dr. Marek Hann, who was Jones’ psychiatrist. Dr. Kudsk’s Physician Certification forms both stated that Jones was temporarily unable to work beginning August 6, 2009. (See AR at Exs. 7, 8.) Dr.

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Bluebook (online)
60 F. Supp. 3d 1000, 2014 U.S. Dist. LEXIS 143631, 2014 WL 4988384, Counsel Stack Legal Research, https://law.counselstack.com/opinion/jones-v-wea-insurance-wiwd-2014.