Kimberly Guest-Marcotte v. Life Ins. Co. of N. Am.

CourtCourt of Appeals for the Sixth Circuit
DecidedApril 1, 2019
Docket18-1948
StatusUnpublished

This text of Kimberly Guest-Marcotte v. Life Ins. Co. of N. Am. (Kimberly Guest-Marcotte v. Life Ins. Co. of N. Am.) 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
Kimberly Guest-Marcotte v. Life Ins. Co. of N. Am., (6th Cir. 2019).

Opinion

NOT RECOMMENDED FOR PUBLICATION File Name: 19a0160n.06

No. 18-1948

UNITED STATES COURT OF APPEALS FOR THE SIXTH CIRCUIT

KIMBERLY J. GUEST-MARCOTTE, ) FILED ) Apr 01, 2019 Plaintiff-Appellant, ) DEBORAH S. HUNT, Clerk ) v. ) ) LIFE INSURANCE COMPANY OF NORTH ) ON APPEAL FROM THE AMERICA; METALDYNE SALARY ) UNITED STATES DISTRICT CONTINUATION PLAN; METALDYNE ) COURT FOR THE EASTERN POWERTRAIN COMPONENTS, INC.; SHORT ) DISTRICT OF MICHIGAN TERM DISABILITY INCOME PLAN OF ) METALDYNE, LLC, ) ) Defendants-Appellees. )

BEFORE: NORRIS, ROGERS, and THAPAR, Circuit Judges.

ROGERS, Circuit Judge. Guest-Marcotte sought short-term disability benefits from the

administrator of her former employer’s ERISA plan, Life Insurance Co. of North America

(“LINA”). After LINA denied her application for benefits, Guest-Marcotte appealed to this court,

where last year we held that LINA’s denial was arbitrary and capricious. On remand, Guest-

Marcotte sought attorneys’ fees under 29 U.S.C. § 1132(g), but the district court denied her request.

The facts of this case, however, compel the conclusion that fees should have been awarded.

Guest-Marcotte suffers from Ehlers-Danlos Syndrome Type III (“EDS”), a rare genetic

disease that is “medically known to cause frequent joint dislocations and subluxations along with

chronic pain,” and which does in fact cause Guest-Marcotte considerable pain. Guest-Marcotte v. No. 18-1948, Guest-Marcotte v. Life Ins. Co. of North America, et al.

Life Ins. Co. of N. Am., 730 F. App’x 292, 303 (6th Cir. 2018). The defendants in this case do not

dispute that Guest-Marcotte has EDS and suffers severe chronic pain as a result.

Guest-Marcotte worked for Metaldyne, LLC, from 2005 to 2013 and was covered by

Metaldyne’s Salary Continuation Plan. The Plan was administered by LINA. After Guest-

Marcotte’s diagnosis and consultation with various doctors, she applied for short-term disability

benefits (“STD benefits”) under the Plan. Under the Plan, a beneficiary is considered disabled “if,

solely because of a covered Injury or Sickness, [she is] [u]nable to perform the material duties of

[her] Regular Occupation; and [u]nable to earn 80% or more of [her] Covered Earnings from

working in [her] Regular Occupation.” Id. at 294. The employee “must provide the claims

administrator, at [the employee’s] own expense, satisfactory proof of Disability before benefits

will be paid.” Id. (emphasis added). Guest-Marcotte held a desk job at Metaldyne, but she

provided evidence from her physicians that she was unable to perform the material duties of that

occupation because of her condition. For example, her physicians asserted that she needed to

“avoid repetitive stress,” could not lift, pull, or push more than five pounds, and would “have to

be able to take ‘frequent breaks.’” Id. at 295.

Despite Guest-Marcotte’s evidence of her disability, LINA denied her benefits after a

cursory review by two case reviewers. Id. In its denial letter LINA wrote that Guest-Marcotte had

failed to show a disability “of such severity that would preclude you from working in your own

occupation.” Id. This is not the language of the Plan, which defines a disability as a condition that

would render a person “unable to perform the material duties” of her occupation, not “preclude

[her] from working in [her] own occupation.”

Guest-Marcotte appealed, twice. The first time around, she provided more medical

evidence of her disability, including “numerous medical records” from her primary physician, Dr.

-2- No. 18-1948, Guest-Marcotte v. Life Ins. Co. of North America, et al.

Kadaj, indicating that she “consistently complained of severe chronic pain,” and that on one night

both of her shoulders had popped out of place and the next day she was “having difficulty moving

her right arm.” Id. She also provided more evidence from Dr. Tinkle, a renowned expert on EDS

who had submitted evidence in Guest-Marcotte’s initial application for benefits. In this first

appeal, Dr. Tinkle repeated his diagnosis and recommendations that Guest-Marcotte not

“lift/push/pull objects of greater than 5 pounds [and should] avoid repetitive motions.” Id. at 296.

Guest-Marcotte also submitted evidence of her disability from her acupuncturist and physical

therapist. Id. LINA again denied her application and “used the same erroneous definition of

‘disability’ that [it] had included in its first denial letter.” Id. at 297. LINA “relied on Guest-

Marcotte’s failure to provide objective medical evidence,” such as clinical examinations, when the

Plan required only “satisfactory” evidence of a disability. Id. (emphasis added).

In her second appeal, Guest-Marcotte submitted even more documentation, as well as

affidavits from Drs. Kadaj and Tinkle stating that Guest-Marcotte’s condition significantly limited

her ability to perform ordinary tasks, such as driving to work and typing. Id. at 298. For a third

time, LINA denied her request and “used the same incorrect definition of ‘disability’” in doing so.

Id. at 299. Moreover, LINA’s third denial letter relied on an incorrect reading of the Plan’s

evidentiary requirements. LINA wrote in the letter that “the clinical findings and test results do

not document her physical impairments [and] [t]here was no clinical evidence that would

demonstrate a functional loss and inability to perform her sedentary occupation.” Id. (internal

quotation marks omitted).

Meanwhile, after LINA’s second denial, Metaldyne had terminated Guest-Marcotte’s

employment. The reason, according to Guest-Marcotte’s doctors, was that she was “unlikely to

recover fully/sufficiently to perform the functions of [her] position.” Id. at 297. Thus, under

-3- No. 18-1948, Guest-Marcotte v. Life Ins. Co. of North America, et al.

LINA’s interpretation of Guest-Marcotte’s medical record, she was not disabled, meaning (under

a faithful interpretation of the Plan’s definition) she was able to perform the material duties of her

occupation. But according to her employer’s interpretation of the same medical record, her

employment should be terminated because she could not perform the material duties of her

occupation.

Guest-Marcotte sued LINA (and Metaldyne), arguing that she was improperly denied

benefits. After the case was removed to federal court, a magistrate judge recommended that Guest-

Marcotte’s claim be dismissed, and the district court adopted the magistrate judge’s

recommendation. See Guest-Marcotte v. Metaldyne Powertrain Components, Inc., No. 15-cv-

10738, 2017 WL 65062 (E.D. Mich. Jan. 6, 2017). Guest-Marcotte appealed that decision to this

court.

We reversed the district court and remanded. Although review of a plan administrator’s

decision is highly deferential, we concluded that “LINA’s review of Guest-Marcotte’s benefits

claim was arbitrary and capricious.” 730 F. App’x at 301. LINA had “brush[ed] aside her claims

of debilitating pain without first performing a physical exam”—an option that was plainly

available under the Plan. Id. at 302. Put differently, “LINA had the option to conduct a physical

examination; yet it elected to discount Guest-Marcotte’s claims of disabling pain without

exercising that option, even though it is undisputed that she has a hereditary disease known to

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