King v. Unum Life Insurance Co. of America

913 F. Supp. 2d 290, 54 Employee Benefits Cas. (BNA) 2044, 2012 WL 6600342, 2012 U.S. Dist. LEXIS 179657
CourtDistrict Court, W.D. Louisiana
DecidedDecember 18, 2012
DocketCivil Action No. 11-2054
StatusPublished

This text of 913 F. Supp. 2d 290 (King v. Unum Life Insurance Co. of America) is published on Counsel Stack Legal Research, covering District Court, W.D. Louisiana primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
King v. Unum Life Insurance Co. of America, 913 F. Supp. 2d 290, 54 Employee Benefits Cas. (BNA) 2044, 2012 WL 6600342, 2012 U.S. Dist. LEXIS 179657 (W.D. La. 2012).

Opinion

RULING

TUCKER L. MELANCON, District Judge.

Before the Court are cross motions for summary judgment filed by plaintiff Daryl King, R. 18, and by defendant Unum Life Insurance Company of America (“Unum”), R. 22, and their respective memoranda in opposition thereto, R. 24, 25. For the reasons that follow, plaintiffs Motion for Summary Judgment will be DENIED and defendant’s Motion for Summary Judgment will be GRANTED.

I. Background1

A. MAPP Construction, LLC’s Long Term Disability Policy and King’s Job Requirements

Plaintiff Daryl King was employed by MAPP Construction, LLC as a Construction Superintendent, Administrative Record, 000060, 000062, and was a participant in a disability plan sponsored by MAPP and insured by Unum under contract number 139922 (the “Plan”), A.R. 000007, which is governed by the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq. (hereinafter “ERISA”).2 Unum served as the Plan Administrator and was vested with the discretion to review claims, to resolve factual disputes, to make decisions regarding eligibility, and' to interpret the Plan. A.R. 000130. The pertinent provisions of the Plan provided that a participant is “disabled” when Unum determines that:

[Y]ou are limited from performing the .material and substantial duties of your regular occupation due to your sickness or injury, and you have a 20% or moré loss in your indexed monthly earnings due to the same sickness or injury.... You must be under the regular care of a physician in order to be considered disabled.

A.R. 000105. Thus, in order, to receive long term disability benefits under the Plan, an employee must be limited from performing the material and substantial duties of his or her “regular occupation.” Regular occupation “means the occupation [the participant is] routinely performing when [his or her] disability begins. Unum will look at [the participant’s] occupation as it is normally performed in the national economy, instead of how the work tasks are performed for a specific employer or at a specific location.” A.R. 000123.

Unum’s Occupation Identification review for plaintiffs job determined that plaintiffs occupation of Construction Superintendent, in the national economy, required [294]*294“[e]xerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly.” A.R. 000164-65. It also required occasional sitting, stooping, kneeling, crouching, crawling, and climbing, and frequent standing, walking, reaching, and keyboard use. Id. Travel was also required. Id.

B. King’s Injury and Initial Treatment

Plaintiff injured his lower back and left leg at his home on February 12, 2010,3 A.R. 000137. He did not cease working for MAPP until August 31, 2010. A.R. 000075. Plaintiff was first examined by Dr. Charles Burnell, an emergency medicine physician, on the day he was injured. A.R. 000279. Plaintiff complained of left lower back pain radiating into his left leg to his knee, with increasing pain that interfered with his ability to drive. A.R. 000282. Dr. Burnell ordered an MRI of his lumbar spine, which showed disk protrusion at L4-5 impinging on the L4 root, small central protrusion at L5-S1, and “[m]ild facet arthropathy and disk degenerative disease.” A.R. 000284-85. Dr. Burnell diagnosed plaintiff with a lumbar herniated disc based on plaintiffs history, the doctor’s physical examination, and the test results. A.R. 000285. He prescribed steroids, pain medication, and muscle relaxants, and referred plaintiff to Dr. Alan Appley, a neurosurgeon. Id.

On the same day, February 12, 2010, plaintiff also saw Dr. Amarendar Rasarla at Lafayette Surgical Specialty Hospital4 and reported that he was “unable to move or do any work at home” and was “constantly having lower back pain with radiation to the left hip and left lateral thigh region.” A.R. 000191. Dr. Kasarla’s physical examination of plaintiff revealed “mild- to moderate tenderness in the left paraspinal muscles at 3-4 region with decrease[d] sensation over left L3^4 dermatones .... ” Id. Dr. Rasarla recommended left L3 and L4 lumbar transforaminal epidural steroid injections, which plaintiff received. Id. Dr. Rasarla also prescribed pain medication. Id. He recommended that plaintiff “rest [at] home today.” A.R. 000193.

On March 22, 2010, on referral from Dr. Burnell, plaintiff was evaluated by neurosurgeon Dr. Alan Appley for aching in the left side of his lower back, tingling in his left leg to his knee, and weakness in his left leg. A.R. 000171. Plaintiff reported that his symptoms improved when he laid down and that medications had given him no relief, but the epidural injection had improved his symptoms. Id. Dr. Appley reviewed plaintiffs February 12, 2010 MRI and confirmed that it showed L4-5 disc herniation, and a small central protrusion at L5-S1. Id. Dr. Appley prescribed physical therapy, stating that “it is safe for him to carefully increase his activities now.” Id. He also said that plaintiff needed “to start some type of home exercise program.” Id. He prescribed a pain medication and noted that if plaintiffs pain increased, he would need to have another epidural injection. Id.

On March 23, 2010, plaintiff began physical therapy with Patricia Boulet. A.R. 000219. Plaintiff reported lower back pain, and Boulet noted that plaintiff had palpatory tenderness and spasms. A.R. 000227. Plaintiff continued physical therapy until June 24, 2010. A.R. 000258.

[295]*295On May 11, 2010, August 23, 2010, and October 14, 2012, plaintiff visited Dr. Burnell and reported chronic pain. A.R. 000371.

On September 3, 2010, plaintiff reported to Dr. Kasarla that the February 12, 2010 epidural injection helped him for a few months, but that his lower back to left leg pain and numbness had increased. Ai?. 000188. Dr. Kasarla gave plaintiff another lumbar epidural steroid injection. Id.

C. Administrative Claims Process

1. Initial Approval

On November 1, 2010, plaintiff completed the initial claim form for benefits, Ai?. 000075, and on November 16, 2010, Dr. Burnell submitted an Attending Physician’s Statement to Unum wherein he opined that plaintiff “is currently unable to perform work duties,” and that plaintiffs restrictions and limitations were “no prolonged sitting ([more than one] hour) [and] no stooping, pushing, pulling, bending over forward[,] except occasionally....” AN 000082-83.

Unum approved plaintiffs Long Term Disability benefit claim on December 8, 2010, and his benefits began effective November 30, 2010. Ai?. 000202. Unum “approved [plaintiffs] benefits because [he was] unable to perform prolonged sitting (greater than one hour), no stooping, pushing, pulling, bending over forward (except occasionally) due to the symptoms related to [his] Lumbar Disc herniation [sic].” Id.

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913 F. Supp. 2d 290, 54 Employee Benefits Cas. (BNA) 2044, 2012 WL 6600342, 2012 U.S. Dist. LEXIS 179657, Counsel Stack Legal Research, https://law.counselstack.com/opinion/king-v-unum-life-insurance-co-of-america-lawd-2012.