Loeffelholz v. Ascension Health, Inc.

73 F. Supp. 3d 1064, 2014 U.S. Dist. LEXIS 175902, 2014 WL 7338812
CourtDistrict Court, E.D. Missouri
DecidedDecember 22, 2014
DocketNo. 4:14CV01158 ERW
StatusPublished

This text of 73 F. Supp. 3d 1064 (Loeffelholz v. Ascension Health, Inc.) is published on Counsel Stack Legal Research, covering District Court, E.D. Missouri primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Loeffelholz v. Ascension Health, Inc., 73 F. Supp. 3d 1064, 2014 U.S. Dist. LEXIS 175902, 2014 WL 7338812 (E.D. Mo. 2014).

Opinion

MEMORANDUM AND ORDER

E. RICHARD WEBBER, Senior District Judge.

This matter comes before the Court on Plaintiff Melissa Loeffelholz’s “Dispositive Motion for Final Summary Judgment” [ECF No. 52] and Defendant Ascension Health’s “Motion for Summary Judgment” [ECF No. 54],

I. FACTUAL AND PROCEDURAL BACKGROUND

A, Introduction and Terms of “the Plan”

This case arises out of the denial of long-term disability “buy-up” benefits to Plaintiff Melissa Loeffelholz. The following is a recitation of facts determined to be undisputed based on “Plaintiffs Statement of Uncontroverted Material Facts in Support of Plaintiff’s Dispositive Motion for Final Summary Judgment” [ECF No. 53], Defendant Ascension Health’s “Response to Plaintiffs Statement of Uncontroverted Facts” [ECF No. 63], and Defendant’s “Statement of Uncontroverted Material Facts in Support of Motion for Summary Judgment” [ECF No. 56].1

[1067]*1067Plaintiff filed suit pursuant to the Employee Retirement Income Security Act (“ERISA”), seeking payment of long-term disability (“LTD”) “buy-up” benefits under the Ascension Long-Term Disability Plan (“the Plan”). At all times relevant, Defendant acted as sponsor and administrator of the Plan, which is governed by ERISA, for the benefit of eligible employees of St. Vincent’s Medical Center (“St. Vincent’s”) in Jacksonville, Florida. Under the Plan, a “determination as to whether a Participant is eligible for a long-term Disability Benefit shall be made as of the last day the Participant was Actively at Work” [ECF No. 30 at 30],

The Plan gives the administrator “discretionary authority to decide all questions arising in connection with the administration, interpretation and application of the Plan” [ECF No. 30 at 21]. The Plan also gives Defendant power to delegate its authority to other administrators, and pursuant to that power, Defendant delegated its discretionary authority regarding claims administration to Sedgwick Claims Management Services (“Sedgwick”). Sedgwick was Defendant’s third-party claims administrator with respect to LTD claims at the time of the denial of benefits in this case.

The Plan allows employees to “buy-up” optional benefits if their employer makes this election in its Adoption' Agreement. In its Adoption Agreement, St. Vincent elected to provide a Core Benefit of 50% of an employee’s Basic Monthly Earnings and an Option Benefit of a 20% “buy-up,” which increases an employee’s benefit amount to 70% of Basic Monthly Earnings. The Plan explains to employees the Core Benefit paid by their employer is 50% of Basic Monthly Earnings and that they have the option of paying for a 20% “buy-up” to 70% of Basic Monthly Earnings.

The Plan, the Adoption Agreement, and the Summary Plan Description (“SPD”)2 all explain in similar language that the Plan does not cover Pre-Existing Conditions. For instance, the Adoption Agreement describes the “Pre-Existing Condition Exclusion” as follows:

The plan does not provide benefits for any disability that is caused by, contributed to, or results from a Pre-existing Condition that was in existence within three (3) months before your effective date of coverage. The Pre-existing Condition Exclusion will not apply after you perform the Material Duties of your regular occupation for at least twelve (12) [1068]*1068months following your effective date of coverage.
If your Optional Benefit amount increases based on a change in elections, after initial eligibility the additional amount will be subject to the Pre-existing Condition Exclusion at the time the change in coverage becomes effective.

[ECF No. 30 at 96-97], The Plan defines “Pre-Existing Condition” as “an Injury or Sickness or any related Injury or Sickness that was in existence within the three-month period ending on the day immediately before the date the Participant becomes covered under this Plan or the date any increased Benefit amount option becomes effective” [ECF No. 30 at 17]. Buy-up benefits under the Plan are subject to the Plan’s Pre-Existing Condition Exclusion, and a Plan Participant is subject to the Plan’s Pre-Existing Condition Exclusion if the Participant becomes disabled within twelve months of the effective date of coverage.

Plaintiff was previously employed by St. Vincent’s as a Capital Campaign Coordinator. During her employment, Plaintiff selected optional buy-up coverage under the Plan effective January 1, 2012. Plaintiff stopped working on November 1, 2012. Because the Plan’s Elimination Period is 180 days from the date of disability, the buy-up benefits would have been payable to Plaintiff as of April 30, 2013. The Plan provided Plaintiff with base LTD coverage, and Defendant approved Plaintiff for and paid Plaintiff the underlying base LTD benefit. However, Defendant denied Plaintiffs claim for buy-up benefits, claiming Plaintiffs disability was caused by a “Pre-Existing Condition” as defined by the Plan. Plaintiff appealed the denial of buy-up benefits and exhausted administrative remedies under the Plan.

B. Administrative Record Evidence3

On September 14, 2012, Plaintiff was involved in a motor vehicle accident, in which her vehicle was struck by another vehicle traveling at approximately forty-five miles per hour. On October 17, 2012, Plaintiff saw her treating dentist, B. Keith Blankenship, DDS. Plaintiff was crying and reported severe pain, expressing a desire for the problem to be “taken care of immediately.” Dr. Blankenship “explained to her that it has taken time to get to the point where she is today and it may take time for healing” [ECF No. 33 at 42], Plaintiff again saw Dr. Blankenship on October 30, 2012, reporting severe pain. Dr. Blankenship instructed Plaintiff to wear a temporary orthotic he had fabricated, and he gave Plaintiff a permanent orthotic on November 1, 2012, the day Plaintiff stopped working. In his attending physician statement, Dr. Blankenship stated Plaintiff “has a TMJ disorder 4 with severe symptoms” [ECF No. 31 at 45].

On November 5, 2012, Plaintiff told her treating oral surgeon, Dr. David Woods, she had a ten-year history of “clenching” and that her jaw had locked closed once a few years prior. On November 29, Plaintiff saw Dr. Blankenship for review of the orthotic he had prepared, and Dr. Blankenship again explained to Plaintiff it took time for healing. On December 4, 2012, Plaintiffs treating neurologist, Dr. Syed [1069]*1069Asad, prepared an attending physician’s statement, indicating his first visit with Plaintiff had been on October 9, 2012. Dr. Asad’s primary diagnosis was dizziness and giddiness, and the secondary diagnosis was visual disturbance. Dr. Asad indicated Plaintiffs anticipated return to work was December 10, 2012, but he also indicated Plaintiffs work restrictions were “unknown.” On January 10, 2013, Plaintiff was seen for follow-up by a neurosurgeon, Dr. Rabin Tawk, who indicated Plaintiff 'had initially presented with headaches. At that visit, Dr. Tawk’ had a CT perfusion scan performed on Plaintiff. Plaintiff had undergone diagnostic cerebral testing on December 14, 2012, which was positive for Moyamoya syndrome.

On January 7, 2013, Plaintiff visited Temporomandibular Joint Disorder (“TMJ”) specialist Dr. Mark Piper.

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Bluebook (online)
73 F. Supp. 3d 1064, 2014 U.S. Dist. LEXIS 175902, 2014 WL 7338812, Counsel Stack Legal Research, https://law.counselstack.com/opinion/loeffelholz-v-ascension-health-inc-moed-2014.