Melvin McCollum v. Life Insurance Co. of N. America

495 F. App'x 694
CourtCourt of Appeals for the Sixth Circuit
DecidedAugust 21, 2012
Docket11-2257
StatusUnpublished
Cited by8 cases

This text of 495 F. App'x 694 (Melvin McCollum v. Life Insurance Co. of N. America) 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
Melvin McCollum v. Life Insurance Co. of N. America, 495 F. App'x 694 (6th Cir. 2012).

Opinion

*696 OPINION

HELENE N. WHITE, Circuit Judge.

Plaintiff-Appellant Melvin McCollum appeals the district court’s order upholding the denial of long-term disability benefits under an insurance policy issued by Defendant-Appellee Life Insurance Company of North America (LINA) and governed by the Employee Retirement Income Security Act of 1974 (ERISA). 29 U.S.C. § 1001 et seq. We REVERSE and REMAND in part and AFFIRM in part.

I.

A. McCollum’s Injury and Disability Benefits

McCollum began working for Fabristeel Products, Inc., in June 1993 as a cold header operator. LINA, doing business as CIGNA Group Insurance (CIGNA), issued a group Long Term Disability (LTD) Income Policy to Fabristeel, as well as a group Life Insurance Policy providing Waiver of Premium (WOP) benefits. JA 30, 322. The LTD Policy provides:

An Employee will be considered Disabled if because of Injury or Sickness: he is unable to perform all the material duties of his regular occupation; and after Monthly Benefits have been payable for 36 months, 1 he is unable to perform all the material duties of any occupation for which he is or may reasonably become qualified based on his education, training or experience.

JA 34. The WOP benefit defines disability similarly: “A covered employee will be deemed ‘disabled,’ as used here, only if he can not do any work for wage or profit.” JA 346. Both policies require proof of continued disability and provide that benefits terminate if McCollum ceases to be disabled.

Around July 9, 1996, McCollum was lifting a 75-pound container of bolts when the handle broke, causing an injury to his right shoulder rotator cuff. 2 He has not worked at Fabristeel since. In November 1996, he underwent right shoulder surgery. McCollum completed physical therapy in May 1997, but the attending physician reported that McCollum had little improvement in his neck or shoulder pain at that time and that as a result he was “permanently disabled from medium or heavy type of work that he was previously doing.” The attending physician also noted “fairly prominent degenerative joint disease throughout the lumbar spine and quite prominent canal stenosis,” noting that any work retraining would “have to take into account the lumbar region as well, with input from other physicians.” 3 JA 82. In addition to his back and shoulder problems, McCollum is obese and suffers from diabetes and hypertension.

Dr. Adam Kellman, McCollum’s longtime treating physician, referred McCol-lum to Dr. Stephen Boodin in July 1997 to assess his back problems. Dr. Boodin reviewed x-rays, CT scans, and an MRI, which revealed, among other, things, signif *697 icant narrowing of the spinal canal at L-4-5 and L-5, S-l. Dr. Boodin then noted that McCollum suffered from “significant degenerative changes in the lumbar spine with a definite lumbar radiculopathy” and explained that “surgical decompression is likely his only rational option.” Dr. Boo-din also noted that epidural steroid injections were not alleviating McCollum’s pain. JA 227-28.

On April 28, 2005, McCollum saw Dr. Stephen Pomeranz for his back pain. Dr. Pomeranz noted that McCollum had severe canal stenosis and spondylolisthesis at L5-S1, along with facet arthrosis contributing to moderate to severe canal stenosis at L4-L5 and L2-L8. JA 80-81. Eventually, in July 2005, McCollum underwent a laminectomy for his back pain. JA 21, 97.

LINA approved LTD benefits for McCollum beginning January 6, 1997. On April 21, 1998, LINA also granted WOP benefits to McCollum, a determination based on two findings: (1) Dr. Kellman’s determination that McCollum was capable of only sedentary work; and (2) a Transferable Skills Analysis (“TSA”), using Dr. Kellman’s sedentary-work finding, that found no job matches suitable for McCol-lum. JA 376-79. On August 11, 1999, LINA began the process of determining whether McCollum was capable of performing any occupation. JA 196. On February 17, 2000, LINA determined that McCollum was totally disabled from performing the work of any occupation and approved LTD benefits on this basis. JA 184, 207. LINA continued to provide LTD and WOP benefits until at least 2005. 4

During the period LINA granted benefits, Dr. Kellman submitted several Physical Ability Assessments (PAA) to LINA as part of the requirement to document continued disability. JA 178-182, 364. In each of these PAAs — December 19, 2002, November 25, 2003, October 18, 2004, September 15, 2005, and July 20, 2006 — Dr. Kellman classified McCollum as capable of performing sedentary work due to his chronic lumbar pain. Apparently satisfied with the findings in these PAAs, LINA continued to provide benefits. McCollum also receives monthly Social-Security disability benefits.

B. LINA Denies Benefits

In August 2006, as part of its periodic review of McCollum’s benefits, LINA requested that McCollum provide a Disability Questionnaire and that Dr. Kellman complete a PAA. This PAA, in contrast to earlier ones, required the physician to specify the number of hours the patient could engage in various activities. JA 128. On September 15, 2006, Dr. Kellman submitted the PAA (“the September PAA”) stating that McCollum could sit frequently, defined as up to 5.5 hours. The September PAA also states that McCollum can occasionally, defined as less than 2.5 hours, stand, walk, lift up to fifty pounds, and carry up to twenty pounds. Dr. Kellman noted that McCollum could frequently balance, occasionally stoop and kneel, and continuously use both hands for fine manipulation and frequently use his hands for simple grasping. Also in contrast to earlier PAAs, the September PAA does not contain a space in which a physician classifies the category of work, such as heavy, medium, light, or sedentary, an insured is capable of performing.

Based on the September PAA, LINA referred McCollum’s file to a Certified Vocational Rehabilitation Counselor, who conducted a TSA on September 21, 2006. JA 130. According to LINA, a TSA “compiles *698 information on your restrictions, limitations, education level, prior work history, and prior training to determine what jobs, if any, you are capable of performing.” JA 357. The TSA, which was explicitly based on the information contained in Dr. Kell-man’s September PAA, listed two jobs— Auto Casting Machine Operator and Nut-Bolt Assembler — that were suitable positions. Both jobs are categorized as “light.” Accordingly, on September 22, 2006, LINA informed McCollum that it was discontinuing WOP benefits:

In summary, based upon the pertinent vocational and medical documentation contained in our file, we have determined you retain the capacity to perform light strength level work. As a result of alternate occupations, we have concluded you do not satisfy the policy definitions of disability as defined the contract.

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