Myers v. Mutual of Omaha Life Insurance

175 F. Supp. 3d 820, 2016 WL 1223278, 2016 U.S. Dist. LEXIS 41405
CourtDistrict Court, N.D. Ohio
DecidedMarch 29, 2016
DocketCASE NO. 4:14cv2421
StatusPublished
Cited by1 cases

This text of 175 F. Supp. 3d 820 (Myers v. Mutual of Omaha Life Insurance) is published on Counsel Stack Legal Research, covering District Court, N.D. Ohio primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Myers v. Mutual of Omaha Life Insurance, 175 F. Supp. 3d 820, 2016 WL 1223278, 2016 U.S. Dist. LEXIS 41405 (N.D. Ohio 2016).

Opinion

MEMORANDUM OF OPINION AND ORDER [Resolving ECF No. 19]

Benita Y. Pearson, United States District Judge

Plaintiff Tina Myers commenced this action under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et seq., against Defendant United of Omaha Life Insurance Company (incorrectly named in the complaint as Mutual of Omaha Life Insurance Company). Myers challenges the administrator’s decision denying her long term disability benefits. The Court has reviewed the parties’ merits briefs, responses, the administrative record, and the governing law. For the reasons that follow, the Court denies Defendant’s motion for judgment on the merits (ECF No. 19) and remands the matter to the plan administrator with instructions.

I. Background

Myers was employed by TecnoCap, LLC as a Customer Service Supervisor. ECF No, 31 ¶ 1 (A.R. 837). Customer Service Supervisor is considered a sedentary strength occupation, which required Myers to exert up to 10 pounds of force occasionally and or a negligible amount of force frequently to lift, carry, push, pull or otherwise move objects. M (A.R. 103-04).

As a TecnoCap employee, Myers participated in the company’s employee welfare benefit plan (“the Plan”), a component of which was the Group Insurance Policy, No. GLTD-OAKUZ (the “Policy”), issued by Defendant, United of Omaha Life Insurance Company (“United”). ECF No. 31 ¶ 2 (A.R. 1-60).

The Policy provides a monthly benefit in the event that a participant became disabled. The Policy defines disabled as follows:

Disability and Disabled mean that because of an Injury or Sickness, a significant change in Your mental or physical functional capacity has occurred in which You are:
(a) prevented from performing at least one of the Material Duties of Your Regular Occupation on a part-time or full-time basis; and
(b) unable to generate Current Earnings which exceed 99% of Your Basic Monthly Earnings due to that same Injury or Sickness.
After a Monthly Benefit has been paid for' 2 years, Disability and Disabled mean You are unable to perform all of the Material Duties of any Gainful Occupation.
Disability is determined relative to Your ability or inability to work. It is not determined by the availability of a suitable position with your employer.

ECF No. 31 ¶ 3 (A.R. 49-50). The Policy provides the following definitions for Material Duties and regular Occupation:

Material Duties means the essential tasks, functions, and operations relating to an occupation that cannot be reasonably omitted or modified. In no event will We consider working an average of more than 40 hours per week in itself to be a part of material duties... One of the material duties of Your Regular Occupation is the ability to work for an employer on a jull-time basis.
Regular Occupation means the occupation You are routinely performing when Your Disability begins. Your regular occupation is not limited to the specific position You held with the Policyholder, but will instead be considered to be a similar' position or activity based on job descriptions included in the most current edition of the U.S. Department of Labor Dictionary of Occupational Titles (DOT). We have the right to substitute [824]*824or replace the DOT with a service or other information that We determine of comparable purpose, with or without notice. To determine Your regular occupation, We will look at Your occupation as it is normally performed in the national economy, instead of how work tasks are performed for a specific employer, at a specific location, or in a specific area or region.

ECF No. 31 ¶ 4 (A.R. 50-51). The Policy excludes benefits for otherwise qualifying injuries or illnesses that existed prior to coverage:

We will not provide benefits for Disability:
(a) Caused by, contributed to by, or resulting from a Pre-existing Condition; and
(b) which begins in the first 12 months after You are continuously insured under this Policy,
A Pre-existing Condition means any Injury or Sickness for which You received treatment, advice' or consultation, care or services including diagnostic meas-urés, or had drugs or medicines prescribed or taken in the 3 months prior to the day You became insured under this Policy.

ECF No. 31 ¶ 5 (A.R. 35). United is vested with sole discretion “to determine eligibility for benefits and to construe and interpret all terms and provisions of the Policy.” ECF No. 31 ¶ 6 (A.R. 6). United makes claim determinations by first reviewing “each claim to ensure that it meets all policy provisions and eligibility requirements.” ECF No. 27-5 at PagelD #: 447 (A.R. 296). United “then review[s] the medical documentation in the file to detei’-mine maximum work capacity if the documented restrictions and limitations are supported by medical evidence.” Id.

Myers’s claim for disability is premised on Lyme disease. Myers contends that she contracted the disease after suffering a tick bite on her scalp around September 2012. ECF No. 27-1 at PagelD #: 277 (A.R. 126). She was employed by Techno-Cap until January 23, 2013, when she stopped working due to symptoms of extreme fatigue, body pain, inability to regulate her body temperature, brain fog, confusion and headaches. ECF No. 31 ¶ 7 (A.R. 837). The day before she stopped working (January 22, 2013), Myers was seen by Nurse Practitioner Renee Brongo. ECF No. 27-9 at PagelD #: 657 (A.R. 506); Blood tests detected the presence of Lyme Disease Antibodies, but the Western Blot and IgG tests for Lyme disease were negative. ECF No. 27-2 at PagelD #: 308-09 (A.R. 157-58). An attending physician statement completed by Brongo on March 18, 2012 indicated a diagnosis of chronic pain, headache, weakness, fatigue, and point tenderness with palpation, and limited Myers’ ability to sit, stand, and walk in an eight hour workday to one hour each. ECF No. 30 ¶ 4 (A.R. 842-43).

Following this testing, Myers saw Dr. Adamovich, who ordered a PICC line placed, and a 28-day treatment for Lyme disease on March 21, 2013. ECF Nos. 27-17 at PagelD #: 1089; 27-18 at PagelD #: 1101 (A.R. 938, 950). Myers was seen by the Visiting Nurses Association over the next month for the administration of IV antibody treatments. ECF No. 31 ¶¶ 16-18 (A.R. 723-34). Dr. Adamovich also referred Myers’s file to Dr. Limbu. Dr. Limbu completed a report on May 31, 2013, which stated that Myers reported multiple joint aches, a positive Parvovirus IgG test and a negative IgM and Western Blot test. ECF No. 27-7 at PagelD #: 560 (A.R. 409). Dr. Limbu concluded that the positive test was in fact a false positive, and that Myers no longer needed antibiotics. ECF No. 27-7 at PagelD #: 561 (A.R. .410). Nonetheless, when ;Myers saw Dr. Adamovich on June 24, 2013, she was assessed with “chronic, [825]*825active” Lyme disease'. ECF No;- 27-8 at PagelD #; 603 (A.R. 452).

Myers continued to seek treatment for Lyme disease with Dr. Joseph Joseph. On July 29, 2013, she underwent additional blood testing that was- positive for acute and chronic Epstein-Barr Virus. ECF No. 30 ¶ 6 (A.R. 219, 236).

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Cite This Page — Counsel Stack

Bluebook (online)
175 F. Supp. 3d 820, 2016 WL 1223278, 2016 U.S. Dist. LEXIS 41405, Counsel Stack Legal Research, https://law.counselstack.com/opinion/myers-v-mutual-of-omaha-life-insurance-ohnd-2016.