Pfenning v. Liberty Life Assurance Co.

354 F. Supp. 3d 826
CourtDistrict Court, S.D. Ohio
DecidedJune 26, 2017
DocketCase No. 3:14-cv-471
StatusPublished
Cited by1 cases

This text of 354 F. Supp. 3d 826 (Pfenning v. Liberty Life Assurance Co.) is published on Counsel Stack Legal Research, covering District Court, S.D. Ohio primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Pfenning v. Liberty Life Assurance Co., 354 F. Supp. 3d 826 (S.D. Ohio 2017).

Opinion

THOMAS M. ROSE, UNITED STATES DISTRICT JUDGE

*827Having prevailed in this Court on their argument that California law provided for a deferential standard of review of non-residents, on appeal Defendant Liberty Life Assurance Company of Boston agreed with Plaintiff Douglas Pfenning that a de novo standard applied. The United States Court of Appeals for the Sixth Circuit remanded the case for an opinion as to who would prevail under a de novo review.

Plaintiff Douglas Pfenning brought this action under § 502(a)(1)(B) of the Employee Retirement Income Security Act of 1972, 29 U.S.C. § 1132(a)(1)(B), against Defendant Liberty Life Assurance Company of Boston to enforce his right to disability benefits, demanding that Liberty account for past benefits and pay future benefits. Pfenning seeks payment of disability benefits during the claimant's "own occupation" period. Pfenning was employed by another insurance company, Farmers Group, Inc., as a Catastrophic Claims Adjuster. Pfenning's occupation with the Plan Sponsor required him to work outside an office environment, actively engaged with the public, doing physical work that required him to lift fifty pounds frequently. Liberty denied Pfenning long-term disability benefits for several reasons including insistence that he was a sedentary office worker. While many Insurance Claims Representatives are engaged in sedentary occupations, Pfenning was not.

I. Background

Farmers Group hired Pfenning in May 2002 as a Field Claims Representative and he enrolled in the company's Employee Welfare Benefit Plan, which is administered by Liberty. (LL000035, LL000465). When he applied for benefits in 2013, Farmers Group employed Pfenning as a "Catastrophic Adjustor-Mid-Loss-Field." (LL000466) According to Pfenning's description on the claims forms, his job requires him to handle mid-loss property claims due to fire, tornado, and hurricane; work 12-14 hours a day for 21 days straight; drive 3,000 miles a month; and climb up and down ladders, roofs and homes in order to inspect damages. (Id. ) The job description provided by Farmers Group, titled Senior Claims Representative-Property, lists similar duties. Under "Essential Job Functions," duties include investigating and confirming coverage, determining liability, establishing damages, reporting the status and negotiating the settlement of claims. (LL000528) It confirms that those employees "assigned to the Catastrophe team will be required to travel away from their residence for a specified period of time, usually consisting of 23 days." (Id. ) Physical demands are listed as bending, pulling sorting, carrying up to 50 lbs., pushing, climbing, reaching, standing, key entering, reading and writing English, walking, kneeling, and seeing. (LL000529) Finally, the description states that "[r]equired job duties are normally performed in a climate-controlled office environment," but the employee may be exposed to certain environments in the field:

"Uncontrolled outside environmental conditions
Excessive Noise Levels
Chemicals
Chemical/Biological Conditions
Moving Mechanical Parts
Areas considered to be dangerous *828Conditions, which could affect the respiratory system or skin such as: fumes, odors, dust, mists, gases, oils, smoke, soot, or poor ventilation."

(Id. )

Under Section 2 of the plan, entitled "Definitions:"

"Disability" or "Disabled" means:

1. For persons other than pilots, co-pilots, and crew of an aircraft:
i. If the Covered Person is eligible for the 24 Month Own Occupation Benefit, "Disability" or "Disabled" means during the Elimination Period and the next 24 months of Disability the Covered Person is unable to perform all of the material and substantial duties of his occupation on an Active Employment basis because of an Injury or Sickness; and
ii. After 24 months of benefits have been paid, the Covered Person is unable to perform, with reasonable continuity, all of the material and substantial duties of his own or any other occupation for which he is or becomes reasonably fitted by training, education, experience, age and physical and mental capacity.

(LL000005) (emphasis added)1

Under Section 4, Disability Income Benefits, the plan states that Liberty will pay disability benefits if, upon request, it receives proof of continued disability and regular attendance of a physician. (LL000012) The "Elimination Period" is defined as "a period of consecutive days of Disability for which no benefit is payable," which is 26 weeks. (LL000003, LL000006)

A. Short-Term Benefits Claim

Pfenning began seeing a physician on April 22, 2013, when he visited Dr. Matthew O'Connell for chronic fatigue. (LL000235) Dr. O'Connell diagnosed him with fatigue, essential hypertension, and depression. (Id. ) Dr. O'Connell also noted that there may be some neuropathy as a result of excessive alcohol intake.2 (Id. ) Pfenning returned to Dr. O'Connell's office August 29, 2013 complaining of daily foot pain, including numbness and tingling in both his legs below the knees, joint swelling, and fatigue. (LL000230-31)

Dr. O'Connell referred Pfenning to a spinal specialist, Dr. David Johnson, who conducted an electromyography (EMG) on September 9, 2013 and found evidence of injury possibly tied to a prior fall or to peripheral neuropathy. (LL000335) Dr. O'Connell ordered an MRI of Pfenning's spine during his visit on September 11, 2013. (LL000229).

On September 17, 2013 Pfenning filed a request for leave from his job for idiopathic neuropathy, with a start date of September 18 and an end date of November 2, 2013.3 (LL000051, Claim Note 1) While his claim was being processed, Pfenning continued to seek medical attention for his condition. He returned to Dr. Johnson on September 26, 2013 complaining of significant swelling in his ankles and lower legs, as well as the constant burning in his feet. (LL000333-34) He followed up with Dr. O'Connell on October 7, 2013 for aggravation *829of the burning and pain in his legs. (LL000223)

During this time, Liberty requested Pfenning's medical files from Dr. O'Connell, along with an Attending Physician Statement. (LL0000570, LL000580, LL000597) Dr. O'Connell's statement characterized Pfenning's prognosis as "poor," classified his physical impairment as a "[s]evere limitation of functional capacity; incapable of minimum activity," and noted that he had to change positions frequently. (LL000562) An MRI of Pfenning's brain raised the possibility of a demyelinating disease, but was not conclusive.4 (LL000399)

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354 F. Supp. 3d 826, Counsel Stack Legal Research, https://law.counselstack.com/opinion/pfenning-v-liberty-life-assurance-co-ohsd-2017.