Shaw v. United Mutual of Omaha Life Insurance Company of America

CourtDistrict Court, D. South Carolina
DecidedJuly 23, 2021
Docket6:19-cv-03537
StatusUnknown

This text of Shaw v. United Mutual of Omaha Life Insurance Company of America (Shaw v. United Mutual of Omaha Life Insurance Company of America) is published on Counsel Stack Legal Research, covering District Court, D. South Carolina primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Shaw v. United Mutual of Omaha Life Insurance Company of America, (D.S.C. 2021).

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF SOUTH CAROLINA GREENVILLE DIVISION

Paramount Shaw, ) Case No.: 6:19-cv-3537-JD ) Plaintiff, ) ) vs. ) ) OPINION AND ORDER United Mutual of Omaha Life Insurance ) Company of North America, ) ) Defendant. ) )

This is an action seeking long-term disability benefits, which is governed by the Employee Retirement Income Security Act (“ERISA”). This matter is before the Court on the parties’ cross motions for Judgment on the Pleadings (DE 13, 14), pursuant to the ERISA Case Management Order (DE 7). For the reasons set forth below, Defendant United Mutual of Omaha Life Insurance Company of North America’s (“United” or “Defendant”) Motion for Judgment on the Pleadings is GRANTED, and Plaintiff Paramount Shaw’s (“Shaw” or “Plaintiff”) Motion for Judgment on the Pleadings is DENIED. I. FINDINGS OF FACT

Based on a review of the cross memoranda and administrative record, the Court finds the following. Shaw was hired to work for Generations Group Homes, Inc. (“Generations”) as a Residential Counselor on December 4, 2017. (DE 12-14, SHAW-002474.) Generations is a group home, and Shaw’s job description included the following: “responsible for the supervision and management of emotionally disturbed children and/or adolescents within a therapeutic residential milieu serving as a positive role model and providing direct supervision of residents to prevent acts of physical or sexual aggression, elopement, property destruction or other behavior that may place the residents, staff, or community at risk.” (DE 14, pp. 2-3.) The job description also indicates that the job requires carrying up to 75 pounds, occasionally, for one to two hours and 76 pounds or more from zero to one hour per day. (DE 12-14, SHAW 002517.) As part of his employment Shaw was insured under a group policy (“Policy”) issued by Defendant United and held by Generations. Specifically, the Policy provided:

“[T]he discretion and the final authority to construe and interpret the Policy. This means that [United has] the authority to decide all questions of eligibility and all questions regarding the amount and payment of any Policy benefits within the terms of the Policy as interpreted by [United]. Benefits under the Policy will be paid only if [United] decide[s], in [its] discretion, that a person is entitled to them. In making any decision, [United] may rely on the accuracy and completeness of any information furnished by the Policyholder or an Insured Person. [United's] interpretation of the Policy as to the amount of benefits and eligibility shall be binding and conclusive on all persons.”

(DE 12-2, Shaw 000309.) The Policy further provided for an exclusion for Pre-Existing conditions: PRE-EXISTING CONDITION EXCLUSION

A Pre-existing Condition means any Injury or Sickness for which You received medical treatment, advice or consultation, care or services, including diagnostic measures, or had drugs or medicines prescribed or taken in the 12 months prior to the day You become insured under the Policy. We will not provide benefits for any Disability caused by, attributable to, or resulting from a Pre-existing Condition which begins in the first 12 months after You are continuously insured under the Policy.

(DE 12-2, Shaw 000305-06.)

Shaw was involved in a motor vehicle accident on March 1, 2018, the date of his effective coverage under the Policy. (DE 12-14, SHAW 002475.) On April 26, 2018, as part of processing Shaw’s short-term disability claim, Defendant issued an assessment (“April Assessment”) of Mr. Shaw’s then current condition and its analysis of a one year look back contained in the Long Term Disability (“LTD”) insurance policy, a period which is March 1, 2017 to February 28, 2018, to determine if there were any pre-existing conditions during that time period that could potentially disqualify Shaw from LTD benefits. (DE 12-1, SHAW-000199-000203.) The April Assessment cites the documents reviewed, including the attending physician statement of Dr. Carole Mercer, an internist who cared for Mr. Shaw and his medical records from Dr. Mercer and other providers for the period of March 10, 2017, to February 12, 2018. These include a lumbar spine x-ray from November 10, 2017, and chest x-ray from December 18, 2017.

The April Assessment also noted Mr. Shaw’s visit to Dr. Mercer on March 22, 2018, for injury incurred as a result of the March 1, 2018, accident indicating he suffered neck pain, bulging (cervical) discs, and (cervical) spinal cord compression and pain and numbness in hands and neck. Dr. Mercer also noted that Mr. Shaw will be consulting with a neurosurgeon. (DE 12-2, SHAW 000201). A medical summary is then given regarding Mr. Shaw’s visits to his health care providers during the look back period, including prostate surgery, coronary artery disease, dilated cardiomyopathy, right inguinal hernia, hydroceles, umbilical hernia, constipation, hypertension, elevated liver enzymes, lumbar facet disease, left lower back pain down leg-aching and fire, which he has had since his twenties, and BPH (benign prostatic hyperplasia). The summary of the medical

analysis states that Mr. Shaw “did not complain or [seek] treatment or medications for neck pain/bulging disc or spinal cord compression during the look back time. . . .” The same observations are cited in the conclusion section. (DE 12-2, SHAW 000202.) The analysis ends with a section entitled “CONSIDERATION/NEXT STEP: None.” On May 1, 2018, Mr. Shaw was examined by Dr. Philip Hodge (“Dr. Hodge”), a neurosurgeon. There are extensive notes of that examination. (DE 12-1, SHAW 0177-00197.) Dr. Hodge noted a diagnosis of “Cervical spondylosis with myelopathy” (SHAW 00177). Dr. Hodge noted that: Cervical spondylosis with myelopathy-Primary Mr. Shaw presents after a motor vehicle accident approximately 1 month ago. Since that time, he has been having bilateral arm numbness tingling and pain. He also reports problems with balance at night and minimal manual dexterity problems. He has increased reflexes on the right lower extremity suggestive of myelopathy. His MRI of the cervical spine shows severe stenosis from C3 to see (sic) 7 and high signal change in the cord at C6-7. I feel that he needs a posterior cervical laminoplasty from C#-C7 to prevent further neurologic deficit. He has a pre-existing condition that was aggravated by his motor vehicle accident.

(DE 12-1, SHAW 00186.) Dr. Hodge’s notes also gave a thorough listing of Mr. Shaw’s past medical history as of May 1, 2018. It included diagnoses such as diabetes, hepatitis, kidney stones, stroke, and other conditions, but there was no reference to any past medical history diagnosis regarding the cervical spine. (DE 12-1, SHAW-000178.) The notes also listed Mr. Shaw’s previous surgical procedures as of May 1, 2018, and contained several surgical procedures such as prostate biopsy and hernia repair, but there were no surgeries listed regarding the cervical spine. (DE 12-1, SHAW-000178-000179). Attached to Dr. Hodge’s notes was the report for a cervical spine MRI performed on Mr. Shaw on April 10, 2018. Among other things, the report identified moderate degenerative disc disease (“DDD”) at C3-C4, degenerative disc at C4-C5, degenerated disc at C5-C6, severe DDD at C6-C7. The report indicates under “impression” among other things, “central canal stenosis at C3-4 through C6-7.” (DE 12-1, SHAW 000189.) On June 1, 2018, Defendant issued a letter to Mr. Shaw indicating that benefits from the Short Term Disability (“STD”) policy were approved for the period of March 7, 2018, through May 4, 2018. Mr. Shaw had surgery on his surgical spine on or around July 21, 2018. (DE 12-8, Shaw 001396.) On July 20, 2018, Mr. Shaw underwent cervical laminoplasty with decompression on C-3-7. Unfortunately, the surgery did not result in him being able to resume working.

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Bluebook (online)
Shaw v. United Mutual of Omaha Life Insurance Company of America, Counsel Stack Legal Research, https://law.counselstack.com/opinion/shaw-v-united-mutual-of-omaha-life-insurance-company-of-america-scd-2021.