Steven Stockman v. GE Life, Disability & Med. Plan

625 F. App'x 243
CourtCourt of Appeals for the Sixth Circuit
DecidedAugust 28, 2015
Docket13-4450
StatusUnpublished
Cited by3 cases

This text of 625 F. App'x 243 (Steven Stockman v. GE Life, Disability & Med. Plan) 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
Steven Stockman v. GE Life, Disability & Med. Plan, 625 F. App'x 243 (6th Cir. 2015).

Opinions

PER CURIAM.1

Defendants-Appellants GE Life, Disability and Medical Plan (“Plan”) and. Metropolitan. Life Insurance Company (“Met-Life”) appeal. a district court decision granting Plaintiff-Appellee’s motion for judgment on the administrative record. In -2009, Plaintiff-Appellee Steven Stock-man. (“Stockman”) was injured in an. accident and lost the use of his left foot for one year. A series of surgeries partially restored Stockman’s use of the foot, but it remains permanently damaged. Stock-man, a beneficiary under the Plan, .submitted a claim for benefits, but the Plan’s administrator, MetLife, denied the claim, determining that any. loss that Stoclonan experienced was neither “permanent” nor “total” and therefore did not qualify for coverage under the policy. After exhausting his administrative remedies, Stockman sued the Plan and MetLife for coverage under the Employee Retirement Security Act of 1974 (“ERISA”). The district court granted Stockman’s motion for judgment on the administrative record and denied MetLife and the Plan’s cross-motion, concluding that Stockman’s injury fell within the Plan’s promise that “the permanent and total loss of function of the hand or foot as a result of an accident after the loss [245]*245has continued for at least 12 consecutive months” would be covered. MetLife and the Plan timely appealed. For the following reasons, we AFFIRM.

I.

A,

Near midnight on October 19, 2009, Steven Stockman fell two stories from a ladder while he was attempting to change a light bulb in his home. Stockman “landed on his feet, and experienced immediate pain in his left foot.” Stockman’s wife, Nicky Leonard (“Leonard”),. drove him to the hospital, where he was admitted to the emergency room and .initially diagnosed with a severe ankle sprain. A subsequent x-ray revealed, however, that Stockman had shattered his heel bone.2

Stockman began treatment with Michael Barnett (“Dr. Barnett”), an orthopedic surgeon, on November 3, 2009. Dr. Barnett affirmed the hospital radiologist’s conclusion that Stockman suffered from “a left calcaneus fracture, a fracture of the heel bone.” Dr. Barnett also diagnosed Stock-man “with a right knee abscess that was draining purulent material,” which had developed from Stockman’s having to crawl on his knee to get around his home. Treatment of the abscess delayed surgery on Stockman’s heel fracture, and Stock-man developed infections of the bone and surrounding soft tissue, as well as an inflammation of the tissue on the bottom of his foot, after the surgery.3 ■'

As a result of his injury, Stockman underwent seven surgeries to repair his foot beginning November 12,2009, and continuing through June 25, 2010.4 Stockman’s foot could not bear weight during this time. On July 1, 2010, nine months after the injury, Dr. Barnett, concluded that Stockman’s foot was “completely non-weight bearing” and that he was unable to use the foot. On July 20, 2010, Dr. Barnett referred Stockman to a plastic sur-' geon, having concluded that his wound was not healing properly. On September 14, 2010, Stockman was “not -putting any weight” on his left foot, and Dr. Barnett gave him a handicap placard- to help him .perform daily life activities. Stockman was still unable to put weight on his foot when Dr. Barnett next saw him the following month.

On November. 9, 2010, Stockman had a follow-up appointment with Dr. Barnett, whose notes from that visit -state:

[246]*246[Stockman] knows that he will never have a normal foot again and may end up with chronic disability from this injury, but he is very happy that he still has his foot and was thankful to me for saving it for him.,

Dr. Barnett also told Stockman to “get out as much as he can on his foot to try and get weight back on [his foot]” and that if Stockman started to “put[ ] weight on [the foot] the bone should start to feel better.” Dr. Barnett stated that he believed Stock-man was “very scared to-do so” and referred him to a physical therapist who he' believed could help Stockman. In a sworn' statement, Dr. Barnett asserted that he believed that the destruction of Stockman’s left heel bone was “permanent.”

The following year, Dr. Barnett noted that on. May 23, 2011, Stockman walked into his appointment, but that he “still had severe sharp .pain in his heel” and “even had to' put his foot up on the table.” On August 30, 2011, the date of Stockman’s last visit, Dr. Barnett noted that Stockman was able to limp into the office.5 At the time, Stockman did not have a cane; he was provided one shortly thereafter, and Dr. Barnett expects that Stockman will have to use it for rest of his life.

Dr. Barnett concluded that Stockman’s injury resulted “in a loss of normal function” because Stockman could not use his foot “for propulsion, for locomotion,”,or “to get around.” When questioned about Stockmans injury and the Plan, Dr. Barnett asserted that Stockman’s loss of normal function had been continuous for at least 12 consecutive months and that he believed “Stockman would have met the definition that the MetLife policy lays out.” Though Dr. Barnett stated that Stockman can “still use [his foot],” he clarified that Stockman will likely require “an assistive device of some kind such as a cane and possibly even a scooter if a traumatic arthritis worsens over time.”

B.

1.

At the time of Stockman’s injury, his wife, was a GE employee covered by the company’s dependent accidental death or dismemberment benefit plan. On November 9, 2010, a little over a year after the accident, she submitted a claim for benefits on Stockman’s, behalf. The claim included a statement from Stockman that he had had “no use of his left foot” since the accident. It also included Dr. Barnett’s statement as Stockman’s attending physician explaining that Stockman had suffered “several set backs [sic ] and complications ... including multiple infections” following the injury. Dr. Barnett’s statement also indicated that Stockman had not been able to bear weight on his left foot since November 3,2009.

On May 31, 2011, MetLife sent a letter advising Leonard and Stockman that it .had received the claim. The letter went on to explain that MetLife needed more information “regarding the extent of [Stockman]’s injuiy(ies).” Under the policy,6 a “[l]oss of hand or foot means the hand or foot is severed at or above the wrist or ankle joint, or means the permanent and total loss of function of the hand or foot as a result of an accident after the loss has continued for at least 12 consecutive months.” MetLife claimed that the [247]*247documentation that had been provided was not conclusive regarding a “permanent and total loss of function” that had “continued for at least 12 consecutive months.” Met-Life requested additional documentation to meet the requirements.' MetLife claims that it received no additional documentation following its request. Stockman claims that he provided the emergency room visit notes, surgery and procedure reports, and other documentation following MetLife’s request for additional documentation.7 ;,

In a letter dated August 9, 2011, Met-Life denied Stockman’s claim for benefits.

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625 F. App'x 243, Counsel Stack Legal Research, https://law.counselstack.com/opinion/steven-stockman-v-ge-life-disability-med-plan-ca6-2015.