Temponeras v. United States Life Insurance Co. of America

185 F. Supp. 3d 1010, 62 Employee Benefits Cas. (BNA) 1333, 2016 U.S. Dist. LEXIS 59787, 2016 WL 2594846
CourtDistrict Court, S.D. Ohio
DecidedMay 5, 2016
DocketCase No. 1:14-cv-700
StatusPublished
Cited by2 cases

This text of 185 F. Supp. 3d 1010 (Temponeras v. United States Life Insurance Co. of America) 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
Temponeras v. United States Life Insurance Co. of America, 185 F. Supp. 3d 1010, 62 Employee Benefits Cas. (BNA) 1333, 2016 U.S. Dist. LEXIS 59787, 2016 WL 2594846 (S.D. Ohio 2016).

Opinion

ORDER

Sandra S. Beckwith, Senior Judge, United States District Court

Plaintiff Margaret Temponeras filed her complaint in this case, challenging Defendant’s denial of her application for benefits under a group long term disability policy issued by the Defendant. (Doc. 1) The parties have each filed motions seeking entry of judgment on the administrative record (Docs. 28 and 29), which are fully briefed and ready for decision. For the following reasons, the Court will grant Defendant’s motion and deny Plaintiffs motion.

FACTUAL BACKGROUND

Margaret Temponeras is a physician and was employed by Unique Pain Management, LLC (‘Unique'), a chronic pain medicine practice. Unique maintained a long term disability insurance plan for its eligible employees that was issued by Defendant, the United States Life Insurance Company of America (‘U.S. Life*). Unique was required to pay regular monthly premiums in order to keep the policy in force. Temponeras became an insured employee under the policy on May 1, 2009. (Doc. 20-3, PAGEID 408) The LTD policy defines “physician” as a medical practitioner licensed in the state where she performs medical services, and acting within the scope of that license. (Id. at PAGEID 413)

Unique’s premium check to U.S. Life for the month of June 2011 was returned by its bank as non-negotiable. U.S. Life’s third-party processor, Allied National, Inc., wrote to Unique on June 16, 2011, notifying it of the non-payment and asking Unique to remit the monthly premium (plus a $25 handling fee) by July 1, 2011. If payment was not received by that date, the LTD policy coverage would lapse as of June 1, 2011 without further notice. (Doc. 20-2, PAGEID 356) Unique failed to send its payment, and Allied National cancelled the policy effective June 1, 2011.

Dr. Temponeras contends that she stopped work on May 19, 2011 due to long[1013]*1013standing chronic conditions of narcolepsy and cataplexy. The American Sleep Association defines narcolepsy as “a chronic neurological disorder caused by the brain’s inability to regulate a stable sleep-wake cycle.” It defines cataplexy as “a sudden loss of muscle tone that causes feelings of weakness and loss of voluntary muscle control.” Cataplexy typically occurs as a second common symptom of narcolepsy (the first being excessive daytime • sleepiness).1 Temponeras concedes that she was not receiving medical treatment for these conditions at that time, or for several years prior to that. She argues that standard narcolepsy treatment (use of stimulants) was not available to her, because they caused cardiac problems when she tried them several years ago. While she apparently was able to practice medicine up to May 19, 2011, she asserts that on that date her narcolepsy prevented her from safely continuing to do so due to her uncontrolled tendency to fall asleep.

On May 17, 2011, two days before Dr. Temponeras asserts that she ceased working due to a disability, the federal Drug Enforcement Administration personally served on her a notice of immediate suspension of her certificate of registration to prescribe controlled substances. The DEA also conducted a search of Unique’s office the same day, and seized its records and inventory. See Temponeras v. State Medical Board of Ohio, 2014-Ohio-225, 2014 WL 280614 (Ohio 10th Dist.App., January 28, 2014), citing the DEA’s show cause order. In that case, the Ohio Court of Appeals affirmed the State Medical Board’s January 11, 2012 decision to indefinitely suspend Dr. Temponeras’ medical license.

Dr. Temponeras completed an application for LTD benefits under Unique’s plan on April 18, 2012. (Doc. 20-3, PAGEID 375-376) She claimed she was disabled on May 19, 2011 due to narcolepsy and breast cancer (for which she underwent surgery in 2006). She identified Dr. Peter Tsai as her primary attending physician, and also listed Dr. Malik and two other providers from whom she had received treatment from 1998 to 2005. Dr. Tsai completed an Attending Physician’s Statement form on April 13, 2012, stating that he first saw Dr. Temponeras on September 20, 2011, with subsequent visits approximately once a month through April 2012. In a box asking for the “date you advised the patient to cease/and or modify work activity,” Dr. Tsai wrote: “9-20-11 retroactive to 5-19-11.” (Id., at PAGEID 398) He opined that Dr. Temponeras’ “narcolepsy cannot be treated due to heart condition.” Typical medications prescribed for that condition are “contraindicated and may be lethal if taken again.2 Patient- cannot work as physician in present field due to danger treating patients and writing prescription if falls asleep constantly even while standing [sic].” (Id., at PAGEID 399)

U.S. Life denied Temponeras’ claim in a June 29, 2012 letter. (Doc. 20-3, PAGEID 431-434) After reviewing the medical records provided by Dr. Tsai, U.S. Life’s letter explained:

Information obtained through an internet search shows your current Doctor of Medicine licenses status as inactive. Actions taken in regard to your license [1014]*1014include a citation issued in June 2011 and a Board Order of Indefinite License Suspension effective January 27, 2012. As of February 10, 2012 the Board’s order is under an appeal review. To be eligible for coverage under the Policy you must be in an eligible Occupational Class. This is defined in the Schedule of Benefits as noted above.
Your occupational class is that of a Doctor of Medicine. The Policy includes a listing of circumstances under which coverage under the Policy is deemed to end, as documented above. Considering the suspension of your license, you were no longer in an eligible class for coverage under the Policy as far back as 2011, when the citation was issued. Information on file further indicates that premiums on the Policy were only paid through June 1, 2011. We do not have medical evidence to support that your disability commenced while in an eligible occupational class and therefore while covered under the Policy.
Furthermore, based upon a complete review of your file, the information does not support disability under the Long Term Disability Plan as of May 19, 2011. There is no information on file that establishes you were disabled from May 19, 2011, through the 90 day Waiting Period and beyond. There is no clinical documentation available from March 23, 2007 until a January 20, 2012 note from Dr. Tsai. The information on file does not clinically establish a change in your condition as of May 19, 2011. The provided clinical information does not substantiate clinical impairments, restrictions or limitations that would prevent you from performing the material duties of your regular job throughout your Plans elimination period and beyond.

(Id. at PAGEID 434)

The policy’s claim procedures required any appeal of this initial decision to be made in writing -within 180 days after receipt of the letter. Temponeras filed a formal written appeal, through counsel, on December 20, 2012. (Doc. 20-1, PAGEID 152-159) With her appeal letter, she submitted additional medical records from Dr. Tsai, including the office note from her initial visit with him on September 20, 2011, and a note dated November 21, 2011. Dr. Tsai wrote then that he first saw Dr. Temponeras on September 20, 2011, “but her disabling condition is a preexisting condition that became unbearable on May 19, 2011.” (Doc. 20-1, at PAGEID 170) Temponeras also submitted a report from Dr.

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185 F. Supp. 3d 1010, 62 Employee Benefits Cas. (BNA) 1333, 2016 U.S. Dist. LEXIS 59787, 2016 WL 2594846, Counsel Stack Legal Research, https://law.counselstack.com/opinion/temponeras-v-united-states-life-insurance-co-of-america-ohsd-2016.