Vega v. Ascension Health

997 F. Supp. 2d 1000, 2014 WL 495449, 2014 U.S. Dist. LEXIS 14719
CourtDistrict Court, E.D. Missouri
DecidedFebruary 6, 2014
DocketCase No. 4:13CV387 HEA
StatusPublished
Cited by1 cases

This text of 997 F. Supp. 2d 1000 (Vega v. Ascension Health) is published on Counsel Stack Legal Research, covering District Court, E.D. Missouri primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Vega v. Ascension Health, 997 F. Supp. 2d 1000, 2014 WL 495449, 2014 U.S. Dist. LEXIS 14719 (E.D. Mo. 2014).

Opinion

OPINION, MEMORANDUM AND ORDER

HENRY EDWARD AUTREY, District Judge.

This matter is before the Court on Plaintiffs Motion for Summary Judgment, [Doc. No. 54], and Defendants’ Motion for Summary Judgment, [Doc. No. 57]. The matter is fully briefed. For the reasons set forth below, Defendant’s Motion is granted, and Plaintiffs Motion is denied.

Introduction

Plaintiff seeks to recover benefits pursuant to Section 502(a)(1)(B) of the Employee Retirement Income Security Act of 1974 (ERISA), under the long term disability plan of his employer. Defendant Ascension Health’s Claims Administrator, Defendant Sedgwick Claims Management Services, Inc. denied Plaintiffs application for long-term disability benefits. Plaintiff appealed the decision. The Claims Administrator’s decision was affirmed. Plaintiff now seeks review of the denial.

Findings of Fact1

Ascension Health sponsors the self-funded Long-Term Disability Plan (“LTD [1002]*1002Plan”) for the benefit of eligible employees of Carondelet Health Network in Tucson, Arizona. The LTD Plan is an employee welfare benefit plan governed by the Employee Retirement Income Security Act. Ascension Health is the LTD Plan Administrator and LTD Plan Sponsor. The LTD Plan provides that the administrator “shall have the discretionary authority to decide all questions arising in connection with the administration, interpretation and application of the Plan.” The LTD Plan gives Ascension Health the power to delegate its authority to other administrators. In accordance with the terms of the LTD Plan, Ascension Health has delegated the discretionary authority with regard to claims administration to Sedgwick, the Claims Administrator. In this regard, the LTD Plan provides:

Discretionary Authority
In carrying out their respective responsibilities under the Plan, the Plan administrator and the claims administrator shall have discretionary authority to interpret the terms of the Plan and to determine eligibility for and entitlement to Plan benefits in accordance with the terms of the Plan.

The LTD Plan defines “Disability/Disabled” in relevant part as follows:

Disability/Disabled You are considered to be Disabled or to have a Disability if due to an Injury or Sickness that is supported by objective medical evidence, you require and are receiving the regular care and attendance of a Licensed Physician and you are following the course of treatment recommended by the Licensed Physician. In addition, one of the following is true:
• You are unable to perform during the first 24 months of benefit payments, or eligibility for benefit payments, each of the Material Duties of your Regular Occupation, and after the first 24 months of benefit payments, any work or service for which you are reasonably qualified taking into consideration your training, education, experience and past earnings ...

The term “Material Duties” is defined in the LTD Plan as follows:

Material Duties The essential tasks, functions and operations, and the skills, abilities, knowledge, training and experience generally required by employers from those engaged in a particular occupation that cannot be reasonably modified or omitted.

The term “Regular Occupation” is defined in the LTD Plan as follows:

Regular Occupation The activities that you regularly performed when your Disability began. In addition to the specific position or job you hold with your Employer, it also includes other positions and jobs for which you have training and/or education to perform in your profession at your Employer or any other employer.

The LTD Plan also provides that it is the participant that has the obligation to submit ongoing Proof of Disability. Therefore, during the first 24 months of receipt of LTD benefit payments, a LTD Plan participant must be unable to perform the activities that he regularly performed when his Disability began, with either his own employer or any other employer, whether in the same job capacity or another for which the Participant has training and/or education.

Plaintiff was 62 years old at the time of filing of his action. Plaintiff was employed as a Stationary Engineer at Carondelet St. Mary’s Hospital, which is a part of Caron-delet Health Network. In this capacity, Plaintiff was responsible for operating all equipment and systems central to the distribution of heating, cooling, steam, water, oxygen and emergency electricity to the [1003]*1003main hospital and other hospital-owned buildings. The physical demands for Plaintiffs position included: continuously (67%-100% of the time) — balancing on even indoor surfaces; handling tools; feeling; functional speech; functional hearing; functional vision; and cognition; frequently (66%-34% of the time) — standing; walking; reaching; lifting less than 10 pounds; and carrying less than 10 pounds while walking through the facility; occasionally (l%-33% of the time) — sitting; lifting 10-50 pounds; carrying 10-50 pounds for up to 50 feet; pushing; pulling; climbing step ladders; stooping/bending; kneeling; and crouching; rarely — crawling; never — reclining; and tasting/smelling.

Plaintiffs last day of work was December 10, 2009, making his first day absent December 11, 2009. Plaintiffs Basic Monthly Earnings on his last day of work were $2849.58.

Plaintiff filed a claim for LTD benefits on or about March 1, 2010, claiming that he became Disabled on or about December 10, 2009 due to right knee pain. On December 10, 2009, Sedgwick acknowledged Plaintiffs claim for LTD benefits.

On March 5, 2010, Sedgwick requested medical records from Dr. Mark Senese, the orthopaedic surgeon that Plaintiff identified as his treating physician in connection with his LTD Application. On March 8, 2010, Sedgwick received an Attending Physician Statement (“APS”) from Dr. Senese, stating that Plaintiffs primary diagnosis was a right knee medial meniscus tear and secondary diagnosis was joint effusion. The APS reflected that the objective evidence supporting disability included an arthroscopy on December 23, 2009 and an intra-articular cortisone injection on the right knee. Dr. Senese opined that Plaintiff did not “remain/continue to be totally disabled from his occupation as a Stationary Engineer.” Rather, Plaintiff was able to perform work sitting 8 hours per day, standing 20 minutes per hour and walking 20 minutes per hour. He was also able to perform overhead reaching, gross handling, and fine fingering 8 hours per day. He could lift, carry, push and pull 10 pounds and could perform sustained work for 8 hours per day.

In spite of this proposed modified work schedule, Plaintiff did not return to light duty work.

Along with the March 8, 2010 APS, Dr. Senese also submitted progress notes from Plaintiffs six visits to Dr. Senese from December 16, 2009 to February 24, 2010. In the December 16, 2009 notes, Dr. Se-nese observed a right knee with mild effusion, mild crepitation, and mild joint line tenderness with no instability, good strength, and neurovascularly intact. Dr. Senese recommended right knee arthros-copy for a partial meniscectomy.

In the subsequent notes, after the arthroscopic surgery, Dr.

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Bluebook (online)
997 F. Supp. 2d 1000, 2014 WL 495449, 2014 U.S. Dist. LEXIS 14719, Counsel Stack Legal Research, https://law.counselstack.com/opinion/vega-v-ascension-health-moed-2014.