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Parker v. Sun Life Assurance Company of Canada

United States District Court, D. Kansas

September 22, 2017

CRAIG PARKER, Plaintiff,



         Plaintiff Craig Parker brings this action under the Employee Retirement Income Security Act of 1974 (“ERISA”), seeking judicial review of Defendant Sun Life Assurance Company of Canada's denial of his claim for long-term disability benefits. This matter is before the Court on the parties' cross motions for summary judgment (Docs. 40 and 43). For the reasons stated below, the Court denies Plaintiff's motion for summary judgment and grants Defendant's motion for summary judgment.

         I. Uncontroverted Facts

         A. The Parties and the Plan

         Plaintiff is a 56-year-old former engineer for Garmin International, Inc. (“Garmin”). He began working as an engineer for Garmin in January of 1997. He stopped working for Garmin on or about April 4, 2014, claiming he suffered from chronic fatigue, fibromyalgia, irritable bowel syndrome (“IBS”), and adrenal insufficiency.[1] When he left Garmin, he was a Design Engineering Team Leader, responsible for “[d]irect[ing] and coordinat[ing] activities of an Electrical Engineering team that is responsible for developing electronic components, products, and systems.”[2] Plaintiff was a salaried exempt employee with an annual salary of $132, 069.60, paid $5, 079.60 every two weeks.[3]

         Garmin sponsored an employee welfare plan that provided long-term disability (“LTD”) benefits to eligible, qualifying participants. This plan is fully funded by a group insurance policy Garmin purchased from Defendant (the “Plan”). Plaintiff was a participant of the Plan.

         The Plan provides LTD benefits of 60% of the employee's Total Monthly Earnings with a maximum monthly benefit of $6, 000 under the following circumstances:[4]

         If Defendant receives Notice and Proof of Claim that an Employee is Totally or Partially Disabled, a Net Monthly Benefit will be payable, subject to the Limitations and Exclusions.

         Proof of Total or Partial Disability must be given to Defendant upon request and at the Employee's expense.

         To be eligible to receive a Net Monthly Benefit, the Employee must:

1. satisfy the Elimination Period with the required days of Total or Partial Disability;
2. provide proof of continued Total or Partial Disability; and
3. have regular and continuing care by a Physician who provides appropriate treatment and regular examination and testing in accordance with the disabling condition.[5]

         For salaried exempt employees such as Plaintiff, the Plan contains the following applicable definitions:

Material and Substantial Duties means, but is not limited to, the essential tasks, functions, skills or responsibilities required by employers for the performance of the Employee's Own Occupation. Material and Substantial Duties does not include any tasks, functions, skills or responsibilities that could be reasonably modified or omitted from the Employee's Own Occupation.
Own Occupation means the usual and customary employment, business, trade, profession or vocation that the Employee performed as it is generally recognized in the national economy immediately prior to the first date Total or Partial Disability began. Own Occupation is not limited to the job or position the Employee performed for the Employer or performed at any specific location.
Total Disability or Totally Disabled means the Employee, because of Injury or Sickness, is unable to perform the Material and Substantial Duties of his Own Occupation.
* * *
To qualify for benefits, the Employee must satisfy the Elimination Period with the required number of days of Total Disability, Partial Disability or a combination of days of Total and Partial Disability.[6]

         The Plan provides that Defendant has discretionary authority to determine benefit eligibility and interpret the terms of the Plan.[7] This discretionary authority includes the right to determine eligibility for benefits, the amount of benefits due, and to construe the terms of the Plan.

         B. Plaintiff's Claim for LTD Benefits

         On October 9, 2014, Defendant received Plaintiff's form request for LTD benefits, dated September 29, 2014.[8] In section 2 of the form, Plaintiff indicated that he first noticed symptoms of his illness in March 2012, and described the nature of his illness/condition as “Dizziness, sweating, and muscle spasms after eating. Symptoms have increased since that time.”[9] Plaintiff listed April 4, 2014, as the last day he worked, and April 7, 2014, as the first day he was unable to work.[10]

         In a letter dated October 22, 2014, Defendant acknowledged receipt of Plaintiff's claim for LTD benefits and informed him that it was awaiting documents from his employer and an Attending Physician's Statement (“APS”) to be completed by his treating doctor.[11] Defendant requested Plaintiff contact it to conduct a telephone interview. It also advised that it had requested records from his doctors and explained the timeframe for its written decision.[12]

         After receiving the requested medical records, Defendant obtained medical records reviews from two registered nurses (“RN”) and an occupational analysis from a vocational consultant. The latter stated, based on her review of the employer's statement and job description and the Economic Research Institute (“ERI”) Occupational Assessor:

[Plaintiff's] occupation [of Design Engineering Supervisor] typically exists in the national economy, according to ERI, at a Light exertion level - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Sitting is required frequently and standing and walking are is [sic] required occasionally.
This occupation also typically requires:
Frequent: reaching, talking, handling, keyboarding, hearing, near acuity, depth perception Occasional: reaching upwards, reaching downwards, fingering, sit/stand option, far acuity and accommodation
* * *
The employer statement indicates that no lifting/carrying any weight is required. This requirement is less than what is required for this occupation as it typically exists in the national economy.[13]

         Both nurses opined that there was insufficient objective evidence in the current medical records to support Plaintiff's claim that he was unable to perform his job.[14] Despite these opinions, after talking to Plaintiff, Defendant referred the matter for a second level review by a medical doctor (“MD”) before making a final determination.[15]

         On February 27, 2015, Calvin P. Fuhrmann, M.D., opined the following in his report to Defendant:[16]

1. [When Plaintiff had double vision, Plaintiff could not work; but this condition had cleared completely after vitamin therapy.][17]
2. [With respect to the claimant's intermittent symptoms of fatigue, muscle weakness, and generalized pain, it] is my considered medical opinion that [he] would be able to function in his usual capacity provided he was given periods of time to rest and this might translate into part-time employment. . . . I do not believe at the present time the claimant is totally unable to carry out his full-time activities, and this is confirmed by the [APS] completed by Dr. Brown in which he said the claimant's symptoms are intermittent.[18]
3. A diagnosis of fibromyalgia and chronic fatigue syndrome is supported.[19]
4. I am unable to identify any specific event or significant change in the claimant's symptomatology other than the fact that he reached a point where he described to his physician that he could not work on a full-time basis.[20]
5. As noted, issues regarding when and how he can work on a full-time basis are still open. What is quite clear is that if he is given appropriate time to rest that he will be able to work on a part-time basis and work through this. Dr. Brown has indicated that he is likely to improve over a 12-to-26-week period. This statement was made in September [2014]. It is apparent to me that the claimant's condition should be reaching the point where he can return to full-time activity. . . . [A diagnosis for chronic Lyme disease] is not supported by the records . . .reviewed.[21]

         Based on Dr. Fuhrmann's report, Defendant approved Plaintiff's request for LTD benefits for a specific period - July 15, 2014 through February 28, 2015. Defendant gave Plaintiff its written decision via a letter dated March 3, 2015.[22] In that letter, Defendant set forth the date of disability as April 7, 2014, calculated Plaintiff's benefits as $6, 000 per month with accrual beginning on July 15, 2014, explained the first check represents benefits payable from July 15, 2014 through February 28, 2015, and future checks will be mailed around the twentieth of the month.[23] The letter stated, in pertinent part:

Your claim for Long Term Disability has been approved under the diagnosis of Chronic Fatigue Syndrome and Fibromyalgia and is subject to [a 24-month limitation].[24]
* * *
[B]enefits are issued on a monthly basis subject to ongoing proof of Total or Partial Disability. Any benefits payable are issued at the end of each month of continued disability. To assist you with sending ongoing proof of loss, we commonly forward periodic attending physician's statements, statements of information, and activity questionnaires. These forms when completed fully and properly, generally will provide sufficient information to determine ongoing benefit eligibility. Please note, however, that sometimes this information may not be sufficient, and we may require further documentation to determine if you qualify for ongoing benefits.
The policy provides a Long Term Disability benefit for a potential maximum benefit period to age 67. For the first 24 months of the benefit period, “total disability” is evaluated against your ability/inability to perform your own occupation as it existed immediately before any period of disability for which a claim is filed. After benefits have been paid for 24 months, “total disability” is evaluated against your ability/inability to perform any gainful occupation for which you are/become suited given your education, training and experience.[25]

         Consistent with the above, on April 8, 2015, Defendant requested Plaintiff have his treating doctors submit statements for his ongoing claim. Drs. Michael Brown and Jude LaClaire submitted APSs on Plaintiff's behalf.

         In a letter dated May 8, 2015, Defendant suspended Plaintiff's LTD benefits as of March 31, 2015, because the then current clinical data did not support total disability beyond that date.

         Defendant explained, in pertinent part:

The Attending Physician Statement signed by Dr. Brown on 4/21/15; although indicated medium function, he also advised your condition is unchanged and that your physical restrictions and limitation[s] vary daily which is conducive (sic) with a diagnosis of Fibromyalgia and Chronic fatigue. Dr. Brown originally felt you were likely to improve over a 12-26 week period which it appears you have with the given opinion of Dr. Brown that you are capable of medium function[;] however we are aware of the Behavioral component that may impact your sustain (sic) function and therefore have requested your claim be reviewed by our medical consultant regarding the Behavioral component. We did not receive the documentation regarding Dr. LaClairs (sic) treatment from you until April 28, 2015 and we need to allow time for the review before making a determination of support of continued Total Disability.[26]

         Defendant thereafter referred the matter for a psychiatric consultant review and another MD review. Defendant received a report from Lisa Jacobus, MSW, LICSW, and a second memorandum from Dr. Fuhrmann. On May 14, 2015, Jacobus wrote:

Documentation in the file does not provide support for an incapacitating psychiatric disorder impacting the claimant's ability to function including ability to work. Records do not contain sufficient clinical information such as comprehensive mental status exam results or information on limitations in day-today functioning to support an incapacitating psychiatric condition. In fact, mental status exam findings that were provided from his primary care provider are mostly unremarkable.
Someone with an incapacitating psychiatric condition would be expected to be engaged in intensive psychotherapy and medication management with a specialist in psychiatric care. Although the claimant is engaged in psychotherapy, he is not engaged in medication management. Of note, the onset of treatment with a therapist, following his last day of work is not necessarily reflective of someone with an incapacitating psychiatric condition.[27]

         On July 25, 2015, Dr. Fuhrman wrote, in pertinent part:

1. [Plaintiff] was seen and evaluated by Dr. Stephen Waller … [who] provided a very detailed analysis of [Plaintiff's] clinical findings. It was Dr. Waller's [conclusion] that [Plaintiff] did not have evidence of Lyme disease, he did not have evidence of infectious meningitis, and . . . clearly noted that [Plaintiff's] mental status was essentially normal… It is my considered opinion that [Plaintiff] had obviously shown significant improvement in his overall central nervous system issues with particular attention to his memory and that the other symptoms of muscle fatigue and weakness were not of the degree that would prevent him from carrying out his usual activities. . . Based on the recently received medical records, it is my considered medical opinion that the claimant does not have evidence of chronic Lyme disease, that his overall symptoms have improved from the point of view of his sinuses, and that there is nothing objective at the present time to corroborate his issues regarding cognitive dysfunction or so-called brain fog.
2. [Plaintiff] does have chronic sinus disease with evidence of functional abnormalities. The claimant has not been on standard therapy for sinusitis as noted and he is currently being followed by a naturopath with a list of apparently 21-plus medications and supplements that have been provided. It is my considered medical opinion that at the present time the claimant's condition has stabilized. He has undergone appropriate sinus surgery. He has been seen by an infectious disease specialist and a pulmonologist, and it is apparent that his condition is such that he would be capable of carrying out full-time sedentary activities.
3. Dr. Waller . . . noted [Plaintiff's] mental status had improved significantly to the point where he was able to relate in significant detail the various aspects of his past medical history, clearly demonstrating that his mental status was not impaired. It should be noted that the claimant was referred for neuropsychological testing and when this information is made available, it will shed further light on his condition. However, what is clear, and it is my considered medical opinion, is that the claimant at the current time is fit for duty.[28]

         Based on these recent consultant reports, Defendant rendered its decision denying LTD benefits beyond March 31, 2015, in a letter dated July 30, 2015 (the “Denial Letter”), stating:

We have determined that you are not eligible for Long Term Disability benefits under the terms and conditions of Group Policy No. 231948 issued to Garmin International Incorporated. In conclusion it is our medical staff's opinion that you have the ability to perform a sedentary level of activity on a sustained basis throughout the day and that based on the current clinical notes the medical documentation does not provide any objective evidence to support any restrictions or limitations from performing the material and substantial duties of your own occupation.
We have determined that you have not satisfied the definition of Total Disability, as defined, to be eligible for continued Long Term Disability benefit consideration and we are formally denying your claim at this time. Benefits have been paid through March 31, 2015 and benefits beyond this date are denied.[29]

         On October 1, 2015, Plaintiff requested an appeal of the July 30 decision. After receiving additional information, Defendant referred Plaintiff's claim for yet another independent medical and psychological records review. Kevin Trangle, M.D., did the medical records review, while Robert P. Odgers, PhD, ABPP, did the neuropsychological file review.

         After reviewing their analyses, in a letter dated April 11, 2016, Defendant upheld its previous determination to terminate Plaintiff's claim effective March 31, 2015 (the “Appeal Denial Letter”).[30] On August 11, 2016, Plaintiff filed the present lawsuit, claiming Defendant's denial of LTD benefits was arbitrary and capricious.[31]

         II. Standards of Review

         A. Summary Judgment Standard

         Summary judgment is appropriate if the moving party demonstrates “that there is no genuine dispute as to any material fact” and that it is “entitled to judgment as a matter of law.”[32]A fact is only material if a dispute over it would affect the outcome of the suit.[33] An issue is only genuine if it ...

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