Pransch v. The Guardian Life Insurance Company of America
OPINION AND ORDER granting 15 defendant's Motion for Judgment affirming ERISA benefits determination and denying 16 plaintiff's cross Motion for Judgment. Signed by District Judge George Caram Steeh. (MBea)
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MICHIGAN
Case No. 16-10723
HON. GEORGE CARAM STEEH
THE GUARDIAN LIFE
OPINION AND ORDER GRANTING DEFENDANT’S
MOTION FOR JUDGMENT AFFIRMING ERISA BENEFITS
DETERMINATION (DOC. 15) AND DENYING PLAINTIFF’S
CROSS MOTION FOR JUDGMENT (DOC. 16)
This case involves a claim by plaintiff Lyle Pransch for short-term
disability benefits under an employee welfare benefit plan (the Plan)
governed by the Employee Retirement Income Security Act of 1974
(ERISA), 29 U.S.C. § 1001, et seq. Defendant the Guardian Life Insurance
Company of America, claims administrator of the Plan, denied coverage for
plaintiff after he failed to provide requested medical documentation of his
disability. Defendant also determined that plaintiff was not covered by the
Plan because his injury occurred at work. Plaintiff brings this lawsuit
claiming that defendant’s decision to deny benefits fails de novo review and
is arbitrary and capricious.
Plaintiff is a former employee of Valeo North America, Inc.. Valeo
sponsors and directly funds a short-term disability insurance plan through
defendant. (Doc. 12 at PageID 773-806). The Plan defines disabled as “a
current sickness or injury [that] causes physical or mental impairment to
such a degree that you are: (a) not able to perform, on a full-time basis, the
major duties of your own job and (b) not able to earn more than this plan’s
maximum allowed disability earnings.” (Doc.12 at PageID 793). The Plan
requires claimants to prove written proof of loss. (Doc. 12 at PageID 791).
The Plan expressly excludes coverage for disabilities “caused by, or related
to. . . job related or on-the-job injury.” (Doc. 12 at PageID 791).
Plaintiff’s disability is back pain. He first noticed this pain while lifting
boxes at work on July 2, 2014. Plaintiff submitted a handwritten statement
on July 3, 2014 as well as numerous medical records regarding his injury.
Plaintiff submitted a claim for short-term disability benefits in July
2014. He received benefits for five days and returned to work. (Doc. 12 at
PageID 627, 632-33). He submitted a second short-term disability claim in
September 2014. Approval was updated periodically following the
submission of forms from plaintiff’s physicians indicating continued
restrictions. (Doc. 12 at PageID 662). Defendant reviewed plaintiff’s claim
file in January 2015. It thereafter denied plaintiff’s benefits, asserting that
he had not provided medical evidence supporting his disability beyond
January 5, 2015. (Doc. 12 at PageID 672). Plaintiff submitted additional
information. Defendant conducted a second review in May 2015 but came
to the same conclusion. (Doc. 12 at PageID 701). Plaintiff submitted an
ERISA Administrative Appeal in August 2015. Defendant requested that
plaintiff submit additional information for its reconsideration review. (Doc.
11 at PageID 367-373). The parties dispute the corresponding exchange
of information. Defendant’s reconsideration review concluded that its prior
decision to deny ongoing benefits was proper because plaintiff had not
provided all of the requested medical records and his injury occurred at
work. (Doc. 14 at PageID 937 – 943). Plaintiff thereafter filed this lawsuit.
II. Standard of Review
A district court reviewing a decision regarding benefits under ERISA
shall “conduct a . . . review based solely upon the administrative record,
and render findings of fact and conclusions of law accordingly.” Wilkins v.
Baptist Healthcare Systems, Inc., 150 F.3d 609, 619 (6th Cir. 1998). A
denial of benefits is subject to the arbitrary and capricious standard of
review if the benefit plan accords discretionary authority to the claims
administrator to “determine eligibility for benefits or to construe the terms of
the plan.” Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989).
Language requiring a participant to submit “written proof of loss” is a clear
grant of discretionary authority warranting arbitrary and capricious review.
Leeal v. Continental Casualty Co., 17 F. App’x 341, 343 (6th Cir. 2001).
“When it is possible to offer a reasoned explanation, based on the
evidence, for a particular outcome, that outcome is not arbitrary or
capricious.” Williams v. International Paper Co., 227 F.3d 706, 712 (6th Cir.
2000) (internal citations omitted).
The denial of benefits at issue here shall be reviewed under the
arbitrary and capricious standard because the Plan vests defendant with
discretion to make benefit determinations. See (Doc. 12 at PageID 791)
(requiring claimants to provide defendant with written proof of loss).
Defendant asserts that, as the claims administrator, not the plan
administrator, it has no liability for the payment of Plan benefits. Defendant
also argues that plaintiff failed to provide all of the requested medical
information necessary to demonstrate continued short-term disability.
Plaintiff counters that he provided everything that was within his ability to
produce. The Court finds it unnecessary to rule on these issues because
even if defendant has liability and plaintiff fulfilled his obligation to furnish
medical information, judgment for defendant is appropriate based on its
determination excluding coverage of work related injuries under the Plan.
Defendant denied plaintiff benefits after determining that his disability
was caused by a work-related injury. The Plan “does not pay benefits for
disability caused by, or related to. . . job related or on-the-job injury.” (Doc.
12 at PageID 791). Plaintiff provided defendant with medical records that
repeatedly illustrate that he was injured at work while lifting boxes.
Progress notes from Dr. Balbir Gandhi reflect that plaintiff stated that “he
was at work loading boxes onto a truck” and “developed a sharp pain” that
“progressively worsened” as “he continued to load the boxes.” (Doc. 11 at
PageID 132). Dr. Rahman stated that plaintiff “injured [his] back at work.”
(Doc. 11 at PageID 180). Dr. Surindar Kaura wrote that plaintiff has
suffered a pain problem “since 2014” when he “was loading boxes on a
rack for work.” (Doc. 11 at PageID 190, 203, 212). Dr. Tyra McKinney
noted that plaintiff “was injured at work lifting boxes.” (Doc. 11 at PageID
290). Plaintiff told her “that he repeatedly lifted boxes and developed sore
aching pain.” (Id.). Dr. Jai Duck Liem noted that, “according to Mr.
Pransch. . . he was allegedly injured at work. . . on July 2, 2014, when he
lifted boxes weighing [ ] between 40-60 pounds and then started having the
severe pain.” (Doc. 11 at PageID 333). Finally, plaintiff’s own hand written
statement, composed the day after his injury, states that he “had a pain on
[his] right side” after finishing loading the 74 wire harnesses and beginning
to load the 72 wire harnesses. (Doc. 11 at PageID 100). Plaintiff wrote
that the pain began around 5pm, worsened around 7pm, and by 8pm,
became so severe that he alerted a co-worker and stated that he needed to
go to the hospital. (Id.).
This evidence is sufficient “to offer a reasoned explanation” for
defendant’s determination that, because plaintiff’s disability was caused by
or related to an on-the-job injury to deny benefits, it was not covered by the
Plan. Williams, 227 F.2d at 712. Defendant’s decision to deny benefits is,
therefore, neither arbitrary nor capricious. Id.
For the reasons stated above, defendant’s Motion for Judgment
Affirming ERISA Benefits Determination, (Doc. 15), is GRANTED.
Plaintiff’s Cross-Motion for Judgment, (Doc. 16), is DENIED.
IT IS SO ORDERED.
Dated: September 14, 2017
s/George Caram Steeh
GEORGE CARAM STEEH
UNITED STATES DISTRICT JUDGE
CERTIFICATE OF SERVICE
Copies of this Order were served upon attorneys of record on
September 14, 2017, by electronic and/or ordinary mail.
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