Clark v. Lincoln National Life Insurance Company
Filing
42
ORDER that Defendant's termination of Plaintiff's LTD benefits is reversed and the matter remanded for further proceedings not inconsistent with this order. Signed by Honorable Timothy D. DeGiusti on 9/20/2018. (mb)
IN THE UNITED STATES DISTRICT COURT FOR THE
WESTERN DISTRICT OF OKLAHOMA
SHARON CLARK,
)
)
Plaintiff,
)
)
v.
)
)
THE LINCOLN NATIONAL
)
LIFE INSURANCE COMPANY, )
)
Defendant.
)
Case No. CIV-15-15-D
ORDER
Pursuant to the civil enforcement provisions of the Employee Retirement
Income Security Act (ERISA), 29 U.S.C. § 1132(a)(1), Plaintiff Sharon Clark
(Clark) brings this action against Defendant, The Lincoln National Life
Insurance Company (Lincoln) in which she alleges her long-term disability
(LTD) benefits were wrongfully terminated. Before the Court are Clark’s
Opening Brief and Lincoln’s Response Brief [Doc. Nos. 30, 32]. The matter is
fully briefed and at issue.1
1
The filing of Plaintiff’s Opening Brief led to an internal docketing error and
delay in the processing of the present case. The Court apologizes for the delay
in issuing this Order and has taken steps to guard against such processing errors
in the future.
BACKGROUND
Clark was employed by McBride Orthopedic Hospital as a Radiologic
Technologist, where she was enrolled for LTD benefits in the McBride
Orthopedic Hospital Employee Benefits Plan, Policy No. 000010086654 (“the
Policy”) offered by Lincoln (R. at 99). The Policy paid monthly disability
benefits following 180 calendar days of disability to an insured who remained
“totally disabled” as a result of an “injury” or “sickness” (R. at 102). The Policy
defined “totally disabled” as follows:
TOTAL DISABILITY or TOTALLY DISABLED will be
defined as follows:
1.
During the Elimination Period and Own Occupation
Period, it means that due to an Injury or Sickness the
Insured Employee is unable to perform each of the
Main Duties of his or her Own Occupation.2
2.
After the Own Occupation Period, it means that due to
an Injury or Sickness the Insured Employee is unable
to perform each of the Main Duties of any occupation
which his or her training, education or experience will
reasonably allow. The loss of a professional license,
an occupational license or certification, or a driver’s
2
The Policy defined “main duties” as job tasks that (1) are normally required
to perform the insured’s occupation and (2) could not reasonably be modified
or omitted. “Main duties” included those job tasks as described in the U.S.
Department of Labor’s Dictionary of Occupational Titles and as performed in
the general labor market and national economy. The Policy further provided
that an employer’s failure to modify or omit other job tasks did not render the
insured unable to perform the main duties of the job.
2
license for any reason does not, by itself, constitute
Total Disability.
(R. at 108).
Clark stopped working on March 2, 2011, due to Osteoarthrosis. On or
about June 3, 2011, she submitted a claim for LTD benefits under the Policy.
Lincoln initially denied her claim, but later determined Clark met the definition
of “total disability” and found she was unable to perform the main duties
related to her occupation (R. at 452, 511). Accordingly, Lincoln approved
thirty-six (36) months of LTD benefits, beginning August 29, 2011, and
concluding on August 29, 2014. On October 3, 2011, Clark was awarded Social
Security Disability Benefits (R. at 479-85). On March 6, 2014, Lincoln advised
Clark that the “Own Occupation Period” would expire August 29, 2014 and no
future benefits would be payable because Clark’s medical records failed to
support a finding of “total disability.” (R. at 227).
In making this determination, Lincoln relied upon a report by Dr. David
Gandy, M.D., who, based on his review of Clark’s medical records, concluded
she would be able to perform “sedentary to light work activities.” (R. at 359).
Lincoln also relied on a vocational assessment performed by Cathy McDonald,
M.A., C.R.C. Ms. McDonald also found that Clark would still be able to
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perform “sedentary work,” as defined by the U.S. Department of Labor.3 Ms.
McDonald determined Clark possessed a number of skills and abilities that
would allow her to perform the main duties of numerous sedentary jobs
contained in the Dictionary of Occupational Titles.
Ms. McDonald found that, based on the information regarding work
history and duties, Clark possessed the following vocational assets: (1) the
ability to understand instructions and underlying concepts, and to reason and
make judgments; (2) The ability to understand the meaning of words and to
use them effectively, (3) comprehend language, understand the relationship
between words and the understanding of words and understand the meaning of
whole sentences; (4) The ability to learn simple processes; (5); The ability to
perform the same task over and over again; (6); The ability to set and meet
standards; (7); the ability for simple verbal and written communication; (8);
the ability and knowledge of how to observe and document observations; and
(9) the ability to work effectively as a team member. Accordingly, the
following positions were identified as examples of positions Clark had the
3
According to the Department of Labor, “sedentary jobs” require sitting most
of the day, with occasional walking or standing, and occasionally lifting less
than ten (10) pounds. 20 C.F.R. § 220.132(a).
4
potential to perform: (1) Coordinator, Skill Training Program, (2) Radiology
Administrator, and (3) Hospital-Insurance Representative (R. at 332-34).
On April 8, 2014, Clark appealed Lincoln’s decision to terminate her
claim for LTD benefits (R. at 203). In response, Lincoln reviewed Clark’s
claim file, including her medical records, to determine whether her medical
records supported a finding that she was totally disabled after the expiration of
the “Own Occupation Period”—August 28, 2014. Clark’s file was reviewed
by Dr. James Boscardin, who determined that Clark had no cognitive issues
related to any documented issues within the medical records and could function
at a sedentary level and could sit unlimited, or certainly for 6 hours at a time
with change of position for comfort and nature calls, and without limitations
on grasping, keying, or typing with either hand (R. at 217). Dr. Boscardin
further found Clark could stand and walk for brief periods at a time, and with
a cane, if necessary (R. at 218).
On June 2, 2014, Lincoln upheld its decision to deny Clark’s claim for
LTD benefits under its belief that the medical documentation did not support
her claim that she was unable to perform the main duties of any occupation
beyond August 28, 2014 (R. at 202). On September 18, 2014, Clark filed her
second and final appeal of Lincoln’s decision to uphold the termination of LTD
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benefits (R. at 181). She submitted additional information following an office
visit with Dr. Corey Ponder on August 19, 2014, including a functional
capacity questionnaire, a physical residual functional capacity assessment, an
office visit note, and an MRI of her thoracic spine (R. at 176-90).
Dr. Ponder’s questionnaires and assessments form indicated that Clark
could sit 5-6 hours a day; stand or walk 0-2 hours a day; frequently finger,
handle, and reach above shoulder level; occasionally lift up to 10 pounds and
rarely lift up to twenty (20) pounds; and never climb, bend or kneel. See id. Dr.
Ponder also noted that Clark frequently experienced pain severe enough to
interfere with attention and concentration needed to perform simple tasks. Id.
Finally, the forms stated Clark had signs/symptoms of impaired sleep, muscle
weaknesses, reduced range of motion, and was using a cane/walking device.
Id. According to Dr. Ponder, Clark’s impairments would cause her to be absent
from work more than four days per month. Id.
The office visit notes with Dr. Ponder reported that Clark’s knees
bothered her, she had problems with her spine, and had a hemangioma with
back pain over the “central aspect.” (R. at 189). Clark reported that her abilities
were about the same and was not taking any narcotics. Id. Clark also reported
her right ankle discomfort was increasing. Id. The examination revealed her
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incisions looked very good, her right knee flexion was just short of full
extension to 115 degrees, her left knee motion was 5-110 degrees, and there
was no effusion or subjective discomfort with passive range of motion. Clark’s
knees were reported as stable, and the x-rays of the knees remain unchanged.
Dr. Ponder noted Clark’s condition was “status quo.” Id.
The physical residual functional capacity assessment reported that Clark
could occasionally lift 10 pounds; could stand and/or walk less than 2 hours in
an 8 hour day; can sit less than 6 hours in an 8 hour day; and can push and or
pull 0.1 hour per day (R. at 183-84). It indicated that Clark required use of a
cane full time due to greatly limited strength and decreased motion of both
legs, and any functional effort lead to increased pain and the need for even
more pain medication (R. at 184). The report noted that spinal stenosis could
lead to neuropathy in both feet and that Clark could never climb, balance,
stoop, kneel, crouch, or crawl. Id. Clark was said to have limited reach in all
directions, but was not unlimited in handling, fingering and feeling (R. at 185).
Clark had no visual or speaking limitations but was reported as having hearing
limitations. Id. She was cautioned to avoid extreme temperatures, wetness,
humidity, noise, vibration, fumes, dust, and hazards (R. at 186).
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The MRI of Clark’s thoracic spine showed intact vertebral bodies with
straight alignment and normal disc spacing (R. at 178). There were no signs of
disc protrusions or compromise of the canal or cord. Id. There were several
hemangiomata with the largest within the left side of the vertebral bodies and
a smaller one near the anterior pedicle. Id. There was no evidence of change
from an earlier exam conducted in September 2011, nor was there any
intermedullar abnormality and the exam of the paravertebral soft tissues found
no discrete abnormality. Id.
On October 21, 2014, Lincoln upheld its decision to deny Clark’s claim
for LTD benefits on the grounds the medical documentation did not support
her claim that she was unable to perform the main duties of any occupation
beyond August 28, 2014 (R. at 176). This action followed.
STANDARD OF REVIEW
Under ERISA, insurance companies are to provide accurate claims
processing by insisting that administrators provide a full and fair review of
claim denials. Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 115 (2008). The
United States Supreme Court has held that a denial of benefits challenged
under ERISA is reviewed under a de novo standard unless the benefit plan
gives the administrator or fiduciary discretionary authority to determine
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eligibility for benefits or to construe the terms of the plan. Firestone Tire &
Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). Lincoln does not contend that
the Policy gives it discretionary authority to determine eligibility for benefits.
See Def. Resp. Br. at 9. Accordingly, the Court exercises a de novo standard of
review.
When applying de novo review in the ERISA context, the role of the
Court is to determine whether the administrator made a correct decision.
Thompson v. Union Sec. Ins. Co., 688 F. Supp. 2d 1257, 1264 n. 34 (D. Kan.
2010) (citing Niles v. American Airlines, Inc., 269 F. App’x. 827, 832 (10th
Cir. 2008) (unpublished)). The standard is not whether “substantial evidence”
or “some evidence” supports the administrator’s decision, it is whether the
plaintiff’s claim is supported by a preponderance of the evidence based on the
Court’s independent review. See id. Although the administrator’s decision is
accorded no deference or presumption of correctness, the administrator’s
decision is still the decision under review. Id. Under this standard, the Court is
generally limited to the administrative record—the materials compiled by the
plan administrator in the course of making its decision. Hall v. UNUM Life Ins.
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Co. of Am., 300 F.3d 1197, 1201 (10th Cir. 2002); Bigley v. Ciber, Inc., 853 F.
Supp. 2d 1079, 1082 (D. Colo. 2011).4
Lastly, although the Court reviews this case de novo, the burden of proof
remains with the plaintiff to prove by a preponderance of the evidence that she
is “disabled” within the meaning of the policy. Thompson, 688 F. Supp. 2d at
1264. To meet this burden, Clark must prove that, as a result of her injury or
medical condition, she is unable to perform at least one of the material duties
of each gainful occupation for which her education, training, and experience
would reasonably allow.
DISCUSSION
Upon de novo review of the administrative record, the Court finds that
Lincoln’s decision to terminate Clark’s LTD benefits should be overturned and
the matter remanded on the narrow grounds stated below.
As noted supra, Clark applied for—and received—Social Security
Disability Benefits (SSD) from the Social Security Administration (SSA). In
4
On February 26, 2018, the Court denied Lincoln’s Motion to Strike and
permitted Clark to supplement the record with a report from Clark’s vocational
expert Kathy Bottroff [Doc. No. 41]. In its order, the Court found that
supplementation was appropriate to conduct an adequate de novo review and
the subject evidence was relevant to Plaintiff’s allegations of a conflict of
interest. Id.
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this regard, Lincoln correctly notes that an award of SSD benefits is not
necessarily determinative of a benefit claim under ERISA because there are
“critical differences” between the social security disability program and
ERISA benefit plans. See Def.’s Resp. Br. at 20 (citing Black & Decker
Disability Plan v. Nord, 538 U.S. 822, 832 (2003)). “But even if the SSA’s
determination is not dispositive, it is still persuasive evidence that [Clark] is,
in fact, unable to work.” Krum v. Hartford Life & Acc. Ins. Co., 942 F. Supp.
2d 1171, 1180 (D. Utah 2013). Lincoln gives mere lip service to the social
security award in its letters denying Clark’s appeal, simply noting the
procedural difference between the two schemes (R. at 179, 205). Indeed, the
two proceedings are different; however, as one sister court observed, “the
disability standard applied by the SSA is not an easy one. To qualify for SSD
benefits, [Clark] had to demonstrate that she was unable, ‘considering her age,
education and work experience, [to] engage in any other kind of substantial
gainful work which exists in the national economy, regardless of whether such
work exists in the immediate area in which she lives.’” See id. (citing 42 U.S.C.
§ 423(d)(2)(A)).
Accordingly, “while [Lincoln] may reasonably believe that a person
meeting the Social Security Disability standard does not necessarily meet the
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any occupation standard under its … Policy, its failure to offer any explanation
of why it believes this statement is true for [Clark’s] case is a factor counseling
reversal.” Krum, 942 F. Supp. 2d at 1181. As further observed by the Krum
court, a plan administrator’s failure to consider a disability finding from the
SSA is a factor supporting reversal. Id. Here, the record is devoid of any
substantive consideration by Lincoln of Clark’s SSD award.
Accordingly, the Court remands this matter to Lincoln for further
explanation of its denial of Clark’s LTD benefits, to include further
consideration of her SSD award. Remand is appropriate where a plan
administrator fails to adequately explain the grounds for its decision. Caldwell
v. Life Ins. Co. of North Am., 287 F.3d 1276, 1288 (10th Cir. 2002).
CONCLUSION
Accordingly, as set forth herein, Defendant’s termination of Plaintiff’s
LTD benefits is REVERSED and the matter REMANDED for further
proceedings not inconsistent with this order.
IT IS SO ORDERED this 20th day of September 2018.
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