The opinion
IN THE UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF MISSOURI
SOUTHERN DIVISION
JAMIE S. FLANAGAN, )
)
Plaintiff, )
)
v. ) Case No. 17-cv-05060-MDH
)
THE LINCOLN NATIONAL LIFE )
INSURANCE COMPANY, )
)
Defendants. )
ORDER
Before the Court are the parties’ cross motions for summary judgment. (Docs. 32 and 34).
Plaintiff claims that she was entitled to long term disability benefits under a group employment
long term disability policy issued by Defendant to Plaintiff’s former employer, but was denied
those benefits. Defendant denies the claim, and argues Plaintiff has not met her burden to establish
that she is totally disabled as defined in the policy at issue. For the reasons set forth herein, the
Court DENIES Lincoln’s motion for summary judgment (Doc. 32) and GRANTS Flanagan’s
motion for summary judgment (Doc. 34).
BACKGROUND
Plaintiff was employed by Lester E. Cox Medical Center as a nurse practitioner beginning
on March 1, 2010 and ending on August 25, 2013. Plaintiff was insured under a group policy of
insurance for long term disability through her employment. Cox Medical established and
maintained the employee welfare benefit plan that included long term disability coverage. Cox
Medical funded its plan, in part, by a Group Long-Term Disability Insurance Policy that Lincoln
issued to Cox Medical. The policy’s certificate of coverage states that Lincoln has sole
discretionary authority to determine eligibility and to administer claims in accord with its
interpretation of policy provisions on the Plan Administrator’s behalf.
When Plaintiff left work in August 2013, she applied for long term disability benefits
through Defendant. As part of her application she submitted an employee statement indicating she
could not work, along with a Long-Term Disability Claim Physician’s Statement completed on
November 17, 2013, by Dr. Hopewell. Dr. Hopewell stated under “objective findings” that
Plaintiff has normal physical exam, x-rays, CT and MRI, spondylolisthesis, failed fusion, and
nerve root scarring. Dr. Hopewell stated he saw Plaintiff every three months and that her
symptoms were constant since August 2010. Dr. Hopewell’s statement also indicates he believed
she was first unable to work on January 1, 2013; that she had a failed lumbar fusion that occurred
on April 1, 2011; and that she would receive no benefit from medical rehabilitation or therapy.
Dr. Hopewell also stated the placement of a spinal cord stimulator had failed and that Plaintiff
would be unable to work without unlimited ability to rest and take breaks. On January 24, 2013,
Dr. Hopewell’s records also note Plaintiff continued to have cervical pain and a recent MRI
showed root scarring.
Defendant states Dr. Hopewell’s Long-Term Disability Claim Physician’s Statement is
incomplete because he failed to complete the section regarding Plaintiff’s Activities of Daily
Living (“ADLs”). This section has been left blank. The section asks whether Plaintiff has lost the
ability to safely and completely perform ADLs without another person’s active hands on help,
including, bathing, dressing, toileting, transferring, continence, and eating. While Dr. Hopewell
failed to indicate whether Plaintiff has lost the ability to do these things, there is nothing in the
record to indicate she has, nor does she claim to have, lost the ability to complete these basic daily
tasks.
On April 22, 2014, Nancy Beisswenger, OTR/L conducted a functional capacity evaluation
and concluded Plaintiff was able to do less than sedentary work. She found Plaintiff could sit for
20 minutes at a time, stand for 10 minutes and walk occasionally. Plaintiff could lift 7 pounds
occasionally, with no frequent lifting. Defendant argues there is no basis for this opinion.
On April 12, 2014, the Social Security Administration found Plaintiff to be permanently
and totally disabled and approved her for SSDI benefits.1 Social Security found Plaintiff to be
disabled as of August 22, 2013, when she left employment.
Defendant denied Plaintiff’s initial claim for benefits on December 14, 2013. On May 6,
2014, Plaintiff appealed the denial submitting Ms. Beiswenger’s report and the Social Security
Decision. Defendant in turn submitted the file to Dr. Karande, board certified in physical medicine
and rehabilitation, for review. After receiving Dr. Karande’s June 9, 2014 report, Defendant
informed Plaintiff that they had again reviewed her claim and decided disability benefits during
the 24 month own occupation period were appropriate and issued a favorable decision on June 16,
2014. Dr. Karande’s report was based on a review of documents, including Dr. Hopewell’s records
from October 2010 through October 2013, and the physician statement dated November 17, 2013.
Dr. Karande’s limitations were consistent with sedentary work, which Defendant found entitled
Plaintiff to benefits which ran from November 23, 2014 to November 24, 2015 for the own
occupation period.
Approximately five months later, on November 24, 2014, Defendant notified Plaintiff it
needed proof of continued disability and requested medical records and additional documentation.
On March 2, 2015, Defendant began investigating whether Plaintiff could meet the standard for
1 Defendant states that the SSDI award is not binding on Lincoln because ERISA claims and SSDI
determinations are two vastly different types of benefit programs.
disability after the “own occupation” period of 2 years. In response, Dr. Hopewell2 completed
Defendant’s Abilities Form on April 21, 2015, stating Plaintiff could never lift or carry any weight,
could sit for 20 minute durations and could stand and walk occasionally.
Defendant obtained a transferable skills analysis from Stacey Nidositko, MS, CRC, a
vocational rehabilitation counselor. Nidositko’s September 23, 2015, report indicates she
reviewed a form completed by Plaintiff, and Dr. Karande’s peer review dated June 9, 2014. The
report does not indicate any review of the treating provider’s medical records. Based on the review
of Dr. Karande’s report, Nidositko found that Plaintiff can perform work as a nurse consultant and
as a call center nurse.
On September 28, 2015, six days after Nidositko’s report was issued, Defendant denied
Plaintiff’s benefits beyond November 24, 2015 – the date the own occupation period changed to
any occupation. During the first two years of disability, Plaintiff must prove she cannot perform
her own occupation to be eligible. The letter states, in part,
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. 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.
Defendant found Plaintiff could perform sedentary work, which is defined as:
Sedentary work involves sitting most of the time, but may involve walking or
standing for brief periods of time. Jobs are sedentary if walking and standing are
only required occasionally (1-33%) and if all other sedentary criteria are met.
Sedentary work may require exertion up to 10 lbs. occasionally and a negligible
degree of exertion on a frequent (34 66%) or constant (67-100%) basis.
2 Dr. Hopewell is the only physician with medical records before the Court who has physically
examined and treated Plaintiff.
Defendant’s letter informed Plaintiff of the following determination:
In summary, it is our determination that based upon your age, education, training,
past work experience and your current abilities, that you are not prevented from
performing work in other occupations, even if you can no longer perform your Own
Occupation. Therefore, you no longer meet the definition of disability in this
policy and benefits will be denied as of 11/24/2015. Your payment for benefits
through 11/24/2015 is being sent under separate cover.
Plaintiff appealed this determination. On March 9, 2016, Defendant obtained a peer file
review from Dr. Thomas, board certified occupational medicine. Dr. Thomas reviewed Dr.
Hopewell’s medical records and file and stated that he agreed with the Abilities Form, with the
exception of the lifting restriction. Dr. Thomas found that Plaintiff could lift up to 7 pounds.
However, Dr. Thomas found that Plaintiff’s function is less than sedentary work and was in
agreement with Dr. Hopewell that she would be unable to work.
Defendant then obtained a second vocational expert report from Brandy Thomas, M.A.,
that agreed with the analysis provided by Nidositko, that Plaintiff could perform sedentary
occupations, including the jobs of nurse consultant and call center nurse. On April 26, 2016,
Defendant denied Plaintiff’s appeal reciting portions of Dr. Hopewell’s report and Dr. Thomas’s
report, but leaving out other findings in the reports. The denial states Plaintiff can perform
sedentary work, which is defined as lifting up to 10 pounds occasionally. Plaintiff points out that
the records, including Defendant’s own reviewing medical expert Dr. Thomas, and the FCE upon
which he relied, limited Plaintiff to lifting 7 pounds or less than sedentary work.
On October 18, 2016, Plaintiff filed a second appeal to Defendant. A vocational expert,
Phil Eldred, conducted an evaluation that was submitted with the appeal. Mr. Eldred opined that
the report of Beisswenger, and the FCE, gave Plaintiff restrictions at less than sedentary work; that
Dr. Karande noted Plaintiff to be at a sedentary work level; that Dr. Hopewell reported less than
sedentary work; and that Dr. Thomas gave restrictions at less than sedentary work which rendered
Plaintiff unemployable and unable to work in any occupation. Mr. Eldred ultimately found
Plaintiff to be unable to work at a sedentary level, unable to return to her previous work, and that
she has no transferable job skills for less than sedentary work.
Defendant then requested additional medical evidence. On February 6, 2017, Defendant
denied Plaintiff’s claim for benefits.3 Defendant stated Plaintiff’s own occupation period ended
on November 24, 2015, and therefore disability beyond that date was evaluated as to whether
Plaintiff could perform the main duties of any occupation for which Plaintiff was qualified.
Defendant stated it reviewed the medical documentation, including Dr. Karande’s report, and
referred Plaintiff to its prior letters dated September 28, 2015 and April 26, 2016. Plaintiff then
filed the current lawsuit.
STANDARD
Both parties have filed motions for summary judgment asking the Court to rule on the
undisputed material facts as a matter of law. Summary judgment is proper if, viewing the record
in the light most favorable to the non-moving party, there is no genuine dispute as to any material
fact and the moving party is entitled to judgment as a matter of law. Fed. R. Civ. P. 56; Celotex
Corp., v. Catrett, 477 U.S. 317, 322-23, 106 S. Ct. 2548 (1986). The moving party is entitled to
summary judgment as a matter of law if they can establish there is “no genuine issue of material
fact.” Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 247, 106 S. Ct. 2505, 2510, (1986). Once
the moving party has established a properly supported motion for summary judgment, the non-
moving party cannot rest on allegations or denials but must set forth specific facts showing that
there is a genuine issue for trial. Id. at 248.
3 During this appeal an internal medical records review was conducted by a nurse who concluded
there was no clinical findings in the file demonstrating functional limitations to support Plaintiff
is unable to perform duties of any sedentary occupation.
The case presents the Court with issues regarding the review of the denial of benefits under
ERISA. Here, the Court reviews this ERISA benefits case for an abuse of discretion, because the
Defendant reserved the sole discretionary authority to determine eligibility and administer claims
under the plan. See Johnson v. United of Omaha Life Ins. Co., 775 F.3d 983, 987 (8th Cir. 2014);
and Cash v. Wal-Mart Grp. Health Plan, 107 F.3d 637, 640–41 (8th Cir. 1997) (internal citation
omitted). Under this standard of review, the court must uphold defendant’s decision “so long as
it is based on a reasonable interpretation of the Plan and is supported by substantial evidence.”
Hampton v. Reliance Standard Life Ins. Co., 769 F.3d 597, 600 (8th Cir. 2014) (internal citations
omitted). “A decision is reasonable ‘if a reasonable person could have reached a similar decision,
given the evidence before him, not that a reasonable person would have reached that decision.’”
Ingram v. Terminal R.R. Ass'n of St. Louis Pension Plan for Nonschedule Employees, 812 F.3d
628, 634 (8th Cir. 2016) (internal citation omitted); see also Carlson v. Standard Ins. Co., 920 F.
Supp. 2d 1028, 1032 (W.D. Mo. 2013) (“The deferential standard does not allow a reviewing court
to reject an administrator’s discretionary decision simply because the court disagrees. The proper
inquiry is whether the plan administrator's decision was reasonable; i.e. supported by substantial
evidence. Substantial evidence means such relevant evidence as a reasonable mind might accept
as adequate to support a conclusion.”) (internal citations omitted).
In addition, the Court must also weigh the Defendant’s inherent conflict of interest as a
plan administrator in both administering the plan and paying benefits. Defendant, as the
administrator, owes a fiduciary duty to the employee claiming benefits under the plan, and also
has a corporate interest in avoiding payment of claims. See Metro. Life Ins. Co. v. Glenn, 554 U.S.
105, 117, 128 S. Ct. 2343, 2351, 171 L. Ed. 2d 299 (2008). As such, this inherent conflict is
considered as a factor in the Court’s review, but does not change the abuse of discretion review.
See Id. The parties agree Plaintiff bears the burden of demonstrating her entitlement to benefits
under the Plan.
DISCUSSION
Here, Plaintiff has the burden to establish that she is disabled after the own occupation
period and that Defendant’s determination that she was not disabled under “any occupation” was
an abuse of its discretion and unreasonable. Plaintiff must establish that due to an injury or
sickness she is unable to perform each of the main duties of any occupation which her training,
education, or experience will reasonably allow. Plaintiff argues the medical opinions of disability
in the record find Plaintiff is unable to perform sedentary work and therefore she should be entitled
to benefits.
The physician medical records before the Court come from Dr. Hopewell, Dr. Karande,
and Dr. Thomas. Dr. Hopewell, Plaintiff’s treating neurologist, opined that Plaintiff could not
perform sedentary work. Dr. Hopewell stated Plaintiff could not work “due to unlimited ability to
rest/take breaks,” and that she was “at maximum improvement.” Dr. Hopewell further stated
Plaintiff could never lift or carry any weight and put further restrictions on her ability to stand,
walk, and sit at below the definition of a sedentary work level.
Dr. Karande, who was hired by Defendant to initially review Plaintiff’s claim, rendered an
opinion on June 9, 2014, that Plaintiff could perform sedentary work. This opinion was rendered
prior to Dr. Hopewell’s April 21, 2015 opinion providing specific restrictions for Plaintiff.
Defendant subsequently hired Dr. Thomas, after Plaintiff’s second appeal, to review Plaintiff’s
claim. Dr. Thomas found Plaintiff unable to perform work at a sedentary work level. Dr. Thomas
rendered this opinion on March 9, 2016. Dr. Thomas agreed with Dr. Hopewell’s opinion, other
than he believed Plaintiff could lift up to 7 pounds (as opposed to no lifting), which is still less
than sedentary work. Dr. Thomas found the FCE test to be valid, and further stated “there is no
medical evaluation to the contrary,” finding Plaintiff’s condition to be “chronic and degenerative”
with “minimal improvement” anticipated. Dr. Thomas’s opinion supports benefits under the
policy. Finally, a functional capacity evaluation completed by Nancy Beisswenger, an
occupational therapist, found Plaintiff’s work level was “less than sedentary.”
The Court finds Defendant’s decision to deny benefits is unreasonable. Here, Plaintiff’s
treating physician and the FCE found Plaintiff’s work level at less than sedentary. Then
Defendant’s own expert, Dr. Thomas, also opined that Plaintiff could not perform sedentary work.
Contrary to this medical evidence and opinion of record, Defendant relied on a prior opinion from
Dr. Karande and selectively noted only portions of the vocational evaluations which supported its
denial of benefits. Further, even after receiving Dr. Thomas’ opinion, that was consistent with
Plaintiff’s own treating physician, Defendant decided to rely instead on the non-physician vocation
report of Brandy Thomas, that was allegedly based on a review of Nidositko’s and Dr. Thomas’s
opinions. Brandy Thomas did not review Dr. Hopewell’s records, or the FCE, but rendered a
report finding Plaintiff could perform sedentary work which contradicted the opinions in the record
upon which she claims she relied. Her opinion was also contradicted by Phil Eldred, whose
vocational evaluation concluded, like Dr. Hopwell and Dr. Thomas, that Plaintiff was unable to
work in any occupation and therefore should be entitled to benefits.
The Court finds Defendant’s denial of benefits, based on the record as a whole, is
unreasonable. Considering an inherent conflict of interest as a factor, Defendant chose to pick
only opinions that supported denial of Plaintiff’s benefits, while ignoring treating physician
records and the medical opinion of one of its own experts that found Plaintiff is unable to perform
work. The Court finds no reasonably objective evaluation of the medical record supports denial
of benefits. The only examining and treating physician, and a physician selected by Defendant, to
review Plaintiff’s records, found Plaintiff to be disabled and unable to perform work. The only
evidence supporting denial of benefits is the opinion of Dr. Karande, who performed a file review
in June 2014, prior to Dr. Hopewell providing his opinion on specific restrictions in April 2015,
and the non-physician opinions who failed to fully review all the medical records, never physically
examined Plaintiff, and whose opinions contradict the opinion of two licensed and fully qualified
physicians who found her to be unable to work.
CONCLUSION
For the reasons set forth herein, and after weighing Defendant’s conflict of interest as a
factor, the Court finds Defendant abused its discretion in denying Plaintiff’s appeal for benefits.
Wherefore, the Court DENIES Defendant’s motion for summary judgment and GRANTS
Plaintiff’s motion for summary judgment. Plaintiff is entitled to judgment as a matter of law on
this claim and shall be awarded such sums that are fair and reasonable under the effective policy
of insurance, including back pay to the date the benefits were terminated as of November 24, 2015,
and pay from the entry of Judgment herein forward. Plaintiff is also entitled to interest on the
unpaid benefits from the date each payment became due, reasonable attorneys’ fees and any costs
expended.
IT IS SO ORDERED.
DATED: December 6, 2018
/s/ Douglas Harpool_______________
DOUGLAS HARPOOL
UNITED STATES DISTRICT JUDGE