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Lord v. American General Life Insurance Company of Delaware

United States District Court, S.D. Georgia, Savannah Division

March 18, 2019




         Presently before the Court are Defendant American General Life Insurance Company of Delaware's Motion for Summary Judgment, (doc. 17), and Plaintiff's Amended First Motion for Leave to File Amended Complaint and Amended Response to Summary Judgment, (doc. 31). In this ERISA action, Plaintiff contests Defendant's decision to deny her continued long-term disability benefits and urges the Court to award her all unpaid benefits due under the subject policy. (Doc. 1-1.) Defendant seeks summary judgment, arguing that the medical evidence of record supports its denial decision. (Doc. 17.) Plaintiff filed a Response in opposition to summary judgment, (doc. 22), to which Defendant filed a Reply, (doc. 26). In addition, Defendant filed a Response opposing Plaintiff's request for leave to amend as futile. (Doc. 30.) 4For the reasons which follow, the Court GRANTS Defendant's Motion for Summary Judgment, (doc. 17), and DENIES Plaintiff's Motion for Leave to Amend, (doc. 31).[1] The Court DIRECTS the Clerk of Court to enter summary judgment in favor of Defendant and to CLOSE this case.


         Plaintiff Michelle Lord originally filed this ERISA action in the State Court of Chatham County. (Doc. 1-1.) On September 7, 2017, Defendant American General Life Insurance Company of Delaware (“American General” or “Defendant”) removed the case to this Court. (Doc. 1.) Discovery closed on January 25, 2018, (doc. 9), and the present motions followed.

         Plaintiff's challenge to Defendant's denial of continued long-term disability benefits arises under the Employee Retirement Income Security Act, 29 U.S.C. § 1001 et seq., commonly known as ERISA.[2] (See Doc. 1.) At the time of her disability claim, Plaintiff was employed as a Protective Services Officer for the Georgia Ports Authority, which provided its employees disability insurance benefits issued under an American General Group Long-Term Disability Policy (the “Policy”). (Doc. 17-1, p. 1; doc. 22-1, p. 2.) The long-term disability (“LTD”) insurance coverage was offered under an employee welfare benefit plan sponsored by the Georgia Ports Authority and subject to ERISA. (A.R. 1046-47, 1071.)[3] Defendant, which issued the Policy to the Ports Authority, also served as its claims administrator. (Id.)

         I. The Policy

         The Policy provides LTD benefits for a “disability, ” as defined by the terms of the Policy, after a 180-day elimination period.[4] (Doc. 17-1, p. 1; doc. 22-1, p. 2.) In determining who is eligible for LTD benefits, the Policy grants Defendant “the sole discretionary authority to determine eligibility, make all factual determinations[, ] and to construe all terms of the group policy.” (A.R. 1071.) Under the Policy, LTD benefits are payable for thirty-six months upon approval; however, such benefits are discontinued after the thirty-six-month period if the insured is capable of “work in any gainful occupation on a part-time basis.” (A.R. 1063 (emphasis in original); see also doc. 17, p. 3.) In pertinent part, the Policy sets forth a “disability” test for continued LTD benefits as follows:[5]

         If you are disabled during the elimination period and the next 36 months, you will continue to receive payments beyond 36 months of disability, if you are also:

• working in any occupation and continue to have a 20% or more loss in your indexed monthly earnings due to your sickness or injury; or
• not working, and due to the same sickness or injury, are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training, or experience.

(A.R. 1052 (emphasis in original); see also doc. 26, p. 2.)

         A “gainful occupation” is one “that is, or can be, expected to provide you with an income equal to 80% of your indexed monthly earnings within 12 months of your return to work.” (A.R. 1053 (emphasis omitted); see also doc. 17, p. 4 n.4.) Thus, LTD benefits cease when, inter alia, American General concludes that the insured is able to work part-time in any gainful occupation, following 36 months of disability payments, and the insured chooses not to. (See A.R. 1063, 1071; see also doc. 17, pp. 3-7.)

         II. Plaintiff Michelle Lord's LTD Claim and Appeal

         Plaintiff's LTD claim stems from two injuries she suffered in connection with her job as a Protective Services Officer-a right elbow injury from an October 2009 motor vehicle accident at the Ports Authority and a left knee injury from a January 2011 fall during law enforcement training. (Doc. 22, p. 1.) Plaintiff began treatment with Dr. Robert Dow Hoffman on March 7, 2011, but approximately four-and-half months later, on June 22, 2011, she stopped working at the Ports Authority due to her knee problems. (A.R. 82-84.) In March 2012, Plaintiff filed a claim for LTD benefits based on osteoarthrosis in her lower leg and medial epicondylitis in her elbow, as diagnosed by Dr. Hoffman. (Doc. 17, p. 2.)

         In connection with the claim, Defendant American General requested medical records from Dr. Hoffman and reviewed Plaintiff's Functional Capacity Evaluation (“FCE”), which was conducted on January 23, 2012. (Id.) The results of Plaintiff's 2012 FCE concluded that she could perform “light” physical demand category level work (“PDC”) and showed that she could occasionally lift: twenty-five pounds twelve inches from floor to waist; twenty-five pounds from floor to waist; fifteen pounds from waist to shoulder; and fifteen pounds as well from waist to overhead. (Id.; see also A.R. 138.) Plaintiff could also bilaterally carry twenty-five pounds. (Id.) Dr. Hoffman concurred with these findings upon review. (Doc. 17, pp. 2-3; see also A.R. 113.) Thereafter, because Plaintiff's position as a Protective Services Office required Medium PDC work but she was found to only be capable of Light PDC work, Defendant determined Plaintiff was disabled within the meaning of the Policy and granted her LTD benefits. (Doc. 17, p. 3.) Defendant approved her claim with a disability onset date of June 25, 2011 and, after accounting for the 180-day elimination period, began payments on December 22, 2011. (Id.) Plaintiff received benefits for the next thirty-six months. (Id.)

         Per the terms of the Policy, Plaintiff's LTD benefits would be discontinued at the end of the thirty-six-month period if Defendant determined that Plaintiff was able to work at any gainful occupation on a part-time basis after December 2014. Accordingly, on November 5, 2015, Defendant began evaluating the status of Plaintiff's disability by asking Plaintiff's current treating physician, Dr. Gerald Chai, questions regarding her functional capacity. (Id.) Dr. Chai did not conduct an FCE but instead opined on Plaintiff's ability based on her most recent office visit, November 11, 2014.[6] (A.R. 563.) Dr. Chai reported that when Plaintiff presented on that day she had “severe” knee and elbow pain, but could continuously lift, carry, push, and pull ten pounds and occasionally do the same with eleven-to-twenty pounds. (Id. at p. 564.) Dr. Chai also reported that she could continuously sit but only occasionally stand, walk, reach, grasp, finger, stoop, or kneel. (Id.) Nonetheless, Dr. Chai concluded Plaintiff could return to work on December 22, 2014, in a job consistent with the limitations he reported. (Id.)

         On January 8, 2015, a clinical nurse case manager reviewed Plaintiff's file for Defendant American General and concluded, in agreement with Drs. Hoffman and Chai, that Plaintiff was capable of Light PDC work activity. (Doc. 17, p. 4.) In addition, Defendant referred Plaintiff's file for an Employability Assessment/Occupational Review conducted by two vocational rehabilitation counselors who concluded that, although Plaintiff no longer had the physical capacity to be a Protective Services Officer, she was capable of performing Sedentary or Light work occupations. (Id.) Based on their findings, the reviewing counselors identified seven gainful occupations Plaintiff could perform that offered wages which met or exceeded Plaintiff's indexed monthly earnings. (Id.) On February 23, 2015, as a result of the information provided by Drs. Hoffman and Chai and the subsequent reviews by other experts as well as the 2012 FCE, Defendant denied Plaintiff's claim for continued LTD benefits. (Id.; see also A.R. 617-26.)

         Plaintiff appealed this decision on May 7, 2015. (Doc. 17, p. 5.) With her appeal, Plaintiff enclosed a Medical Assessment of Ability to Do Work-Related Activities form which was prepared by Steven V. Bischof, D.O. in April 2015. (Id.) Dr. Bischof's assessment indicated that Plaintiff could never bend, squat, crawl, climb, or reach, and that she could not stand, sit, or walk for six to eight hours in a day, but Dr. Bischof also stated he had not seen Plaintiff as a patient since July 2, 2014. (A.R. 632-33.) In addition, Dr. Bischof commented that he was “not the patient's orthopedic physician, pain management physician, or physical therapist, ” that his assessment “was based on a single evaluation today, ” and that he had “[n]ot treated the patient in a long time for these medical problems.” (Id. at p. 634.) Subsequently, Plaintiff submitted another Medical Assessment of Ability to Do Work-Related Activities form, this one prepared by Dr. Christopher J. Oldfield on May 27, 2015. (Doc. 17, p. 5; see also A.R. 639-41.) Although Dr. Oldfield's assessment form indicated similar functional limitations as those noted by Dr. Bischof, Dr. Oldfield left the majority of the form blank, including the sections for “Other Limitations, ” “Remarks, ” “Medical Basis, ” “Duration, ” and “Additional Comments.” (Id.)

         On August 25, 2015, Plaintiff supplemented her appeal with additional medical records and an FCE dated April 22, 2015. (Doc. 17, pp. 5-6; see also A.R. 644-78.) Among the medical records were several reports from Dr. Chai which agreed with Plaintiff's 2012 FCE finding that she had the ability to work at the Light PDC level.[7] (Doc. 17, pp. 5-6.) The two most recent reports from Dr. Chai, dated June 9 and August 11, 2015, detailed treatment Plaintiff received for her knee and elbow pain but did not mention work restrictions. (Id. at n.6; see also A.R. 645, 647.)

         Plaintiff's 2015 FCE, conducted by West Rehab at Work, found her capable of engaging in Sedentary PDC work. (Doc. 17, p. 6; see also A.R. 653-60.) The 2015 FCE also stated that Plaintiff exhibited “inconsistent effort” and declined several tests due to reported pain, causing the examiner to conclude that a Sedentary PDC evaluation “represents her participation in today's FCE, and not her potentially full capabilities.” (A.R. 660.) Although the examiner, Jenna Gardner-Morgan, P.T., D.P.T., found Plaintiff capable of Sedentary PDC work, no final recommendation on returning to work was made because Plaintiff did not offer a formal job description for Dr. Gardner-Morgan to consider in light of the FCE. (Id.)

         Finally, in addition to the supplemental records and FCE submitted by Plaintiff on appeal, Defendant commissioned an extensive peer review, by Dr. Allen Mirasol, of Plaintiff's disability file. (Doc. 17, p. 6; see also A.R. 682-83.) In his September 21, 2015 report, Dr. Mirasol found that Dr. Chai's objective examinations did not establish “any significant functional limitations” and that the 2015 FCE was not “a valid indicator of [Plaintiff's] physical demand level, as inconsistent effort was noted.” (A.R. 685.) Similarly, Dr. Mirasol discounted Dr. Bischof's assessment of Plaintiff's ability to do work-related activities because it rested on a single day of evaluation and contained “significant discrepanc[ies]” from Dr. Chai's objective findings and the functional evaluations. (Id.) As to the 2012 FCE, Dr. Mirasol noted its ‚Äúresults support a return to ...

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