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Johnston v. Commerce Bancshares, Inc.

United States District Court, W.D. Missouri, Western Division

August 28, 2017




         This ERISA action arises from Defendant Prudential Insurance Company of America's (“Prudential”) decision to terminate Plaintiff John Johnston's (“Plaintiff”) long-term disability benefits under a policy purchased by Defendant Commerce Bancshares, Inc. (“Commerce”). Plaintiff alleges Prudential and Commerce improperly terminated benefits to which he was entitled under the policy.

         Now before the Court are the parties' cross motions for summary judgment. Holding that Commerce is not a proper party to this lawsuit because it had no involvement in any decision to grant or deny benefits to Plaintiff, and that Prudential's decision to deny Plaintiff benefits under the policy was not an abuse of discretion, Prudential and Commerce's motions are GRANTED (Docs. 55, 57) and Plaintiff's motion is DENIED (Doc. 59).

         Summary Judgment Standard

          A moving party is entitled to summary judgment “if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law.” Fed.R.Civ.P. 56(a). The movant bears the initial responsibility of explaining the basis for its motion, and it must identify those portions of the record which demonstrate the absence of a genuine issue of material fact. Torgerson v. City of Rochester, 643 F.3d 1031, 1042 (8th Cir. 2011).


         The Court finds the material, undisputed facts to be as follows.[1]

         Commerce employed Plaintiff in its computer department as an Enterprise Storage Engineer. As part of his compensation package, Commerce provided him with a long-term disability insurance policy (“the Plan”) which it purchased from Prudential.

         The Plan's provisions.

         The Plan states that Prudential is the claims administrator, and Prudential “as Claims Administrator has the sole discretion to interpret the terms of the Group Contract, to make factual findings, and to determine eligibility for benefits. The decision of the Claims Administrator shall not be overturned unless arbitrary and capricious.” Administrative Record (“R.”) at 100 (Doc. 54).

         The Plan defines disability as when: “[1] you [the claimant] are unable to perform the material and substantial duties of your regular occupation due to sickness or injury; [2] you are under the regular care of a doctor; and [3] you have a 20% or more loss in your monthly earnings due to that sickness or injury.” R. at 69. Prudential determines whether a claimant meets the definition of disability. R. at 69. It provides Prudential may stop sending payments if the claimant fails “to submit proof of continuing disability satisfactory to Prudential.” R. at 78. The Plan also provides,

[Prudential] may request that you send proof of continuing disability, satisfactory to Prudential, indicating that you are under the regular care of a doctor. . . . Prudential will deny your claim or stop sending you payments if the appropriate information is not submitted.

R. at 90.

         Plaintiff's illness and the initial claim approval.

         On June 14, 2013, Plaintiff stopped working because of hydrocephalus[2] which, doctors later learned, was caused by a colloid cyst in the third ventricle of his brain. The hydrocephalus, in turn, caused Plaintiff to develop neuropsychological problems.

         It is unknown exactly when Plaintiff began experiencing changes in his health attributable to the cyst. Plaintiff's wife reports his behavior began changing in 2007, when he started becoming increasingly angry. Sometime after 2010, the family began seeking mental health treatment because of his behavior change, which the family attributed to depression and Plaintiff not sleeping well due to sleep apnea. In June of 2012, Plaintiff began losing control over his urine, and shortly after that, his stool. He also began experiencing problems with his gait. He was eventually referred to a neurologist who could not find anything wrong and referred him back to a psychiatrist.

         During a subsequent visit with a psychiatrist, Plaintiff's wife interjected that he was having serious problems and requested an MRI because she feared he may have had a stroke. The psychiatrist then ordered an MRI which revealed a colloid cyst and enlarged ventricles in his brain.

         In July of 2013, Plaintiff underwent brain surgery to remove the cyst and relieve the pressure on his brain. Following the surgery, a neurologist, psychologist, and physical medicine and rehabilitation doctor all treated Plaintiff.

         Plaintiff filed his claim for long-term disability benefits on October 8, 2013. The rehabilitation doctor submitted a statement on October 10, 2013, in which he opined Plaintiff was permanently disabled with moderate to severe cognitive impairments and decreased memory, judgment, attention, and problem solving.

         On October 24, 2013, a Prudential team comprised of team lead Kellie Tattersall, clinician Laurel Cox, R.N., vocational rehabilitation specialist David Carey, and disability claims manager Justin Huth, discussed Plaintiff's claim. Ms. Cox noted Plaintiff had undergone two rounds of neuropsychological testing, most recently in October 2013, and that it would be helpful to have the results of that testing in determining the severity and prognosis of Plaintiff's illness. Ms. Cox noted it did not appear necessary to obtain the raw data underlying the neuropsychological testing at that time.

         As best the Court can determine, during this meeting Prudential decided to approve Plaintiff's claim for long-term disability benefits, at least through the duration of his physical therapy.[3] On November 7, 2013, Prudential sent Plaintiff a letter stating:

We have approved your LTD claim. We have reviewed the medical information provided by your treating physician and have determined that you are currently disabled from your regular occupation as defined in the enclosure. This letter outlines some of the programs and benefits that are available. Whenever possible, we want to work with you on your return to work efforts.
. . .
To be eligible to receive benefits, you must be continuously disabled from performing the material and substantial duties of your regular occupation through the entire elimination period. Since you have met this requirement, your LTD claim has been approved and benefits begin effective December 12, 2013.
. . .
At this time we have requested the results of your two Neuropsychological examinations from Patrick Caffrey, Ph.D. and Eric Eckhmd-Johnson, Ph.D. Please contact these providers to obtain the medical records and advise of our request. This information is needed for the ongoing review of your claim and benefits beyond December 31, 2013.

R. at 761-62.

         Prudential's subsequent denial of the claim.

         At some point, it is unclear when, [4] Prudential received the results of the July 2013 and October 2013 neuropsychological testing. Mr. Huth and Ms. Cox discussed the October results. Mr. Huth noted the results were not considered valid due to Plaintiff's inconsistent performance. It appeared from the neuropsychological testing that Plaintiff had some cognitive impairment, but it could not be determined how much. Mr. Huth also noted that with cognitive therapy and behavioral health counseling, at “least partial improvement would be expected.” R. at 823. Mr. Huth and Ms. Cox agreed that Plaintiff would not have sustained capacity for work at the time, but that Mr. Huth would follow up with Plaintiff in two to three months after he had obtained therapy and counseling.

         Sometime in March of 2014, Plaintiff underwent another surgery to place a shunt in his brain because the ventricles in his brain had not returned to their normal size after the prior surgery to remove the cyst.

         On March 11, 2014, Linda Gasowski discussed the claim with Mr. Huth, Ms. Cox, and Mr. Carey. They decided to refer Plaintiff's file to a physician for review because of the claim's multiple ...

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