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Conner v. Ascension Health

United States District Court, E.D. Missouri, Eastern Division

June 19, 2018

LISA CONNER, Plaintiffs,
v.
ASCENSION HEALTH and SEDGWICK, Defendants.

          MEMORANDUM AND ORDER

          AUDREY G. FLEISSIG UNITED STATES DISTRICT JUDGE

         This is an action under Section 502(a)(1)(B) of the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1132(a)(1)(B), for disability benefits under an employer sponsored disability benefit plan. This matter is before the Court on the cross motions for summary judgment filed by Defendants Ascension Health and Sedgwick and by Plaintiff Lisa Conner. ECF Nos. 36 and 39. Also before the Court is Defendants' motion to strike Plaintiff's Exhibit. ECF No. 53. For the reasons set forth below, the cross motions for summary judgment will be denied, and the case will be remanded to the plan administrator for reevaluation. Defendants' motion to strike will be denied as moot.

         BACKGROUND

         This case arises out of the denial of long-term disability benefits. Prior to May 2013, Plaintiff was employed at St. Vincent's Medical Center as a perioperative nurse, and she was eligible to participate in the Ascension Health Long-Term Disability Plan (“LTD Plan”). The LTD Plan provides:

Disability or disabled means that due to an Injury or Sickness which is supported by objective medical evidence, the Participant requires and is receiving from a Licensed Physician regular, ongoing medical care and is following the course of treatment recommended by the Licensed Physician; and . . . the Participant is unable to perform:
(A) during the first 24 months of Benefit payments, or eligibility for benefit payments, each of the Material Duties of the Participant's Regular Occupation; and
(B) after the first 24 months of Benefit payments . . . any work or service for which the Participant is reasonably qualified taking into consideration the Participant's training, education, experience and past earnings.

ECF No. 17 at 65-66.

         Under the LTD Plan, “[t]he Claims Administrator [has] the discretionary authority to decide all questions arising in connection with matters” set forth in the LTD Plan. Further, the LTD Plan provides that “[a]ny interpretations or determinations made pursuant to such discretionary authority of the Claims Administrator shall be upheld in judicial review unless it is shown that the interpretation or determination was an abuse of discretion.” Id. at 75. In other words, the LTD Plan gives the Claims Administrator, or in this case, Sedgwick, “discretionary authority to determine whether a Participant is eligible to receive or continue to receive a Benefit under the Plan . . .” Id.

         Plaintiff was involved in a motor vehicle accident on May 20, 2013, causing injuries to Plaintiff's neck, left shoulder, and left arm. Plaintiff was treated by her primary care physician, Dale Tucker, M.D., and she stopped working on May 22, 2013. In June 2013, Plaintiff underwent surgery to repair her rotator cuff, which was torn in the accident.

         In August 2013, Plaintiff began treating with Stephen Kramarich, M.D., a spine and pain management physician, on a monthly basis. His treatment notes reflect that Plaintiff experienced chronic pain in her neck, left shoulder, and left arm following the accident, and he prescribed medications to manage Plaintiff's pain. Plaintiff complained of cognitive limitations due to her pain medication (ECF No. 22 at 308), and a number of Dr. Kramarich's treatment notes indicate that Plaintiff was exhibiting “signs and symptoms involving cognition.” ECF No. 19 at 15, 19, 23, 27, 31.[1]

         On September 27, 2013, Plaintiff exhausted short-term disability benefits, and her claim was converted to a claim for long-term disability (“LTD”) benefits. Under the LTD Plan, a participant is eligible for benefits beyond 24 months only if she is disabled from any occupation for which she is reasonably qualified. Sedgwick approved Plaintiff's LTD claim on November 20, 2013, with benefits beginning on November 27, 2013 and ending on November 26, 2015.

         On September 2, 2015, a Sedgwick nurse case manager reviewed Plaintiff's claim to determine whether she was eligible to continue receiving benefits beyond November 26, 2015, the last day of the 24-month period. On November 12, 2015, Plaintiff underwent a functional capacity evaluation (“FCE”). The FCE indicated that Plaintiff was able to occasionally lift up to 20 pounds, but was unable to reach overhead with her left upper extremity. The FCE concluded that Plaintiff was able to function in the light physical demand category. The FCE also noted that Plaintiff was taking a number of medications, including MS Contin for pain; Lortab for breakthrough pain; Zanaflex, a muscle relaxer; Celexa for depression; Estradiol for hormones; Fiorinal for migraines; and Xanax for sleep and anxiety. Plaintiff was driven to her FCE appointment by a family member due to her taking MS Contin. ECF No. 19 at 330-38.

         A LTD transferable skills analysis (“TSA”) was performed on behalf of Sedgwick, which relied heavily on the FCE. The TSA identified multiple occupations suitable for Plaintiff's training, experience, education, and physical abilities, including ...


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