United States District Court, E.D. Missouri, Eastern Division
MEMORANDUM AND ORDER
NANNETTE A. BAKER, UNITED STATES MAGISTRATE JUDGE.
matter is before the Court on Defendant Ascension Health
Alliance d/b/a/ Ascension's (“Ascension”)
Motion for Summary Judgment, filed September 21, 2018. (Doc.
44). The motion is fully briefed and ready for disposition.
The Court will grant Defendant's motion.
relevant times Plaintiff Ayana Powers-Taylor was employed as
a Medical Assistant at Sacred Heart Health System
(“Sacred Heart”), in Pensacola, Florida. (Doc. 46
at 1, 4). As a Medical Assistant, Plaintiff's
responsibilities included assisting with treatments ordered
by physicians and nurse practitioners, interviewing patients,
measuring vital signs, and recording information on
patients' charts. Plaintiff has an associate's of
science degree in medical assisting and worked as a medical
assistant for more than 20 years. (AR 0108-0110, 0176-0177,
was the sponsor and administrator for the self-funded
Long-Term Disability Plan (“LTD
Plan”) available to eligible employees of Sacred
Heart. (AR 5, 12, 45). In accordance with the terms of the
LTD Plan, Ascension delegated the discretionary authority
with regard to claims administration to Sedgwick Claims
Management Services, Inc. (“Sedgwick”), the
Claims Administrator. (AR 17, 47).
Plan contains the following relevant definitions:
1.12 Disability or Disabled means that due
to an Injury or Sickness which is supported by objective
(a) 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 . . .
(1) 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 Benefits payments, or
eligibility for Benefits payments, any work or service for
which the Participant is reasonably qualified taking into
consideration the Participant's training, education,
experience and past earnings.
1.26 Material Duties means the essential
tasks, functions and operations, and the skills, abilities,
knowledge, training and experience generally required by
employers from those engaged in a particular occupation that
cannot be reasonably modified or omitted.
1.40 Regular Occupation means the activities
that the Participant regularly performed when the
Participant's Disability began. In addition to the
specific position or job the Participant holds with the
Participant's employer, Regular Occupation also includes
other positions and jobs for which the Participant has
training and/or education to perform in the Participant's
profession at the Participant's Employer or any other
employer. If the Participant's Regular Occupation
involves the rendering of professional services and the
Participant is required to have a professional or
occupational license in order to work, the Participant's
Regular Occupation is as broad as the scope of his or her
(AR 7-8, 11, 13).
January 7, 2015, Plaintiff was recovering from a hysterectomy
when she developed periumbilical pain, and was found to have
an acute bowel injury and underwent a bowel resection. (AR
116-118, 144-145). Due to the surgery and its complications,
Plaintiff received maximum short-term disability
(“STD”) benefits under another plan-the Ascension
Short-Term Disability Payroll Program-pursuant to which
Plaintiff claimed disability as of January 5, 2015. (AR
111-130, 2058). As Plaintiff approached the April 5, 2015,
exhaustion date for STD benefits, her claim was transferred
to Sedgwick to determine whether she qualified for Long-Term
Disability (“LTD”) benefits. (AR 111-130, 2068).
April 6, 2015, Sedgwick notified Plaintiff that she had been
approved for LTD benefits from April 5, 2015 until April 30,
2015. (AR 2048). The letter Plaintiff received from Sedgwick
advised her that in order to qualify for future benefits, she
must continue to be unable to perform the material and
substantial duties of her Own Occupation, demonstrated by
medical updates from her treating physicians. (AR 152-153).
Plaintiff's obstetrician/gynecologist Elizabeth Dunning
Tucker (“Dr. Tucker”) completed an Attending
Physician Statement (“APS”) on April 8, 2015, in
which she opined that Plaintiff was disabled from her Own
Occupation due to “surgical f/u”. (AR 166-168).
Dr. Tucker noted that her prescribed course of treatment for
Plaintiff's post-operative complications was
“supportive treatment with follow-up, ” and
stated that Plaintiff's condition caused
“limitations/restrictions” on her ability to
lift, or to sit and stand for prolonged periods. Id.
In response to a question asking when Plaintiff would be
released to full duty work, she wrote, “pending.”
Id. Throughout 2015, Sedgwick Disability Benefits
Examiner Shenitha Buchanan (“Ms. Buchanan”)
monitored Plaintiff's medical condition, and based on the
medical information provided by Plaintiff and her treating
physicians, Sedgwick continued to approve LTD benefits. (AR
2023, 2028, 2031-35, 2043-46, 2048-49).
26, 2015, Dr. Tucker opined that Plaintiff continued to be
disabled from her Own Occupation, but in this report, she
described the primary diagnosis as “diffuse arthritis,
” and that Plaintiff had been referred to a
rheumatologist for “severe diffuse arthritis.”
(AR 203-207). On May 27, 2015, Plaintiff's
rheumatologist, Ellen W. McKnight (“Dr.
McKnight”), submitted to Sedgwick medical records that
noted a primary impression of “inflammatory
polyarthritis, ” and that further workup is indicated
to confirm a diagnosis. (AR 210-233). On June 1, 2015, Dr.
Tucker submitted additional medical records, in which she
opined that Plaintiff had “healed from the surgery,
” but that she still could not work due to arthritis.
(AR 248-249). Thereafter, from June 1, 2015 through May 26,
2016, Plaintiff received LTD benefits based on a primary
diagnosis of rheumatoid arthritis. (AR 270-399).
26, 2016, Sedgwick warned Plaintiff that they would deny
benefits if updated medical records from her treating
physicians were not timely received. (AR 419-20). At the end
of May, 2016, Ms. Buchanan began to question whether there
was sufficient medical evidence to substantiate the existence
of a disability from Plaintiff's Own Occupation, and Ms.
Buchanan recommended a review of Plaintiff's case by a
Nurse Case Manager (“NCM”). (AR 2004). On June 9,
2016, after not receiving updated medical records from Dr.
Tucker or Dr. McKnight, Sedgwick
“soft” denied Plaintiff's claim. (AR 422-23).
Shortly after that, Dr. Tucker submitted further medical
records indicating that Plaintiff ...