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Powers-Taylor v. Ascension Health Inc.

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

June 24, 2019




         This 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.


         At all 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, 2058).[2]

         Ascension was the sponsor and administrator for the self-funded Long-Term Disability Plan (“LTD Plan”)[3] 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).

         The LTD Plan contains the following relevant definitions:

1.12 Disability or Disabled means that due to an Injury or Sickness which is supported by objective medical evidence,
(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[4]; 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.[5]
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 license.

(AR 7-8, 11, 13).

         On 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).

         On 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).

         On May 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).

         On May 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”[6] denied Plaintiff's claim. (AR 422-23). Shortly after that, Dr. Tucker submitted further medical records indicating that Plaintiff ...

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