United States District Court, E.D. Missouri, Eastern Division
C. HAMILTON UNITED STATES DISTRICT JUDGE.
matter is before the Court on Defendant Life Insurance
Company of North America (“LINA”)'s Motion
for Summary Judgement (ECF No. 30), and Plaintiff Melanie
Lapidus' Motion for Summary Judgement (ECF No. 31). The
Court will take up both motions together. The motions are
fully briefed and ready for disposition.
was employed by BJC Healthcare as Vice-President of Medical
Benefits. (ECF No. 37, ¶ 1, Defendant's Statement of
Uncontroverted Material Facts (“Defendant
Facts”)). As Vice-President of Medical Benefits, the
Plaintiff “[p]lans, develops, and executes strategic
initiatives related to the development and growth of a
managed care provider network for the system.”
Id. ¶ 2, citing AR LINA0308. Defendant asserts
that the job is sedentary, involving sitting, brief periods
of standing and/or walking and lifting, carrying pushing and
pulling 10 pounds occasionally. Id. ¶ 3, citing
The Terms of the Policy
January 1, 2013, Defendant issued Group Policy FLK-980126
(“the Policy”) to BJC. Defendant evaluated
Plaintiff's claim for short-term disability (STD) and
long-term disability (LTD) benefits and her subsequent
appeals. Id. ¶ 5. The Policy is governed by the
Employee Retirement Income Security Act of 1974, 29 U.S.C.
1001 et seq. (“ERISA”) and provides
disability benefits to qualifying BJC employees. Id.
¶¶ 6-7. Under the Policy, Plaintiff was designated
as a Class 7 employee. Id. ¶ 9. Class 7
employees are defined as “[a]ll active, fulltime
employees classified as Vice President level or above with
one or more years of service, regularly scheduled to work a
minimum of 35 hours per week or 70 hours per pay
period.” Id. ¶ 8.
the “Schedule for Benefits for Class 7”
disability is defined as:
[T]he employee is considered disabled if, solely because of
Injury or Sickness,  he or she is: (1) unable to
perform the material and substantial duties of his or her
Regular Occupation; and (2) unable to earn 80% or more of his
or her Indexed Earnings from working in his or her Regular
The Insurance Company will require proof of earnings and
Id. ¶ 10 (citing AR LINA0028). The Policy also
An Employee's coverage will end on the earliest of the
following dates:…(3) the date the Employee is no
longer in an eligible class…[or] (5) the last day of
the month the Employee is no longer in Active
Service… Disability benefits will be
payable to an Employee who is entitled to receive Disability
Benefits when the Policy terminates if he or she remains
disabled and meets the requirements of the Policy.
Id. ¶14 (citing AR LINA0041). The Policy
further permits Defendant to offset the monthly disability
payment by any “Other Income Benefits” an
employee receives, which include but are not limited to
social security disability benefits. Id. ¶16
(citing AR LINA0043-44). The Policy also contains a provision
called “Assumed Receipt of Benefits.”
Id. ¶17. The provision states:
The Insurance Company will assume the Employee … [is]
receiving benefits for which they are eligible from Other
Income Benefits. The Insurance Company will reduce the
Employee's Disability Benefits by the amount from Other
Income benefits it estimates are payable to the
Employee… The insurance company will waive Assumed
Receipt of Benefits … if the Employee: (1) provides
satisfactory proof of application for Other Income Benefits;
(2) signs a Reimbursement Agreement; Provides satisfactory
proof that all appeals for Other Income benefits have been
made unless insurance company determines that further appeals
are not likely to succeed; and (4) submits satisfactory proof
that Other Income Benefits were denied.
Id. ¶ 17 (citing AR LINA0044-45).
Plaintiff's Claim for Short-term Disability
2002, Plaintiff ruptured two discs in her lumbar spine.
Id. ¶ 18. Plaintiff sought medical treatment
and was advised that she could either have surgery or attempt
to manage her condition through physical therapy and
exercise. (Plaintiff Facts ¶ 17). Plaintiff declined to
have surgery for her condition and instead utilized physical
therapy, exercise, steroid injections and chiropractor visits
to manage her condition. (Defendant Facts ¶ 19). In
2013, Plaintiff began seeking treatment from Dr. Jacob
Buchowski, an orthopedist. (Plaintiff Facts ¶ 19).
Plaintiff was diagnosed with degenerative lumbar scoliosis,
and in 2015, the Plaintiff began experiencing numbness in her
left leg. (Defendant Facts ¶ 20). Dr. Buchowski
advised Plaintiff that the feeling in her legs would, at some
point, not return and that the nerves involved controlled
more than just her ability to walk. (Plaintiff's Facts
January 18, 2016, Plaintiff had spinal fusion surgery.
(Defendant Facts ¶ 21). Plaintiff applied for STD
benefits through the Defendant on January 25, 2016.
Id. ¶ 36. On January 26, 2016, Defendant
approved Plaintiffs claim for STD benefits, with benefits
payable as of January 23, 2016. (Defendant Facts ¶ 22,
citing AR LINA0964-965). On January 29, 2016, Plaintiff
underwent a second spinal surgery. Id. ¶ 23.
The second surgery was to irrigate and debride a portion of
the Plaintiff's spine. (Plaintiff Facts ¶ 30). On
February 15, 2016, Plaintiff had a follow up appointment with
Dr. Buchowski. Id. ¶ 34. He recommended that
Plaintiff continue with physical therapy and recommended
adjusting the Plaintiffs pain medication. Id.
extended Plaintiff's STD benefits until April 3, 2016,
for “time for [additional] healing”. (Plaintiff
Facts ¶¶ 40-41). Defendant again extended
Plaintiff's STD benefits through April 26, 2016.
Id. ¶ 45. Defendant noted that Plaintiff's
“job required her to have ‘prolonged standing,
walking, and sitting' that she was ‘currently
ambulating with a walker and need[ed] to take many Oxycodone
per day to keep up with the pain' and she was
‘[u]nable to tolerate anything regarding sitting,
standing'” Id. ¶ 46, citing AR
LINA0882. Defendant then extended Plaintiff's STD
benefits through May 3, 2016, due to Plaintiff's
“femoral nerve damage” and need to be “in a
wheelchair” inability “to walk at all, [and]
taking oxycodone” and Id. ¶¶ 47-48,
citing AR LINA0884.
April 21, 2016, Plaintiff saw Dr. Chi-Tsai Tang who performed
an EMG/Nerve Conduction Study on the Plaintiff and found
“[a]cute/subacute left-sided femoral neuropathy.”
Id. ¶ 51, citing AR LINA0286-87. On April 27,
2016, the Plaintiff was seen by Dr. David Rubin and Dr. John
Nay for an MRI. They further requested “[a] study of
the left femur and thigh … but the patient was unable
to tolerate further imaging.” (Id. ¶ 52;
Defendant Response, at 13, citing AR LINA0293).
2, 2016, Plaintiff called Defendant to report her condition
and that she had been to the hospital on May 1, 2016 due to
her inability to walk and the pain worsening and radiating
from left leg to right leg. (Plaintiff Facts ¶49).
Defendant subsequently extended Plaintiff's STD benefits
through May 20, 2016. Id. ¶ 54. On May 4, 2016,
Plaintiff began treatment at Washington University's Pain
Management Center under the care of Dr. Michael Bottros for
her “left lower extremity pain post spine
fusion.” Id. ¶ 57, quoting AR LINA0136.
On May 9, 2016, Defendant extended Plaintiffs STD benefits
through June 30, 2016. (Defendant Facts ¶ 24, citing AR
LINA1046-1047). On May 31, 2016, Plaintiff underwent a spine
radiography. (Plaintiff Facts ¶ 61).
2, 2016 treatment note from Dr. Bottros stated:
[Plaintiff] returns to [Pain Management Clinic] today for
follow up of left knee/leg and low back pain. She previously
underwent bilateral sacroiliac joint injections as well as
left saphenous nerve injection. She states that these
injections provided her with some significant relief.
However, she believes that the injections are starting to
wear off. She has weaned herself off oxycodone completely.
Her only opioid currently is OxyContin regimen which we have
her wean off as indicated below. Overall, she believes that
her overall improvement in pain relief continues to proceed
well, waiting about 50% improvement in pain since her initial
visit with us. She denied any new numbness, weakness, bowel
or bladder incontinence.
(Defendant Facts ¶ 26, citing AR LINA0927). On June 9,
2016, a ClaimManager for Defendant, spoke with the Plaintiff
over the phone. Plaintiff explained that she was
“feeling the pain more than she was previously' and
that she was ‘unable to sit comfortably.'”
(Plaintiff Facts ¶ 66).
21, 2016, Dr. Bottros reported:
Patient had left thermal radiofrequency ablation of sacral
lateral branch nerves at left L5, S1, S2, S3 on June 2, 2016.
She reports since that procedure she has experienced
significant relief of pain, but the location of her pain has
shifted. She states she has begun to experience pain the
posterior aspect of the knee. Her pain is basically more than
50% reduced from her initial consult while she is 80% reduced
from her initial opioids.
(Defendant Facts, citing AR LINA0136-137).Dr. Bottoros gave
the Plaintiff a steroid injection. (Plaintiff Facts ¶
69). On June 23, 2016, the Claim Manager spoke to the
Plaintiff. Id. Facts ¶ 70. Plaintiff stated
that the steroid injection had “made her pain
worse” and was “unable to walk.”
Id. Plaintiff further stated that she was
“‘experiencing pain in her knee [and] her
leg' and that her ‘[w]alking problems [had]
quadrupled, or more'” and that she was
“‘unable to do anything at home' and had to
‘put ice at least once every hours [sic] in
her sacroiliac joint due to pain.'” Id.,
(quoting AR LINA01236-1238). Plaintiff reported that she
“cannot work at all as her job requires her to have
meetings all day and speak to providers.” Id.
¶ 71 citing AR LINA01238. The Claims Manager also spoke
with a member of Dr. Buchowski's staff who stated that
Plaintiff was “‘not doing well at all' and
was ‘not released to [return to work]…' as
her ‘condition is worsening.'” Id.
¶ 72, citing AR LINA01232.
29, 2016, Defendant extended Plaintiff's STD benefits
through July 15, 2016, which was the last day on which she
was eligible to receive STD benefits, and transitioned
Plaintiff's claim to the LTD disability unit.
Id. ¶ 73, citing AR LINA0890, 1121-22. A nurse
case manager for the Defendant noted that Plaintiff had
“‘significant back history including 9 level
fusion' ‘pain posterior knee,' ‘antalgic
gait, significant tenderness sacroiliac joint, [and] positive
faber/ganseln bilaterally;' that she had ‘severe
limitations to ADL [activities of daily living] due to
ongoing pain/ limits to function;' and that the
‘[m]edical [records] on file demonstrate[d] a function
loss thru BTD [benefits termination date] as evidenced by
gait deficits/ continued pain/treatments limiting ADL's
post 9 level fusion.'” Id. ¶ 75,
citing AR LINA0890; LINA001221-22). On July 11, 2016,
Defendant reaffirmed its decision to extend STD benefits
through the July 15, 2-16, benefits termination date.
Id. ¶ 76.
Plaintiff's LTD Claim
received Plaintiff's application for LTD benefits on July
6, 2016. Id. ¶ 78. Plaintiff's claim for
LTD benefits was assigned to Claims Manager Marquicha Ladell.
Id. ¶ 79. Claims Manager Ladell requested
information from BJC including copies of her pay stubs prior
to Plaintiff's last day worked. Id. ¶ 80.
In determining whether to grant LTD benefits, Case Manager
Ladell reviewed the medical information in Plaintiff's
STD claims file and the terms and conditions of the Policy.
(Defendant Response, at 21).
12, 2016, Plaintiff completed a “Disability
Questionnaire & Activities of Daily Living” (ADL)
form from the Defendant. (Defendant Facts ¶ 28). The ADL
form asked the Plaintiff whether she was working, to which
she responded “yes” and stated that she was
working for BJC “10 hours per week in the office [and]
10 from home.” Id. ¶ 29, quoting AR
LINA0121-123. Plaintiff further answered that she expected to
return to work July 18, 2016 but noted she would be
performing a modified job. Id. Plaintiff also
indicated that she was receiving and would continue to
receive 100% of her salary through July 15, 2016.
Id. ¶ 31.
19, 2016 treatment note from Dr. Buchowski states:
[Plaintiff] has returned to work part-time (10 hours a week
at work and 10 hours per week at home). She is no longer on
oxycodone and is taking tramadol instead. She states that she
is able to ambulate for relatively long distances without
substantial leg pain or any significant leg numbness (which
she could not do for approximately 2 years prior to surgery)
… On physical examination, the patient is
well-developed, well-nourished woman appearing her stated
age. She is alert, oriented, and is in no acute distress. She
ambulates with a normal gait. She is able to stand on her
toes, stand on her heels, and is able to stand on each leg
independently. She does not need to use any assistive
devices. She is able to squat down and rise back up. She
stands in normal coronal and sagittal alignment. Motor
strength examination demonstrates normal motor strength
throughout the lower extremities. Reflexes are normal and are
symmetric throughout. Babinski sign is negative. There is no
clonus, Her incision is healed… Plain radiographs
demonstrate evidence of a posterior spinal fusion with
instrumentation from T10 to S1/illium with a decompression
from L3 to L5 and TLIFs at ¶ 4-L5 and L5-S1. Overall
alignment looks excellent…
Id. ¶ 32, citing AR LINA0198-199.
August 15, 2016, Dr. Bottros reported:
[Plaintiff] returns to PMC [pain management clinic] today for
continuing low back pain and LLE pain. On her last visit on
7/25/16 she had thermal RF performed on the genicular nerves
of the left knee. She states that she is no longer
experiencing pain directly over the knee, but she has begun
to experience pain superior and inferior to the knee which
she states wraps all around the leg. She states she had
continued to experience some relief with naltrexone.
She reports she recently purchased Quell pain relief devise
to use on her left knee. She states it has been providing
great relied. She states her pain can be as high as an 8/10
in the L knee, but with the Quell devise it goes down to
2/10. She rates the pain 5-6/10 in her low back and states
that although in the past it was located primarily on the
left side, she has begun to experience more main on the right
as well recently which has been gradually worsening. Her last
bilateral SI injection was three months ago. She states her
pain is exacerbated by movement and relieved by ice.
Id. ¶ 33, citing AR LINA0212-213.
approved Plaintiff's LTD claim on August 18,
2016. (Defendant Response, at 22).
Defendant's rationale for approving Plaintiff's LTD
benefits was stored in Workbench. (Plaintiff Facts ¶
86). The Workbench entry states:
8/17/16 CM recommends approving claim based on STD staffing
on 7/11/16, which states medical on file demonstrates a
functional loss through BTD (7/15/16) as evidenced by gait
deficits/continued pain/treatments limiting ADL's post
Id. ¶ 87, citing AR LINA001113.
Defendant Stops Payment of LTD Benefits
August 18, 2016, Defendant requested Plaintiff's last two
paystubs from BJC to calculate her LTD benefit amount.
(Defendant Facts ¶ 38, citing AR LINA0171). Defendant
received those paystubs on September 7, 2016. Id.
¶ 39, citing AR LINA0231. Defendant then followed up
with BJC because Plaintiff had been receiving her full time
pay through 8/26/16. Id. ¶ 40. BJC alerted
Defendant that Plaintiff was an exempt employee who receives
full time pay even when working part time. Id.
¶ 41, citing AR LINA0229.
Policy's definition of Disability requires the employee
to be unable to earn 80% of her indexed earnings. On
September 20, 2016, Defendant notified Plaintiff that her
benefits were not payable. Id. ¶¶ 41-42.
Plaintiff states that the modified work arrangement was not
satisfactory to BJC and that she was terminated on September
18, 2016 effective December 31, 2016. (Plaintiff Facts
¶108, citing AR LINA0205). In a letter dated
November 9, 2016, the Plaintiff reported to Defendant that
she ceased work for BJC effective on December 31, 2016.
(Plaintiff Facts ¶117). Plaintiff contends that while
Defendant never paid any LTD benefits to Plaintiff it would
have done so upon confirmation of Plaintiff's salary.
(Plaintiff Facts ¶ 91).
Defendant Denies Plaintiffs LTD Claim
December 1, 2016, Defendant denied Plaintiffs LTD benefits
claim. (Plaintiff Facts ¶ 134). On April 20, 2017,
Plaintiff submitted an appeal of Defendant's denial of
her LTD benefit claim. On May 22, 2017, Defendant again
denied Plaintiff's claim. Id. ¶ 191. On
November 17, 2017, Plaintiff filed a second appeal.
Id. ¶ 203. On February 7, 2018, Defendant
denied the Plaintiff's ...