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Conner v. Ascension Health

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

December 26, 2019

LISA CONNER, Plaintiff,
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 previously came before the Court on cross motions for summary judgment filed by Defendants Ascension Health and Sedgwick and by Plaintiff Lisa Conner. ECF Nos. 36 and 39. On June 19, 2018, the Court denied the motions and remanded the case to the plan administrator for further evaluation. Now, the parties have again filed cross motions for summary judgment following the plan administrator's continued denial of disability benefits. The motions have been fully briefed and are ready for disposition. For the reasons set forth below, Defendants' motion for summary judgment will be granted in part and denied in part, and Plaintiff's motion for summary judgment will be denied.

         BACKGROUND

         This case arises out of the denial of long-term disability benefits. For the purposes of the motions before the Court, the record establishes the following facts. 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;[1] 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.[2]

AH 62.[3]

         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.” AH 74. In other words, the LTD Plan gives the Claims Administrator, 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 reported difficulties working due to her inability to concentrate and her worry that she would make a mistake. Plaintiff stopped working on May 22, 2013, after she was diagnosed with a rotator cuff tear and cervical strain and pain.

         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.

         Plaintiff identified her treating physicians as Dr. Tucker; Stephen Augustine, D.O., an orthopedic surgeon; Lynn Norman, D.O., an orthopedic surgeon who later replaced Dr. Augustine in the practice; and Stephen Kramarich, M.D., a spine and pain management physician. The medical records reflect the following.

         In June 2013, Dr. Augustine performed surgery on Plaintiff's left shoulder to repair her rotator cuff, which was torn in the accident. On August 19, 2013, Dr. Augustine completed a Fitness for Duty Certification stating that Plaintiff could return to work with a lifting restriction of 25 pounds. Sedgwick consulted with Ascension Health to determine whether it could accommodate such a restriction in Plaintiff's nursing job. Ascension Health responded that it could not accommodate that restriction, so Plaintiff remained off work.

         In August 2013, Plaintiff began treating with Dr. Kramarich on a monthly basis to manage her pain following surgery. Dr. Kramarich's 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. He also administered cervical epidural steroid injections between September and October 2013.

         On November 11, 2013, Dr. Kramarich opined that Plaintiff remained disabled, but deferred comment on Plaintiff's limitations and return-to-work status to Dr. Tucker. On December 5, 2013, Plaintiff reported to Dr. Tucker that she was experiencing side effects from the medication that she had been prescribed. AH 326. Dr. Tucker's notes reflect that the dosage was reduced, and “[t]he side effects have completely resolved.” Id. He also noted that physical therapy decreased Plaintiff's pain intensity.[4]

         Plaintiff treated with Dr. Kramarich in January, February, and March 2014 to obtain refills of her pain medication. On February 3, 2014, Plaintiff saw Ashutosh Pradhan, M.D., a neurologist, for her neck pain. Dr. Pradhan found her neck range of motion to be “normal” and was “unimpressed” with the MRI of Plaintiff's cervical spine. Plaintiff never followed up with Dr. Pradhan.

         On February 6, 2014, Plaintiff treated with Ronak Patel, D.O., and complained of continued aching and burning pain. Dr. Ronak noted that Plaintiff “is currently taking Norco with moderate pain relief and no side effects.” AH 388.

         On February 24, 2014, Plaintiff complained to Dr. Tucker about pain in her left shoulder and increased frequency of headaches. Dr. Tucker adjusted Plaintiff's medications after she complained of unsteadiness in the morning, and he was hopeful that the new medication would help with headaches.

         Plaintiff's treatment records reflect that she continued to complain of left shoulder pain in March, April, July, and September 2014. On April 23, 2014, Dr. Norman noted that Plaintiff did not have much pain with range of motion and had fair strength in her arm at 30 degrees. Dr. Norman indicated on an April 25, 2014 disability update that Plaintiff may be able to return to work with light duty, which Dr. Norman would discuss with Plaintiff at her next appointment.

         On September 9, 2014, Dr. Kramarich noted that Plaintiff was experiencing “signs and symptoms involving cognition, ” but he did not include any other description or notations. AH 497. That same day, Plaintiff underwent PHQ-9[5] and GAD-7[6] tests at Riverside Pain Physicians, which reflected that Plaintiff was experiencing “minimal” depression (score 2/27) and “minimal anxiety” (score of 3/21). In the patient survey, Plaintiff reported no issues with concentration.

         Dr. Kramarich's treatment notes from November and December of 2014 continue to include the “signs and symptoms involving cognition” notation with no further details. However, his notes between September 2014 and February 2015 reflect that Plaintiff was oriented to person, place, and situation; that Plaintiff's judgment and insight were seemingly intact; and that Plaintiff readily participated in decision-making and expressed understanding. The last notation reflecting any issues related to cognition appears on treatment notes from January 2015.

         On December 2, 2014, Dr. Norman performed an arthroscopy, exploration, and debridement of Plaintiff's left shoulder. At a follow-up visit on January 25, 2015, Plaintiff ...


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