Collins v. Life Ins. Co. of N. Am.

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BRANDON COLLINS, Plaintiff, v. LIFE INSURANCE COMPANY OF NORTH AMERICA, Defendant.

No. 6:21-cv-1756-WWB-DCI

United States District Court, M.D. Florida, Orlando Division

March 24, 2023

ORDER

WENDY W. BERGER UNITED STATES DlSTRICT JUDGE

THIS CAUSE is before the Court on the parties' cross Motions for Summary Judgment (Doc. Nos. 16, 17), and the parties' respective Responses (Doc. Nos. 22, 23) and Replies (Doc Nos. 24, 25).

I. BACKGROUND

Brandon Collins filed the instant action against Life Insurance Company of North America (“LINA”) under the Employee Retirement Security Act (“ERISA”), as amended, 29 U.S.C § 1001, et seq., seeking review of LINA's denial of long-term disability (“LTD”) benefits.

Collins was employed by Estes Express Lines (“EEL”) in the heavy-duty occupation of Materials Handler, a dock worker. (Doc 14-1 at 9, 14, 32; Doc. 14-7 at 136). Collins's occupation required him to exert fifty to one-hundred pounds of force occasionally, twenty-five to fifty pounds of force frequently, or ten to twenty pounds of force constantly to move objects. (Doc. 14-7 at 136). Collins stopped working on March 10, 2019, due to a torn rotator cuff and two herniated discs caused by two motor vehicle accidents. (Doc. 14-1 at 9; Doc. 14-6 at 202).

Collins was covered by EEL's short-term disability plan (“STD”) and its LTD plan. (Doc. 14-1 at 87; Doc. 14-5 at 24; Doc. 14-8 at 106-108). Defendant initially provided LTD coverage under Group Policy No. FLK-980233 (the “Plan”), finding Collins could not perform his occupation as Materials Handler. (Doc. 14-9 at 149-150). After an identified period of time passes, however, benefits are only payable under the Plan if the claimant is unable to work in “any occupation for which [he is], or may reasonably become, qualified based on education, training or experience[.]” (Doc. 14-14 at 425). Accordingly, on April 10, 2020, LINA advised Collins that LINA would review his claim to determine if he continued to qualify for benefits under the “any occupation” standard. (Doc. 14-5 at 9192).

A. The Plan Documents

The Plan provides that after disability benefits have been payable for twelve months, a claimant is disabled if he is “unable to perform the material duties of any occupation for which he . . . is, or may reasonably become, qualified based on education, training or experience; and . . . unable to earn 60% or more of his . . . Indexed Earnings.” (Doc. 14-14 at 484). The Plan requires:

The Insurance Company will pay Disability Benefits if an Employee becomes Disabled while covered under this Policy. The Employee must satisfy the Elimination Period, be under the Appropriate Care of a Physician, and meet all the other terms and conditions of the Policy. He or she must provide the Insurance Company, at his or her own expense, satisfactory proof of Disability before benefits will be paid. The Disability Benefit is shown in the Schedule of Benefits.

(Id. at 495). The Amendatory Rider to the Policy provides that “[t]he Plan Administrator has appointed the Insurance Company as the named fiduciary for deciding claims for benefits under the Plan, and for deciding any appeals of denied claims.” (Id. at 509).

The Plan further states that a certificate of insurance (“COI”) is to be provided to the insureds and that the “certificate will list the benefits, conditions and limits of the Policy.” (Id. at 504). In addition, the Supplemental Information document provides that the Supplemental Information and the Certificate provided to Collins make up the Summary Plan Description (“SPD”) as required by ERISA. (Id. at 428). The SPD, which includes the COI, provides:

The Plan Administrator has appointed the Insurance Company as the named fiduciary for adjudicating claims for benefits under the Plan, and for deciding any appeals of denied claims. The Insurance Company shall have the authority, in its discretion, to interpret the terms of the Plan, to decide questions of eligibility for coverage or benefits under the Plan, and to make any related findings of fact. All decisions made by the Insurance Company shall be final and binding on Participants and Beneficiaries to the full extent permitted by law.

(Id. at 429).

B. The Medical Records

Plaintiff underwent an anterior cervical discectomy with arthroplasty on March 14, 2019, to address his neck issues. (Doc. 14-1 at 106). On March 26, 2019, Collins's treating orthopedic surgeon, Dr. Jason Highsmith, noted Collins's statement that his symptoms had improved post-procedure, but he had some postoperative pain. (Doc. 14 7 at 47). Collins was unable to increase his range of motion, but the tingling into the left upper extremity was improving. (Id.). On June 15, 2019, Collins had a procedure with Dr. Francis McCormick to address his left shoulder. (Doc. 14-2 at 11-13). On August 9, 2019, Collins expressed that he had diminished pain and was working on strengthening, range of motion, and returning to recreational activity. (Doc. 14-13 at 87-88).

On September 5, 2019, Collins was in a third motor vehicle accident that worsened his neck and shoulder pain. (Doc. 14-5 at 63).

On March 25, 2020, Collins saw Dr. Nicholas Newsum with complaints about a finger deformity; Dr. Newsum concluded that the deformity was very functional and discharged Collins from care. (Doc. 14-10 at 158-160). On March 31, 2020, Plaintiff had a procedure with postoperative diagnosis of lumbar disc disruption at ¶ 4-L5. (Doc. 14-5 at 117).

Based on the medical records provided by Collins, a reviewing physician conducted a medical director review of the disability file and determined that Collins had no restrictions for sitting, standing, walking and reaching at or above waist level, could occasionally reach below waist/desk level, lift/carry up to twenty pounds, push/pull up to fifty pounds, climb ladders, stoop, crouch, squat, crawl, or kneel, and could frequently lift/carry up to ten pounds, push/pull up to twenty pounds, and climb stairs. (Doc. 14-6 at 203). A Transferable Skills Analysis (“TSA”) was conducted, and it was determined that Collins could perform the sedentary occupation of Repair-Order Clerk. (Id.). Consequently, on October 29, 2020, LINA informed Plaintiff that he no longer met the Policy's definition of disabled under the “any occupation” standard. (Id. at 201-204). Collins appealed and provided additional medical records of epidural injections he received in 2020, and an MRI of the lumbar spine. (Doc. 14-6 at 123, 144, 269; Doc. 1413 at 21-22).

Thereafter, Dr. Alen Nourian, a specialist in orthopedic surgery, performed an External MD Appeals Review. (Doc. 14-7 at 22-32). Dr. Nourian concluded that Collins was “functionally limited to a moderate degree” because he continued to have low back pain. (Id. at 27). Dr. Nourian noted the recent lumbar disc disruption at ¶ 3-4 and L5-S1, and Collins's flare ups. (Id.). Dr. Nourian's February 12, 2021 report suggested the following restrictions and limitations:

Sitting: unrestricted

Standing: occasionally 15 minutes at a time, up to 1 hours total per day

Walking: occasionally 15 minutes at a time, up to 1 hours total per day

Lifting: occasionally up to 15 lbs.

Carrying: occasionally up to 15 lbs.

Pushing: occasionally up to 15 lbs.

Pulling: occasionally up to 15 lbs.

Climbing stairs: occasionally

Balancing: never

Stooping: occasionally

Kneeling: occasionally

Crouching: occasionally

Crawling: never

Reaching: occasionally overhead/below waist; unrestricted desk level

Use lower extremities for foot controls: unrestricted BLE

Fine manipulation: unrestricted [right upper extremity] and occasionally [left upper extremity]

Simple and firm grasping: unrestricted [right upper extremity] and occasionally [left upper extremity]

(Id. at 27-28). Dr. Nourian noted that Collins's treating providers had not commented on Collins's work status or level of functional limitation in their records. (Id. at 27). Collins directs the Court's attention to Dr. Highsmith's October 22, 2020 letter that stated “Brandon Collins is currently under my care. Due to recent surgery he is unable to work until further notice.” (Doc. 14-6 at 120).

On February 24, 2021, Dr. Nourian included an addendum in his report after he considered additional medical records that indicated Collins had thoracic disruption at T8 T9 through T10-T11, which would contribute to pain with sitting. (Doc. 14-7 at 31). Accordingly, Dr. Nourian revised his opinion regarding sitting, finding that Collins could sit constantly, thirty-minutes at a time, up to six hours total per day with the ability to frequently change positions every half hour with a two-minute “stand and stretch” break. (Id.).

On March 2, 2021, a TSA was performed by Rehabilitation Specialist Stacey Nidositko. (Doc. 14-7 at 39). Ms. Nidositko reviewed Collins's job description, and September 2019 and June 2020 Disability Questionnaires, the Dictionary of Occupational Titles, the OASYS, and the Medical Review Addendum from Dr. Nourian. (Id.). Ms. Nidositko identified two sedentary occupations, information clerk and surveillance-system monitor, that Collins could perform. (Id.).

On March 8, 2021, LINA issued Collins notice of its adverse determination. (Doc. 14-7 at 135-138). Thereafter, Collins provided a ruling by an Administrative Law Judge (“ALJ”), entered on March 10 2021, that Collins was eligible for Social Security Disability Insurance (“SSDI”) benefits. (Doc. 14-8 at 126, 131, 134-137). The ALJ found that Collins's ongoing neck, low back, and shoulder complaints limited him to performing less than a full range of sedentary type work activities. (Id. at 136). Notably, the ALJ found that Collins “can . . . sit for up to six (6) hours in an 8-hour...