Dawson v. Cigna Corp.

261 F.Supp.3d 1275

Chernequa DAWSON, Plaintiff,

v.CIGNA CORPORATION and Life Insurance Company of North America, Defendants.

Civil Action No. 16-23502-Civ-Scola

United States District Court, S.D. Florida.

Signed May 31, 2017

Entered June 1, 2017

Chernequa Dawson, Houston, TX, pro se.

Gregory Michael Dell, Alexander Arthur Palamara, Cesar Gavidia, Jr., Dell & Schaefer, Hollywood, FL, for Plaintiff.

Shari Lyn Gerson, Ft. Lauderdale, FL, Brian K. Furgala, GrayRobinson, P.A., Orlando, FL, for Defendants.

Order on Cross-Motions for Summary Judgment

Robert N. Scola, Jr., United States District Judge

This matter is before the Court on the parties' cross motions for summary judgment (ECF Nos. 23, 25). For the reasons explained in this Order, the Plaintiff’s Motion for Summary Judgment (ECF No. 25) is denied , and the Defendants' Motion for Summary Judgment (ECF No. 23) is granted .

1. Background

This is an ERISA benefits denial case. Chernequa Dawson is a former Care Transition Coordinator ("CTC") Nurse Care Manager for Cigna Corporation ("Cigna"). (Pl.'s Statement of Material Facts ¶ 1, ECF No. 26.) Cigna sponsors both a Short Term Disability Plan ("SD Plan") and a Long Term Disability Plan ("LD Plan") for its employees. (Def.'s Statement of Material Facts ¶ 1, ECF No. 24; Pl.'s Statement ¶ 2.) The LD Plan provides continuing income for employees whose covered disability lasts longer than the maximum SD Plan benefit period. (Def.'s Statement, ¶ 4.) Cigna pays the SD Plan benefits out of its general assets, while Life Insurance Company of North America ("LINA") insures the benefits under the LD Plan. (Def.'s Statement ¶¶ 3, 6.) LINA determines eligibility and benefit amounts under both the SD and LD Plans. (Id. ¶¶ 2, 5.) Dawson participated in both plans. (Pl.'s Statement, ¶ 2.)

The Summary Plan Description for the SD Plan states, in relevant part: "You have a covered disability ... if, because of a medical condition related to an accident, illness or pregnancy:

• You are unable to perform the essential functions of your current or a similar role for at least six consecutive scheduled work days;

• The essential duties that you cannot perform cannot be reassigned to another person in order to accommodate your return to work;• You cannot, based on your lack of work experience or on work restrictions related to your medical condition, be reassigned to another position within 15% of the market value of your current role; and

• Your physician provides objective medical evidence to support his or her assessment of your medical condition.

(Pl.'s Statement ¶ 4; Def.'s Statement ¶ 11.)

The LD Plan states, in relevant part, "The Employee is considered Disabled if, solely because of Injury or Sickness, he or she is unable to perform all the material duties of his or her Regular Occupation or a Qualified Alternative." (Pl.'s Statement ¶ 5.) An employee’s ability to work under the LD Plan is based on: (1) medical evidence submitted by the employee; (2) consultation with the employee’s physician; (3) evaluation of the employee’s ability to work by not more than three independent experts if required by the insurance company; and (4) an offer of employment that meets the employee’s capacity to do the work is made by the employer. (Admin. R. at 40, ECF No. 22-1.) Among other requirements, an employee must satisfy the "Elimination Period" before the employee is eligible to receive benefits. (Id. at 47.) The Elimination Period is defined as "the period of time an Employee must be continuously Disabled before Disability Benefits are payable." (Id. ) The LD Plan states that the Elimination Period is the later of the date the 26th weekly benefit in any rolling 12-month period is payable under the SD Plan, or the date the employee’s participation in an employer-approved transitional work arrangement ends. (Id. at 41.)

On July 10, 2014, Dawson was injured when a man in an electric wheelchair ran over her feet and pinned her against the wall of an elevator. (Id. ¶ 9.) Dawson subsequently had over fifty medical appointments with twelve different medical professionals during a one-year period. (Pl.'s Mot. for Summ. J. at 17.) Shortly after the incident, Dawson filed a claim for benefits under the SD Plan. (Pl.'s Statement ¶ 10.) There is no dispute that Dawson met the requirements to receive benefits under the SD Plan from July 11, 2014 through September 6, 2014, and that she did in fact receive benefits during that time period. (Id. ¶ 11; Def.'s Statement of Material Facts in Resp. to Pl.'s Mot. ¶ 11, ECF No. 29.)

By letter dated October 8, 2014, LINA denied Dawson’s claim for benefits under the SD Plan effective September 6, 2014, finding that the "medical information on file did not provide evidence of a functional impairment restricting you from performing your every day job duties." (Pl.'s Statement ¶ 12; Def.'s Statement ¶ 14, ECF No. 24; Admin. R. at 488, ECF No. 22-1.) A claim manager, senior claim manager, nurse care manager, and medical director reviewed Dawson’s claim. (Admin. R. at 488, ECF No. 22-1.)

The denial letter explained that Dr. Kiva Davis’s notes from her July 21, 2014 examination of Dawson stated that the examination "was mostly within normal limits, mild, [sic] limitation in your hips" and that Dawson was "voluntarily restricted ... the range of motion in your knee was at 90 degrees, your reflexes were equal, there were no bruises, skin discoloration, or swelling." (Id. ) Dr. Davis’s notes from her September 2, 2014 examination stated that Dawson would not allow her to complete the exam due to pain. (Id. ) On September 9, 2014, Dr. Davis stated that Dawson was not able to return to work until she had an orthopedic evaluation. (Id. ) The letter noted that a nurse case manager had contacted Dr. Davis for clarification since Dawson’s level of functional impairment was unclear. (Id. ) The letter does not state whether the nurse case manager actually spoke with Dr. Davis. (Id. )

The Medical Director’s review of Dawson’s file found that "the provider’s restrictions are not supported by any acceptable clinical or laboratory findings. The diagnostics were inconsistent with other substantial evidence in your claim file." (Id. ) The letter concluded, "We acknowledge that you may have been experiencing symptoms related to your lower leg injury. However, the medical information received does not support how you are unable to perform your light occupation as a Nurse Case Manager beyond September 6, 2014." (Id. )

Dawson appealed LINA’s decision. (Pl.'s Statement ¶ 13; Admin. R. at 418-421, ECF No. 22-2.) By letter dated January 21, 2015, LINA upheld its decision to deny Dawson’s claim for benefits. (Pl.'s Statement ¶ 14.) An Appeal Senior Associate and a Medical Director reviewed Dawson’s complete file. (Admin. R. at 477, ECF No. 22-1.) The letter noted that Dr. Davis’s evaluations of Dawson on September 2, 2014 and October 2, 2014 were limited or could not be performed due to Dawson’s pain. (Id. ) The letter noted that Dawson had an orthopedic evaluation with Dr. Kenneth Berliner on October 10, 2014. (Id. ) Dr. Berliner documented that Dawson had difficulty with ambulation, was using a cane, experienced tenderness of the lumbar spine, and had motor group test scores of 2-3 out of 5. (Id. ) However, Dr. Berliner observed that Dawson’s feet showed no scarring, swelling, or discoloration at the site of the injuries, and the x-rays that Dr. Berliner reviewed from the date of the accident showed no fractures or dislocations. (Id. ) Dr. Berliner’s report stated that he was unable to complete a reasonable examination at that time. (Id. )

The letter further noted that on October 14, 2014, Dawson had an evaluation with Dr. Kevin Prentice. (Id. ) Dr. Prentice documented tenderness in Dawson’s lower extremities, but his examination revealed "minimal strength deficits at 4/5" and no asymmetric or sensory deficits. (Id. ) Dr. Prentice’s examination was limited due to Dawson’s complaints of pain. (Id. ) The letter concluded that "There was no clinical evidence that would demonstrate a functional loss and inability to perform your occupation beyond September 6, 2014." (Id. )

Dawson filed a second appeal, which LINA denied by letter dated June 10, 2015. (Id. ¶¶ 15-16.) In support of her second appeal, Dawson provided the results of a Functional Capacity Evaluation ("FCE"), as well as updated medical records. (Pl.'s Mot. for Summ. J. at 4, ECF No. 25.) A Medical Director reviewed Dawson’s complete file. (Admin. R. at 465, ECF No. 22-1.) The denial letter noted that the FCE was dated January 8, 2014, which was prior to Dawson’s injuries. (Id. ) The letter reviewed in detail the notes from Dawson’s March 19, 2015 visit to Dr. Grover, the results of an April 2, 2015 MRI, and the notes from a March 23, 2015 rheumatology consultation with Dr. Peer. (Id. ) The letter noted that Dr. Grover documented some decreased sensation, range of motion, and tenderness in Dawson’s back, and tenderness, decreased range of motion and strength in Dawson’s knees, among other things. (Id. ) Dr. Peer noted that Dawson’s February 25, 2015 laboratory results were "unremarkable" and observed Dawson to be in "mild distress." (Id. ) Dr. Peer noted a decreased range of motion in Dawson’s spine, and "diffuse tenderness of muscles and joints." (Id. ) He diagnosed Dawson with "fibromyalgia, chronic pain syndrome, chronic pain due to trauma and long-term use of NSAIDs." (Id. ) Dr. Peer adjusted Dawson’s medications and advised her "to get plenty of sleep and do aerobic exercises." (Id. ) The denial letter concluded that, although there were some positive findings in the doctors' examinations, "there are no documented measured loss [sic] of ability to perform the duties of you [sic] job. Please understand that we are not stating that your conditions did not exist, but that the objective clinical evidence on file is not supportive of functional impairment to the degree that you would have been unable to...