Dorris v. Cummins Engine Co., Inc. Group Ins. Plan

470 F.Supp.2d 797

Karen DORRIS, Plaintiff, v. CUMMINS ENGINE COMPANY, INC. GROUP INSURANCE PLAN; Long Term Disability Plan of Cummins Engine Company, Inc., Cummins, Inc.; Connecticut General Life Insurance Company; and Life Insurance Company of North America; Defendants.

No. 3:04-0983.

United States District Court, M.D. Tennessee, Nashville Division.

December 19, 2006.

COPYRIGHT MATERIAL OMITTED

John D. Wood, James A. Streett, Branham & Day, P.C., Brentwood, TN, for Plaintiff.

David A. Thornton, Jennifer M. Eberle, Bass, Berry & Sims, Memphis, TN, for Defendants.

MEMORANDUM

TRAUGER, District Judge.

This action arises out of plaintiff Karen Dorris's claim for an award of long-term disability ("LTD") benefits, pursuant to an employee disability income policy ("the Policy"), maintained and partially self-insured by her former employer, Cummins Engine Company, Inc. ("Cummins"). Currently pending before the court are cross-motions for judgment on the administrative record by defendants (Docket No. 74) and by plaintiff (Docket No. 77) and responses thereto (Docket Nos. 79 and 80).

I. FINDINGS OF FACT

The facts are gleaned from the administrative record, which was Melt by-defendants on March 21, 2005 (Docket No. 32 & Attachs.), supplemented by defendants on May 18, 2005 (Docket No. 39) and on August 15, 2006 (Docket No. 72), and by plaintiff on August 24, 2006 (Docket No. 73).¹

The Plaintiff

Karen Dorris worked for Cummins for almost fifteen (15) years. (LINA KD 211). Her position as a customer service representative at Cummins required her, at a minimum, to sit continuously for 5.5 or more hours per day, reach frequently at desk level, and occasionally walk and stand. (LINA KD 249). During 2001, Ms. Dorris began to experience fatigue, extreme pain, headaches, stiffness, and sensitivity to light. (LINA KD 149). Her ability to perform the usual activities of daily living began to decline. (Id.) She was "practically bed- or chair-bound for 2-3 days at a time." (Id.) She had once been very active in community and her stepchildren's activities, but her participation in such activities became dependent on how she felt on a given day, (LINA KD 0211). She described her mind as "foggy" and her memory "a problem." (Id.) She often felt faint, nauseated, and confused. (LINA KD 0212).

Between 2001 and 2003, six physicians of various specialties examined Ms. Dorris and concurred in a diagnosis of fibromyalgia. Dr. Paulo Acosta, a neurologist, diagnosed her with fibromyalgia in January 2002. (LINA KD 1208-10). Dr. Thomas John, a rheumatologist, was consulted on February 5, 2002, and concurred in the diagnosis of fibromyalgia. (LINA KD 131). On March 3, 2002, Dr. Michael Lee, an ENT physician, concluded that Ms. Dorris suffered from fibromyalgia, migraines, and possibly the medications used to treat her conditions. (LINA KD 129). On December 13, 2002, Dr. John Nwofia, a pain medicine specialist, found that Ms. Dorris met all the criteria for fibromyalgia syndrome with myglasisas. (LINA KD 128). On January 15, 2003, Dr. Jimmy Wolfe, a neurologist, found that Ms. Dorris had at least 15 of 18 paired "trigger points" consistent with fibromyalgia. (LINA KD 135-36). On July 7, 2003, Dr. Joseph Ozenne, an internal medicine specialist, stated that Ms. Dorris had "the most severe case of fibromyalgia [he] had ever seen." (LINA KD 577-78).

Ms. Dorris also suffered from a number of concurrent, aggravating conditions documented by her physicians, including migraines, Epstein Barr Virus and cytomegalovirus infections, obstructive sleep apnea, restless leg syndrome, and symptoms associated with connective tissue disease. (LINA KD 577-578, 149, 130).

The Defendants

According to defendants, the Policy was issued by Equitable Life Assurance Society of the United States and assumed by Connecticut General Life Insurance Company ("CGLIC") (Docket No. 75 at 1-2); CGLIC was the claims administrator of the Policy during the relevant time period, and CGLIC made all decisions to deny disability benefits to Ms. Dorris (Docket No. 64 at 3); CGLIC would be responsible for paying the first twenty-four (24) months of disability benefits if awarded in this action, and Cummins, Inc. would be responsible for paying the remaining portion of any judgment for disability benefits entered in this action (Id.); and all health care and dental coverage options described in this stipulation are self insured by Cummins, Inc., subject to employee contributions and the other applicable terms and conditions. (Id.)

The Policy

Cummins maintains a LTD policy for its employees. (Docket No. 1 111). Initially, under plan documents represented by CIGNA Group Insurance ("CIGNA")² to be controlling, in order to be "totally" disabled, Ms. Dorris had to prove she was unable to perform "any and every duty pertaining to [her] employment." (LINA KD 150, 227, 852, 928). Under the plan documents which CIGNA now claims are controlling, in order to be "totally" disabled, Ms. Dorris had to prove she was unable to perform "all duties pertaining to [her] employment." (LINA KD 895, 1823). Specifically, the Policy states

You [the claimant] are "totally disabled" if you are unable during the first two (2) years (which includes six (6) months of salary continuance) of a period of disability to do all duties pertaining to, your employment. For the rest of the period of disability you must not be able to do any work for compensation or profit for which you may be reasonably fitted by learning or experience.

You will not be deemed disabled if you do any work for compensation or profit (including self-employment), or during a period in which you are not under the direct care of a doctor. This direct care starts when the doctor examines you.

(LINA KD 895, 1823).

Claimants "must give proof of such disability that will satisfy the Claims Administrator." (LINA KD 1824). The Policy also provides that the monthly benefit will be reduced by what the individual receives from the Social Security Administration and that a claimant "must apply for Social Security disability benefits before [one] can receive full long-term disability payments." (LINA KD 1823).

Ms. Dorris's Disability Claim Filed

Ms. Dorris received short term disability benefits in the amount of 100% of her salary between November 3, 2001 and February 3, 2002, and in the amount of 75% of her salary between February 4, 2002 through May 3, 2002. (LINA KD 1204).

Ms. Dorris submitted her application for LTD benefits under the Policy on March 28, 2002, claiming she became disabled due to intense pain, fibromyalgia, fatigue, and frequent headaches. (LINA KD 1202-13). According to her application, her sickness began in January 2001, she last worked on November 2, 2001, and she was totally disabled as of December 13, 2001. (LINA KD 1202-04).

In her application, Ms. Dorris identified four attending physicians: Drs. Acosta, Ozenne, John, and Salcedo. (LINA KD 1202). Ms. Dorris also submitted an "Attending Physician's Statement of Disability" dated April 18, 2002, completed by Dr. Acosta. (LINA KD 1208-10). In that Statement, Dr. Acosta recounted that he first treated Ms. Dorris on January 28, 2002.(/d.) He diagnosed her with having obstructive sleep apnea and fibromyalgia, described Ms. Dorris's subjective symptoms as "chronic fatigue and sleepiness," and noted objective findings of "abnormal sleep tests." (LINA KD 1210). He indicated that she could balance for greater than five (5) hours; reach, walk, sit, and stand for up to 2.5 hours; and climb, stoop, kneel, crouch, and crawl for zero (0) hours. (LINA KD 1208). He also indicated she could lift and carry ten (10) pounds, and she could push and pull ten (10) to twenty (20) pounds. (Id.) Based on these findings, Dr. Acosta concluded that Ms. Dorris's disability was "total" with regard to her own occupation and any occupation, that she was a suitable candidate for further physical rehabilitation service, that her present job could not be modified to allow for handling her impairments, and that she was not a suitable candidate for vocational rehabilitation. (Id.)

On May 1, 2002, CIGNA notified Ms. Dorris via letter that her application had been received. (LINA KD 1199-1201). The letter requested that Ms. Dorris provide an authorization for the release of medical records. (Id.) On May 1, 2002, CIGNA requested medical records for Ms. Dorris from Drs. John, Salcedo, and Acosta via facsimile marked "Urgent" and "Please Reply." (LINA KD 1195-98, 1191-94, 1187-90). CIGNA only received medical records from Dr. Acosta. (LINA KD 1143). In those records, Dr. Acosta reiterated that Ms. Dorris's diagnoses were fibromyalgia (primary) and obstructive sleep apnea (secondary). (LINA KD 0425). He noted that her current subjective complaints were sleep disturbance, headaches, swelling in extremities, diffuse musculoskeletal pain, facial pain, fatigue, morning stiffness, numbness/tingling, "creepy crawly" sensation in legs, hyper sensitivity to light, sound, and/or touch, dysequilibrium, chest discomfort, anxiety, intermittent confusion, and leg cramps. (LINA KD 0425, 0439). Dr. Acosta's current clinical findings were "severe aching pain in both extremities, bilateral occipul at muscle insertions, trapezius (bilateral) at upper borden, 2nd nb bilateral at costochrondal junction, bilateral knee (medially), low cervical (C5-C7), supraspinatus bilateral, gluteal bilateral, bilateral lateral epicondyle, greater trochanter bilateral, and restless legs syndrome." (LINA AR 0439). He noted that he had utilized the following treatment options in Ms. Dorris's care: physical therapy, antidepressants, NSAID's, home exercise, muscle relaxants, analgesics, relaxation therapy, and neurontin. (Id.)

In his "Physical Ability Assessment" ("PAA") of Ms. Dorris dated May 10, 2002, Dr. Acosta checked boxes indicating that Ms. Dorris's "Current Level of Functionality" was sedentary, and that she could perform light work...