Lisa Conner (“Conner”) worked as a perioperative nurse at St. Vincent’s Medical Center. Through her employment, she held a policy under the Ascension Health (“Ascension”) Long-Term Disability Plan. This plan was administered by Sedgwick. The language of the plan explained that:
“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:
- during the first 24 months of Benefit payments, or eligibility for benefit payments, each of the Material Duties of the Participant’s Regular Occupation; and
- 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.”
Further, the plan provided Sedgwick, as Claims Administrator, had “discretionary authority to determine whether a Participant is eligible to receive or continue to receive a Benefit under the Plan . . . .”
On May 20, 2013, Conner was in a car accident that left her with injuries to her neck, left arm, and left shoulder. Several days later, her doctor, Dale Tucker, M.D., diagnosed her with cervical strain and pain and a rotator cuff tear. By September, Connor had depleted her short-term benefits and she sought long-term disability benefits. Her claim was approved on November 20, 2013, and benefits continued through November 26, 2015.
Around June of 2013, Connor had surgery on her rotator cuff. The next month, Connor was cleared to return to work with a restriction of lifting up to 25 pounds. Sedgwick reached out to Ascension Health to see if that could be accommodated. Ascension explained that it would not be able to do so, therefore Connor did not go back to work. On April 25, 2014, a Dr. Norman indicated that Connor might be able to go back to work if she was assigned to light duty. About a year later, Sedgwick told Connor that her benefits would end if she was unable to show that she could not meet the “any occupation definition” of disability. Sedgwick also asked Connor to fill out a Daily Activities Review.
Connor finished the Daily Activities Review on May 11, 2015. In her review, she stated that she could walk short distances unassisted and could carry out light housework on her own. She did, however, indicate that she had trouble washing and styling her hair, as well as getting dressed. She limited herself from lifting heavy pans or pots of water, and could not push a grocery cart. She overall stated that “[i]f I found a job that I could physically perform, my anxiety/depression, daily headaches, and medications that I take would prevent me from being a dependable employee.”
Six months later, Connor had a functional capacity evaluation (“FCE”). The results of the evaluation showed that Connor could lift up to 20 pounds on occasion, but that she could not reach above her head with her left upper extremity. The FCE also said that she could do light physical work. Using the FCE as a guide, Catherine Phillis-Harvey, MS, prepared a long-term disability transferable skills analysis (“TSA”). This analysis indicated that there were several occupational options available for Connor as a result of her skill set and experience, including those of nurse consultant, school nurse, office nurse, and nurse instructor. Because of this analysis and her medical records, Sedgwick opted to terminate Connor’s long-term disability benefits.
Connor then appealed and submitted an argument that the medication caused cognitive impairments that would prevent her from working in any job. She also provided medical records to this effect from her treating physicians. Sedgwick then had a board-certified psychologist, Dr. Susan Orenstien, review these records. The psychologist opined that Connor did not have “impaired functioning requiring restricting or limitations due to a primary mental health condition.” Sedgwick also had an orthopedic surgeon, Dr. Martin Mendelssohn, review Connor’s file and he found that there were no restrictions on her ability to work. Connor then filed the instant suit.
At that time, the court held that Sedgwick had not completely evaluated her claims related to the medication. This resulted in a remand to reopen the record for additional review. Connor then had a vocation expert complete an independent TSA. This expert then stated that Connor would not have been able to work as an office nurse, nurse consultant, or school nurse because she did not have the appropriate training, education, or experience. Phillis-Harvey, the original evaluator of the TSA, stated that Connor had enough work experience to perform those occupations. In addition, Phillis-Harvey indicated that those jobs allowed for accommodations related to sitting, walking, and standing.
Dr. Mendelssohn took this additional information and stated that his original opinion that Connor could return to work was unchanged. Dr. Orenstien then stated that “there remains no clinical evidence supporting functional impartment due to a primary mental health condition.” Sedgwick further had a Dr. Howard Grattan, pain management specialist, review Connor’s file. He opined that his review of the record did not find any restrictions or limitations that were supported. Relying on Drs. Mendelssohn, Orenstien, and Grattan, Sedgwick affirmed its denial of Connor’s claim.
Connor filed a new motion for summary judgment, arguing that: 1) Sedgwick had not provided a reasonable explanation for the denial of her benefits; 2) Sedgwick’s new understanding that Connor has no restrictions is an abuse of discretion, and; 3) Sedgwick did not consider Connor’s medication side effects. Overall, the court held that because Sedgwick’s decision was reasonable and supported by sufficient evidence, it would not disturb that decision. More specifically, the court ruled that Sedgwick provided detailed reasons for its decisions and highlighted Connor’s lack of objective support for her claims. Therefore, the court ruled in favor of Ascension Health and Sedgwick and ruled against Connor.[Note: this claim was not handled by the Ortiz Law Firm. It is merely summarized here for a better understanding of how Federal Courts are handling long term disability insurance claims.]
Here is a copy of the decision in PDF: