Brown v. Life Insurance Co. of North America

Citations: 7 F. Supp. 3d 1125; 2014 U.S. Dist. LEXIS 36003; 2014 WL 1092084Docket: Case No. 2:12-cv-02087-LDG (PAL)

Court: District Court, D. Nevada; March 18, 2014; Federal District Court

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Kimberly Brown filed a lawsuit against Life Insurance Company of North America (LINA) under 29 U.S.C. 1132(a)(1)(B), claiming wrongful termination of her long-term disability benefits. The parties opted for a summary bench trial and submitted motions for judgment based on the administrative record. The Court found that while LINA generally managed the benefits determination appropriately, it disagreed with LINA’s November 10, 2011, decision that Brown was not disabled as defined by the plan. 

Brown, a reservations manager for VEBA, Inc., stopped working in August 2006 for brain surgery and returned part-time in February 2007 but experienced worsening symptoms, leading to her cessation of work in August 2007. Despite undergoing gamma knife surgery in December 2008, she remained unable to work. Under the VEBA plan, a person is considered disabled if they cannot perform their regular occupation or earn 80% of their indexed earnings. 

Brown filed for disability benefits on August 3, 2007, supported by medical documentation, including a diagnosis from Dr. Staci Ross indicating cognitive disorder and adjustment disorder impacting her ability to work. LINA initially approved her claim, and she began receiving benefits on January 30, 2008. The Court confirmed its jurisdiction under 28 U.S.C. 1381 and ERISA, and the venue was deemed proper. It concluded by granting Brown’s motion and denying LINA’s motion for judgment.

The VEBA plan stipulates that LINA will consider that the Employee and dependents are receiving eligible benefits from Other Income Benefits, which will lead to a reduction in the Employee's Disability Benefits by the estimated amount of these benefits. LINA will waive Assumed Receipt of Benefits, except for Disability Earnings from work performed while receiving Disability Benefits, if the Employee meets certain conditions: providing proof of application for Other Income Benefits, signing a Reimbursement Agreement, proving that all appeals for Other Income Benefits have been made unless further appeals are deemed unlikely to succeed, and submitting proof of denial for Other Income Benefits. LINA may assist the Employee in applying for Social Security Disability Income (SSDI) Benefits, and if the Employee does not cooperate with this process, LINA will reduce Disability Benefits by the estimated SSDI amount.

Brown applied for SSDI with LINA’s assistance and received benefits starting February 1, 2008, which included retroactive payments that she reimbursed to LINA. LINA subsequently reduced her benefits by the amount of SSDI received. After 24 months of Disability Benefits, the Employee is deemed disabled if unable to perform duties of any occupation for which they are qualified or earn 60% or more of Indexed Earnings. LINA requires ongoing proof of earnings and continued disability. The plan specifies that benefits will end when LINA determines an Employee is not disabled.

In August 2009, LINA informed Brown that the definition of disability would change on January 30, 2010, and requested her to complete a Disability Questionnaire and provide authorization for LINA to obtain medical information. LINA contacted Brown’s doctors for updated information and notified her on February 9, 2010, that they had not completed the review to determine her eligibility for 'any occupation' benefits. They clarified that ongoing payments during the review did not imply liability. On October 18, 2010, LINA reiterated that they were reviewing her eligibility and requested further documentation.

Brown self-reported an inability to work due to various mental health issues including depression, anxiety, PTSD, and cognitive deficits, citing specific limitations like chronic fatigue, memory loss, and difficulty using a computer. LINA sought updated medical information from her doctors throughout early 2011, indicating the possibility of an Independent Medical Examination (IME) to assess her functional capabilities. Participation in the IME was mandatory but would incur no cost to Brown. 

In May 2011, Dr. Miles Morgan assessed Brown, identifying a cognitive deficit linked to meningioma and noting her psychiatric issues, including anxiety and depression. Dr. Morgan highlighted her impaired memory and inability to multitask, concluding he could not predict her return to work. He recognized prior recommendations from Dr. Ross regarding her work capacity and suggested that her cognitive disorder might be permanent, but indicated that her inability to work was not solely due to her treated conditions.

LINA later referred Brown to Dr. Thomas F. Kinsora for an independent evaluation. Dr. Kinsora’s findings, based on assessments conducted in September and October 2011, indicated that Brown did not exhibit significant cognitive limitations that would hinder her occupational capabilities. He noted some mild issues with fine motor control and spatial reasoning but found her executive skills intact. Overall, he assessed her attention, concentration, and cognitive flexibility as low to high average, suggesting that these factors were unlikely to significantly impact her functional abilities.

Kimberly exhibits significant attention, concentration, and cognitive flexibility challenges, particularly under stress or in noisy environments, despite no evident issues during testing. Her medical history and psychological adjustments contribute to plausible complaints regarding attention, concentration, and memory. While she reports ongoing fatigue, excessive sleep, and light sensitivity, her cognitive performance does not indicate major obstacles to occupational engagement or retraining. However, her depression and anxiety may hinder cognitive efficiency. 

Dr. Kinsora observes that Kimberly desires to return to work but lacks confidence due to her psychiatric issues, which impede her efforts. She has withdrawn from social interactions and has shown no proactive steps to rebuild her work skills. Dr. Kinsora identifies significant barriers to performing repetitive tasks due to fatigue, low endurance, and light sensitivity, suggesting that with appropriate breaks, stamina support, and low-light accommodations, she might improve her performance. Stress exacerbates her fatigue, frustration, and irritability, affecting her rationality and interactions.

Despite these challenges, her ability to meet set limits and standards appears intact, contingent upon necessary accommodations for her fatigue and light sensitivity. She experiences frequent syncope episodes that require workplace safety accommodations. Dr. Kinsora notes potential mild multitasking difficulties, worsened by frustration. He assigns her a Global Assessment of Functioning (GAF) score of 50. Dr. Morgan concurs with Kinsora's findings. A Transferable Skills Analysis by Vince Engel confirms that Kimberly's limitations stem from the neuropsychological evaluation and highlights her strong executive skills but challenges with multitasking. Engel reports her Indexed Earnings at $3,964.26 against a wage requirement of $2,378.56.

Engel identified six occupations suitable for Brown based on her transferrable skills, including her original role as a reservations manager. On November 10, 2011, LINA notified Brown that she no longer met the definition of Disability for any occupation, citing a comprehensive review of her medical records and a transferrable skills analysis. This analysis highlighted occupations aligning with Brown's skills and wage requirements. Following this decision, Brown appealed, presenting additional medical documentation and arguing that LINA's analysis inadequately considered necessary accommodations, failed to account for her impairments as measured by a GAF score of 50, overlooked the SSA's prior disability determination, and did not inform her of needed information for her appeal. 

LINA's review included evaluations by Dr. Richard Hall, who found no significant neurological or physical impairments in Dr. Rowley’s records, and deemed Dr. Morgan’s conclusions unsupported. Behavioral Health Specialist Dr. Carol Flippen also concluded that Brown's medical information did not indicate a functional mental impairment post-November 11, 2011. On July 25, 2012, LINA denied Brown's appeal, prompting her to file a lawsuit. The Court will review LINA's determination de novo, as the plan does not grant LINA discretion in claims decisions. The policy's terms govern, and while the Summary Plan Description (SPD) grants LINA discretion, it does not alter the policy itself. The Court acknowledges the SSA’s 2008 disability award but clarifies that such determinations do not bind ERISA long-term disability plan assessments, allowing LINA to evaluate Brown's disability status for "any occupation."

LINA was not required to determine that Brown's receipt of Social Security Disability Benefits (SSDB) automatically indicated she was disabled for any occupation. Instead, LINA had the responsibility to assess whether, after January 2010, Brown was unable to perform the essential duties of any job that would yield 60% of her indexed earnings. The record shows that LINA was aware of the SSA's disability benefits award but noted that the supporting clinical information was not detailed and the SSA did not provide a rationale for its decision. LINA made its determination independently, reviewing medical information generated post-SSA award.

The administrative record includes evaluations from Dr. Kinsora, who assessed Brown's cognitive functioning in 2011, and Dr. Morgan, who agreed with Dr. Kinsora’s findings. Dr. Kinsora acknowledged Brown’s subjective complaints regarding fatigue and light sensitivity but concluded that her cognitive performance did not pose significant barriers to employment or vocational retraining. Dr. Flippen’s review corroborated Dr. Kinsora’s assessment, noting some cognitive limitations but ultimately stating they would not impede Brown's ability to work or pursue vocational training.

Dr. Kinsora did not suggest that Brown required vocational retraining to engage in occupational activities, stating her limitations were not substantial enough to hinder her in that regard. Dr. Morgan, while agreeing with Kinsora's evaluation, expressed that Brown could retain employment with necessary accommodations, yet he failed to specify her limitations, the required accommodations, or potential career paths.

Dr. Morgan opines that Brown cannot return to work without retraining but fails to specify how he reached this conclusion or to identify any occupations where Brown could work without such retraining. Dr. Kinsora rated Brown’s Global Assessment of Functioning (GAF) score at 50, indicating serious limitations in social or occupational functioning, while Dr. Morgan assigned a score of 60. Dr. Flippen supports the appropriateness of a GAF score of 50 for someone functioning at a higher level despite serious limitations, emphasizing that GAF scores reflect a clinician’s judgment on overall functioning.

Dr. Kinsora observed that Brown has developed a belief system about her cognitive skills that does not align with her actual test performance, and noted her tendencies to avoid confronting her work challenges through excessive sleep. He identified various psychiatric issues contributing to her lack of self-confidence. Engel’s Transferable Skills Analysis outlines six occupations Brown could potentially perform based on her skills, although it lacks explicit justification for how these roles accommodate her limitations. The Analysis indicates that Brown's ability to perform these jobs may be constrained by significant fatigue, stress management issues, and limited interpersonal interactions, yet it does not fully support the conclusion that she could earn a substantial income under these conditions.

Dr. Kinsora highlighted Brown's functional barriers related to repetitive tasks, stress, and social interactions, as well as additional factors such as fatigue, depression, anxiety, and light sensitivity that affect her performance. He underscored the necessity for accommodations, such as breaks and support for stamina, to enhance her work capacity. Although Brown's skills for meeting performance standards appear intact, they are contingent upon appropriate accommodations for her limitations. Overall, Dr. Kinsora's assessment suggests that Brown's ability to function effectively in a work environment is highly dependent on these accommodations.

Brown retains the ability to direct, control, and plan her work, but Dr. Kinsora acknowledged limitations affecting her effectiveness. While Brown can meet some job demands, she requires accommodations for light sensitivity, eye strain, and fatigue. Engel’s Analysis identifies the reservations manager position as suitable for Brown, assigning it a 100% earning value; however, Brown contested this in her appeal, emphasizing her inability to perform under high-pressure conditions required for the role. Engel's credibility is questioned due to this disconnect. LINA's reliance on the Transferable Skills Analysis in denying Brown's disability claim is criticized, as their denial letter offers minimal engagement with Brown's concerns and fails to substantiate Engel's conclusions regarding her capacity to earn at least 60% of her indexed earnings in any suitable occupation. The court asserts that simply being able to work in any occupation does not equate to meeting the criteria for disability under the plan, particularly when considering necessary accommodations. The court concludes that the administrative record does not support a finding of Brown's disability as defined by the plan. Consequently, the court denies the defendant's motion for judgment and grants the plaintiff's motion, ordering the plaintiff to propose a judgment within seven days, with provisions for the defendant to object and the plaintiff to reply.