Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-2_05-cv-02041/USCOURTS-arwd-2_05-cv-02041-0/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 29:1001 E.R.I.S.A.: Employee Retirement

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IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

FORT SMITH DIVISION

JANET L. STRUNK PLAINTIFF

v. Civil No. 05-2041

UNUM LIFE INSURANCE

COMPANY OF AMERICA DEFENDANT

O R D E R

Now on this 6th day of November, 2006, the captioned matter

comes on for review, and from the Administrative Record, and the

briefs of the parties, the Court finds and orders as follows:

1. Plaintiff Janet L. Strunk (“Strunk”) is a participant in

a short term disability plan (the “Plan”) provided by her

employer, Healthsouth Corporation, and insured under a group

insurance policy (the “Policy”) by Unum Life Insurance Company of

America (“Unum”). Strunk was found eligible for benefits under

the Plan, but later terminated, and now appeals the termination

decision.

2. The Plan is governed by the provisions of the Employee

Retirement Income Security Act (“ERISA”). Denial of ERISA

benefits is “reviewed on a de novo standard unless the benefit

plan gives the administrator or fiduciary discretionary authority

to determine eligibility for benefits or to construe the terms of

the plan.” Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101,

115 (1989). If the administrator has discretionary authority, its

eligibility decisions are reviewed for abuse of that discretion.

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Groves v. Metropolitan Life Insurance Co., 438 F.3d 872 (8th Cir.

2006).

The Plan here provides that “[w]hen making a benefit

determination under the policy, Unum has discretionary authority

to determine your eligibility for benefits and to interpret the

terms and provisions of the policy.” The Court will, therefore,

review Hartford’s benefits decisions for abuse of discretion. 

3. The abuse of discretion standard has been described as

follows:

In applying an abuse of discretion standard, we must

affirm if a reasonable person could have reached a

similar decision, given the evidence before him, not

that a reasonable person would have reached that

decision. A reasonable decision is fact based and

supported by substantial evidence. We may consider both

the quantity and quality of evidence before a plan

administrator. And we should be hesitant to interfere

with the administration of an ERISA plan.

Groves, 438 F.3d 872, 875 (internal citations and quotation marks

omitted).

“Substantial evidence” is “more than a scintilla but less

than a preponderance.” Leonard v. Southwestern Bell Corp.

Disability Income Plan, 341 F.3d 696, 701 (8th Cir. 2003).

Although abuse of discretion review puts a heavy burden on a

participant whose benefits have been terminated, it does not

amount to “rubber-stamping the result.” A termination decision

must be reasonable, i.e., “supported by substantial evidence that

is assessed by its quantity and quality.” Torres v. UNUM Life

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Insurance Co. of America, 405 F.3d 670, 680 (8th Cir. 2005). 

4. With the foregoing principles in mind, the Court has

examined the Administrative record, from which it has derived the

following relevant facts:

* The Policy provides, in relevant part, that a

participant is disabled “when Unum determines that: you

are limited from performing the material and substantial

duties of your regular occupation due to your sickness

or injury. . . .”

* The Policy further provides that a claim ends on the

occurrence of any one of several defined events. For

our purposes, the relevant event is “the date you are no

longer disabled under the terms of the plan. . . .”

* On June 24, 2003, Strunk, a Medical Records Supervisor

at Healthsouth, submitted a claim under the Plan to

Unum. The diagnosis supporting her claim was

“cervicalgia,” or neck pain. Strunk sought benefits

starting June 11, 2003, having gone off work on June 10,

2003. 

* Starting in late June, 2003, Strunk tried physical

therapy as a treatment for her neck pain. This was not

helpful, and Dana Rabideau, M.D., Strunk’s physician,

referred Strunk to an neurosurgeon.

* An entry in Unum’s Activity Log dated June 26 and 27,

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2003, indicated that Kathy Cook in Human Resources,

presumably at Healthsouth, was contacted by Unum and

informed Unum that light duty was not available in

Strunk’s position. The entry also noted that “[p]er

account database,” Healthsouth “does not accommodate.”

* On July 1, 2003, Unum wrote Strunk and informed her that

her claim for short term disability benefits had been

approved from June 25, 2003, through July 7, 2003. The

letter advised Strunk that if she could not return to

work on July 8, 2003, she would be required to have her

attending physician provide medical records, a list of

activities she could not perform and an explanation for

the restrictions, and a copy of her treatment and return

to work plans. The letter instructed Strunk to “[m]ake

this letter available to your physician(s) and request

that your physician(s) mail or fax this information to

us,” and cautioned that “[a] note from your physician

saying you cannot return to work will not be acceptable

without the supporting medical data listed above.”

* On July 17, 2003, Strunk saw Anthony Capocelli, M.D., a

neurosurgeon. Dr. Capocelli diagnosed a disc herniation

at C6-7, and recommended an anterior cervical discectomy

and fusion.

* On August 4, 2003, Dr. Capocelli performed the

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recommended procedure.

* On September 16, 2003, Strunk returned for her first

post-operative visit. Dr. Capocelli noted that the

surgical wound was well-healed, and that Strunk was

“just having some relatively mild stiffness in the neck

and occasional pain effected by turning in certain

positions which I would expect is fairly normal at this

time.” He planned on follow-ups as needed, and

released Strunk to return to work for four hours a day

as of September 29, 2003, for a period of two weeks,

after which he indicated that he would allow her to

“progress to full time hours.”

* On September 30, 2003, Dr. Capocelli’s nurse made a note

in Strunk’s chart, stating that Strunk “came into office

- states is unable to work 4 hours due to work requires

8 hours [with no] restrictions - given note for off work

until 10/13/03 & then return @ 8 hrs.”

* On October 1, 2003, Unum notified Strunk that her short

term benefits had been approved through October 12,

2003, noting that it was Unum’s understanding that

Strunk would be returning to work on October 13, 2003.

* On October 6, 2003, Strunk called Unum and told the

claims examiner that she had been terminated by her

employer.

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* On December 3, 2003, Unum called Healthsouth and spoke

to an employee there who confirmed that Strunk had not

returned to work, and that she did not have any details

about why, but that “she had an LTD [long term

disability] form on her desk to fill out and send to us

‘when she gets around to it’.”

* On December 23, 2003, Strunk was examined by Dr.

Capocelli, who noted that she had returned to work for

a few days “and was having pain and difficulties and

apparently was fired from her job. She was unable

really to do the job with some significant symptoms

after only 1-2 hours and it was our thought at that time

that we went ahead and took her off of work.

Subsequently to that, she has not been able to come to

see us until now and is unable to work during that time

period.” As for her current condition, Dr. Capocelli

noted that Strunk “continues to have ongoing radicular

pain though improved,” that she had “spasms in the

trapezius,” and that “[n]eurologically, she is intact,

but does have clear cut radicular symptomatology better

than previous but certainly present.” Dr. Capocelli

ordered an MRI and cervical spine x-rays, and stated

that in the interim, “I believe at this point that she

is disabled and unable to work.”

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* Also on December 23, 2003, Unum notified Strunk that it

had reviewed her short term disability claim, and that

“[b]ased on the information in our file, there is no

disability supported by medical documentation.” Unum

stated that benefits would not be paid beyond October

12, 2003, and the claim would be closed.

* On December 30, 2003, Strunk underwent an MRI and x-rays

of her cervical spine. The MRI was reported as “#1

Anterior screw and side-plate device at C6-7 without

complication. #2 Small central to left-sided focal disk

protrusion at C2-3 and a small central disk bulge at C3-

4. Neither of these results in a significant canal

stenosis.” The x-rays were reported as “[p]ostsurgical

findings of C6 to C7 as described. Degenerative

spurring apparent in the mid cervical area. Some

anterior ligamentous ossification also incidentally

noted at C3-4 and C4-5. No acute change from prior

study 08/04/03.”

* On January 19, 2004, Strunk’s attorney lodged an appeal

on her behalf with Unum. In his letter he noted that

Strunk had “attempted to return to work as directed,”

but that “[p]rior to transitioning from part-time to

full-time work on a trial basis as recommended by her

treating neurosurgeon, HealthSouth released the Claimant

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from work on or about 10/1/03. Stated grounds were that

Claimant was occupying a full-time job and therefore was

expected to do full-time work, but was unable to do so.”

The letter further stated that it was “Claimant’s

position that she is totally disabled and unable to work

as of 12/23/03.”

* On February 12, 2004, in response to a question from

Unum, a Healthsouth employee stated that Strunk

“returned to work for 10 hrs during payperiod 09/21 -

10/04/03. Her term date was on 10/03/03 - it was a

voluntary quit.”

* On March 2, 2004, Dr. Capocelli examined Strunk, stating

that “according to her studies [she] remains stable but

she is continuing to have residual difficulties. At this

point, I do not believe she is ever going to be able to

return to her premorbid work duty and at this point she

is disabled. Though she has had some improvement to the

point that she can at least be moderately function [sic]

with her activities of daily living, there is no way

that she can return to her premorbid work duty. This is

also compounded by multiple other medical problems in

addition to her underlying spine disease all of which

culminate in her inability to return to her premorbid

work. At this point, we will just followup with her

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p.r.n. [as needed].”

* On March 22, 2004, Richard Tyler, M.D., an orthopedic

surgeon, reviewed Strunk’s file for Unum. It was Dr.

Tyler’s opinion that the “[r]ecord does not provide any

explanation for failure to seek medical attention during

hiatus of more than three months,” from September 16

until December 23, 2003, and that the examination on

December 23 was “unremarkable.” Dr. Tyler’s opinion was

that Strunk’s continuing neck and right upper extremity

pain would support limitations on “repetitious

rotational or flexion/extension mobilization of the

neck,” but would not support an inability to “carry out

activities while sedentary.” Dr. Tyler also stated that

the additional tests ordered by Dr. Capocelli in

December, 2003, would provide a better understanding of

Strunk’s clinical status. 

* Also on March 22, 2003, Unum notified Strunk that it had

completed appellate review of her claim and had

determined that the decision to deny benefits was

appropriate. It based this decision on the unexplained

lack of medical treatment between September 16, 2003,

and December 23, 2003, “for symptoms [Strunk] claims are

disabling,” and the lack of support for restrictions or

limitations during the time Strunk was released to work.

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It also noted “the claim that her employment was

terminated because of her inability to perform the job

duties on a full time basis appears unfounded.”

* On April 13, 2004, Dr. Capocelli signed a “To Whom It

May Concern” note stating that “Strunk was seen in our

clinic on 12-23-03 which was the earliest possible

appointment that we could see her after she called us on

09-30-03 regarding her work status. We did try to get

her in sooner than that, but unfortunately due to

scheduling problems were unable to see her until 12-23-

03 and hence, the delay in making final recommendations

regarding her work, etc.”

* Also on April 13, 2004, Strunk’s attorney wrote Unum,

enclosing various medical reports. The attorney stated,

with regard to Strunk’s termination at Healthsouth:

“The claimant attempted to return to work on 9/29/03 as

instructed in the doctor’s note attached above. She

worked for 4 hours the first day, 4 hours the second

day, and 2 hours the next day for a total of 10 hurs.

She was instructed that if she could not do a full time

job she would be placed on personal leave and that at

the end of any personal leave there would not be a

position available to her and she would not be returned

to work. This is not a voluntary quit, but an

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involuntary termination, contrary to the doctor’s

orders. It is obvious that the claimant was terminated

because she could not perform the ‘material and

substantial duties’ of her job even with modifications

and omissions.”

* On May 10, 2004, Unum notified Strunk that it had again

upheld the denial of benefits. The letter explained

that the additional medical documentation supplied by

Strunk did not “document any acute or significant

changes from the prior studies done on August 4, 2003,

and that while Dr. Capocelli “reference[d] multiple

medical problems, . . . he does not provide any

description on how these medical problems affect Ms.

Strunk’s ability to perform the duties of her

occupation.” It further noted “there still exists a

substantial period of time in which there are no medical

records, physical exams, or testing to support a lack of

functional ability,” and that the medical records “still

do[] not explain why Ms. Strunk did not return to work

full time as instructed by Dr. Capocelli.” The letter

also stated Unum’s perception that Healthsouth had

offered to allow Strunk to continue her personal leave.

* On May 28, 2004, Dr. Capocelli signed a “To Whom It May

Concern” note stating that “we did attempt to return

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this patient to full work, but throughout this time

period, the patient was unable to tolerate the work

secondary to low back pain and difficulty relating to

her injury. The result was that she was taken off work.

Though the studies did not show any definitive changes,

the underlying nerve injury from the original herniation

has left the patient functionally unable to perform her

premorbid work activity.”

5. When the foregoing history of this claim is viewed as a

whole, the Court finds substantial evidence supporting Unum’s

conclusion that Strunk’s benefits should be terminated as of

October 12, 2003. Certainly it cannot be said that no reasonable

person could have reached the decision reached by Unum in this

case. 

Under the terms of the Policy, it is a basis for termination

of benefits that a participant is no longer disabled under the

terms of the plan,” i.e., that she is no longer “limited from

performing the material and substantial duties” of her regular

occupation due to her sickness. There is substantial evidence

that Strunk had reached this point by October 12, 2003. Strunk

had a good outcome from her fusion, and was experiencing only

normal pain and stiffness five weeks after surgery. She was in

good enough shape that Dr. Capocelli released her to return to

work as of September 29, 2003, with no limitation other than that

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she ease back into full-time work with a two-week period of parttime work. The release was later altered to allow her to simply

return to work full-time as of October 13, 2003, with no

limitations on time or function.

In spite of the second release to work, it appears that

Strunk tried to return to work part-time at the earlier date, and

that Healthsouth, unwilling to allow part-time work, terminated

Strunk before she reached the date when she had been released to

work full-time. The evidence does not, however, support a

conclusion that Strunk tried to work and was unable to perform the

essential duties of her job. The chart entry of Dr. Capocelli’s

nurse on September 30, 2003, was to the effect that Strunk could

not work four hours because her job required her to work eight

hours. Strunk’s attorney explained the termination as being based

on Strunk’s not being able to work a full eight hours immediately

upon her return to work.

 As for Strunk’s physical condition, Dr. Capocelli placed no

restrictions on her return to work except easing into it by

working four hours a day at first, and on September 30, 2003,

after being told that Healthsouth would not permit that, he

allowed her to wait until October 13, 2003, and then return to

work full-time with no restrictions. In December, Dr. Capocelli

noted that Strunk continued to have radicular pain, but that she

was “improved,” and that even with trapezius spasms she was

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“better than previous.” The MRI and x-rays taken on December 30,

2003, were unremarkable. Dr. Capocelli’s opinion in March was

that Strunk “remains stable,” albeit with “residual difficulties.”

While Dr. Capocelli stated that Strunk was disabled, until the

final “To Whom It May Concern” note, he gave no explanation for

why he held this opinion, and his medical records offer nothing to

justify it. The May 28, 2004, note, while it offers “underlying

nerve injury” as a basis for a finding of disability, is not

supported by any nerve studies, nor is it particularly credible in

light of Dr. Capocelli’s position on Strunk’s work ability in

September.

Dr. Tyler, reviewing Dr. Capocelli’s records and the

radiologic studies, pointed out the unexplained three-month gap in

treatment from September 16, 2003, to December 23, 2003, and the

unremarkable physical findings in December. While Strunk and Dr.

Capocelli suggest that scheduling problems explain the gap, Unum

was certainly justified in finding such an explanation less than

credible on the part of both patient and physician, given their

position that in the wake of a serious operation the patient was

deteriorating from “return to work” status to “disabled.”

Dr. Tyler felt that Strunk would need certain accommodations

in her job, but that she was capable of carrying out sedentary

work. Healthsouth’s reluctance to offer those accommodations does

not merit a finding of disability for purposes of the Plan,

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although it may well be a legitimate subject of litigation for

other reasons.

For all these reasons, the Court finds that the decision of

Unum was supported by substantial evidence, and should be

affirmed.

IT IS THEREFORE ORDERED that the decision of Unum Life

Insurance Company of America to terminate the short term

disability benefits of Janet L. Strunk is affirmed.

IT IS SO ORDERED.

 /s/ Jimm Larry Hendren 

JIMM LARRY HENDREN

UNITED STATES DISTRICT JUDGE

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