Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alnd-7_02-cv-00889/USCOURTS-alnd-7_02-cv-00889-0/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 29:1132 E.R.I.S.A.-Employee Benefits

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IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF ALABAMA

WESTERN DIVISION 

DIANN DUNN, )

Plaintiff, )

 )

vs. ) Civil Action Number

 ) 7:02-cv-0889-UWC

PROVIDENT LIFE & ACCIDENT )

INSURANCE COMPANY, )

 )

Defendant. )

FINDINGS OF FACT 

 AND 

CONCLUSIONS OF LAW

In this case arising under the Employee Retirement Income Security Act, 29 U.S.C.

§ 1001, et seq. (“ERISA”), Plaintiff Diann Dunn claims that Defendant Provident Life &

Accident Insurance Company (“Provident”) unlawfully denied her claim for long-term

disability benefits (“LTDB”). Based on the parties’ evidentiary submissions and the

Statement of Agreed and Disputed Facts, (R., Doc. 23), the Court makes the following

Findings of Fact and Conclusions of Law.

 FINDINGS OF FACT

1. On October 7, 1996, Plaintiff worked for Mercedes-Benz U.S. International, Inc.,

(“Mercedes-Benz”) at its vehicle manufacturing facility in Vance, Alabama. Plaintiff was

assigned to the Paint Shop. 

FILED

 2005 Mar-30 PM 04:21

U.S. DISTRICT COURT

N.D. OF ALABAMA

Case 7:02-cv-00889-UWC Document 28 Filed 03/30/05 Page 1 of 8
2. At all material times, Mercedes-Benz paid premiums to Provident for sickness and

disability insurance covering its employees, including Plaintiff. Provident pays the claims

from its own funds. The denial of a claim therefore inures to Provident’s financial benefit.

3. Under the terms of the Provident policy:

You are disabled if due to your sickness or injury you meet 

the following definition of disability:

Own Occupation Disability Definition. During the own 

occupation period, you are disabled from your own occupation 

if due to sickness or injury you:

(1) are unable to earn at least the Own Occupation Income 

Level; or

(2) are unable to perform each of the material duties 

of the occupation that you regularly perform for the

employer . . ..

Any Occupation Disability Definition. During the Any Occupation period, you are disabled from any occupation if due to sickness or injury you:

(1) are unable to earn at least the Any Occupation Income 

level while working in any occupation; or are unable to 

perform each of the material duties of any occupation for 

which you are reasonably fitted by education, training, 

or experience. 

 . . .

There is a benefit offset for, among other things, Social Security 

total disability payments.

(R., Doc. 25, Pl.’s Evidentiary Submissions at pp. 886, 889.)

4. The maximum period for “own occupation” disability benefits (“OODB”)

under the Provident insurance policy is two years.

5. If Plaintiff remains totally disabled at the expiration of the OODB period, her

Case 7:02-cv-00889-UWC Document 28 Filed 03/30/05 Page 2 of 8
1

 Plaintiff had undergone back surgery in February 1996– a microdiskectomy at left LSS1.

benefits would continue until she reaches the age of sixty-five (65) while so disabled. 

6. On November 21, 1997, while lifting and bending at work, Plaintiff sustained

an injury to her back.1 Nearly three months later, she underwent a L4-5 diskectomy. Her

claim for worker’s compensation benefits was denied based on a finding that her back

problem was not work-related.

7. In February 1998, Plaintiff had back surgery again. Plaintiff’s doctor released

Plaintiff to return to “light duty” work on April 27, 1998. Provident paid Plaintiff short

term disability benefits (“STDB”) during the period of this illness. 

8. Plaintiff returned to “light duty” work in May, 1998, and she worked

approximately three weeks until May 30, 1998. Plaintiff has been unable to work, and

has not worked, since that time.

9. On July 20, 1998, Plaintiff’s treating physician, Dr. Rick L. McKenzie of West

Alabama Neurological Spine Consultants, Inc., opined that Plaintiff’s disability was

permanent and recommended medical retirement.

10. At all material times, Plaintiff has been willing to work. For example, in

November 1998, Plaintiff indicated to a Provident representative that she was willing to

try working at a light or sedentary job; but she would not remain in one position for long

periods of time and had to alternate between sitting and standing.

11. On November 18, 1998, Provident approved Plaintiff for two years of

Case 7:02-cv-00889-UWC Document 28 Filed 03/30/05 Page 3 of 8
2

 Arachnoiditis is the inflammation of the fibrous membrane surrounding the spinal cord. 

The arachnoid membrane forms the middle of three coverings of the central nervous system. 

See PDR MEDICAL DICTIONARY 121 (Marjory Spraycar ed., Medical Economics 1995).

OODB. 

12. Plaintiff subsequently applied to Provident for “any occupation” disability

benefits (“AODB”), claiming that she was totally disabled for work in any occupation. 

13. Plaintiff’s condition has not improved since November 18, 1998.

14. Dr. John Brockington, a neurologist in Tuscaloosa, became her treating

physician in 1999. 

15. Based on an MRI of her spine, Dr. Brockington opined that Plaintiff suffers

from mild degeneration, scarring from surgery, and lumbar arachnoiditis.2

 He opined

that Plaintiff is severely impaired and unable to work. In his view, Plaintiff’s problem is

not a condition producing severe, intractable pain.

16. In July 2001, Dr. Brockington wrote to Provident:

[Plaintiff] is a patient of mine, who I have been treating for chronic

low back pain due to lumbosacral arachnoiditis. This condition 

produces significant chronic pain, loss of range of motion, and has

resulted in her inability to perform any job on a consistent regular 

basis. She is on numerous medications, but has persistent symptoms 

despite this . . ..

(R., Doc. 16. at Ex. 37.)

17. Provident investigated Plaintiff’s claim for AODB to support its foregone

conclusion to deny the claim. When it was reported that Plaintiff had been seen

coaching her daughter’s softball team “without any noticeable pain or discomfort,”

Case 7:02-cv-00889-UWC Document 28 Filed 03/30/05 Page 4 of 8
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 Specifically, he recommended 1) updated medicals, 2) additional surveillance, 

3) clinical review, 4) vocational referral for a transferrable skills analysis (“TSA”), 5) advance

pay to Plaintiff through the end of the OODB period, and 6) closing the case.

Provident hired video surveillance investigators on three separate occasions to confirm

the report, and, more generally, to confirm that Plaintiff’s daily activities were

inconsistent with her claim of long term disability. These investigations failed to

confirm either that Plaintiff had recently coached her daughter’s softball team, or that

Plaintiff’s daily activities were inconsistent with her claim of permanent disability.

18. Early on in the investigative process, on June 15, 2000, Provident’s case

handler, Jonathan Etchison, recommended that the claim be processed superficially and

that at the end of his recommended stages,3

 the file be closed and the claim denied.

19. Provident ostensibly relied on the opinions of three physicians to deny

Plaintiff’s claim: Dr. George Seiter, Dr. John M. Bolinger, and Dr. Burton McDaniel. 

Dr. Seiter, an orthopedist, could not dispute the treating physician’s diagnosis of

arachnoiditis. Dr. Bolinger, a psychiatrist, was of the opinion that “[Plaintiff’s]

symptoms of depression in and of themselves are not disabling, but it is the discomfort

and pain experienced as a result of her degenerative joint disease and lumbar

arachnoiditis that are the primary difficulties prohibiting the [Plaintiff] from returning to

work.” (R., Doc. 25, Pl.’s Evidentiary Submissions at Ex. 1, p. 498.) Dr. Burton

concluded that Plaintiff’s “primary impairment appears to be psychological.” (Id. at p. 

505.)

20. The consultative opinions of Drs. Seiter, Bolinger, and McDaniel, singly and

Case 7:02-cv-00889-UWC Document 28 Filed 03/30/05 Page 5 of 8
in combination, are an insufficient basis on which to deny Plaintiff’s AODB claim.

21. In August 2000, the Social Security Administration approved Plaintiff for

Social Security Benefits. 

22. On January 1, 2001, Provident notified Plaintiff it denied her application for

AODB. Plaintiff pursued an administrative appeal of the denial. Provident denied the

appeal for a final time on January 3, 2002.

23. Provident’s denial of Plaintiff’s claim for AODB was arbitrary and

capricious.

24. Plaintiff is entitled to monthly AODB of $2,078.00, less an offset for Social

Security disability benefits in the approximate amount of $720.00

CONCLUSIONS OF LAW

1. This court has jurisdiction of this action.

2. The heightened arbitrary and capricious standard of review is applicable. Levison

v. Reliance Standard Life Ins. Co., 245 F.3d 1321 (11th Cir. 2001); Buckley v. Metro. Life,

115 F.3d 936, 939 (11th Cir. 1997); Maracek v. BellSouth Telecomm. Inc., 49 F.3d 702

(11th Cir. 1995).

3. It was arbitrary and capricious for Provident to accord little deference to the

opinions of Plaintiff’s treating physician, while according total deference to consultative

physicians who never examined Plaintiff and whose opinions were questionable and

inconsistent with each other.

The failure of Provident to consider the Social Security Administration’s

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determination that Plaintiff is totally disabled in determining whether she is entitled to “any

occupation” disability benefits is arbitrary and capricious, especially where, as here, it

utilized that determination in offsetting Plaintiff’s indubitable entitlement to “Own

Occupation” disability benefits. Kirwan v. Marriott Corp., 10 F.3d 784, 789 n.32 (11th Cir.

1994).

CONCLUSION

By separate order, judgment will be entered in favor of Plaintiff and against

Provident.

Done this 30th day of March, 2005.

______________________________

 U.W. Clemon

 Chief United States District Judge

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