Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ared-5_04-cv-00047/USCOURTS-ared-5_04-cv-00047-2/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

EASTERN DISTRICT OF ARKANSAS

PINE BLUFF DIVISION

JOE D. RATLIFF PLAINTIFF

vs. CASE NO. 5:04CV00047GH

GUARANTEE LIFE INSURANCE

COMPANY DEFENDANT

ORDER

Plaintiff filed this action pursuant to the provisions of the Employee Retirement

Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001 et seq. seeking partial disability

benefits under an employee welfare plan sponsored by his former employer, BKD, LLP

(BKD). BKD provides disability benefits to eligible employees under a group disability

policy issued to BKD, LLP, Policy Number GL000010032202 (Plan). The Plan is insured

by Jefferson Pilot; BKD is the Plan Administrator; and Jefferson Pilot is the Claims

Administrator.

Plaintiff was a partner in the accounting firm of BKD. On January 16, 2003, he

submitted a claim for long term disability benefits (LTD). He listed as his physicians J.

Wm. Nuckolls, M.D., and David C. Hicks, M.C. He stated that he suffered from chest pain

and had first been diagnosed with his condition in 1990. Plaintiff further stated that his

company required him to work 2700 hours per year, and that his physician advised him to

work no more than 40 hours per work. At the time of the application, plaintiff was still

working as an accountant. Plaintiff was terminated by BKD on May 31, 2003 because he

voluntarily reduced his hours. 

Plan participants are entitled to Partial Disability benefits when, according to the

Plan, the employee is unable to perform one or more of the material substantial duties of

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an employee’s regular occupation, or unable to perform such duties full-time; and is

engaged in Partial Disability Employment. Full-time means the average number of hours

the employee was regularly scheduled to work at his regular occupation. Partial Disability

Employment means the employee is working at his occupation but because of a partial

disability, the employee’s hours or production are reduced; one or more main duties of the

job are reassigned; or the employee is working at a lower paid occupation. Partial

Disability Monthly Benefits will be paid after the elimination period if the employee is (1)

disabled; (2) engaged in partial disability employment; (3) earning at least 20 percent of

predisability income when partial disability employment begins; (4) under the regular care

of a physician; and (5) submits proof of continued partial disability, physician’s care and

reduced earning to the insurer upon request.

There are few medical records in support of plaintiff’s claim for disability benefits.

Dr. Nuckolls completed a physician’s statement dated January 3, 2003. He noted that

plaintiff suffered from coronary artery disease, but stated that there is nothing that plaintiff

should not do, although he needed to diet and exercise to reduce his stress. Because of

this, Dr. Nuckolls recommended that plaintiff decrease his work hours to forty a week so

that he could reduce his stress and take care of himself. On January 6, 2003 Dr. Nuckolls

wrote to defendant to further explain his January 3rd rating. 

This is a rather unusual situation in that Mr. Ratliff is not disabled. I wrote

a letter on September 10, 2002, which was address to “To Whom It May

Concerned” [sic] that , due to health reasons, he should restrict his activity

to forty hours a week. As is documented in the copies of various medical

records of his, Mr. Ratlitff has had coronary bypass procedure and has

multiple risk factors including exogenous obesity, hypertension, coronary

artery disease, diabetes mellitus, and hyperlipidemia. . . . 

His work schedule as a CPA apparently involves a lot of stress and long

hours. This stress is not good for him and the long hours apparently keep

him from leading an appropriate lifestyle, such as exercise. I feel that if he

were limited to forty hours a week, he would be able to better take care of

himself, exercise, check his sugars, pay more attention to his diet, and have

less stress. If he did work only forty hours a week and took advantage of the

time off to do the above and corrected his obesity, then I think his chance for

another coronary event would be greatly reduced. If he continues his

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current work schedule and lifestyle, then I think it is likely that he will have

another coronary event in the near future, i.e., within the next several years.

Dr. Nuckolls also stated that Dr. Hicks, plaintiff’s cardiologist, had not placed any

limitations on plaintiff. 

Plaintiff also submitted medical records from his cardiologist, David C. Hicks. Dr.

Hicks noted that plaintiff had an inferior infarction in 1990 and angioplasty of his coronary

artery at that time. He developed unstable angina and had emergency coronary artery

bypass grafting times three in March 2001. In an Office Visit report dated August 5, 2002,

Dr. Hicks found plaintiff to be stable, and instructed plaintiff not to return for an office visit

for another six months.

Defendant denied plaintiff’s claim for LTD benefits on April 25, 2003. Defendant

noted that the information obtained from Dr. Nuckolls did not evidence a disability or

conditions which prevent plaintiff from performing each of the main duties of his

occupation.

Plaintiff appealed defendant’s decision on May 9, 2003, but did not submit any new

or additional information. He argued that because he had decreased his working hours

to 40 per week, he was engaged in Partial Disability Employment and entitled to Partial

Disability benefits. Defendant, on June 23, 2003, denied plaintiff’s claim for partial

Disability benefits, finding that plaintiff failed to establish that his medical condition was

disabling at the time he reduced his hours, i.e., that there was no proof that plaintiff is

currently partially or totally disabled due to his coronary condition, or that his condition

currently restricts him from performing the duties of his occupation on a full time basis.

Plaintiff again appealed defendant’s decision, submitting a letter from Dr. Nuckolls

dated October 15, 2003. In his letter, Dr. Nuckolls states: 

As I understand it, Mr. Ratliff is required to work 3,000 hours per year as a

partner at BK&D. A person working 40 hours a week for 52 weeks would

work 2,080 hours. Mr. Ratliff’s health problems include two stents for

coronary artery blockage. He has a number of risk factors, which if not

controlled would statistically increase his change of having another coronary

event which could be lethal. Those risk factors include exogenous obesity,

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hypertension, diabetes mellitus, hyperlipidemia and stress.

If he continues to work 3,000 hours per year this will certainly increase his

level of stress over a person who works one-third that much, i.e. 40 hours per

week. If he were to work 40 hours per week, he would have more time for

dealing with his other risk factors. I think he would be able to watch his diet

better as he would have time to plan a healthy diet instead of eating junk food

“on the go.” He would also have time for the appropriate amount of exercise

that he should get and would be able to check his blood sugars as they need

to be checked and hopefully bring this under control.

The gist of this is that if he continues to work 3,000 hours per year, I am

concerned that he would not be able to modify his risk factors as they should

be modified. If he were to work a 40 hour week and if he were to take

advantage of this time to modify his risk factors he should statistically

improve his chances for longevity.

On December 18, 2003, defendant denied plaintiff’s appeal. Defendant found that

the medical evidence did not support a finding of totally or partially disabled under the terms

of the Plan. Defendant noted that the medical records did not show that plaintiff was

under the regular care of a physician as required by the Plan.

Where a plan gives the administrator “discretionary authority to determine eligibility

for benefits,” the Court reviews the administrator’s decision for an abuse of discretion.

Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). Here, the plan provides

defendant with discretionary authority to determine eligibility for benefits. 

Under the abuse of discretion standard, the administrator’s decision will be upheld

if it is reasonable, that is supported by substantial evidence. Fletcher-Merit v. Noram

Energy Corp., 250 F. 3d 1174, 1179 (8th Cir. 2001). “While the administrator’s decision

need not be supported by a preponderance of the evidence, there must be ‘more than a

scintilla.’” House v. Paul Revere Life Ins. Co., 241 F.3d 1045, 1048 (8th Cir. 2001) (citation

omitted). Thus, the Court may only overturn the administrator’s decision if it is found to

be arbitrary and capricious, that is, unreasonable or unsupported by substantial evidence

in the record. 

The Court cannot find that the decision is unreasonable or arbitrary and capricious.

The record does not support that plaintiff suffers from a disability but will only suffer the

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possibility of another coronary event if he continues his current lifestyle. A person is not

disabled based on what might happen in the future. 

Plaintiff suffered from coronary artery disease since 1990 and continued until June

1, 2003, to work at his job as an accountant. There was no medical event that triggered

plaintiff’s application for LTD benefits; rather plaintiff was responding to his physician’s

advise to reduce his stress and other factors that put plaintiff at risk of another heart attack.

Plaintiff voluntarily reduced his hours which caused his employer to terminate his position.

Plaintiff’s actions does not amount to a finding that he is partially disabled under the plan.

Rather, plaintiff reduced his hours to change to a healthier lifestyle

Plaintiff further argues that defendant’s action is discriminatory in that a female

partner received partial disability benefits. Section 510 of ERISA, 29 U.S.C. § 1140,

provides protection from discrimination “that interferes ‘with the attainment of any right to

which such participant may become entitled under the plan.’” Jefferson v. Vickers, Inc., 102

F. 3d 960, 964 (8th Cir. 1996). Discrimination claims under ERISA are analyzed under the

burden-shirting analysis set forth in McDonnell Douglas Corp. v. Green, 411 U.S. 792, 802-

05 (1973). See Id. Plaintiff has not provided any case law to support that he can state a

discrimination claim for denial of benefits against the insurer. As defendant is not plaintiff’s

employer, defendant took no adverse employment action against him. Furthermore, that

defendant granted benefits to one covered employee but not another does not establish

discrimination. Defendant has the discretion to determine who is eligible for benefits, and

determinations are made on an individualized basis. Because each person’s medical

record is unique, plaintiff cannot establish that he is similarly situated to the female

employee. 

In sum, the Court finds that the Administrator’s decision is supported by substantial

evidence and that plaintiff is not entitled to disability benefits under the Plan.

Accordingly, the complaint is hereby dismissed with prejudice.

IT IS SO ORDERED this 24th day of April, 2006 .

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 ___________________________________ UNITED STATES DISTRICT JUDGE

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