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Eastin v. Reliance Standard Life Ins. Co.

United States District Court, Sixth Circuit

August 23, 2013




This matter is before the Court on the parties' motions for judgment on the pleadings (Docs. 16, 17) and plaintiff's motion to strike (Doc. 21).

Having previously heard oral argument and taken these motions under submission, the Court now issues the following Memorandum Opinion and Order.

Factual and Procedural Background

A. Plaintiff's Managerial Duties Involved "Light" To "Sedentary" Work

In 1991, Plaintiff began working for the Castellini Company and became insured under its policy. She was first diagnosed with fibromyalgia in 1998, and with "trigeminal neuralgia" in 2002. She began missing a considerable number of work days in 2006 and 2007 due to "episodes" that occurred once or twice a year. By 2008, she was experiencing more than one episode a week. When she stopped working in late February 2008 and submitted a disability claim, she was employed as the "MIS Manager" and had held that position for about ten years. She was forty-six years old. Her managerial position encompassed the company's computer and information system functions across multiple locations. Plaintiff's duties included managing maintenance contracts, the programmers' projects and timelines, the network, security, and backup systems. See, e.g., Doc. 16-1 at 1, 4; Doc. 25 at 4; AR 149, 156, 168, 427, 678, 696-98, 703.

The record indicates that, at its most difficult, Plaintiff's managerial position could involve "light" work. "Light" work involves lifting up to twenty pounds at a time, and a significant amount of walking or standing. Other sources in the record indicate that Plaintiff's position generally involved "sedentary" work. "Sedentary" involves ten pounds at most and only occasional walking and standing. See AR 197 (footnotes).

For example, when Plaintiff applied for disability benefits in 2008, she indicated the job had "no physical requirements, but a lot of mental requirements, memory, decision making, quick thinking, etc., " that she was unable to perform. Id. at 703; see also id. at 156. The employer's portion of the disability claim, however, provided that the job involved "frequent" walking, which would make the job "light." See id. at 698. When Defendant denied her appeal in 2012, it applied Department of Transportation-type definitions, and classified the managerial position as a combination of "light" and "sedentary." See id. at 197. DOT-analogous jobs identified by a rehabilitation specialist indicated that performing computer-related work can require effort in the "light" range. See id. at 679-83.

B. The Terms Of The Policy

The policy pays benefits if four criteria are met. The insured must: (1) be "totally disabled" by a "sickness or injury" covered under the plan; (2) be "under the regular care of a physician;" (3) be past the "elimination period, " and (4) submit "satisfactory proof" of the disability. Id. at 18. "Sickness" means "illness or disease." Id. at 11.[1]

"Total disability" is defined by what the insured can or cannot do with respect to different jobs. The policy pays benefits for thirty-six months when the insured "cannot perform the material duties of his/her regular occupation." Id. Thereafter, the policy pays benefits when the insured "cannot perform the material duties of any occupation, " meaning an occupation "that the insured's education, training or experience will reasonably allow." Id. To be capable of performing "any occupation" requires that the insured perform every material duty of the position on a "full-time basis." Id.

Benefits terminate on the earliest of four events: the date the insured dies, "ceases to be totally disabled, " or "fails to furnish the required proof of total disability, " or the date the "maximum duration of benefits" expires, which for Plaintiff will be when she reaches her mid-sixties. Id. at 19; see also id. at 9. Benefit payments are offset when the insured receives benefits from other sources, such as the Social Security disability award Plaintiff received. See id. at 18, 583.

Benefits are limited when "mental or nervous disorders" are present, including "depressive disorders" or "somatoform disorders, " the latter meaning "psychosomatic illness." Id. at 22. When a "total disability" is "caused by or contributed to by mental or nervous disorders, " the policy will not pay benefits "beyond an aggregate lifetime maximum duration of twenty-four... months, " unless the insured is "in a hospital or institution at the end of the twenty-four... month period." Id.

C. Assessing & Diagnosing Fibromyalgia

When Plaintiff quit working in 2008, she complained that her "constant fatigue, widespread pain, [inability] to think clearly" was due to fibromyalgia, her "mouth/teeth pain" was due to "trigeminal neuralgia, " and these symptoms rendered her unable to work. Id. at 700, 703. Plaintiff's treating physician at the time, John B. Kelly, provided the "attending physician" portion of the 2008 claim form. See id. at 704-05. He indicated Plaintiff's primary diagnoses were fibromyalgia and trigeminal neuralgia. Id. at 704. He listed "depression" as a "secondary condition[] contributing to [her] disability." Id.

As defined by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NAIMS):[2]

Fibromyalgia syndrome is a common and chronic disorder characterized by widespread pain, diffuse tenderness, and a number of other symptoms....
Although fibromyalgia is often considered an arthritis-related condition, it is not truly a form of arthritis... because it does not cause inflammation or damage to the joints, muscles, or other tissues. Like arthritis, however, fibromyalgia can cause significant pain and fatigue, and it can interfere with a person's ability to carry on daily activities. Also like arthritis, fibromyalgia is considered a rheumatic condition, a medical condition that impairs the joints and/or soft tissues and causes chronic pain.
* * * * *
In addition to pain and fatigue, people who have fibromyalgia may experience a variety of other symptoms including:
cognitive and memory problems (sometimes referred to as "fibro fog")
* * * * *
The causes of fibromyalgia are unknown, but there are probably a number of factors involved.
* * * * *
Research shows that people with fibromyalgia typically see many doctors before receiving the diagnosis. One reason for this may be that pain and fatigue, the main symptoms of fibromyalgia, overlap with those of many other conditions. Therefore, doctors often have to rule out other potential causes of these symptoms before making a diagnosis of fibromyalgia. Another reason is that there are currently no diagnostic laboratory tests for fibromyalgia; standard laboratory tests fail to reveal a physiologic reason for pain. Because there is no generally accepted, objective test for fibromyalgia, some doctors unfortunately may conclude a patient's pain is not real, or they may tell the patient there is little they can do.
A doctor familiar with fibromyalgia, however, can make a diagnosis based on criteria established by the American College of Rheumatology (ACR): a history of widespread pain lasting more than 3 months, and other general physical symptoms including fatigue, waking unrefreshed, and cognitive (memory or thought) problems.
Pain is considered widespread when it affects all four quadrants of the body, meaning it must be felt on both the left and right sides of the body as well as above and below the waist. ACR also has ...

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