Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Watson v. Western & Southern Financial Group Flexible Benefits Plan

United States District Court, E.D. Kentucky, Northern Division, Covington

August 16, 2019

DEVONA WATSON PLAINTIFF
v.
WESTERN & SOUTHERN FINANCIAL GROUP FLEXIBLE BENEFITS PLAN DEFENDANT

          MEMORANDUM OPINION AND ORDER

          WILLIAM O. BERTELSMAN, UNITED STATES DISTRICT JUDGE

         Plaintiff brought this action under the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1001 et seq., after Defendant denied Plaintiff's application for short-term disability benefits, despite the fact that treating physicians and medical records corroborate that Plaintiff is unable to perform the duties of her occupation because she suffers from Grade IV osteoarthritis in her knees, a condition that is compounded by her morbid obesity. Plaintiff seeks the benefits she was denied, plus pre-judgment interest and attorney fees.

         This matter is now before the Court on the parties' cross-motions for judgment on the administrative record. (Docs. 23, 24).[1] The Court dispenses with oral argument because the materials in the record adequately present the facts and legal contentions. For the reasons that follow, the Court concludes that Defendant's decision to deny Plaintiff short-term disability benefits was arbitrary and capricious.

         FACTUAL AND PROCEDURAL BACKGROUND

         A. General Background

         Plaintiff Devona Watson worked as a Senior Case Analyst at Western & Southern Life Insurance Co. (Doc. 22, AR at 270).[2] Since at least 2013, Watson has suffered from severe osteoarthritis in both knees, which is exacerbated by the fact that she is morbidly obese. Id. at 248, 267-68. In August 2017, Watson applied for short-term disability (“STD”) benefits. At the time, she had been an employee of the company for over 28 years. Id. at 244, 270. As an employee, Watson was covered by the Western & Southern Financial Group Flexible Benefits Plan (the “Plan” or “Western & Southern”). (AR at 70, 72, 86).[3]

         1. The Plan Terms

         Under the Plan, STD benefits “are equal to two-thirds” of the employee's weekly earnings. (AR at 150). An individual who has been covered for at least four years and “becomes Temporarily Disabled” can receive up to 26 weeks of STD benefits. See (AR at 149-50). “Temporarily Disabled” or a “Short-term Disability” is defined in the Plan as “a disablement resulting from Sickness or Injury of such a nature that as a result” the employee “is unable to perform the normal duties of [their] regular occupation for any employer.” Id. at 84 (emphasis added).

         Although that definition includes more than what Watson's employer deems the “normal duties” of a Senior Case Analyst, Watson's job description does state that she “works in an office setting and remains continuously in a stationary position for long periods of time while working at a desk, on a computer or with other standard office equipment, or while in meetings.” Id. at 279.[4] In addition, “[e]xtended hours [are] required during peak workloads or special projects.” Id.

         2. Watson's Treatment History & STD Benefits Application

         a. Dr. Kunath

         On August 2, 2017, Watson weighed 411 pounds when she presented to her rheumatologist, Dr. Arthur Kunath. (AR at 271-72; see Id. at 266-67). Dr. Kunath observed that Watson “just looks miserable.” Id. at 272. In his assessment, Watson suffers from morbid obesity and Grade IV osteoarthritis of the knees, “with limited capacity now to walk.” Id. at 272. Based on his review of Watson's x-rays, Dr. Kunath noted that “she does in fact have significant Grade IV [osteoarthritis] of the medical compartments of her knees.” Id. Dr. Kunath's instructions were for Watson to visit Dr. Teresa Koesler at Western & Southern to “see if there is any way we can get bariatric surgery approved.” Id. “If that is not possible, ” Dr. Kunath concluded, “then I'm going to have to put her on disability.” Id. (emphasis added).

         In considering other alternatives, Dr. Kunath noted that a “regular wheelchair” was not an option “because of significant problems starting now in her right shoulder, ” so the “only other option” at the time was “maybe a motorized wheelchair.” But even this seemed “problematic” due to Watson's weight. Id.

         In summarizing the history of Watson's condition, Dr. Kunath noted:

[Watson] states that the problems continue to slowly worsen. She is having greater and greater difficulty getting to her desk at work and getting back out to the car at night. Someone picks her up and drops her off but she states it is getting more and more painful. Once she gets to her desk she is able to do her work but if she has to do any more walking during the day it is very difficult.
Now the problem is her weight is 411 pounds today. I told her the only answer to her problems would be a gastric sleeve surgery or bariatric surgery . . . and then get her weight down and then get her knees replaced but [Watson] states that Western [&] Southern will not pay for any type of bariatric surgery . . . The patient does look miserable. Other than that, I think we're going to just have to put her on Disability.

(AR at 273) (emphasis added).

         Watson later received a letter from Western & Southern, dated August 15, 2017, requesting medical documentation to substantiate an unspecified number of absences from work. Id. at 264. To be considered for STD benefits, the letter advised Watson that by September 14, 2017, she was required to submit the application form attached to the letter and the following documentation: (1) a medical diagnosis; (2) a medical treatment plan; (3) her anticipated return-to-work date; and (4) copies of office records pertaining to the relevant period of disability. Id.

         On August 16, 2017, the Benefits Department received a note from Dr. Kunath, stating: “Patient no longer able to work. Will be on short term disability for [the] next 60 days for her severe osteoarthritis of [her] knees.Id. at 265 (emphasis added). Watson then submitted her short-term disability benefits application. Id. at 270.

         On August 25, 2017, Dr. Kunath sent a healthcare provider certification via facsimile to Western & Southern. Id. at 267. Watson's “essential job functions” and “job description” were attached. Id. Dr. Kunath noted Watson's diagnosis as “severe O.A. [osteoarthritis] of [the] knees complicated by obesity which prevents patient ambulating any distance.” (AR at 268). In response to the question whether the associate is “unable to perform any of his/her job functions due to the condition, ” Dr. Kunath marked the box for “Yes” and wrote: “Unable to attend meeting/ get to her desk/ or sit for extended periods of time.” Id. In the section at the bottom of the form for “additional information, ” Dr. Kunath restated the diagnosis and reiterated that Watson is:

Unable to ambulate to desk, unable to walk to meetings or get around in office. She needs both knees replaced but no surgery will do until loses [sic] significant weight. We are taking her off work for [a] minimum [of] 6 months to see if knees will decrease in symptoms with limited ambulation.

Id. As a result of her medical condition, Dr. Kunath noted that Watson would be “incapacitated” and estimated that this would be the case for a period of six months (August 7, 2017, to February 7, 2018). Id. During this time, Dr. Kunath stated: Watson was to work “0 hour(s) per day; 0 days per week.” Id.

         Dr. Kunath's prognosis of Watson was anything but promising. He noted that the probable duration of Watson's condition was “indefinite” and her anticipated return to work was “unknown at this time [sic] possibly 2/7/18.” Id. at 267.

         b. Dr. Hummel

         The Benefits Department requested that Watson be evaluated by an orthopedic surgeon. See (AR at 235). Watson did just that on September 13, 2017, when she visited Dr. Matthew T. Hummel's office. He noted that Watson “comes in today for evaluation from Dr. Kunath” and “for an opinion on her ability to do activities.” Id. at 248. At the appointment, Watson weighed 420 pounds. Id. Dr. Hummel related in his notes that:

[Watson is] in a wheelchair today, morbidly obese with a significant history of long-term lower extremity pain, particularly with both knees. She has undergone a series of treatments with Dr. Kunath, everything ranging from anti-inflammatories, pain medications and injections with minimal help. The pain itself has been going on for three to four years. She has also seen her primary care physician, Dr. Allnutt. The pain she describes in both knees . . . [is] ¶ 8 or a 9/10 pain with activity. It even hurts at ¶ 4/10 at rest. It is a constant aching, grinding and stiffness and she has trouble ambulating.

(AR at 248). Dr. Hummel's physical examination of Watson was “difficult” and he related that it “is really difficult for the patient to ambulate due to her size” and “[s]he cannot really get up on the exam table.” Id. Dr. Hummel further evaluated Watson's functional capacity and reported that:

Range of motion of both knees is near full extension and flexion to about 90 but it is more of a mechanical block due to her thigh. She has crepitus that is audible. She has pain with range of motion. The rest of the exam is very difficult to do just due to size.

Id. at 249. Dr. Hummel reviewed Watson's x-rays and concluded that they “show[ed] severe tricompartmental osteoarthritis, bilateral knees, genu varum with bone-on-bone articulation, eburnation and spurring in all three compartments without evidence of bony lesion or fracture.” Id. Dr. Hummel's diagnosis: “Severe bilateral knee osteoarthritis.” Id.

         Although Dr. Hummel concluded that Watson “is not a surgical candidate” because “she is just too much of a high risk patient, ” Dr. Hummel reported that Watson needed to “find a way to get healthy enough to undergo knee replacements simply due to the fact that that arthritis is probably significantly limiting.” Id. at 249.

         3. Initial Denial of STD Benefits

         Jen Segrist, a registered nurse with the Benefits Department of Western & Southern, sent a denial letter to Watson on September 26, 2017. The letter stated that the department “has reviewed the medical information submitted on 09/25/2017” (the previous day). (AR at 247). The letter recited verbatim the Plan language that defines a qualifying disability and then summarily stated:

The medical documentation submitted fails to support your claim for short-term disability benefits under the Plan. Your request for additional [STD] has been denied. No additional information is necessary for you to perfect your claim.

Id. (emphasis added). The letter goes on to advise Watson on how to pursue an appeal:

[Y]ou may file an appeal by following the instructions on the enclosed review procedure for rejected Benefits Claims. In your appeal, you should submit all information in support of your claim, as the ...

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.