United States District Court, E.D. Kentucky, Northern Division, Covington
MEMORANDUM OPINION AND ORDER
WILLIAM O. BERTELSMAN, UNITED STATES DISTRICT JUDGE
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.
matter is now before the Court on the parties'
cross-motions for judgment on the administrative record.
(Docs. 23, 24). 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
AND PROCEDURAL BACKGROUND
Devona Watson worked as a Senior Case Analyst at Western
& Southern Life Insurance Co. (Doc. 22, AR at
270). 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,
The Plan Terms
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).
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
In addition, “[e]xtended hours [are] required during
peak workloads or special projects.” Id.
Watson's Treatment History & STD Benefits
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.
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.
summarizing the history of Watson's condition, Dr. Kunath
[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).
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.
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.
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
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
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.”
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.
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.”
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
Initial Denial of STD Benefits
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 ...