The opinion of the court was delivered by: Susan Webber Wright United States District Judge
Plaintiff Jerry D. Anthony ("Anthony") brings this action under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132(a)(1)(B), against Layne Christensen Company ("Layne") and Unum Life Insurance Company of America ("UNUM"). Before the Court are the parties' motions for summary judgment (docket entries #29, #39, #41).
After carefully considering the motions, as well as each response and reply, the Court concludes that Anthony's motion for summary judgment should be granted in part and denied in part, and Defendants' motions should be denied. For the reasons that follow, Anthony's claim for short term disability ("STD") benefits will be granted, and Anthony's claim for long term disability ("LTD") benefits will be dismissed without prejudice for failure to exhaust administrative remedies.
Anthony worked for Layne as a welder, and he qualified as a beneficiary of the Layne Christensen Short-Term Disability Plan ("STD Plan") and the Layne Christensen Long-Term Disability Plan ("LTD Plan"). Both plans are employee welfare benefit plans governed by ERISA.
Layne funds the STD Plan and serves as the Plan Administrator, but has delegated authority to UNUM to administer claims.*fn1 UNUM insures the LTD Plan through a group policy and administers claims and benefits under the LTD Plan. Docket entry #31, Ex. 2. Under the terms of the STD Plan,*fn2 benefits are payable for a maximum period of 26 weeks. Under the LTD Plan, disability income benefits are payable after a 180-day elimination period, and benefits are payable for a maximum period determined by the applicant's age at the time of his or her disability. Id.
On January 14, 2003, Anthony submitted a claim for STD benefits for time off work for detoxification and treatment for alcohol dependency. The attending physician's statement submitted along with Anthony's claim, completed by Judson N. Hout, M.D., lists his diagnosis as "alcohol dependency continuous." UAMS00007. Under the heading "referring physician or other treating physicians", Dr. Hout's statement reads: "If Psychiatrist is needed will see Asin A. Shah . . . . Upon discharge he will be referred to Dr. Harris for medical management." Id. Anthony's claim was approved and paid, and he returned to work on or before February 3, 2003.
On October 16, 2003, Anthony entered the Central Arkansas Veterans Healthcare System Domiciliary Care Unit for detoxification and participation in a 30-day inpatient program for alcohol dependency. UACL00017. On October 30, 2003, Anthony submitted a claim for STD income benefits. UACL00014-16. Along with his claim form, Anthony submitted an "attending physician's statement", completed by Katherine Clifton, a nurse practitioner. The statement lists "alcohol dependency" as Anthony's primary diagnosis and states that he should be able to return to work after his discharge on November 21, 2003. UACL00014. Clifton also completed a Family Medical Leave Act certification form stating that Anthony had no work restrictions and required no medical treatment for his alcohol dependency.
In a letter to Anthony dated November 7, 2003, UNUM approved Anthony for STD benefits from October 21, 2003 through November 21, 2003. UACL00035. The letter advises:
If you cannot return to work on 11/22/2003 for medical reasons, you are required to have your attending physician(s) provide the following medical information to support your continued disability. This medical information must provide us with an understanding of how your medical condition continues to affect your work capacity.
* All current medical records (including treatment notes, procedure notes, and test results) from all treating providers from 10/2003 to the present.
* A list from your physician indicating the activities you cannot and should not do along with an explanation of the medical reasoning supporting these restrictions and limitations.
* A copy of your treatment plan and return to work plan from your physician.
Anthony did not return to work on November 22, 2003. On December 3, 2003, UNUM received, by facsimile transmission, a letter from Dr. John E. Harris, stating as follows:
I have been treating Mr. Anthony for over the past two years. He suffers from chronic airway obstruction that results from emphysema. Due to this condition, Mr. Anthony becomes extremely fatigued with walking short distances, lifting, climbing stairs or any other type of exertional activity.
I have referred Mr. Anthony for additional testing at this time. After the results of these tests have been obtained, he will be referred to physical therapy for strength training to improve his capacity to resume his activities of daily living. If you have further questions concerning this matter, please do not hesitate to call me . . . .
UNUM contacted Dr. Harris and Anthony and requested additional medical records. UACL00047-49. On December 18, 2003, Dr. Harris sent UNUM a medical evaluation form, initialed and apparently completed by Dr. Harris. UACL00052. The form indicates that Anthony made a return office visit to Dr. Harris on November 24, 2003, complaining of shortness of breath. Under the heading "assessment" Dr. Harris made three entries, one of which is legible and reads: "COPD." Id. at UACL00043. Dr. Harris also gave UNUM a radiology report of a December 17, 2002 esophagram. UACL00051. The report indicates that Anthony had been experiencing trouble swallowing and states that the x-rays showed a prior lung resection and a gastrectomy. Id.
On December 17, 2003, UNUM sent Dr. Harris a written request for medical records requesting:
* ALL medical records including office notes, tests performed and results, treatment plan, referrals, current medications from 11/2003 to the present, and estimated return to work. Also, include current restrictions and limitations preventing this patient from performing his/her occupation. * Office notes from 11/2003 to the present
On January 6, 2004, Dr. Harris's office sent UNUM additional medical records, via facsimile transmission, which included the following:
* A radiology report of a November 5, 2003 CAT scan of Anthony's chest, finding emphysema and esophageal irregularity. UACL00070-72.
* A medical evaluation form initialed by Dr. Harris, indicating that Anthony made a return office visit on January 4, 2004, complaining of a skin rash. UACL00068. Under the heading "assessment" Dr. Harris made four entries, one of which is legible and reads: "COPD - stable." Id.
* An radiologist's interpretation of a CAT scan of Anthony's neck, noting a history of dysphagia ...