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Spears v. Unum Life Insurance Company of America

May 14, 2007

CLAYTON O'NEAL SPEARS PLAINTIFF
v.
UNUM LIFE INSURANCE COMPANY OF AMERICA DEFENDANT



The opinion of the court was delivered by: Susan Webber Wright United States District Judge

ORDER

Plaintiff Clayton O'Neal Spears ("Spears") brings this action under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132(a)(1)(B), against Unum Life Insurance Company of America ("UNUM"), seeking review of UNUM's decision to deny him long term disability benefits. Before the Court are Spears's motion for summary judgment (docket entries #9, #10, #11) and Unum's motion for judgment on the record (docket entries #15, #16, #17). After carefully considering the parties' filings, and the stipulated, administrative record (docket entry #5), the Court finds that UNUM's decision should be upheld.

I. Background

Spears, born March 8, 1967, was employed by Perry L. Butcher & Associates, Architects LTD ("Butcher") as a project manager. Spears is a high school graduate, and his job duties at Butcher included producing and reviewing architectural documents (AR 15-16.) Spears participated in Butcher's short-term disability ("STD") and long-term disability ("LTD") plans, which are administered by UNUM and insured by policies issued by UNUM.

On April 5, 2004, Spears filed a claim for STD benefits, stating that he had been unable to work since March 17, 2004 due to severe headaches, dizziness, blurred vision and nausea. (AR 13-17.) In support of his claim, Spears submitted a physician's statement dated April 7, 2004 by Dr. Traci Ivey, diagnosing Spears with "maxillary sinusitis, headache, [history] brain mass." (AR 13). Under the heading restrictions and limitations, Dr. Ivey wrote: "Pt. experiencing dizziness, headaches, and visual disturbance. No heights, sharp instruments." (AR 13.) Dr. Ivey provided the following objective findings: "MRI from 4/2/04 shows an arachnoid cyst in the posterior, cranial fossa and increased signal density within the bilateral frontal/peri-ventricular white matter." Id.

By letter dated April 20, 2004, UNUM informed Spears that his claim for STD benefits had been approved through March 30, 2004. (AR 38.) UNUM advised Spears that it would not consider extending his benefits beyond March 30, 2004 without additional medical information indicating how his medical condition continued to affect his work capacity. (AR 38.)

Dr. Ivey referred Spears to Dr. John Lee, an ear, nose, and throat specialist, to investigate whether his dizziness was caused by a sinus infection. Dr. Lee examined Spears on April 28, 2004, and concluded that his symptoms were not related to sinusitis or an ear, nose or throat problem. (AR 56). In a letter to Dr. Ivey, Dr. Lee stated: "The posterior fossa arachnoid cyst may be congenital or incidental in nature, but I have seen occasional reports of these causing headaches or balance problems. I agree with the [decision to consult a neurologist] . . . ." (AR 58.)

In a progress note dated April 30, 2004, Dr. Ivey wrote that Spears was scheduled to see a neurologist, Dr. Ryan Kaplan, on June 11, 2004. (AR 56.) Dr. Ivey noted: "He states he just does not feel he can do his job related to his dizziness." (AR 56.)

In a letter dated May 19, 2004, UNUM notified Spears that based on additional medical information provided by Dr. Ivey, his STD benefits had been extended through June 11, 2004. The letter states that UNUM would not consider extending his benefits beyond June 11, 2004 unless it received additional medical information indicating how his medical condition continued to affect his work capacity. (AR 70.)

Clinic notes dated June 21, 2004 by Dr. Ivey state that Dr. Kaplan examined Spears and determined that his headaches were related to his arachnoid cyst. (AR 99.) Dr. Ivey wrote that Dr. Kaplan would follow Spears's headaches and dizziness, and Spears continued to have dizzy spells and state that he was unable to work. (AR 99.)

By letter dated July 27, 2004, UNUM informed Spears that his STD benefits had been extended for the duration of the STD policy period. (AR 116.) UNUM informed Spears that his file had been forwarded to a disability benefits specialist to determine whether he qualified for LTD benefits. Id.

In determining Spears's claim for LTD benefits, UNUM considered Dr. Kaplan's assessment of Spears's condition. Kaplan's initial consultation report dated June 11, 2004 states that Spears's arachnoid cyst could be the cause of his headaches. Dr. Kaplan's report concludes as follows:

We will be requesting the old scan so a comparison can be made. I would also be inclined to do a spinal tap as well as check some basic labs. When he follows up with me on Monday, we will try to get these labs done. One final consideration would be epilepsy. He did have seizures when a child and epileptic discharges can lead to bad headaches. Furthermore, he does have spells of staring and he has woken up with his tongue sore in the morning. We may potentially need to get an EEG in the future. (AR 176.)

UNUM also received a report comparing an MRI of Spears's brain taken August 2, 2004 with an MRI taken April 2, 2004. (AR 261.) The report states that the appearance of the brain was slightly improved, and the arachnoid cyst was unchanged. Dr. Kaplan examined Spears on August 13, 2004 and reported that Spears felt better and his headaches were "not as bad." (AR 281.) Kaplan noted: "I will also be sending him to the neurosurgeons to have this cyst evaluated." (AR 281.)

By letter dated August 24, 2004, UNUM advised Spears that his claim for LTD benefits had been approved for a period of disability from June 15, 2004 through August 14, 2004. (AR 274.) UNUM informed Spears that he would not qualify for continued benefits unless he remained disabled as defined in the Butcher's LTD plan. The letter states: "Based on the medical information received from your treating physician and our experience with your condition, we expect that you will have treatment in the near future to resolve your medical condition and allow you to return to your occupation." (AR 274.)

Multiple times between November 2004 and February 2005, UNUM attempted to obtain updated information regarding Spears's medical condition and whether his cyst had been removed. (AR 297-335.) Spears failed to return UNUM's calls or provide any information about his condition. Id. On February 22, 2005, UNUM informed Spears that if additional information was not received by March 25, 2005, it would decide his claim based on the information it had. (AR 333-335.) UNUM informed Spears that, pursuant to the policy terms, UNUM needed proof that he was under ...


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