United States District Court, W.D. Arkansas, El Dorado Division
Susan O. Hickey United States District Judge
Plaintiff Vitina Ganter filed this Complaint against Defendants Sun Life Assurance Company of Canada (“Sun Life”) and CHS/Community Health Systems, Inc., Long Term Disability Insurance Plan (“CHS”) pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et seq., alleging that her long term disability benefits were wrongly denied. Before the Court is Plaintiff’s Motion for Judgment on the Record. (ECF No. 24). Defendants have filed objections and their own Motion for Judgment on the Record. (ECF No. 27). Plaintiff has filed a response to Defendants’ Motion. (ECF No. 29). The Court finds this matter ripe for consideration.
From November 5, 2010 until August 23, 2012, Plaintiff was employed as a Licensed Practical Nurse by South Arkansas Home Health in El Dorado, Arkansas. South Arkansas Home Health is owned and operated by CHS. Her job duties involved providing prescribed medical treatment and personal care services to ill, injured, convalescent, and handicapped persons. Plaintiff was eligible for disability insurance coverage under an insurance policy offered by CHS and Sun Life. On October 11, 2011, Plaintiff elected to participate in the insurance coverage. On August 23, 2012, Plaintiff ceased working, stating that she could no longer work due to a fractured back, daily headaches, and pain, numbness, and tingling shooting down her neck and back to her legs, feet, and fingertips, caused by a fall on a wheel chair ramp at a patient’s home in February 2012 and aggravated in July 2012. Plaintiff stated that she was unable to perform the important duties of her job on a regular basis, and she filed for Long Term Disability (“LTD”) benefits under the insurance policy, claiming that she was totally disabled. Sun Life determined that Plaintiff was not eligible for LTD benefits and declined to make any payments. This denial of benefits is currently before the Court for review.
I. The Disability Plan
Sun Life is the insurer of the Policy and also serves as its claims administrator. As the claims administrator, Sun Life has the discretion to determine eligibility under the Policy and entitlement to benefits in accordance with the terms of the Policy. Policy participants are eligible for LTD benefits if they are found to be totally or partially disabled. The Policy defines “Total Disability or Totally Disabled” as follows:
[D]uring the Elimination Period and the next 24 months, the Employee, because of Injury or Sickness, is unable to perform the Material and Substantial Duties of his Own Occupation. After Total or Partial Disability benefits combined have been paid for 24 months, the Employee will continue to be Totally Disabled if he is unable to perform with reasonable continuity any Gainful Occupation for which he is or becomes reasonably qualified for by education, training, or experience.
The loss of a professional license or occupational license or the inability to obtain or qualify for a license for any reason does not, in itself, constitute Total Disability.
To qualify for benefits, the Employee must satisfy the Elimination Period with the required number of days of Total Disability, Partial Disability or a combination of days of Total and Partial Disability.
(ECF No. 14, Exh. 8, Pg. 98); SUN00802.
The policy further defines “Own Occupation” as:
the usual and customary employment, business, trade, profession or vocation that the Employee performed as it is generally recognized in the national economy immediately prior to the first date Total or Partial Disability began. Own Occupation is not limited to the job or position the Employee performed for the Employer or performed at any specific location.
(ECF No. 14, Exh. 8, Pg. 97); SUN00801.
Sun Life, after reviewing the record, determined that the objective medical evidence did not support Plaintiff’s claimed disability under the terms of the ...