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Dardick v. Unum Life Insurance Company of America

United States District Court, D. Colorado

October 19, 2017

JOHN DARDICK, Plaintiff,
v.
UNUM LIFE INSURANCE COMPANY OF AMERICA, a Maine corporation, and FIRST UNUM LIFE INSURANCE COMPANY, a New York corporation, Defendants.

          ORDER

          Lewis T. Babcock, Judge.

         This case is before me on the parties' Joint Motion for Determination [Doc # 43]. After consideration of the parties' briefs, the record, and the case file, and for the reasons stated below, I grant the motion and enter judgment in favor of Defendants.

         I. Background

         Plaintiff is a former vice president of Westcon Cloud Services. Administrative Record (“AR”) 42. This case arises out of Defendants Unum Life Insurance Company of America and First Unum Life Insurance Company's (collectively “Unum”) denial of Plaintiff's claim for disability benefits under the group disability benefits plan provided by Westcon Group, Inc. (“Westcon”). Plaintiff's claim against Unum is governed by the Employee Retirement Income Security Act of 1974 (“ERISA”).

         A. Plaintiff's Medical History

         Plaintiff, now in his early 60's, has a long history of cardiovascular health issues dating back to when he suffered a heart attack while in his 30's. AR 72. Following his heart attack, Plaintiff underwent a coronary bypass grafting procedure and did relatively well following this procedure. Id.

         In July of 2015, Plaintiff was seen by Nelson P. Trujillo, M.D., who first began treating Plaintiff in 2000, for complaints of chest pain, shortness of breath, and fatigue. AR 72 & 843. Dr. Trujillo reported that Plaintiff denied that he was experiencing depression or anxiety. AR 73. After a physical examination, Dr. Trujillo noted that Plaintiff had “[p]remature severe coronary artery disease with progressive symptoms concerning for recurrence/progression of his underlying atherosclerosis;” an abnormal nuclear stress test; and symptoms that were “clearly concerning.” AR 74. Dr. Trujillo instructed Plaintiff to exercise daily by taking a 20 minute walk. Id.

         Dr. Trujillo summarized a coronary angiogram performed on Plaintiff on July 17, 2015 as showing that Plaintiff was “incompletely revascularized with severe right distal coronary artery atherosclerosis, single mammary artery by-pass[, ] and distal LAD artherosclerosis.” AR 842. Dr. Trujillo further summarized that Plaintiff's “ejection fraction was reduced at 45%” as of July of 2015. Id.

         On July 28, 2015, Plaintiff participated in a treadmill exercise stress test. AR 75-6. The recorded results reflect “[n]o exercise induced ECG changes;” a score consistent with “low cardiovascular risk (< 1% annual mortality);” and an abnormal study with exercise induced angina pectoris but normal heart rate and blood pressure response. AR 75.

         On August 31, 2015, Plaintiff underwent a percutaneous coronary intervention (“PCI”), or coronary angioplasty, procedure that was deemed successful. AR 497. During this procedure, Dr. Trujillo placed a stent in Plaintiff's right circumflex artery “although the right coronary artery remained too narrow to stent.” AR 497 & 526.

         Plaintiff was seen by Dr. Trujillo on September 18, 2015 for follow-up on the August 31, 2015 PCI. AR 142-44. Dr. Trujillo noted that Plaintiff continued to have angina with exertion and some rest angina with stress/anxiety and that he was “as completely revascularized as he can be after recent PCI.” AR 142 & 144. Dr. Trujillo again reported that Plaintiff denied that he was suffering from anxiety or depression AR 143.

         In addition to his cardiovascular health issues, Plaintiff had surgery on October 30, 2015 for “repair of left distal biceps insertion.” AR 211. The surgeon noted in his operative report that Plaintiff suffered from longstanding left elbow pain and had felt something snap in his elbow when he was pushing a wheelbarrow. Id. The surgeon further noted that Plaintiff had persistent pain and “altered neurological symptoms” in his arm. Id.

         Plaintiff again saw Dr. Trujillo for follow-up on December 23, 2015. AR 261-3. Dr. Trujillo reported that an echocardiogram taken a few days earlier showed an ejection fraction of 50-55% and that Plaintiff continued to have exercise angina “in a stable fashion.” AR 261. Dr. Trujillo assessed Plaintiff with “coronary artery disease involving native coronary artery of native heart with other form of angina pectoris;” angina pectoris; fatigue; and improving cardiomyopathy. AR 263. Dr. Trujillo noted that Plaintiff's ejection fraction had improved “at least 5-10% with initiation of beta blocker and up titration of drug” and recommended “continued aggressive medical therapy.” Id. Dr. Trujillo again reported that Plaintiff denied that he was suffering from anxiety or depression AR 262.

         B. Plaintiff's Disability Plan

         Plaintiff asserted his claim for disability benefits under Unum Policy No. 465018001 (the “Plan”). AR 312. Under the Plan, Unum is obligated to pay Plaintiff 60% of his monthly earnings in the event he becomes disabled. AR 317. The Plan defines disability as follows:

you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and
you have a 20% or more loss in your indexed monthly earnings due to the same sickness of injury.
After 24 on these of payments, you are disabled when Unum determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.

AR 334. The Plan defines the relevant terms set forth in bold above as follows:

MATERIAL AND SUBSTANTIAL DUTIES means duties that ... are normally required for the performance of your regular occupation; and cannot be reasonably modified or omitted.
REGULAR OCCUPATION means the occupation you are regularly performing when your disability begins. [Unum] will look at your occupation as it is normally performed in the national economy, instead of how the work tasks are performed for a specific employer or at a specific location.
SICKNESS means an illness of disease. Disability must begin while you are covered under the [P]lan.

AR 347-49. Plan benefits “are administered by the insurer and provided in accordance with the insurance policy issued to the Plan.” AR 350. The Plan expressly delegates discretionary authority to make benefit determinations to Unum. AR 355. Benefit determinations “include determining eligibility for benefits and the amount of any benefits, resolving factual disputes, and interpreting and enforcing the provisions of the Plan.” Id.

&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;C. Plaintiff's ...


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