United States District Court, D. Colorado
T. Babcock, Judge.
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.
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
Plaintiff's Medical History
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.
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.
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.
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.
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.
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.
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.
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.
Plaintiff's Disability Plan
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
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.”