United States District Court, D. Minnesota
Carol R. Johnson, Plaintiff,
Mutual of Omaha Life Insurance Company, Defendant.
Mark Nolan, Esq., Nolan Thompson & Leighton, Bloomington, MN, on behalf of Plaintiff.
Jeffrey W. Thone, Esq., and James T. Keig, Esq., Stephenson, Sanford & Thone, PLC, Wayzata, MN, on behalf of Defendant.
MEMORANDUM OPINION AND ORDER
ANN D. MONTGOMERY, District Judge.
On June 17, 2014, the undersigned United States District Judge heard oral argument on Plaintiff Carol R. Johnson's ("Johnson") and Defendant Mutual of Omaha Life Insurance Company's ("United") cross-motions for summary judgment [Docket Nos. 17, 23]. The parties dispute whether Johnson was wrongfully denied short-term and long term-disability coverage. For the reasons set forth below, Johnson's motion for summary judgment is denied and United's motion for summary judgment is granted in part and denied in part.
A. The Policies
Plaintiff Johnson began working for LANDesk Software, Inc. ("LANDesk") on November 22, 2010 as a territory manager. Jeffrey W. Thone Aff. [Docket No. 20] Ex. A. Administrative Record ("AR") 535. Johnson participated in LANDesk's employee group welfare benefit plans, United's Group Short-Term Disability insurance policy (the "STD Policy"), AR 1-51, and a Long-Term Disability insurance policy (the "LTD Policy"), AR 52-114.
The policies each provide:
AUTHORITY TO INTERPRET POLICY
The Policyholder [LANDesk] has delegated to Us [United] the discretion to determine eligibility for benefits and to construe and interpret all terms and provisions of the Policy. Benefits under the Policy will be paid only if We [United] decide, after exercising Our discretion, that the Insured Person is entitled to them. In making any decision, We may rely on the accuracy and completeness of any information furnished by the Policyholder, an Insured Person or any other third parties.
AR 6, 42, 57.
1. The STD Policy
The STD Policy provides for a maximum weekly payment of $1, 000 for a maximum period of 12 weeks for a continuous period of disability. AR 22.
The STD Policy defines several terms:
Disability and Disabled means that because of an Injury or Sickness, a significant change in Your mental or physical functional capacity has occurred in which:
(a) during the Elimination Period, You are prevented from performing the Material Duties of Your Regular Job (on a part-time or full-time basis) or are unable to work Full-Time; and
(b) after the Elimination Period, You are:
(1) prevented from performing the Material Duties of Your Regular Job (on a part-time or full-time basis) or are unable to work Full-Time; and
(2) unable to generate Current Earnings which exceed 99% of Your Weekly Earnings due to that same Injury or Sickness.
Disability is determined relative to Your ability or inability to work. It is not determined by the availability of a suitable position with Your employer.
Sickness means a disease, disorder or condition, including pregnancy, for which you are under the care of a Physician. Disability must begin while you are insured under the Policy. Sickness does not include elective cosmetic surgery or procedures.
Regular Care means:
(a) You visit a Physician as frequently as is medically required, according to standard medical practice, to effectively manage and treat Your disabling condition; and
(b) You receive Appropriate Care and Treatment.
Appropriate Care and Treatment means medical care and treatment that meet all of the following:
(a) It is received from a Physician whose expertise, medical training and clinical experience are suitable for treating Your Injury or Sickness;
(b) It is Medically Necessary;
(c) It is consistent in type, frequency and duration of treatment with relevant guidelines based on national medical research or published by health care organizations and government agencies;
(d) It is consistent with the diagnosis of Your condition; and
(e) Its purpose is to improve Your medical condition and thereby aid in Your ability to return to work.
Physician means any of the following licensed practitioners:
(a) a doctor of medicine (MD), osteopathy (DO), podiatry (DPM) or chiropractic (DC);
(b) a licensed doctoral clinical psychologist; or
(c) where required by law, any other licensed practitioner who is acting within the scope of his/her license.
Medically Necessary means care that is ordered, prescribed or rendered by a Physician or Hospital and is determined by Us, or a qualified ...