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Dahlka v. Unum Life Insurance Co. of America

United States District Court, W.D. Wisconsin

June 11, 2018

JAMES R. DAHLKA, Plaintiff,
v.
UNUM LIFE INSURANCE COMPANY OF AMERICA and ILLINOIS TOOL WORKS, INC., Defendants.

          OPINION AND ORDER

          BARBARA B. CRABB DISTRICT JUDGE

         In this civil suit for monetary relief, plaintiff James Dahlka contends that defendant Unum Life Insurance Company of America’s determination that he did not satisfy the elimination period with respect to his claim for long-term disability benefits was arbitrary and capricious, in violation of his rights under the Employment Retirement Income and Security Act (ERISA), 29 U.S.C. § 1132(a)(1)(B). Before the court are the parties’ cross motions for summary judgement. Dkt. #12 and #16.

         Plaintiff asserts that Unum acted arbitrarily and capriciously in denying benefits by: (1) issuing multiple denials that amounted to a “moving target”; (2) using an erroneous vocational standard for light work and not the actual job requirements provided by plaintiff’s employer; (3) failing to consider plaintiff’s failed work attempts after he underwent surgery; and (4) not considering plaintiff’s treating provider evaluations. He also seeks attorney fees and costs under 29 U.S.C. § 1132(g)(1) on the ground that defendants’ position is not substantially justified. Defendants argue that: (1) defendant Unum is entitled to summary judgment because it reviewed plaintiff’s claim fully and fairly and had a rational basis for denying it; (2) plaintiff has no independent basis for asserting a claim against defendant Illinois Tool Works; and (3) even if defendant Unum acted arbitrarily and capriciously, plaintiff’s benefits are subject to an offset for plaintiff’s estimated Social Security Disability Insurance benefits.

         For the reasons stated below, I find that defendant Unum did not act arbitrarily and capriciously in denying plaintiff benefits. Accordingly, I am granting defendants’ motion for summary judgment and denying plaintiff’s motion for summary judgment with respect to Unum’s denial of plaintiff’s claim for long-term disability benefits. Because plaintiff does not contest defendants’ contention that he does not have an independent basis for asserting a claim against defendant Illinois Tool Works, I also am dismissing plaintiff’s claims against his employer.

         From the parties’ proposed findings of fact and the administrative record (AR), I find the following facts to be undisputed.

         UNDISPUTED FACTS

         A. The Parties and the Policy

         Plaintiff James Dahlka is a resident of Chippewa County, Wisconsin, and was employed as a manufacturing general technician by defendant Illinois Tool Works, Inc. at its plant in Chippewa Falls, Wisconsin. Defendant Unum Life Insurance Company of America is an insurance company authorized to conduct business in Wisconsin.

         On March 7, 2011, plaintiff signed a copy of a job description for the position of manufacturing general technician at Illinois Tool Works. The brief description focused on the particular tasks involved with monitoring molding machines and equipment to maintain production demands and parts quality and did not include any exertional requirements. AR 39.

         Around February 1, 1985, Unum issued a group long-term disability insurance policy to Illinois Tool Works for the benefit of its eligible employees. AR 76. The policy terminated on July 1, 2013. Under the policy, Unum had the “discretionary authority” to determine an employee’s eligibility and to construe the terms of the policy. Id. at 80. The policy provides for an “elimination period,” meaning that benefits do not begin until after a claimant has been continuously disabled for a consecutive period of 180 days or the expiration of the short-term disability benefit period. AR 78. If the claimant’s disability stops during the 180-day elimination period for any period of 30 days or less, the disability is treated as continuous for calculating the 180 days of continuous disability. However, the days that a claimant is not disabled do not count toward the satisfaction of the 180-day elimination period. Id. at 82. Under the policy, “disability” and “disabled” mean that because of injury or sickness:

1. the insured cannot perform each of the material duties of his regular occupation; and
2. after benefits have been paid for 24 months, the insured cannot perform each of the material duties of any gainful occupation for which he is reasonably fitted, taking into consideration training, education or experience, as well as prior earnings; or
3. the insured, while unable to perform all of the material duties of his regular occupation on a full-time basis, is:
a. performing at least one of the material duties of his regular occupation or another occupation on a part-time or full-time basis; and
b. earning currently at least 20% less per month than his indexed pre-disability earnings due to that same injury or sickness.

AR 85.

         B. Plaintiff’s Surgery, Short-Term Disability and Work Attempts

         In 2011, plaintiff reported having severe foot and ankle pain in his right leg. On June 12, 2013, plaintiff’s podiatrist, Dr. Mark Schumaker, restricted plaintiff from work because of the pain. AR 573. On June 18, 2013, Dr. Schumaker diagnosed calcaneal navicular coalition, ankle instability, a torn anterior and posterior talofibul ligament and a partial tear of the anterior tibial fibular ligament. Id. at 522-23.

         On July 17, 2013, plaintiff filed a short-term disability claim with Aetna Life Insurance Company and received benefits under that plan until approximately May 22, 2014. Plaintiff’s short-term disability benefits were supposed to terminate on January 1, 2014, but because of a processing error by Aetna, the benefits continued longer than they should have. AR 309.

         On July 24, 2013, Dr. Schumaker performed calcaneal and navicular coalition resection surgery on plaintiff’s right foot and ankle and restricted plaintiff from working until September 16, 2013 so that he could recover from the surgery. AR 283, 340, 526. On September 18, 2013, plaintiff attempted to return to work without restrictions, but he worked for only two shifts. Id. at 338. On September 24, 2013, Dr. Schumaker limited plaintiff to a “sit down job.” Id. at 342. Because plaintiff’s employer could not accommodate that restriction, Dr. Schumaker issued another work restriction on September 27, 2013, stating ...


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