United States District Court, D. Utah, Central Division
JON E. SADLER, Plaintiff,
UNITED OF OMAHA LIFE INSURANCE CO. Defendant.
MEMORANDUM DECISION & ORDER
Honorable Dustin B. Pead United States District Court
matter comes before the court on Plaintiff Jon E. Sadler
(“Mr. Sadler”) and Defendant United of Omaha Life
Insurance Co.'s (“United of Omaha”) cross
motions for summary judgment. The parties in this case
consented to United States Magistrate Judge Dustin B. Pead
conducting all proceedings, including entry of final
judgment. The court, having carefully considered the
parties' submissions, relevant legal authorities and oral
argument of counsel, concludes as follows and grants United
of Omaha's motion for summary judgment and denies Mr.
Saddler's cross motion for summary judgment.
part of his employment as a senior production planner with
Moxtek Inc., Mr. Sadler participated in an employee welfare
benefit plan (the “Plan”) that provided eligible
employees with coverage under both short-term disability
(“STD”) and long-term disability
(“LTD”) insurance policies issued by United of
LTD policy grants United of Omaha authority to interpret
their language and states:
By purchasing the Policy, the Policyholder grants Us the
discretion And the final authority to construe and interpret
LTD policy also grants United of Omaha the authority to make
benefits decisions, stating:
Benefits under the Policy will be paid only if We decide, in
Our discretion, that a person is entitled to
Sadler's Disability Claim
Sadler submitted a claim for STD benefits on October 22,
2015. In his claim Plaintiff indicated that he
suffered from mononucleosis, beginning in September 2015, and
his last day worked was September 30, 2015.
Sadler's claim also included an attending physician
statement (“APS”) from Dr. Karyn Springer
(“Dr. Springer”). Dr. Springer explained that
“fatigue & fevers limit [Mr. Sadler's] ability
to work” and listed his functional restrictions as
“relative rest, [and] supportive
Springer further indicated that Mr. Sadler should be able to
work full-time in 3-6 months.
United of Omaha approved and paid Mr. Sadler's STD claim
under the Policy for the maximum benefit duration of 11
weeks, through December 31, 2015.
Thereafter, the claim was reviewed under the LTD
Sadler completed a Supplementary Report of Disability
claiming total disability. He reported suffering from a
painful foot and indicated that his fatigue had
an APS dated February 19, 2016, Dr. Springer provided
diagnoses of infectious mononucleosis, diabetes, chest pain,
and left shoulder bursitis. The APS also offered the
following restrictions for Mr. Sadler: (1) sit up to five
hours; (2) stand up to two hours; and (3) walk up to two
hours, in each eight-hour work day.
United of Omaha medical consultant, Nurse Denise Theisen
(“Nurse Theisen”), summarized Mr. Sadler's
medical records. Based on her review, Nurse Theisen provided
opinions on Plaintiff's various medical
March 22, 2016, United of Omaha a letter informing Dr. Spring
that it did not have medical findings or documentation of
consistent treatment to support Mr. Sadler's claim for
ongoing benefits. United of Omaha asked Dr. Springer to state
whether she agreed with the assessment.
her April 1, 2016, response, Dr. Springer stated that she
considered Mr. Sadler disabled. She explained that Plaintiff
suffered from chronic fatigue, related to his medication side
effects, and mononucleosis. Dr. Springer noted that tests for
the EBV early antigen were positive, and in order to recover
from his various surgeries, stroke, and chronic fatigue, Mr.
Sadler was unable to work for any extended period of
Nurse Theisen analyzed the additional information provided.
While the medical documentation showed a history of various
medical conditions, Nurse Theisen concluded that Mr. Spring
had no complications or obvious physical functional
impairments related to the medical conditions and his
treatment was conservative.
a result, United of Omaha determined there was no evidence of
any significant physical, mental, or cognitive impairment
that would preclude Mr. Sadler from his previous work
demands. United of Omaha recognized that Mr. Sadler had been
seen by multiple providers but found his treatment to be
conservative and controlled with medications. Defendant
failed to find anything in the record that prevented Mr.
Sadler from returning to work in his regular occupation on a
full-time basis, and his surgeon had cleared his return to
work as of December 2015.
Based on its review of the claim information, medical
records, correspondence, and analysis provided by its medical
reviewer, United of Omaha approved Mr. Sadler's LTD
benefits under the Policy from January 1, 2016 to April 14,
2016. Defendant, however, denied benefits beyond the April
14, 2016 date.
Sadler appealed United of Omaha's benefit termination on
September 29, 2016.
part of its review on appeal, United of Omaha continued
gathering medical records from Mr. Sadler's physicians,
including an updated physical assessment and mental capacity
assessment from Dr. Springer.
Moxtek also submitted a letter in support of the appeal
stating Plaintiff suffered serious health conditions for the
previous eight years.
Occupational Analysis was conducted and found that the
material duties of Mr. Sadler's occupation primarily
involved scheduling and coordinating the flow of work within
or between departments such that the physical demand
characteristics were generally at the sedentary
United of Omaha also requested an independent medical review
by Kent Crossley, M.D. (“Dr.
part of his review, Dr. Crossley analyzed Plaintiff's
medical records. Dr. Crossley opined that Mr. Sadler's
medical problems were well managed and would not interfere
with his ability to function in the workplace. For the
referenced period of time, Dr. Crossley did not find any
evidence of an impairment that would prevent Mr. Sadler from
performing his occupation.
After analyzing all the medical records, occupational
requirements, claim and appeals information and multiple
medical consultations, United of Omaha informed Mr. Sadler
that the prior denial of his claim for benefits beyond April
14, 2016 was appropriate.
doing so, United of Omaha provided a list of documents and
reports that were reviewed as part of his appeal. This
included: 1) the LTD application; (2) attending physician
statements; (3) physical assessment form dated 10/28/16; (4)
mental capacity assessment dated 11/2/2016; (5) appeal
letter; (6) medical records from IHC; (7) job description;
(8) medical records from Dr. Wilkinson; (9) medical records
from Dr. Baker; (10) prescription history; (11) medical
records from Dr. Bunch; (12) a letter from Sadler's
employer; (13) request for reasonable accommodation form;
(14) a return to work form dated 2/24/15; (15) Lincoln
Financial Group disability forms; (16) medical records from
S. Clayson, NP, neurology dated 12/16/15; (17) medical
records from M. Jensen, PA-C, pain medicine dated
12/2/14-7/6/16; (18) medical records from S. Schauss, PA-C,
for sleep; (19) a vocational consultant review; (20) and an
independent physician consultant review by Dr. Crossley,
dated January 3, 2017.
United of Omaha acknowledged that Mr. Sadler was assessed
with several chronic conditions, but determined that the
clinical findings did not support any conditions that would
result in functional impairment or work limitations that
precluded Mr. Sadler from performing the material duties of
his regular occupation beyond April 14, 2016.
Sadler commenced this lawsuit on August 30,
parties agree that the Plan is “interpreted under the
Employee Retirement Income Security Act of 1974, as amended
THE STANDARD OF REVIEW IS ARBITRARY AND CAPRICIOUS.
ERISA, summary judgment can be “a vehicle for deciding
the case [where] the factual determination of eligibility for
benefits is decided solely on the administrative record, and
the non-moving party is not entitled to the usual inferences
in its favor.” Generally, the applicable standard of
review is de novo, “unless the benefit plan gives the
administrator or fiduciary discretionary authority to
determine eligibility for benefits or construe the terms of
the plan.” In circumstances where the plan grants
discretionary authority to the administrator, then the
arbitrary and capricious standard of review applies to the
the United of Omaha Policy clearly states that benefits
“will be paid only if We decide, in Our discretion,
that a person is entitled to them.” This language
vests the plan administrator with the discretionary authority
to determine benefit eligibility and therefore the arbitrary
and capricious standard of review applies.
an arbitrary and capricious review, the court is not tasked
with “determining whether [the claimant] was, in the
district court's view, entitled to . . .
benefits.” Rather, the court must determine
“whether the administrator's actions were arbitrary
and capricious.” A plan administrator's
interpretation is not arbitrary and capricious if it is
reasonable and based on substantial evidence in the
THE COURT TREATS UNITED OF OMAHA'S INHERENT CONFLICT OF
INTEREST AS A FACTOR IN ITS REVIEW OF THE DENIAL.
United of Omaha Has an Inherent Conflict as Both ...