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Own Occupation/Any Occupation Benefit Periods and Medical Evidence: W.D.Ky.

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  • Own Occupation/Any Occupation Benefit Periods and Medical Evidence: W.D.Ky.

    In a fairly straightforward case from Kentucky, the court delves into the distinction between the Own Occ/Any Occ standard. The Plaintiff was employed with Wal-mart when she was injured on the job and subsequently applied for LTD. The Defendant requested the appropriate medical documentation, and provided the Plaintiff an initial approval for the benefits. Under the terms of the plan, she was entitled to Any Occ benefits for the first 12 months. The Plaintiff was denied after the 12 month period, and this action followed.

    Beginning on July 12, 2016, in order to be entitled to LTD benefits under the Policy, Moody had to show that she was “unable to perform, with reasonable continuity, the Material and Substantial Duties of” “any occupation that [she] is or becomes reasonably fitted by training, education, experience, age, physical and mental capacity.” (D.N. 13, PageID # 54, 55) Based on the evidence in the record, Liberty’s initial determination that Moody failed to satisfy this burden was rational in light of the Plan’s provisions. Liberty’s denial letter outlined the medical documentation from Moody’s treating physician Dr. Shea. (Id., PageID # 148) It summarized Dr. Shea’s agreement with the following assessment regarding Moody’s capabilities: (i) frequent walking and standing; (ii) unlimited sitting with ability to change positions as needed; (iii) occasional lifting/carrying/pushing/pulling up to 25 pounds; (iv) occasional bending and twisting; and (v) occasional kneeling/stooping/squatting. (Id.) The letter also explained the occupations for which Moody had been evaluated to be capable to perform based on the agreed-upon assessment. (Id., PageID # 149)
    The court goes on to cite ample caselaw from the Sixth Circuit that shapes its approach to the case at bar, ultimately finding:

    light of the foregoing caselaw, the Court concludes that it was not arbitrary and capricious for Liberty to discount Moody’s subsequent submissions on appeal. Despite these records, Liberty chose to credit the reports of its consulting physicians and find that Moody could work. Given the circumstances, this was a reasonable decision. First, it was neither arbitrary nor capricious for Liberty to discount the handwritten recommendations that appear on Dr. Shea’s March 16, 2016 letter. Nearly one month following his drafting of the letter, Dr. Shea sent a fax to Liberty in which he agreed with Dr. Kasuganti’s recommendations. (See D.N. 13, PageID # 131–132; cf. id., PageID # 167) Given the inconsistency between the opinions expressed in Dr. Shea’s letter and subsequent fax, it was not unreasonable for Liberty to place greater weight on the opinion expressed in the fax, which aligns with the conclusions reached by the consulting physicians. See Wical, 191 F. App’x at 372. Moreover, as in Raskin, Dr. Shea did not provide any new medical evidence to support his change of opinion. (See D.N. 13, PageID # 131–34) Indeed, the letter’s handwritten recommendations are refuted by Dr. Shea’s own medical notes. Throughout his treatment notes, Dr. Shea opines that Moody suffers “no neurologic deficit.” (See, e.g., id., PageID # 275) His notes also cite the MRIs that Moody received and which indicate that she has experienced merely “mild” degenerative change. (Id., PageID # 268, 270) It was therefore reasonable for Liberty to place greater emphasis on Dr. Shea’s earlier findings, which were based on Moody’s MRIs and noted that while the range of motion of Moody’s neck was limited, “there [was] no neurologic deficit and [she had] good strength in her hand.” (Id., PageID # 275)
    The entire opinion is attached below.
    Attached Files
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