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Gilcrest v. Unam Life Insurance Co. of America

June 30, 2006


The opinion of the court was delivered by: Judge Gregory L. Frost

Magistrate Judge Abel


In this Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq. ("ERISA") action, Plaintiff Robert Gilcrest ("Gilcrest") appeals the decision of Defendants Unum Life Insurance Company ("Unum") and Government ("GLC") to terminate his long-term disability benefits. (Doc. # 1). The parties have filed cross-motions for judgment on the administrative record, and briefing on those motions is now complete. (Docs. # # 24, 25, 27, 28). See also Wilkins v. Baptist Healthcare Sys., 150 F.3d 609, 619 (6th Cir. 1998).

For the reasons that follow, the Court DENIES Gilcrest's motion (Doc. # 25) and GRANTS the motion of Unum and GLC. (Doc. # 24).


GLC formerly employed Gilcrest. During his employment with GLC, Gilcrest was eligible for, and a participant in, GLC's employee welfare benefit plan ("Plan"). The Plan was established and maintained pursuant to the provisions ofERISA. Unum was the plan administrator and also paid benefits under the Plan. (AR 272, 285).*fn1

Gilcrest injured his back on September 12, 2003 while he was still a GLC employee. Subsequent to his injury, Gilcrest applied for and was granted short term disability benefits under the Plan. Gilcrest also applied for and received Social Security disability benefits. After his eligibility for short-term benefits expired, Gilcrest applied for and was awarded long term disability benefits. (AR 781-784). Unum suspended those benefits effective October 12, 2004 upon determining that his back injury did not prohibit him from performing his regular occupation. Id. at 782.

The parties dispute neither the nature nor the extent of Gilcrest's injury. In addition, the parties agree on the work limitation placed on Gilcrest by his physician, Dr. Joseph Shehadi, M.D. ("Shehadi"); specifically, Gilcrest was prohibited from lifting more than twenty-five (25) pounds. Id. at 769. Rather, in an unusual twist on the standard ERISA case, the parties disagree on the appropriate job description for Gilcrest's position with GLC.

I. Plan Language

The plan defines "disabled" as follows

You are disabled when Unum determines that: - 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 or injury.

After 36 months 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 297). "Limited" means "what [the insured] cannot or [is] unable to do." Id. at 319. The phrase "material and substantial duties" describes duties that "are normally required for the performance of [the insured's] regular occupation, and cannot be reasonably omitted or modified." Id. The Plan defines "regular occupation" as "the occupation [the insured is] routinely performing when [the insured's] disability begins. Unum will look at [the insured's] 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." Id. at 321. Lastly, "gainful occupation" means "an occupation that is or can be expected to provide [the insured] with an income within 12 months of your return to work, that exceeds 80% of [the insured's] indexed monthly earnings, if [the insured is] working, or 60% of [the insured's] indexed monthly earnings, if [the insured is] not working." Id. at 318.

The Plan also stated that benefit payments "may be reduced by deductible sources of income and disability earnings." Id. at 276. The Plan defined "deductible sources of income" as "income from deductible sources listed in the Plan which [the insured] receive[s] or is entitled to receive." Id. at 318. Social Security benefits were listed in the Plan as a type of deductible source of income. Id. at 300. Moreover, the Plan stated that Unum had the right to recover any overpayments due to any error Unum made in processing an insured's claim and any overpayments from the insured's receipt of deductible sources of income. Id. at 281.

II. Job Description

Several documents in the claim file are pertinent to the issue of Unum's selection of Gilcrest's job description. In Gilcrest's initial application for short term disability benefits, Linda Barckett ("Barckett"), GLC's benefits administrator, checked a box on the form indicating that Gilcrest's position as an assistant site manager was classified as a medium occupation requiring lifting of twenty-one to fifty pounds. Id. at 16. Attached to that document was GLC's job description ...

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