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Mantica v. Unum Life Insurance Company of America

United States District Court, D. Maryland

March 11, 2019

PAMELA MANTICA Plaintiff,
v.
UNUM LIFE INSURANCE COMPANY OF AMERICA Defendant

          MEMORANDUM OPINION

          Richard D. Bennett United States District Judge.

         Plaintiff, Pamela Mantica ("Ms. Mantica") brings this action under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001, et seq., against Defendant Unum Life Insurance Company of America ("Unum"), seeking a declaration of entitlement to disability benefits, payment of back benefits plus interest, and payment of attorney's fees and costs. (Compl., ECF No. 1.) Unum paid Ms. Mantica monthly long-term disability benefit payments from April 2015 through April 2017 and then determined that Ms. Mantica was no longer eligible for the benefit. (ECF No. 14-1 at 1.) Ms. Mantica claims that she is entitled to ongoing disability benefits, has timely pursued the appeals process, and exhausted all administrative appeals prior to filing suit. (ECF No. 1 at ¶¶ 18-19.) Currently pending before this Court are Defendant Unum Life Insurance Company of America's Motion for Summary Judgment (ECF No. 14) and Plaintiffs Cross Motion for Summary judgment (ECF No. 13). The parties' submissions have been reviewed and no hearing is necessary. See Local Rule 105.6 (D. Md. 2018). As explained herein, application of Maryland law to this ERISA case requires this Court to perform a de novo review of Ms. Mantica's claim for long-term disability benefits, which requires credibility determinations and findings of fact. Therefore, Defendant Unum Life Insurance Company of America's Motion for Summary Judgment (ECF No. 14) shall be DENIED, Plaintiffs Cross Motion for Summary Judgment (ECF No. 13) shall be DENIED, and this case shall proceed to a bench trial on the Evidentiary Record with additional witness testimony.[1]

         BACKGROUND

         I. Ms. Mantica's Occupation

         Ms. Mantica is a college graduate, holding both a Bachelor of Science Degree and a Registered Professional Nurse Degree. (ER 316, 333.) She has computer technology skills as well as experience in home care nursing, ICU/CCU nursing, teaching, training, public speaking, and sales of medical devices. (ER 318-19.) Ms. Mantica was hired as an Acute Support Consultant II by Alere, Inc. ("Alere") on November 17, 2008. (ER 5). Her job description included the requirement to travel to provide clinical and technical training, assisting in performing and writing studies, educating staff on products, supporting a sales team, resolving customer complaints and inquiries, maintaining knowledge of pertinent federal and other regulations, creating and maintaining product implementation programs, and devising strategies for account retention. (ER 253-54, 258.) The job requirements placed it at the "Light" level of exertion as defined in the Dictionary of Occupations Titles, 4th ed. (1991, Revised). (ECF No. 13-1 at 21; ER 274.)

         II. The Plan & Policy

          Alere purchased Unum group long-term disability insurance policy 574975 003 (the "Policy") on January 1, 2009 as part of its employee benefit plan (the "Plan"), and the Policy covered Ms. Mantica as a full-time employee. (ER 54, 85.) In its capacity as Plan Administrator, Alere delegated discretionary authority for the Policy's interpretation and claim determinations to Unum. (ER 91.)

         The Policy, in pertinent part, defines disability 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 24 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.
You must be under the regular care of a physician in order to be considered disabled.
The loss of a professional or occupational license or certification does not, in itself, constitute disability.
We may require you to be examined by a physician, other medical practitioner and/or vocational expert of our choice. Unum will pay for this examination. We can require an examination as often as it is reasonable to do so. We may also require you to be interviewed by an authorized Unum Representative.

(ER 67.) "Regular Occupation" is defined as "the occupation you are routinely performing when your disability begins." (ER 84.) "Gainful Occupation" is defined as "an occupation that is or can be expected to provide you with an income within 12 months of your return to work that exceeds: 80% of your indexed monthly earnings, if you are working, or 60% of your indexed monthly earnings, if you are not working." (ER 81.) "Material and Substantial Duties" is defined as duties that are "normally required for the performance of your regular occupation; and cannot be reasonably omitted or modified." (ER 82.) "Indexed Monthly Earnings" is defined as "monthly earnings adjusted on each anniversary of benefit payments by the lesser of 10% or the current annual percentage increase in the Consumer Price Index." (ER 82.) There is an "Elimination Period" of 180 days (ER 55), which is defined as "a period of continuous disability which must be satisfied before you are eligible to receive benefits from Unum." (ER 81; see also ER 61.)

         The proof of claim for long term disability must include:

- that you are under the regular care of a physician;
- the appropriate documentation of your monthly earnings;
- the date your disability began;
- the cause of your disability;
- the extent of your disability, including restrictions and limitations preventing you from performing your regular occupation; and
- the name and address of any hospital or institution where you received treatment, including all attending physicians.

(ER 57.)

         III. Ms. Mantica's Disability Claim

         A. Initial Claim

         Unum approved Ms. Mantica's short term disability benefits on November 11, 2014, [2]effective on her last day of work, October 30, 2014. (ECF No. 13-1 at 2; ECF No. 14-1 at 2; ER 5, 123.) According to Unum, the primary diagnosis was lumbar radiculopathy, and the secondary diagnosis was spinal stenosis (low back pain). (ECF No. 14-1 at 2.) By April 2015, Ms. Mantica's condition had not improved and ...


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