United States District Court, D. South Dakota, Southern Division
Janelle Jansen, Plaintiff: Peter J. Bendorf, Bendorf Law
Firm, PLLC, Sioux Falls, SD.
Lincoln Financial Group, The Lincoln National Life Insurance
Company, Group Long Term Disability Insurance For The
Employees of The Minute Clinic Group of Employers, The Minute
Clinic Group of Employers, Defendants: Christopher R.
Hedican, LEAD ATTORNEY, Baird Holm LLP, Omaha, NE; Steven D.
Davidson, PRO HAC VICE, Baird Holm LLP, Omaha, NE.
AND ORDER DENYING PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT
AND GRANTING DEFENDANTS' MOTION FOR SUMMARY
A. LANGE, UNITED STATES DISTRICT JUDGE.
Janelle Jansen filed suit under 29 U.S.C. §
1132(a)(1)(B) claiming that Defendants improperly denied her
benefits under a long-term disability plan governed by the
Employee Retirement Income Security Act of 1974 (ERISA), 29
U.S.C. § § 1001-1461. Doc. 11-1. The parties
filed cross-motions for summary judgment on whether Jansen
met the insurance plan's definition of " Totally
Disabled" and was therefore entitled to benefits. For
the reasons explained below, this Court denies Jansen's
motion and grants the Defendants' motion.
Court draws the facts from the administrative record and the
portions of the statements of material facts that are either
undisputed or not subject to genuine dispute. This dispute
arises out of Jansen's claim of disability under the
ERISA-governed plan of her former employer the Minute Clinic.
Minute Clinic offers employees long-term disability insurance
through its benefit plan (the Plan). Doc. 28 at ¶ 2;
Doc. 31 at ¶ 1; Doc. 24-2 at ¶ 1; Doc. 37 at ¶
1. The Lincoln National Life Insurance Company (Lincoln)
insures and administers the Plan and has discretionary
authority to construe the terms of the Plan and make
eligibility determinations. Doc. 28 at ¶ ¶ 2, 6;
Doc. 31 at ¶ ¶ 1, 3; Doc. 24-2 at ¶ 2; Doc. 37
at ¶ 2; Doc. 28-2 at 64. The Plan provided for long-term
disability benefits if an insured was " Totally
Disabled" as defined by the Plan, under the regular care
of a physician, and submitted proof of disability to Lincoln
upon request. Doc. 28-2 at 71. The Plan has two different
definitions of " Totally Disabled" or " Total
Disability" depending on the time frame for which
benefits are sought. The first definition applies during the
" Own Occupation
Period," which begins after the initial ninety-day
elimination period and lasts through the following
twenty-four months. Doc. 28 at ¶ 3; Doc. 31 at ¶ 1;
Doc. 28-2 at 54, 71. During the Own Occupation Period,
Totally Disabled " means that due to an Injury or
Sickness the Insured Employee is unable to perform each of
the main duties of his or her regular occupation." Doc.
28 at ¶ 3; Doc. 31 at ¶ 1; Doc. 28-2 at 71. Once
the Own Occupation Period expires, a second, more restrictive
definition of Totally Disabled kicks in: " it means that
due to an Injury or Sickness the Insured Employee is unable
to perform each of the main duties of any gainful occupation
which his or her training, education or experience will
reasonably allow." Doc. 28 at ¶ 3; Doc. 31 at
¶ 1; Doc. 28-2 at 71.
Plan also contains a " Specified Injuries or Sicknesses
Limitation," which states:
If an Insured Employee is Disabled primarily due to one or
more of the Specified Injuries or Sicknesses defined below;
then Partial or Total Disability Monthly Benefits:
1. will be payable subject to the terms of this Policy; but
2. will be limited to 24 months for any one period of
Disability; unless the Insured Employee is confined to a
Hospital. " Specified Injuries or Sicknesses"
include any Mental Sickness, or Substance Abuse, as defined
Doc. 28 at ¶ 4; Doc. 31 at ¶ 2; Doc. 28-2 at 77.
The Plan defines " Mental Sickness" as:
any emotional, behavioral, psychological, personality,
adjustment, mood or stress-related abnormality, disorder,
disturbance dysfunction or syndrome; regardless of its cause.
It includes, but is not limited to:
1. schizophrenia or schizoaffective disorder;
2. bipolar affective disorder, manic depression, or other
3. obsessive-compulsive, depressive, panic or anxiety
These conditions are usually treated by a psychiatrist, a
clinical psychologist or other qualified mental health care
provider. Treatment usually involves psychotherapy,
psychotropic drugs or similar methods of treatment.
Doc. 28 at ¶ 4; Doc. 31 at ¶ 2; Doc. 28-2 at 77.
was a nurse practitioner for the Minute Clinic in Minnesota
until October 27, 2009, when, at age fifty-four, she stopped
working because of non-ischemic congestive heart
failure. Doc. 28 at ¶ ¶ 2, 7; Doc. 31
at ¶ ¶ 1, 3; Doc. 24-2 at ¶ 2; Doc. 37 at
¶ 2. An echocardiogram performed that day showed that
Jansen's ejection fraction was below normal at
thirty percent. Doc. 28-4 at 224. Doctors treated Jansen with
heart medications and the placement of a biventricular
implantable cardioverter-defibrillator (ICD), a device used
to control cardiac arrhythmias. Doc. 28-4 at 219, 221,
223. Thereafter, Jansen submitted a claim for long-term
disability benefits with Lincoln. Doc. 28-4 at 194. Lincoln
determined that Jansen was unable to perform the main duties
of her occupation as a nurse practitioner and awarded her
long-term disability benefits effective January 26, 2010.
Doc. 28 at ¶ 8; Doc. 31 at ¶ 3; Doc. 24-2 at ¶
3; Doc. 37 ¶ 3; Doc. 28-4 at 194-196.
the following year and a half, Jansen treated with internist
Dr. Donald Somers, cardiologist Dr. Luis Pagan-Carlo, and
psychiatrist Dr. Molly Silas. At a March 2010 appointment
with Dr. Pagan-Carlo, Jansen reported feeling " pretty
well" overall but still having some fatigue. Doc. 28-3
at 344. Dr. Pagan-Carlo remarked in his notes that Jansen
walked around the unit with him " at a relatively rapid
pace" without experiencing shortness of breath or being
unable to talk. Doc. 28-3 at 345. Jansen's ejection
fraction had increased to fifty percent and Dr. Pagan-Carlo
believed that she was " doing well." Doc. 28-3 at
345. According to Dr. Somers's notes from an April 2010
appointment, Jansen was " making very slow but steady
progress." Doc. 28-4 at 160. On May 13, 2010, Dr.
Pagan-Carlo completed an attending physician's statement
form from Lincoln. Doc. 28-4 at 146-48. He identified
Jansen's work capacity as " medium," which
meant that she could occasionally lift up to fifty pounds,
frequently lift up to twenty-five pounds, and typically be on
her feet a minimum of six hours out of an eight-hour workday.
Doc. 28-4 at 148. He also marked on the form that Jansen was
not totally disabled from her job or any other job and that
she could return to work part time at five hours a day. Doc.
28-4 at 147.
Somers's suggestion, Jansen began seeing Dr. Silas for
psychiatric treatment. Doc. 28-3 at 306. Jansen had a history
of psychiatric issues, having previously been diagnosed with
depression and bipolar II disorder. Doc. 28-2 at 408, 441;
Doc. 28-3 at 11. Her past treatment for these conditions
included electroconvulsive therapy, Doc. 28-2 at 419-28,
three voluntary hospitalizations in 2004, Doc. 28-2 at
407-11, 434-37; Doc. 28-3 at 9-16, and psychotropic
medications, Doc. 28-3 at 12, 81-83, 87-120. When Jansen saw
Dr. Silas for an initial evaluation on May 21, 2010, she was
not depressed or manic, and Dr. Silas rated her concentration
as good. Doc. 28-3 at 306. Dr. Silas concurred with the prior
diagnosis of bipolar II disorder
and adjusted Jansen's psychotropic medications. Doc. 28-3
at 304-309. After seeing Jansen on May 27, 2010, Dr.
Pagan-Carlo wrote that he had trouble communicating with her
and opined that she may have been " in a bipolar
crisis." Doc. 28-3 at 343.
visited Dr. Silas again on June 23, 2010. Doc. 28-3 at 302.
Jansen reported doing well, with fewer symptoms of
depression. Doc. 28-3 at 302. Dr. Silas noted that
Jansen's thought process, memory, affect, judgment,
insight, and speech were normal and assessed Jansen as doing
" significantly better" on the adjusted medication
regimen. Doc. 28-3 at 302. Although Jansen exhibited an
impaired affect and appearance and had thoughts of suicide
when she saw Dr. Silas in June and September of 2010, other
aspects of her mental function, including her speech,
insight, memory, judgment, and orientation, remained normal.
Doc. 28-3 at 300-01.
early October 2010, Jansen learned that the Social Security
Administration had determined that she became disabled under
the Administration's rules as of September 10, 2010. Doc.
28-4 at 33. Jansen saw Dr. Silas for a follow up on October
8, 2010, during which Jansen reported that she had enjoyed a
recent trip to Italy and that she was getting " a little
bit better." Doc. 28-3 at 298. Dr. Silas noted that
Jansen was negative for suicidal ideation and that her mental
function appeared normal. Doc. 28-3 at 298. She assessed
Jansen as having bipolar II disorder and anxiety disorder but
as doing " fairly well." Doc. 28-3 at 298. Jansen
saw Dr. Pagan-Carlo five days later. Doc. 28-3 at 338. She
complained of occasional chest and back pain and said that
although she had traveled to Italy, she got more tired than
she thought appropriate. Doc. 28-3 at 338. Given Jansen's
history and complaints of chest pain, Dr. Pagan-Carlo ordered
a nuclear stress test, Doc. 28-3 at 339, which came back
normal, Doc. 28-3 at 336.
reported worsening depression, low energy, and poor
concentration when she saw Dr. Silas in December 2010. Doc.
28-3 at 296. She told Dr. Silas of a week-and-a-half period
when she did not get out of bed or shower. Doc. 28-3 at 296.
Dr. Silas noted that Jansen was negative for suicidal
ideation and that her mental function was normal. Doc. 28-3
at 296. She assessed Jansen as having an increase in
depression and adjusted her medication. Doc. 28-3 at 296.
Jansen's mood was better when she visited Dr. Silas the
next month. Doc. 28-3 at 295. Dr. Silas recorded that
although Jansen's appearance and affect were impaired,
the remaining aspects of her mental function were normal.
Doc. 28-3 at 295.
February 4, 2011, Jansen saw Dr. Pagan-Carlo's
physician's assistant (PA), complaining of an increase in
chest and back discomfort. Doc. 28-3 at 334. The PA noted
that Jansen had " just recently returned from a trip to
Key West where she was quite active doing parasailing, jet
skiing, snorkeling, etc. and was pretty much on the go the
whole time she was there." Doc. 28-3 at 334. Jansen
reported that she had experienced a dramatic decrease in
energy and some exertional shortness of breath since her
return. Doc. 28-3 at 334. Unsure of the etiology of
Jansen's symptoms, the PA ordered a stress test. Doc.
28-3 at 336. The test
was normal and showed that Jansen's ejection fraction was
sixty-three percent. Doc. 28-3 at 351-52. After seeing Jansen
on February 23, 2011, Dr. Silas diagnosed her as having
bipolar II disorder, anxiety disorder, and posttraumatic
stress disorder. Doc. 28-3 at 294. She recorded that
Jansen's affect was impaired and that she was having
suicidal thoughts, but that other aspects of Jansen's
mental function were normal. Doc. 28-3 at 294.
Silas completed an attending physician's statement form
from Lincoln on April 1, 2011. Doc. 28-3 at 408-09. She
identified Jansen as having a class three mental impairment,
which meant that Jansen was able to engage in only limited
stress situations and interpersonal relationships. Doc. 28-3
at 408. When asked on the form whether Jansen was totally
disabled from her job and any other work, Dr. Silas checked
" yes" and wrote " cardiac related." Doc.
28-3 at 409. She marked that Jansen's disability would
not improve in the future. Doc. 28-3 at 409. At a followup
with Dr. Pagan-Carlo's PA later that month, Jansen
reported exertional nausea and fatigue along with pain in her
shoulder blades. Doc. 28-3 at 330. The PA remained uncertain
about the etiology of Jansen's shoulder pain but felt
that Jansen's two normal stress tests within the last six
months made it unlikely that ischemia was the cause. Doc.
28-3 at 332.
moved from Minnesota to Sioux Falls, South Dakota in July
2011 to be closer to her family. Doc. 28-3 at 255. She began
treating with psychiatrist Dr. William Fuller, internist Dr.
Richard Nelson, and cardiologist Dr. Bruce Watt. Jansen's
first appointment in Sioux Falls was on July 7, 2011, with
Dr. Fuller. Doc. 28-3 at 255. She reported having four
depressive swings since January 2011, during which she had
increased anxiety, low energy, and difficulty meeting her
responsibilities. Doc. 28-3 at 255. A mental status
examination that day was normal, with Jansen displaying a
logical thought process and good concentration and focus.
Doc. 28-3 at 256. Dr. Fuller, who had treated Jansen for a
" fairly lengthy period of time" in the past, wrote
that her " history of bipolar illness is very well
documented. I have ...