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Jacobs v. Prudential Insurance Company of America

United States District Court, E.D. Louisiana

July 31, 2015

KARL JACOBS
v.
PRUDENTIAL INSURANCE COMPANY OF AMERICA, ET AL., SECTION

ORDER & REASONS

ELDON E. FALLON, District Judge.

Before the Court are Defendants Prudential Insurance Company of America's ("Prudential") Motion for Judgment on the Administrative Record (Rec. Doc. 87) and Lockheed Martin Corporation's ("Lockheed Martin") Motion for Summary Judgment (Rec. Doc. 89). Having reviewed the applicable law and memoranda, the Court now issues this Order & Reasons.

I. BACKGROUND

This case is before the Court as an appeal of Prudential's denial of Plaintiff Karl Jacobs' Accidental Death and Dismemberment ("AD&D") benefits claim for Total and Permanent Disability. Mr. Jacobs was a participant in Lockheed Martin's group benefits plan ("the Plan"), which is governed by the Employee Retirement Security Act ("ERISA"), 29 U.S.C. ยง 1001, et seq. (Rec. Doc. 87-1 at 2). Mr. Jacobs avers he became totally disabled as a result of a work-related accident on May 16, 2001 and is entitled to AD&D benefits.

II. UNDISPUTED FACTS

On May 16, 2001, a steel handle of a milling machine struck Mr. Jacobs in the chest, causing him to be thrown in the air and landing on the back of his right shoulder. (Rec. Doc. 87-6 at 17, 110). The machine also caught his leg as he landed. (Rec. Doc. 87-6 at 17, 110). Mr. Jacobs sustained injuries to his both his shoulders and his knees. Dr. Marleece Barber, Lockheed Martin's company doctor, saw Mr. Jacobs and diagnosed him with a left thoracic contusion and mild cervical strain, and restricted him to light duty, including no lifting, pushing, or pulling over fifteen (15) pounds. (Rec. Doc. 87-5 at 183). Mr. Jacobs later saw Dr. James Gosey for injuries to his shoulders and knee. (Rec. Doc. 87-6 at 33). On July 31, 2002, Mr. Jacobs underwent right shoulder arthroscopy with decompression and was out of work following the surgery until the end of September 2003. (Rec. Doc. 87-5 at 107; 87-6 at 110, 169). Mr. Jacobs underwent a left knee arthroscopy on February 14, 2003, due to a tear of the medial meniscus, and underwent a left shoulder arthroscopy on May 30, 2003 due to a degenerative shoulder joint and partial rotator cuff tear. (Rec. Doc. 87-5 at 6, 133). On December 8, 2003, Mr. Jacobs underwent a right knee arthroscopy due to a torn medial meniscus and underwent a follow-up right knee arthroscopy on December 19, 2003. (Rec. Doc. 87-5 at 53-54). Mr. Jacobs underwent a right should arthroscopic surgery on November 24, 2004 due to a degenerative shoulder joint. (Rec. Doc. 87-5 at 109).

In 2006, Mr. Jacobs retained three attorneys who assisted him in pursuing his workers compensation claims related to the May 16, 2001 accident: David Benedict, Harold Bartholomew, and James Bates. (Rec. Doc. 89-4 at 4, 7). Mr. Jacobs testified that he specifically went to see Harold Bartholomew concerning the issue of whether or not he was entitled to accident and sickness insurance. (Rec. Doc. 8904 at 7). Mr. Jacobs further testified that he also asked Mr. Bates to handle this issue, but Mr. Bates told him they needed to focus on Mr. Jacobs' workers compensation claim first. (Rec. Doc. 89-4 at 8).

On August 24, 2007, The Social Security Administration ("SSA") found Mr. Jacobs disabled for the period of July 31, 2002 until January 4, 2004 because he was unable to perform a full range of sedentary work. (Rec. Doc. 87-6 at 40). Mr. Jacobs was represented by attorney David Benedict during these proceedings, which included a hearing where Mr. Jacobs along with vocational expert, Karen Harrison, testified. (Rec. Doc. 87-6 at 43). The SSA ordered the retroactive payment of disability insurance benefits for that time period. (Rec. Doc. 87-6 at 41). The SSA also concluded that as of January 4, 2004, Mr. Jacobs had obtained medical improvement and that

[a]fter January 4, 2004, the claimant has the following residual capacity: lift and carry 10-15 pounds occasionally; sit 6-8 hours total in an 8-hour work day, walk and/or stand 2-4 hours told in an 8-hour work day, and perform work, which does not require overhead work, knelling, crawling, squatting or climbing of ropes or ladders.

(Rec. Doc. 87-6 at 39-40). The SSA thus held that Mr. Jacobs was not disabled as of January 4, 2004. (Rec. Doc. 87-6 at 40).

Mr. Jacobs returned to Lockheed Martin under the SSA's return-to-work program. Mr. Jacobs went on medical leave effective May 2, 2007 and officially retired on September 1, 2007 with medical retirement benefits and full, long-term disability. (Rec. Doc. 87-6 at 142). As an employee, Mr. Jacobs participated in Lockheed Martin's group benefits plan, which is governed by ERISA. Mr. Jacobs' plan provides for AD&D benefits. This Plan provision states:

If, while insured under the Policy, you suffer accidental bodily injury which independent of all other causes, results in your permanent and total disability, you may receive a Permanent Total Disability Benefit at the end of 12 months you are permanently and totally disabled provided:
1. Beginning no later than 30 days after the covered accident, you are unable to perform the duties of your job, and
2. After one year and for the rest of your life thereafter you are unable to work at any job suitable to your education, training or experience or any job for which you can become qualified for by reason of education, experience, or training.

(Rec. Doc. 87-7 at 13). The Prudential certificate of insurance that was in effect when Mr. Jacobs filed his claim for benefits states that AD&D coverage is available for Total and Permanent Disability. (Rec. Doc. 87-1 at 4). Under the Plan, "a person is Totally and Permanently Disabled when: (1) Total Disability exists; and (2) Total Disability is such that condition (2) of the Total Disability definition will be met for the rest of the person's lifetime." (Rec. Doc. 87-9 at 28). Total Disability is defined as follows:

A person is Totally Disabled when:

(1) The person is now working at any job for wage or profit; and
(2) Due to accidental bodily injury;
(a) the person is not able to perform, for wage or profit, the material and substantial duties of that person's occupation; and
(b) beyond one year after the person sustains the injury, the person is not able to perform, for wage or profit, the material and substantial duties of any job for which the person is reasonably fitted ...

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