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Lohr v. Unitedhealth Group Incorporated

United States District Court, M.D. North Carolina

July 10, 2015

DONNA LOHR, Plaintiff,
v.
UNITEDHEALTH GROUP INCORPORATED, Defendant.

MEMORANDUM OPINION AND ORDER

N. CARLTON TILLEY, Jr., Senior District Judge.

This suit arises from a dispute between Plaintiff Donna Lohr and Defendant UnitedHealth Group Incorporated ("United") regarding United's denial of Ms. Lohr's claim for short-term disability ("STD") and, consequently, long-term disability ("LTD"). As a result, Ms. Lohr alleges, among other things, a violation of her rights under the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§ 1001-1461 ("ERISA").[1] The case is before the Court on Defendant's Motion for Judgment on the Administrative Record (Doc. #27).[2] For the reasons set forth below, Defendant's Motion will be GRANTED.

I.

A.

Ms. Lohr worked as a claims representative for United since 2005. (R. at 4.)[3] In that role, she was "responsible for providing expertise of general claims support to teams in reviewing, researching, investigating, negotiating, processing and adjusting claims" and was required to "[p]roactively identify solutions to non-standard requests" and to "solve moderately complex problems." (Id. at 108.) As a benefit of her employment, Ms. Lohr received STD insurance through the UnitedHealth Group Short-Term Disability Plan (the "STD Plan") and LTD insurance through the UnitedHealth Group Long-Term Disability Plan (the "LTD Plan").

Under the terms of the STD Plan, STD benefits are payable beginning "after the Claims Administrator determines that you are Disabled, and you have been Disabled for a period of five consecutive business days (which is also a seven-consecutive-calendar-day period)." (Id. at 101.) The STD benefits would remain payable for a 180-day period thereafter. (Id.at 103.) Under the terms of the LTD Plan, a participant is not eligible to receive LTD benefits unless he or she is "Disabled for each day of a 180-day calendar day period of time that starts on the first day of which [the Claims Administrator] determines that [he or she is] Disabled." (Id. at 113.)

In order for a participant in the STD Plan to be considered Disabled, the following four conditions must be met:

• You have been seen face-to-face by a Physician about your Disability within 10 business days of the first day of absence related to the Disability leave of absence;
• Your Physician has provided Medical Evidence that supports your inability to perform the material duties of your Own Occupation;
• You are under the Regular and Appropriate Care of a Physician; and
• Your Medical Condition is not work-related and is a Medically Determinable Impairment.

(Id. at 101; see also id. at 129 (defining "Disabled" under the STD Plan as being "unable to perform with reasonable continuity the Material Duties of your Own Occupation because of a non-work related Medical Condition"). Cf. id. at 112, 129 (defining "Disabled" under the LTD Plan).)

In order to qualify as a "Medically Determinable Impairment" under the fourth requirement, a "physical or mental impairment must be established by Medical Evidence consisting of signs, symptoms and laboratory findings, and not only by the individual's statement of symptoms." (Id. at 130.)

Of particular importance here, coverage under the Plans ends on "[t]he 90th day of a leave of absence, paid or unpaid, that is approved by [United] in writing, including Disability leave." (Id. at 100, 110.) In a section entitled "If Your Disability Leave Extends Beyond 90 Days, " the Governing Documents further explain:

If your approved Disability leave of absence extends beyond 90 days, your STD and LTD Plan coverage ends on the 90th day. However, if you are receiving STD Benefits or LTD Benefits at the time your coverage ends, you will continue to be eligible for STD Benefits or LTD Benefits as long as you continue to be Disabled under the ...

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