United States District Court, M.D. Florida, Fort Myers Division
GEORGE T. GOROS, Plaintiff,
SUN LIFE ASSURANCE COMPANY OF CANADA, Defendant.
OPINION AND ORDER 
POLSTER CHAPPELL UNITED STATES DISTRICT JUDGE
matter comes before the Court on consideration of the
Honorable Carol Mirando's Report and Recommendation (Doc.
29), filed on June 28, 2017. Judge Mirando recommends that
Plaintiff George T. Goros' (“Goros”) Motion
for Summary Judgment (Doc. 22) be denied, and that Defendant
Sun Life Assurance Company of Canada's (“Sun
Life”) Motion for Summary Judgment (Doc. 19) be
granted. (Doc. 29 at 41-42). Thereafter, Goros filed his
objections (Doc. 30), and Sun Life responded in opposition
(Doc. 31). The matter is ripe for review.
case involves an attempt to recover insurance benefits under
the Employee Retirement Income Security Act
(“ERISA”) under a group policy (the
“Policy”) issued by Sun Life to Goros' former
employer, United Plastic Fabricating Inc. (“United
Plastic”). From October 1995 to November 2012, Goros
was the Executive Vice President of Manufacturing Operations
for United Plastic. (Docs. 14-1 at 105; 14-4 at 58). In that
role, he wielded administrative responsibility for three
manufacturing plants in Michigan, Massachusetts and Florida.
(Doc. 14-1 at 115). Notably, the Policy included a long-term
disability income provision (the “Long Term Disability
Policy”) and a life insurance waiver of premium
provision (the “Premium Waiver Policy”)
(collectively, the “Disability Benefits”). (Doc.
14-1 at 34, 60).
the Long Term Disability Policy provides a monthly benefit to
replace the income a disabled person could otherwise earn.
(Doc. 14-1 at 77). Its terms state that eligibility for
monthly benefits hinges on the production of proof of
continued total or partial disability and the continuing care
of a doctor who provides regular examinations in accordance
with the disabling condition. (Doc. 14-1 at 77). It also
requires such information to be provided to Sun Life upon
request. (Doc. 14-1 at 77).
the Premium Waiver Policy provides for the continuation of
life insurance coverage over a totally disabled individual
without payment of premiums. (Doc. 14-1 at 60). Its terms
allow Sun Life to require periodic proof of the continuation
of the total disability condition and to designate a doctor
to examine the individual as often as is reasonable. (Doc.
14-1 at 60). Importantly, both the Long Term Disability
Policy and the Premium Waiver Policy grant Sun Life total
discretionary authority to make all final decisions regarding
an individual's eligibility for benefits. (Doc. 14-1 at
this backdrop, on November 18, 2012, Goros first visited Dr.
Daniel Kunz, D.O. to seek treatment for lower-back and hip
pain and stiffness he claimed had persisted for the previous
two years. (Doc. 14-1 at 145). While being examined, Goros
further claimed he experienced such a loss in his range of
motion he could no longer drive. (Doc. 14-1 at 145). Dr. Kunz
diagnosed Goros with ankylosing spondylitis, arthritis that
affects the spine. (Doc. 14-1 at 148). Goros was prescribed a
medication called Simponi to reduce his symptoms and to
prevent spinal fusion. (Doc. 14-1 at 148). Thereafter, Goros
continued to work at United Plastic until November 20, 2012,
when he ceased employment-related activities. (Docs. 14-1 at
103; 14-4 at 58).
January 4, 2012, Goros filed a claim for benefits under the
Long Term Disability Policy. (Doc. 14-1 at 103-116). With
that filing, Dr. Kunz submitted an opinion that Goros had
severe limitations in his functional capacity, and could not
drive or sit for more than three hours, could not walk for
more than four hours, and could not function in a full-time
or part-time employment capacity. (Doc. 14-2 at 7-8).
Subsequently, Sun Life obtained an occupational analysis of
Goros' position as the Executive Vice President of
Manufacturing Operations for United Plastic, which was
classified as light work (the “Occupational
Analysis”). (Doc. 14-2 at 126). The Occupational
Analysis stated that the demands of light work included
“exerting up to 20 pounds of force occasionally or up
to 10 pounds of force frequently, or a negligible amount of
force constantly to move objects[, ]” as well as
“occasional traveling.” (Doc. 14-2 at 126).
also participated in an in-person interview with a Sun Life
representative on January 22, 2013. (Doc. 14-4 at 54-63).
While speaking about his medical history, he stated his joint
problems stretched back to the late 1990's, but that some
doctors since then had attributed his ailments to his
personal activities. (Doc. 14-4 at 58). In November of 2012,
Goros stated his pain had become excruciating, and it was
then that he sought treatment from Dr. Kunz. (Doc. 14-4 at
59). Notably, Goros also indicated that he was a motorcycle
enthusiast, and tearfully contemplated the probability he
would never again be able to ride his motorcycle. (Doc. 14-4
its evaluation, on March 4, 2013, Sun Life had Dr. Nadia
Habal, M.D. conduct a peer review of Goros' medical
records. (Doc. 14-4 at 73-79). After doing so, Dr. Habal
opined that it was not medically reasonable for Goros to
sustain full time light work employment, regardless of
whether there were restrictions or modifications. (Doc. 14-4
at 78-79). Likewise, she opined that it was not medically
reasonable for Goros to sustain full time sedentary
employment. (Doc. 14-4 at 79).
on March 7, 2013, after conducting the Occupational Analysis,
an in-person interview and a peer review of Goros'
medical records, Sun Life approved Goros' request for
benefits under the Long Term Disability Policy. (Doc. 14-4 at
86). On May 17, 2013, Sun Life also approved Goros'
benefits under the Premium Waiver Policy. (Doc. 14-5 at 55).
November 22, 2013, Sun Life offered Goros $202, 351.80 to
discharge its obligation to pay the totality of the Long Term
Disability Policy. (Doc. 14-6 at 18-19). Similarly, Sun Life
offered Goros $46, 009.60 to discharge its obligation to pay
the totality of the Premium Waiver Policy. (Doc. 14-6 at
25-26). Goros indicated he was not interested in the offer
regarding the Long Term Disability Policy, but would consider
the offer regarding the Premium Waiver Policy. (Doc. 14-1 at
9-10). No final agreement on either provision was ever
April 4, 2014, Sun Life began conducting an update of
Goros' claim file. (Doc. 14-6 at 28). During the process,
Sun Life requested proof of Goros' continued disability
and conducted a background check. (Doc. 14-6 at 28, 47-64).
Upon reviewing the results of the background check, however,
Sun Life discovered that in June of 2013, Goros' ex-wife
had posted on social media she was “[h]ome from 5 hrs
of riding. 300 miles. Back from 3 great days at bike week
w[ith] [Goros].” (Doc. 14-6 at 52). Among other posts,
she also uploaded a picture with Goros on December 30, 2013,
with the caption “[Goros] is ready for our Christmas
drive down the coast!” (Doc. 14-6 at 55).
triggered, from April 25, 2014 until April 27, 2014 Sun Life
conducted video surveillance of Goros. (Doc. 14-6 at 65-82).
On the morning of the first day, a Sun Life representative
observed Goros getting in and out of a vehicle, driving,
walking quickly, bending, leaning forward, pushing a lawn
fertilizer spreader in the yard outside his home, examining
sprinklers and stomping on the ground. (Doc. 14-6 at 68-69).
In the afternoon, Goros went to a bar where he was observed
sitting on a barstool, leaning against the bar, drinking
martinis, and periodically exiting to smoke cigarettes over
the course of one hour and 50 minutes. (Doc. 14-6 at 70). The
Sun Life representative then made conversation with Goros,
who was seemingly unaware of the representative's true
identity. (Doc. 14-6 at 70). Goros represented that he was
selling his home and moving to Florida, and that he owned and
used a motorcycle. (Doc. 14-6 at 70). Goros further
represented that he was retired, but that he had a separate
business to purchase appreciating properties and sell them
for profit. (Doc. 14-6 at 70).
morning of the second day, Goros was observed driving back to
the same bar he had frequented on the previous day. (Doc.
14-6 at 72). Once there, he opened the trunk, reached in, and
bent at the waste to acquire a plastic bag containing
multiple items. (Doc. 14-6 at 72). He then closed the trunk,
walked to the front door of the bar, and entered. (Doc. 14-6
at 72). Shortly thereafter, he exited, retrieved an item from
the passenger side of his vehicle, and then re-entered the
bar. (Doc. 14-6 at 72). Later, Goros drove to another
property he owned, an office supply store and a home goods
store, and was seen bending at the waste to remove a floor
mat from his vehicle, shaking the floor mat, and placing it
back into his vehicle. (Doc. 14-6 at 72).
third day, Goros was observed bending at the waist and knees,
carrying a piece of glass under his arm, carrying a metal
table frame above his head, carrying a wood table with the
help of another person, and carrying a couch with the help of
another person. (Doc. 14-6 at 74-76). As the day progressed,
Goros was seen at a restaurant, where he bent down while
smoking a cigarette, and thereafter at a home development
store, where he pushed a shopping cart, picked up items such
as small tables and plants, and placed them in the shopping
cart. (Doc. 14-6 at 78-79). Upon returning to his home, Goros
was again observed picking up a small table from the ground
and carrying it. (Doc. 14-6 at 81).
Life also obtained additional video surveillance of Goros
between May 18, 2014 and May 24, 2014. (Doc. 14-7 at 4-16).
While Goros was not seen on the first day of surveillance, on
the second day Goros was observed getting in and out of a
newly purchased sports car, driving to a bank, an office
supply store, and to the same bar he had been seen at during
the prior surveillance. (Doc. 14-7 at 4-8). He remained at
the bar during the afternoon, exiting intermittently to smoke
cigarettes and converse with individuals. (Doc. 14-7 at 7-8).
third day, Goros was seen driving the sports car to a
doctor's office, and then to a pharmacy. (Doc. 14-7 at
9). After driving the sports car back to his home, he rode as
a passenger to the same bar he had frequented on previous
dates. (Doc. 14-7 at 9). He was again observed leaving the
bar intermittently to smoke cigarettes, converse with
individuals, and at one point, he was seen squatting to pick
up a cigarette from the ground. (Doc. 14-7 at 9).
fourth day, Goros was seen driving an SUV to a pharmacy and
returning to his residence. (Doc. 14-7 at 10-11). And while
he remained in his home for the remainder of the day, on the
fifth day he was observed walking around his neighborhood
carrying poster board, and then driving his sports car back
to the same bar he had frequented on prior occasions, exiting
intermittently to smoke cigarettes and converse with other
individuals, but otherwise remaining there until the late
afternoon. (Doc. 14-7 at 11-12). Then, on the last day, Goros
was seen conducting a garage sale at his home, wherein ...