Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

STITH v. PRUDENTIAL INSURANCE COMPANY OF AMERICA

February 14, 2005.

CRYSTAL STITH, Plaintiff,
v.
PRUDENTIAL INSURANCE COMPANY OF AMERICA, Defendant.



The opinion of the court was delivered by: JEROME SIMANDLE, District Judge

OPINION

This matter comes before the Court on cross-motions for summary judgment by Defendant Prudential Insurance Company of America and Plaintiff Crystal Stith. Plaintiff alleges that Prudential's decision to terminate her long-term disability benefits under a group contract of insurance for disability coverage with Plaintiff's employer violates Section 502(a) of the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132(a). The principal issue to be addressed is whether Plaintiff has demonstrated that Prudential's decision to discontinue benefits was arbitrary and capricious upon review of the administrative record existing at the time Prudential made its determination. For the reasons discussed herein, Defendant's motion for summary judgment will be denied and Plaintiff's will be granted.

  BACKGROUND

  This case arises out of a denial of disability benefits by the Defendant, Prudential Insurance Company of America ("Prudential"), to the Plaintiff, Crystal Stith ("Stith"). Plaintiff seeks payment of disability benefits under an employee welfare benefit plan, as defined by ERISA, as amended, 29 U.S.C. § 1001, et seq. The ERISA plan was established and maintained by Stroock & Stroock & Lavan, LLP ("Stroock"), for the purpose of providing disability benefits to its employees. The Plaintiff was employed as a Client Accounting Operations Manager by Stroock from February 1981 to December 22, 1998 when she stopped working, claiming total disability.

  On January 18, 1999, Plaintiff applied for disability benefits, contending that she was disabled due to the effects of interstitial cystitis. This condition, for which there is no cure, causes severe pain and burning in the pelvic area, and a frequent and urgent need to urinate. In support of her application, numerous medical records were attached or obtained, including a letter dated January 18, 1999, prepared by Dr. Michael A. Pontari, a urologist responsible for Plaintiff's care, who is an associate Professor of Urology at Temple University School of Medicine. Dr. Pontari supported Plaintiff's application for disability, indicating that Plaintiff was unable to return to work. (Plaintiff's Ex. B.) Plaintiff first came under Dr. Pontari's care in August, 1998, when he furnished a comprehensive examination report to her forwarding physician, Andrew Weitzel, D.O., dated August 27, 1998. (PRU 0537-0538.) Dr. Pontari addressed her chronic pain and prescribed hydroxyzine in addition to the Elavil and Percocet which had been prescribed. (Id.)

  On April 13, 1999, Defendant approved Plaintiff's claim for short-term disability, indicating that benefits had been issued for the period December 29, 1998 through March 31, 1999. The Defendant further indicated that the Plaintiff satisfied the definition of total disability throughout the 13-week "Elimination Period" for long term disability benefits and that her claim was approved, effective March 23, 1999. The Defendant also informed Plaintiff that the information received from Dr. Pontari supported its conclusion that Plaintiff was able to work with unlimited access to a restroom. Defendant also mentions a conversation with Dr. Pontari, who indicated that Plaintiff was able to work as of April 5, 1999. As a result, Defendant terminated Plaintiff's benefits as of April 5, 1999. On May 1, 1999, the Plaintiff appealed the denial by Prudential in writing, attaching additional medical records. Furthermore, on May 20, 1999, Dr. Pontari wrote a letter to Defendant's Disability Consultant indicating that because of the Plaintiff's ongoing pelvic pain she was still unable to work. (Plaintiff's Ex. H). On June 14, 1999, Defendant again wrote to Plaintiff indicating that further medical records were requested from Plaintiff's treating physicians. (Plaintiff's Ex. I.)

  On July 26, 1999, Defendant notified Plaintiff that her benefits would be reinstated for the period from April 5, 1999 through August 31, 1999. Defendant based this decision upon the review of additional medical documentation it had requested and a conversation with Plaintiff about her daily activities. (Plaintiff's Ex. J.) The letter also advised Plaintiff of her right to appeal the decision.

  On August 5, 1999, Dr. Pontari again wrote to the Defendant, indicating that Plaintiff was still disabled and that it would be reasonable to extend Plaintiff's disability until January 1, 2000. (Plaintiff's Ex. K.) Furthermore, Plaintiff's family physician, Leonard M. Kabel, D.O. also wrote to the Defendant, opining that Plaintiff was still unable to work as of September 9, 1999. (Plaintiff's Ex. L.)

  On December 2, 1999, Defendant informed Plaintiff's representative at that time, Dr. Lifrak, of its decision to reinstate Plaintiff's long term disability benefits as of September 1, 1999. (Plaintiff's Ex. O.) On March 21, 2000, Dr. Lifrak wrote to Defendant, confirming a conversation regarding a proposed lump-sum settlement of Plaintiff's claim. (Plaintiff's Ex. P.)

  Plaintiff continued to receive monthly long-term disability benefits until May 1, 2001, when the Defendant terminated her benefits. Defendant based its decision on the finding that Plaintiff was not disabled. Total disability exists under the long term disability (LTD) aspect of the policy when Prudential determines that all of these conditions are met:
(1) Due to sickness or accidental injury both of these are true:
(a) You are not able to perform, for wage or profit, the material and substantial duties of your occupation.
(b) After the Initial Duration of a period of Total Disability, You are not able to perform, for wage or profit, the material and substantial duties of any job for which you are reasonably fitted by your education, training or experience.
(2) You are not working at any job for wage or profit.
(3) You are under the regular care of a Doctor.
(See Andrews Cert. Exhibit A, at p. 19.)

  The initial duration under the Plan for LTD benefits for total disability is 24 months. At the conclusion of the initial duration, Prudential will conduct an evaluation to determine the claimant's eligibility for benefits beyond that period. See Andrews Cert. Exhibit B.

  Meanwhile, it is noted, the Social Security Administration found Ms. Stith to be totally disabled as of December 15, 1998, for which benefits have been paid to her since March of 1999 under the Social Security Act, 42 U.S.C. § 405, et seq., pursuant to a finding made after a hearing by ALJ Daniel W. Shoemaker on January 29, 2003. (Pl. Ex. X, PRU 0266-0272.)

  On October 20, 2003, Plaintiff filed the instant Complaint.

  ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.