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