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Kim Su Ferro v. Cigna Group Insurance et al

May 13, 2011


The opinion of the court was delivered by: Chesler, U.S.D.J.



This matter comes before the Court on two motions for summary judgment, pursuant to FED. R. CIV. P. 56: 1) the motion by Defendant Life Insurance Company of North America ("Defendant"); and 2) the cross-motion by Plaintiff Kim Su Ferro ("Plaintiff"). For the reasons stated below, Defendant's motion will be granted in part and denied in part, and Plaintiff's cross-motion will be denied.

In brief, this case arises from a dispute over disability insurance benefits. The following facts are undisputed. Defendant issued a long-term disability insurance policy to Plaintiff. Plaintiff made a claim and received benefits. When Defendant discontinued Plaintiff's benefits, Plaintiff used Defendant's in-house appeal process to challenge the decision to deny her claim. The appeals were denied.

On December 9, 2009, Plaintiff filed a Complaint and, subsequently, an Amended Complaint, asserting three counts: 1) violation of ERISA by wrongfully terminating benefits; 2) violation of ERISA by wrongfully withholding benefits; and 3) violation of ERISA by wrongfully demanding payment of a balance due. On July 7, 2010, this Court granted Defendant's motion to dismiss and dismissed the second and third counts. Defendant filed an Answer asserting two counterclaims: 1) breach of contract in regard to a balance due on an alleged overpayment of benefits; and 2) unjust enrichment in regard to this alleged overpayment. Defendant has moved for summary judgment on the First Count of the Amended Complaint and on both counterclaims. Plaintiff has cross-moved for summary judgment on the Amended Complaint only.

The parties agree on the legal standard to be applied to this Court's review of Defendant's denial of benefits. As the Third Circuit recently held:

We review a challenge by a participant to a termination of benefits under ERISA § 502(a)(1)(B) under an arbitrary and capricious standard where, as here, the plan grants the administrator discretionary authority to determine eligibility for benefits. An administrator's decision is arbitrary and capricious if it is without reason, unsupported by substantial evidence or erroneous as a matter of law.

Miller v. Am. Airlines, Inc., 632 F.3d 837, 844-845 (3d Cir. 2011) (citations omitted). In agreeing to this standard, Plaintiff implies agreement that the plan granted the administrator discretionary authority to determine eligibility for benefits.

Defendant presents an extensive case to persuade that its decision to terminate benefits was not neither arbitrary nor capricious. The burden of proof on this claim, however, rests with Plaintiff. The actual argument section of Plaintiff's moving papers is just under one and one-half pages long. The first three paragraphs restate the legal standard. In the following paragraphs, Plaintiff makes the sole point that "[t]wo of the three doctors that the defendant forwarded the Functional Capacity Evaluation to, disagreed with the decision." (Pl.'s Br. 6.) Plaintiff argues that Defendant ignored these two medical opinions, and that therefore the decision was arbitrary and capricious.

Plaintiff's brief does not offer any citations to the record. Plaintiff's L. Civ. R. 56.1 Statement of Material Facts contains no citations to any evidence of record. It appears from Plaintiff's factual statements, however, that Plaintiff contends that treating physicians Drs. Grable and Oppenheim disagreed with the Functional Capacity Evaluation ("FCE").

In response, Defendant asserts that the decision to terminate benefits was based on more evidence than the FCE and the medical reviews of same. Defendant points to the letter dated August 24, 2005 which it sent to Plaintiff, setting forth the evidence upon which it based its decision to terminate her benefits. (Wohlforth Cert. at LINA 00165-00169.)

The letter begins by stating that, on April 15, 2005, Plaintiff underwent a functional capacity evaluation which essentially found no relevant functional physical limitations. (Id. at 00165.) The letter then noted that surveillance of Plaintiff on the day of the FCE showed no physical limitations. (Id. at 00166.) The letter next states that the FCE report was sent to four of Plaintiff's treating physicians, and only Dr. Grable responded to state that he disagreed with the results. (Id. at 00166.) Because one physician disagreed with the FCE results, an independent medical evaluation ("IME") was conducted by Dr. Lower. (Id.) Dr. Lower concluded that Plaintiff had no significant orthopedic problems that would render her unemployable. (Id. at 000167.) Defendant again sent the IME report to Plaintiff's four treating physicians for review, and only Dr. Grable wrote back to disagree with the results. (Id.) A "Nurse Case Manager" reviewed all these materials, and this resulted in the determination that Plaintiff had no condition severe enough to prevent her from resuming employment, as defined under the disability policy. (Id. at 000168.)

Plaintiff was given the opportunity to respond to Defendant's opposition to Plaintiff's cross-motion, but made no submission.

This Court has before it, on the one hand, record evidence presenting a detailed explanation of the evidence Defendant used in making its decision and, on the other, Plaintiff's undocumented assertion that ...

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