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Gail A. Connor v. Sedgwick Claims Management Services

June 24, 2011

GAIL A. CONNOR, PLAINTIFF,
v.
SEDGWICK CLAIMS MANAGEMENT SERVICES, INC., ET AL., DEFENDANTS.



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

OPINION

Plaintiff, Gail A. Connor, seeks reinstatement of her long term disability benefits from Defendant PNC Corp. & Affiliates Long Term Disability Plan (hereinafter "Defendant"). The long term disability plan at issue is an employee welfare benefit plan governed by the Employee Retirement Income Security Act (hereinafter "ERISA"), 29 U.S.C. § 1001 et seq.. The Court is called upon to determine whether the denial of Plaintiff's long term disability benefits was arbitrary and capricious, and, therefore, unlawful pursuant to 29 U.S.C. § 1132(a)(1)(B). Plaintiff moves for summary judgment [Doc. 23] and Defendant cross-moves for summary judgment*fn1 [Doc. 27]. For the reasons expressed below, the Court will grant in part and deny in part Plaintiff's Motion and deny Defendant's Cross-Motion.

I. JURISDICTION

Plaintiff brought his claims pursuant to ERISA and this Court has jurisdiction over her claims under 28 U.S.C. § 1331 and 29 U.S.C. § 1132(d)(e)&(f).

II. BACKGROUND

Plaintiff, Gail A. Connor, worked for PNC Bank Corp.*fn2 (hereinafter "PNC") as a "Branch Manager III" from September 27, 2004 through October 10, 2006. As an employee of PNC, Plaintiff participated in the PNC Corp. & Affiliates Long Term Disability Plan (hereinafter "Plan"). This Plan, an employee welfare benefits plan, is governed by ERISA and provides long term disability (hereinafter "LTD") benefits, of up to 70% of their base salary, to employees of PNC who are out of work for longer than ninety (90) days. Under the Plan, a claimant is entitled to receive LTD benefits when, after the expiration of ninety (90) days, he or she is "Totally Disabled" or has a "Total Disability." Under the Plan a covered person is "Totally Disabled" and has a "Total Disability" when "because of Injury or Sickness: [t]he participant cannot perform each of the materials duties of his or her regular occupation; and [a]fter benefits have been paid for 24 months, the participant cannot perform each of the material duties of any gainful occupation for which he or she is reasonably fitted by training[,] education or experience." Plan, Doc. 30, Exhibit 4 at AR 333.

The Plan identified PNC as the Plan Administrator, and gave it discretionary authority to interpret the terms of the Plan and administer benefits. In addition, the Plan contained a provision that permitted the Plan Administrator to "appoint or employ individuals or firms to assist in the administration of the Plan . . .". Plan, Doc. 30, Exhibit 4 at AR 344. Pursuant to this provision, PNC entered into an Administrative Services Agreement with a third party company, Sedgwick Claims Management Services, Inc. (hereinafter "Sedgwick"). In the agreement, PNC expressly delegated to Sedgwick its discretionary authority to determine a claimant's eligibility for LTD benefits.*fn3

On or about January 17, 2007, more than ninety (90) days after her last day of active employment, Plaintiff filed her application for LTD benefits with Sedgwick.*fn4 On her application, Plaintiff stated that she stopped working because of Systemic Lupus Erythematosus (hereinafter "lupus") and Raynaud's disease. She specifically complained that her disability caused "difficulty with movements such as walking, bending, sitting . . . standing, lifting" and using her hands. Employee Application for Benefits, Exhibit 4 at AR 307. In support of Plaintiff's application, Stephen L. Burnstein, D.O. (hereinafter "Dr. Burnstein"), her rheumatologist, submitted a Treating Physician's Statement (hereinafter "Statement").*fn5 This Statement indicated Plaintiff's primary diagnosis as lupus and secondary diagnosis as Raynaud's Disease. Dr. Burnstein also noted that the limitations or restrictions that prevent Plaintiff from performing the essential functions of her job occur "if she is exposed to cold temperatures or cold drafts or UV light stress -physical/emotional." Treating Physician's Statement, Doc. 30, Exhibit 4 at AR 312.

As further evidence of Plaintiff's disability, Dr. Burnstein submitted to Sedgwick a letter he sent to her primary care physician. In this letter, he concluded Plaintiff has rhupus*fn6 , a condition that is a combination of rheumatoid arthritis and lupus. To support this diagnosis, Dr. Burnstein provided both objective and subjective evidence of Plaintiff's disability. He specifically noted that laboratory studies completed several months ago revealed that Plaintiff's double-stranded DNA was "mildly" elevated and her ANA was "positive."*fn7 Doc. 30, Exhibit 4 at AR 314. In his description of her current condition he reported "[t]here is no weakness or atrophy. There are no abnormal NP findings. There are no FMS tender points."*fn8 Doc. 30, Exhibit 4 at AR 315. Although Dr. Burnstein's physical examination did not reveal that Plaintiff had any tenderness, swelling, deformity or limitation of motion, his January 12, 2007 medical records noted Plaintiff's subjective complaints of joint pain, swelling, fatigue and weakness. Finally, Dr. Burnstein indicated that in an eight-hour day Plaintiff could sit for three hours, stand for two hours, walk for one hour and view a computer screen for two hours.*fn9

On March 15, 2007, Sedgwick informed Plaintiff that her "[m]edical information indicates" she is "unable to continue" her employment and that her benefits were approved on the "basis" of her "medical restrictions and limitations associated, but not limited to, the current diagnosis of Lupus."*fn10 Doc. 30, Exhibit 3 at AR 277. The letter also conditioned Plaintiff's further receipt of benefits on her continued ability to meet the Plan's definition of "Total Disability." It informed her that "[o]n a periodic basis" Sedgwick "will need to verify your ongoing eligibility for benefits" by "requesting information from you and your attending physicians." Id. at 278.

Several months later, on November 21, 2007, Sedgwick informed Plaintiff that "based upon a lack of current treatment information on file supportive of continuing total disability" her "claim for Long Term Disability benefits was formally suspended."*fn11 Doc. 30, Exhibit 3 at AR 243. This suspension was in effect until Plaintiff or Dr. Burnstein submitted proof that she was "Totally Disabled." On November 27, 2007, Dr. Burnstein replied to Sedgwick's letter and identified Plaintiff's prognosis for full or part-time employment as "poor."*fn12 Doc. 30, Exhibit 1 at AR 059. In support this determination, he provided medical records from March 5, 2007, June 5, 2007, August 23, 2007, October 9, 2007 and November 2, 2007.

Dr. Burnstein's March 5, 2007 records indicated Plaintiff complained of morning stiffness, headaches, fatigue and some nausea. Her physical examination revealed some warmth, swelling and tenderness in the joints of her hands and feet. Dr. Burnstein's records, however, did not note any limitations on Plaintiff's ability to stand, sit or walk, nor did he mention any other limitations of Plaintiff.

The medical records from June 5, 2007 noted Plaintiff complained of fatigue, but admitted it was better with medication. Plaintiff failed to report any dizziness, numbness or weakness, and her physical examination did not reveal any pain or swelling. Dr. Burnstein's records did not indicate any limitations on Plaintiff's ability to stand, sit or walk, nor did he mention any other limitations of Plaintiff. The physician concluded that Plaintiff's rhupus was "stable" with methotrexate and plaquenil.*fn13 Doc. 30, Exhibit 1 at AR 071.

Plaintiff's August 23, 2007 medical records indicated she complained of fatigue. She, however, did not report any dizziness, headache, numbness or weakness to Dr. Burnstein, nor did his physical examination of her reveal any pain or swelling. The records also failed to note any limitations on Plaintiff's ability to stand, sit or walk.

Dr. Burnstein's October 9, 2007 medical records mentioned a rheumatoid arthritis "flare up" and that Plaintiff reported fatigue, morning stiffness, soreness in shoulders and that methotrexate was "not doing anything." Doc. 30, Exhibit 1 at AR 063. The physical examination revealed some swelling and tenderness in the joints of Plaintiff's hands and feet. Dr. Burnstein's records, however, did not note any limitations on Plaintiff's ability to stand, sit or walk, nor did he indicate any other limitations of Plaintiff.

Dr. Burnstein's November 2, 2007 medical records do not contain any noteworthy observations. On December 10, 2007, Sedgwick, after receipt of Dr. Burnstein's medical records, informed Plaintiff that it would reinstate her LTD benefits.

On February 6, 2008, Plaintiff forwarded Sedgwick medical records from her December 19, 2007 visit with Dr. Burnstein. These records indicated Plaintiff reported headaches and morning stiffness lasting approximately two hours. Dr. Burnstein's physical examination revealed some swelling in the joints of Plaintiff's hands and feet. Plaintiff also mentioned she experienced daily pain in the range of 6-7 on a scale of ten, but "feels better." Doc. 30, Exhibit 1 at AR 078. Dr. Burnstein's records did not discuss any limitations on Plaintiff's ability to stand, sit or walk, nor did he indicate any other limitations of Plaintiff.

On July 9, 2008 and again on August 6, 2008, Sedgwick reminded Plaintiff that the definition of "Total Disability" and "Totally Disabled" changes after benefits have been paid for twenty-four (24) months.*fn14 According to Sedgwick, Plaintiff's eligibility for LTD benefits "in accordance with the 'Own Occupation' . . . definition of total disability will end" on January 8, 2009. Doc. 30, Exhibit 3 at AR 227 & AR 229. The letter further stated that beginning on January 9, 2009, in order to continue her receipt of LTD benefits, Plaintiff must establish eligibility under the "Any Occupation" definition of total disability. Id. In preparation for this change, Sedgwick requested that Plaintiff provide additional medical information documenting her disability.

In response, Plaintiff submitted a Report of Disability dated July 30, 2008. This report indicated "no changes" in her condition. PNC LTD Report of Disability, Doc. 30, Exhibit 1 at AR 093. The submission to Sedgwick also contained a July 29, 2008 Report of Disability from Dr. Burnstein. This report indicated Plaintiff's objective symptoms of disability were "tender hand joints." LTD Report of Disability, Exhibit 1 at AR 095. Dr. Burnstein further noted that in an eight-hour workday, Plaintiff could sit, stand and walk for one hour and that her restricted actions included "lifting/carrying, use of hands in repetitive actions, use of feet in repetitive movements, reaching above shoulder level, bending, squatting [and] crawling." Id.

On September 10, 2008, Sedgwick again requested an update from Dr. Burnstein. Several days later, on September 18, 2008, Dr. Burnstein replied and essentially reiterated the same information he previously provided Sedgwick. According to Dr. Burnstein, Plaintiff has morning stiffness, cannot sit or stand for more than 1-2 hours a day, has arm stiffness, has restricted motion in joints and has difficulty with fine grasping and manipulation. He then expressed his doubt that Plaintiff could return to gainful employment. Dr. Burnstein also sent to Sedgwick the records from Plaintiff's June 23, 2008 office visit.*fn15 Her medical records indicated that she complained of fatigue, morning stiffness for approximately two hours and that she "gets more frequent infections."*fn16 Doc. 30, Exhibit 2 at AR 114. Plaintiff, however, did not report any headaches, dizziness, numbness or weakness. Her physical examination revealed tender points in the joints of her hands. The records, however, did not note any limitations on Plaintiff's ability to stand, sit or walk, nor did Dr. Burnstein mention any other limitations of Plaintiff.

Shortly after receiving Dr. Burnstein's report, Sedgwick contacted a third-party, Network Medical Review, to independently review Plaintiff's LTD claim. This company subsequently assigned physician Dennis Payne, Jr. M.D.*fn17 (hereinafter "Dr. Payne") to review the LTD claim.*fn18 Although he never examined Plaintiff, Dr. Payne reviewed her medical files. After this review, he concluded that "[t]he medical record data do[es] not contain specific details of any objective findings of systemic lupus." Doc. 30, Exhibit 2 at AR 128. In reaching this conclusion, Dr. Payne considered that Plaintiff had a positive ANA and positive double-stranded DNA, but that the overall "symptomatology described" was "not consistent with a connective tissue process." Id. at 128-29. Therefore, according to the physician, Plaintiff presented no medical evidence that she was disabled from lupus or any other rheumatological disease.*fn19 Dr. Payne's report did not specifically discuss the rhupus diagnosis.

On October 24, 2008, Sedgwick informed Plaintiff that, as of September 30, 2008, she was no longer eligible to receive LTD benefits because she was no longer "Totally Disabled" under the terms of the Plan. The denial letter reiterated the findings of Dr. Payne's report and largely focused on his conclusion that Plaintiff lacked objective medical evidence of a disability.

Although Sedgwick's letter informed Plaintiff that she had a right to appeal within 180 days, it did not specifically inform her what type of evidence she must present on appeal to perfect her LTD claim.*fn20

Shortly after the receipt of Sedgwick's denial letter Plaintiff retained counsel. On January 16, 2009, Plaintiff's attorney appealed Sedgwick's October 24, 2008 decision. In addition to the appeal letter, Plaintiff submitted (1) a letter from Dr. Burnstein dated December 23, 2008,*fn21 (2) a decision of the Social Security Administration (hereinafter "SSA") dated April 7, 2008, granting Plaintiff disability benefits,*fn22 (3) a copy of Plaintiff's prescription records and (4) a statement from Plaintiff containing her self-reported subjective side effects from her medications.

After receipt of Plaintiff's appeal, Sedgwick again contacted Network Medical Review to independently review her LTD benefits claim. The company assigned Dr. Tanya Lumpkins, M.D.*fn23 (hereinafter "Dr. Lumpkins") to conduct the review.*fn24 Although she never examined Plaintiff, Dr. Lumpkins concluded, after a through review of her medical history, that Plaintiff was not disabled because her medical records failed to "substantiate the severity of either systemic lupus erthematosus or rheumatoid arthritis." Doc. 30, Exhibit 2 at AR 200. In support of this conclusion, Dr. Lumpkins focused on a lack of objective evidence about the severity of Plaintiff's lupus and rheumatoid arthritis.

On March 6, 2009, Sedgwick upheld its denial of Plaintiff's appeal. Approximately one week later, on March 12, 2009, Plaintiff initiated this lawsuit. Over one year later Plaintiff moved for summary judgment. Shortly thereafter, Defendant filed its cross-motion for summary judgment.

III. DISCUSSION

A. Standard for Summary Judgment

Summary judgment is appropriate where the Court is satisfied that "the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law." Celotex Corp. v. Catrett, 477 U.S. 317, 330 (1986); Fed. R. Civ.P. 56(c).

An issue is "genuine" if it is supported by evidence such that a reasonable jury could return a verdict in the nonmoving party's favor. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). A fact is "material" if, under the governing substantive law, a dispute about the fact might affect the outcome of the suit. Id. In considering a motion for summary judgment, a district court may not make credibility determinations or engage in any weighing of the evidence; instead, the nonmoving party's evidence "is to be believed and all justifiable inferences are to be drawn in his favor." Marino v. Indus. Crating Co., 358 F.3d 241, 247 (3d Cir. 2004) (quoting Anderson, 477 U.S. at 255).

Initially, the moving party has the burden of demonstrating the absence of a genuine issue of material fact. Celotex Corp., 477 U.S. at 323. Once the moving party has met this burden, the nonmoving party must identify, by affidavits or otherwise, specific facts showing that there is a genuine issue for trial. Id. Thus, to withstand a properly supported motion for summary judgment, the nonmoving party must identify specific facts and affirmative evidence that contradict those offered by the moving party. Anderson, 477 U.S. at 256-57. A party opposing summary judgment must do more than just rest upon mere allegations, general denials, or vague statements. Saldana v. Kmart Corp., 260 F.3d 228, 232 (3d Cir. 2001).

B. Timeliness of Plaintiff's Claim

Defendant contends summary judgment should be entered on its behalf because Plaintiff filed her initial claim for LTD benefits approximately eight days late. Thus, according to Defendant, she failed to timely file her claim, as required by the Plan. Plaintiff seemingly acknowledges her untimeliness. She argues, however, that because her failure to timely file the benefits claim never formed a basis for Sedgwick's denial of the claim, Defendant is barred from raising untimeliness as a post hoc justification for the denial of the LTD benefits. In response, Defendant postulates that, in an attempt to modify the terms of the Plan, Plaintiff's argument improperly raises principles of waiver and estoppel.

The Court disagrees with Defendant's characterization of the timeliness issue. Our role in the present matter is to determine whether Sedgwick abused its discretion and improperly denied Plaintiff's LTD benefits claim. To resolve this inquiry, the Court examines Sedgwick's rationale for denying the benefits claim, as evidenced by the administrative record and explained in its denial letters to Plaintiff. Although Defendant now attempts to raise a timeliness issue with Plaintiff's claim, Sedgwick never denied her claim on that basis. Rather, it was denied on substantive grounds entirely unrelated to timeliness. Furthermore, any concern over timeliness is absent from the administrative record and both of the denial letters sent to Plaintiff. See Haisley v. Sedgwick Claims Mgmt. Servs., Inc., ____ F. Supp.2d ____, No. 08-1463, 2011 WL 818669, at * 12 (W.D.Pa. March 2, 2011) (concluding ...


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