United States District Court, D. New Jersey
DENNIS M. CAVANAUGH, District Judge.
This matter comes before the Court upon (1) Motion for Summary Judgment by Plaintiff Sylvia Rodriguez ("Rodriguez" or "Plaintiff") (Pl.'s Mot. for Summ. J., May 24, 2013, ECF No. 15), and (2) Motion for Summary Judgment by Reliance Standard Life Insurance Company ("Reliance" or "Defendant") (Def.'s Mot. for Summ. J., May 24, 2013, ECF No. 16). Pursuant to Fed. R. Civ. P 78, no oral argument was heard. Based on the following and for the reasons expressed herein, Plaintiff's Motion for Summary Judgment is denied and Defendant's Motion for Summary Judgment is granted.
Plaintiff was employed by GAF Materials Corporation as a Global Lead Analyst. As an employee benefit, Plaintiff was covered under Reliance's standard long term disability insurance policy. On or about July 26, 2008, Plaintiff asserts that she became disabled as a result of the effects of Chronic Fatigue Syndrome and related symptoms. On December 4, 2008, Plaintiff applied for long term disability benefits stating that she was no longer able to work. Defendant paid long term disability benefits to Plaintiff during the period from January 22, 2009 to November 11, 2009 when it attempted to terminate payment. Plaintiff filed an appeal and payments were reinstated on October 21, 2010. By letter dated January 21, 2011 (the "Termination Letter"), Matrix Absence Management, Inc., acting on behalf of Defendant, informed Plaintiff that her long term disability benefits were being terminated.
As defined by the Policy, to qualify for disability during the initial 24-month period of coverage, an Insured must demonstrate an inability to perform material duties of her regular occupation. To qualify for benefits after 24 months, a claimant must be unable to perform the duties of "any occupation" which is defined as an inability to perform the material duties of any occupation that her education, training or experience reasonably allow. In addition, under the Mental or Nervous Disorders Limitation, benefits are not payable beyond 24 months for any disability that is caused by or contributed to by a Mental Disorder, including anxiety and depression.
The Termination Letter includes the following language: "Based on the documentation provided, it appears that your Total Disability is caused by or contributed to by a Mental or Nervous Disorder." The Letter also makes reference to an Independent Medical Exam showing that Plaintiff did not meet the criteria for Fibromyalgia and that no findings were made demonstrating physical impairment from sedentary work. In addition, the Termination Letter explained that the medical records received from Drs. Richard Podell and King reflected continued complaints of fatigue but did not provide sufficient medical evidence to support continued restrictions and limitations that would prevent less than sedentary work capacity.
Plaintiff appealed the termination of her benefits. After a review, Defendant sent Plaintiff a letter, dated August 7, 2012 (the "Appeal Decision Letter"), upholding the decision to terminate benefits. The Appeal Decision Letter quotes from the reports of five independent physicians and concludes that Plaintiff is not sufficiently impaired from any of her physical conditions to preclude her from doing sedentary work. The Appeal Decision Letter also provides that based on the evidence in the administrative record, "it is reasonable to conclude that her primary impairment is psychiatric in nature with somatic manifestations." The Appeal Decision Letter points to a note by one physician that Plaintiff was crying and depressed during one of her examinations and also notes that several of Plaintiff's own treatment providers recommended psychiatric medications to manage Plaintiff's symptoms. Essentially, the Appeal Decision Letter holds that there is sufficient evidence to deny Plaintiff benefit coverage beyond 24 months on either of the two following grounds: (1) Plaintiff is not totally physically disabled and is capable of sedentary work or (2) a mental or nervous disorder contributes to Plaintiff's disability.
On August 2, 2012, Plaintiff filed suit in this Court, pursuant to Section 502(a)(1)(B) of ERISA, 29 U.S.C. 1132(a)(1)(B), seeking to recover the payment of long term disability insurance. Plaintiff argues that there is no evidence or diagnosis in the record demonstrating that Plaintiff has a mental or nervous disorder. Plaintiff further asserts that there is no evidence in the file that her stamina and other symptoms had improved to the point that she could perform sedentary duty type work, or even that her stamina had been tested. Finally, Plaintiff argues that Defendant violated federal regulations by failing to advise Plaintiff what information she would need to perfect her appeal.
STANDARD OF REVIEW
A. Summary Judgment
Summary judgment is granted only if all probative materials of record, viewed with all inferences in favor of the nonmoving party, demonstrate that there is no genuine issue of material fact and that the movant is entitled to judgment as a matter of law. See Celotex Corp. v. Catrett , 477 U.S. 317, 330 (1986); FED. R. CIV. P. 56(c). The moving party bears the burden of showing that there is no genuine issue of fact. Id . "The burden has two distinct components: an initial burden of production, which shifts to the non-moving party if satisfied by the moving party; and an ultimate burden of persuasion, which always remains on the moving party." Id . The non-moving party "may not rest upon the mere allegations or denials of his pleading" to satisfy this burden, but must produce sufficient evidence to support a jury verdict in his favor. Id . at 322; see also FED. R. CIV. P. 56(e); Matsushita Elec. Indus. Co. v. Zenith Radio Corp. , 475 U.S. 574, 586 (1986). "In determining whether there are any issues of material fact, the Court must resolve all doubts as to the existence of a material fact against the moving party and draw all reasonable inferences - including issues of credibility - in favor of the non-moving party." Newsome v. Admin. Office of the Courts of the State of N.J. , 103 F.Supp.2d 807, 815 (D.N.J. 2000), aff'd, 51 Fed.App'x 76 (3d Cir. 2002) (citing Watts v. Univ. of Del. , 622 F.2d 47, 50 (D.N.J. 1980)).
B. Standard of Review for Denial of Benefits Claim Under ERISA
A denial of a benefits claim brought pursuant to ERISA is typically reviewed under a de novo standard, "unless the plan grants discretionary authority to the administrator or fiduciary to determine eligibility for benefits or interpret the terms of the plan." Estate of Schwing v. The Lilly Health Plan , 562 F.3d 522, 525 (3d Cir. 2009) (citing Firestone Tire & Rubber Co. v. Bruch , 489 U.S. 101, 115 (1989). Where the plan grants the administrator discretionary authority, as it does here, the court reviews the administrator's exercise of that authority under an "arbitrary and capricious standard." Schwarzwaelder v. Merrill Lynch & Co. , 606 F.Supp.2d 546, 557 (W.D. Pa. 2009) (citing Firestone , 489 U.S. at 115). Under the arbitrary and capricious standard, "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, 845 (3d Cir. 2011) (quoting Abnathya v. Hoffmann-La Roche, Inc. , 2 F.3d 40, 45 (3d Cir. 1993)); See also Orvosh v. Program of Grp. Ins. for Salaried Emples. of Volkswagen of Am., Inc. , 222 F.3d 123, 129 (3d Cir. 2000) ("[A] plan administrator's decision will be overturned only if it is clearly not supported by the evidence in the record or the administrator has failed to comply with the procedures required by the plan."). To ...