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YUHAS v. PROVIDENT LIFE AND CAS. INS. CO.

August 2, 2001

DEBORAH YUIIAS, PLAINTIFF,
v.
PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY, DEFENDANT.



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

MEMORANDUM DECISION AND ORDER GRANTING DEFENDANTS MOTION FOR SUMMARY JUDGMENT

Plaintiff Deborah Yuhas sues defendant Provident Life and Casualty Insurance Company ("Provident") for legal and equitable relief pursuant to the Employee Retirement Income Security Act of 1974 ("ERISA), 29 U.S.C. § 1001, et seq.*fn1 Plaintiff contends that she is entitled to long term disability ("LTD") benefits because she is physically disabled. Defendant moves for summary judgment

For the reasons stated below, defendant's motion for summary judgment is granted.

FACTUAL BACKGROUND

On a motion for summary judgment the Court views the facts most favorably to the non-moving party — in this case, the plaintiff.

The facts of this case are largely undisputed.*fn2 Plaintiff, a graphic designer for the New York Daily News, became totally disabled due to a mental condition in December 1988. On or about June 25, 1989, plaintiff filed a claim for disability. On November 15, 1989, defendant approved plaintiffs claim for disability, and plaintiff began receiving monthly disability checks. Plaintiff was notified that she was entitled to receive disability benefits for a twenty-four month period only, because her disability was due to a "nervous, emotional, mental disease or disorder[]." (Roberts Aff. at Ex. A.) Plaintiff received benefits until June 1991, when the checks ceased.

On October 8, 1991, defendant advised plaintiff that the twenty-four month benefit period had expired on June 25, 1991, and that no further benefits would be paid. Defendant's letter also informed plaintiff that, under ERISA, plaintiff had the right to appeal defendant's denial of benefits. Appeals were required to reach defendant within 60 days of plaintiffs receipt of the October 8, 1991 letter denying her claim.

On December 2, 1991, plaintiff asked that her claim determination be reevaluated, and that her benefits be extended until June 25, 1992. Plaintiffs letter of appeal alleged that, in addition to her mental injuries, in the twenty-four month she was mentally disabled, plaintiff sustained debilitating physical injuries in a car accident which left her totally disabled.

In January 1992, defendant informed plaintiff that the company's ERISA Appeals Committee ("the Committee") had denied her LTD claim because she had failed to submit any documentation of total physical disability due to the accident.

During the following two years, plaintiff continued to submit evidence to defendant of her physical injuries, in the form of medical reports and bills. By letter on May 28, 1992, and again on August 5, 1992, defendant reaffirmed the Committee's denial of plaintiffs LTD claim, noting that the sixty day appeal period for plaintiffs LTD claim had expired. Defendant reiterated that because the twenty-four month limitation on benefits for emotional or mental disorders had passed, and the medical evidence submitted by plaintiff failed to include any "objective findings" to substantiate her claim of total physical disability, plaintiff could not recover further LTD benefits.

The Guild-News then asked, on plaintiffs behalf, that the Committee again review the additional medical evidence plaintiff had submitted. On December 18, 1992, defendant wrote the Guild-News a letter, explaining that, although the sixty clay appeal period had long past, the Committee had reviewed plaintiffs file as a courtesy. The Committee found again that plaintiff was not entitled to further LTD benefits. In the letter "cc'd" to plaintiff, defendant wrote:

Although the recent medical information received from her treating physician indicates a disability due to a mental or nervous condition, it does not support that as of the end of the 24 month mental and nervous limit, June 25, 1991, ihat [sic] Ms. Yuhas had a physical disability. Also, her LTD file does not reflect any medical documentation of a physical disability at the end of the mental and nervous limit either. Therefore, her LTD claim was closed according to the policy provision . . .

Nearly one year later, on December 13, 1993, upon receipt of additional information from plaintiffs orthopedic physician, the Committee reviewed plaintiffs file yet again. This time, the Committee found, based on the new evidence, that plaintiff had been physically disabled at the time the LTD benefits for her mental disorder ceased. Therefore, she was entitled to a retroactive payment of benefits from October 1, 1991 through May 13, 1993.

However, plaintiffs medical records from May 13, 1993 indicated that the ankle injury she allegedly suffered in the automobile accident had improved enough for her to return to work. Therefore, plaintiff was not eligible for benefits after May 13, 1993, as her "physical condition was not severe enough to prevent her from being employed."*fn3 Apparently, plaintiffs mental condition had not improved, since defendant asked that she name a "Court appointed guardian or conservator" to accept the benefits on her behalf. Defendant's lawyers believed that, according to plaintiffs file, ...


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