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BILLINGER v. BELL ATLANTIC

January 9, 2003

MALISSA BILLINGER, PLAINTIFF,
V.
BELL ATLANTIC, BELL ATLANTIC AS PLAN ADMINISTRATOR AND TRUSTEE OF THE DISABILITY AND RETIREMENT PLANS FOR EMPLOYEES OF BELL ATLANTIC, THE DISABILITY AND RETIREMENT PLANS FOR EMPLOYEES OF BELL ATLANTIC, UNNAMED TRUSTEES AND FIDUCIARIES OF THE DISABILITY AND RETIREMENT PLANS FOR BELL ATLANTIC AND AETNA U.S. HEALTHCARE AS PLAN ADMINISTRATOR AND TRUSTEE OF THE DISABILITY AND RETIREMENT PLANS FOR EMPLOYEES OF BELL ATLANTIC, DEFENDANTS.



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

   
DECISION AND ORDER GRANTING DEFENDANTS' MOTION FOR SUMMARY JUDGMENT

This is an action concerning claims by the plaintiff for long-term disability benefits under the NYNEX Long Term Disability Plan (the "Plan") issued by Verizon Communications, Inc. ("VERIZON") s/h/a BELL ATLANTIC, BELL ATLANTIC as Plan Administrator and Trustee of THE DISABILITY AND RETIREMENT PLANS FOR EMPLOYEES OF BELL ATLANTIC, THE DISABILITY AND RETIREMENT PLANS FOR EMPLOYEES OF BELL ATLANTIC, UNNAMED TRUSTEES and FIDUCIARIES of the DISABILITY AND RETIREMENT PLANS FOR BELL ATLANTIC, and administered by defendant AETNA LIFE INSURANCE COMPANY ("AETNA") s/h/a AETNA U.S. HEALTHCARE as Plan Administrator and Trustee of THE DISABILITY AND RETIREMENT PLANS FOR EMPLOYEES OF BELL ATLANTIC. The plaintiff made claims for long-term disability benefits to commence on or about March 7, 2000. Plaintiffs claims for long term disability benefits were based upon her allegation that she was unable to work due to her subjective complaints and symptoms of fibromyalgia. However, after a full review of all of the plaintiffs medical proof, her claim for long-term disability benefits was denied. Plaintiff appealed this decision, and AETNA, as Plan Administrator, upheld the denial of plaintiffs request after reviewing all of the medical proof and reports submitted by the plaintiff. AETNA concluded that, while the plaintiff may suffer from the condition known as fibromyalgia,*fn1 her physical limitations were not debilitating enough to constitute a long-term disability under the Plan.

The well-settled standard of review for a long-term disability claim under an employee benefit plan is the "arbitrary and capricious standard" when the claims administrator is granted discretionary authority to determine eligibility for benefits, as was the case here. Thus, a court cannot disturb the decision of the claims administrator unless it determines that the denial of benefits constitutes an abuse of discretion. After reviewing the record, I conclude that the decision was not arbitrary and capricious, in view of the entirety of the evidence. The determination of the claims administrator, AETNA, was well within its discretion, and was supported by substantial evidence. Plaintiff's related state law claims, alleging promissory estoppel and breach of contract (Counts 4 and 5 of the Complaint) are preempted under ERISA and are also dismissed.

STATEMENT OF FACTS

The plaintiff*fn2 was an employee of VERIZON (formerly known as Bell Atlantic and NYNEX) and held a position as a customer service/sales representative. (Ex. B, 00050).*fn3 She held this position from February, 1991 through February, 1999 at which point she stopped working as the result of her alleged disability. (Ex. B, 00171). As an employee, the plaintiff was entitled to and was afforded benefits under an employee benefit plan issued and funded by VERIZON. (See Williams Aff., Ex. A; Scott-Monck Aff. ¶ 2). The claims were administered by AETNA, the Claims Services Provider under the Plan. (Williams Aff. ¶ 3).

In or about the end of February, 1999, the plaintiff stopped working as the result of her alleged disability. (Ex. B, 00171). On April 13, 1999, plaintiff returned to work for approximately two hours. However, due to complaints of pain, she left work permanently. (Ex. B, 00221). Plaintiff has not returned to work at VERIZON since that day. From February 1999 through February 2000, plaintiff received short-term disability benefits and workers' compensation benefits. (Compl. ¶ 11; Ex. B, 00013).

On or about December 29, 1999, plaintiff submitted the required forms with the exception of the Attending Physician Statements from her treating doctors. (See Ex. B, 00172-174; 00024; 00150-152). The plaintiff did not specifically identify the nature of her disability. She did state that she could no longer use a computer, telephone, or stand without experiencing pain. (Ex. B, 00172).

AETNA subsequently received Attending Physician Statements ("APS") from plaintiffs primary care physician, Dr. Ira Sutton, dated January 10, 2000 (Ex. B, 00141-142) and her private rheumatologist, Dr. Mark Burns dated February 24, 2000 (Ex. B, 00139-140). These APS's diagnosed plaintiff with fibromyalgia. (Ex. B, 00139, 00141).

AETNA requested an independent medical examination ("IME") of plaintiff which was conducted by Dr. Robert Marini on March 16, 2000. (Ex. B, 00124). In addition, AETNA obtained surveillance video of the plaintiff on March 16, 2000, and a Functional Capacity Evaluation ("FCE") of plaintiff was conducted on May 16, 2000. (Ex. B, 00057-71).

By letter dated June 5, 2000, AETNA denied the plaintiffs request for long-term disability benefits based upon Dr. Marini's independent medical examination, the surveillance video, and the results of the FCE. (Ex. B, 00026-28).

By undated handwritten letter, which AETNA received on June 12, 2000, plaintiff appealed the initial denial of her LTD disability claim stating that she was disabled due to "severe neck problems" that she claimed to have suffered since 1993 and "swelling in left side of [her] neck" and in her ankles. (Ex. B, 00044-48). The plaintiff did not submit additional medical documentation with her request for appeal.

However, AETNA reviewed other medical documentation in plaintiffs claims file, including IME reports prepared by Drs. Mascarenhas and Morrissey. In this regard, on August 30, 1999, in connection with plaintiffs short-term disability claim, Dr. Bento R. Mascarenhas, a rheumatologist, examined plaintiff and concluded that she had elements of psychogenic*fn4 rheumatism and total body pain, but found no evidence of any significant arthritic disorder. (Ex. B, 00163). He also stated that his examination of plaintiff was limited because of plaintiffs "presumed anticipation of any pain during the examination, however gentle." (Ex. B, 00163). He found that plaintiff was capable of returning to sedentary work part-time starting at 2-hours a day and progressing further. (Ex. B, 00163).

In addition, AETNA reviewed an IME report prepared by Dr. James Morrissey, an orthopedist. On December 16, 1999, plaintiff was examined by Dr. Morrissey in connection to her workers' compensation claim. He also reported that plaintiffs subjective complaints of pain and self-limiting behavior during the examination prevented him from completing a full examination. (Ex. B, 00144-00145). Dr. Morrissey concluded there were "no objective findings of musculoskeletal abnormality and soft mass, left supraclavicular region." (Ex. B, 00144-145). Dr. Morrissey could not certify her disability for workers' compensation. (Ex. B, 00145).

By letter dated June 14, 2000, AETNA acknowledged receipt of the appeal and asked that plaintiff provide any additional documentation that she believed should be considered by AETNA no later than August 5, 2000. (Ex. B, 00029-30). On June 19, 2000, plaintiff submitted a copy of her Notice of Fully Favorable Decision from the Social Security Administration. (Ex. B, 00040).

By letter dated August 18, 2000, AETNA advised the plaintiff that it was adhering to its initial determination denying her claim for long-term disability benefits. The denial was based upon AETNA's Medical Consultant's review of the following information: (1) APS by Dr. Sutton dated 8/11/99; (2) APS's by Dr. Burns dated 12/29/99; (3) IME performed by Dr. Mascarenhas dated 8/30/99; (4) IME performed by Dr. Morrissey dated 12/16/99; (5) IME performed by Dr. Marini dated 3/16/00; (6) Video surveillance tape dated 3/16/00; (7) FCE performed on 5/16/00; (8) Social Security ...


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