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BILLINGER v. BELL ATLANTIC
January 9, 2003
MALISSA BILLINGER, PLAINTIFF,
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
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.
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.
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,
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 ...