United States District Court, N.D. New York
March 31, 2004.
KATHERINE O. CASEY, Plaintiff,
FIRST UNUM LIFE INSURANCE COMPANY, Defendant
The opinion of the court was delivered by: FREDERICK SCULLIN, Chief Judge, District
Plaintiff Katherine O. Casey commenced this action by filing a
summons and complaint in state court on January 5, 2000. Defendant First
UNUM Life Insurance Company ("First UNUM") removed the action to this
Court on February 18, 2000, on the ground that "[t]his action is governed
by ERISA." See Notice of Removal at ¶ 5.
Defendant subsequently filed a motion for summary judgment. By
Memorandum-Decision and Order dated September 5, 2001, this Court
granted Defendant's motion with respect to Plaintiff's breach of contract
claim because, as Plaintiff's counsel conceded, ERISA preempted
that claim. See Memorandum-Decision and Order, dated
September 5, 2001, at 7 n.3. The Court, however, denied Defendant's
motion with respect to Plaintiff's claim that Defendant wrongfully
terminated her disability benefits pursuant to ERISA. The Court remanded
the case to Defendant with instructions to consider all relevant
evidence, to apply the appropriate standards, and to reach a
determination as to whether Plaintiff is, in fact, disabled within the
meaning of the Plan. See id. at 15. The Court further instructed
Plaintiff that she was to inform the Court in writing of the result of
Defendant's review process, including appeals, and the effect of that
result on the continued viability of her action. See id. at 16.
Upon completion of the review process, Plaintiff moved for summary
judgment on her ERISA claim and Defendant moved for judgment on the
administrative record. The Court will address each of these motions in
In October 1994, Defendant issued Group Long Term Disability Policy No.
457187 (the "Policy") to Jowonio School, Plaintiff's former employer. The
Policy is an employee benefits plan within the meaning of the Employment
Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et
seq. ("ERISA"), and was designed to provide long term disability
income benefits to eligible employees. See Declaration of Bruce
Dominick, sworn to March 26, 2001 ("Dominick Decl.," at ¶ 3.
In September 1995, Plaintiff began working as a full-time employee at
Jowonio School as an Administrative/Accounting Assistant. Her job duties
included maintaining staff records, therapist time sheets, child
attendance records, billing for all special needs children, interaction
with employees regarding benefits, input of financial data to the
general ledger, reconciliation of bank statements, tracking accounts
receivable and accounts payable, typing, and, when the secretary was
absent, office coverage, which included reception of visitors, answering
phones, copying and filing. See Declaration of Walter Kogut,
dated May 17, 2001, Exhibit "A" (Transcript of the Deposition of
Katherine O. Casey, dated January 16, 2001 ("Casey Tr.")), at 18. After
the birth of her first child, Plaintiff requested, and was granted,
permission to work three days per week. See Casey Tr. at 20, 22.
Her duties remained the same. See id. at 19.
In January 1997, Ms. Casey fell down some stairs in her home and
injured her back. Although she experienced some pain after the fall, she
did not immediately see a doctor or miss time from work. However, on July
2, 1997, Plaintiff sought treatment from Dr. Greenky, an orthopedist,
whose notes indicate a diagnosis of a herniated disk. See
Dominick Decl., Exhibit "A," at 33. On that same day, on Dr. Greenky's
advice, Plaintiff left work on short term disability because of her back
On October 10, 1997, Ms. Casey filed an application for long-term
disability benefits under the Policy. See Dominick Decl.,
Exhibit "A," at 17-19. At that time, Ms. Casey was working part-time,
twenty-one hours per week. By letter dated November 7, 1997, Defendant
approved her application and began paying her benefits. See id.,
Exhibit "A," at 20.
From November 1997 until January 1999, Defendant continued to pay
Plaintiff disability benefits under the Policy. See Dominick
Decl. at ¶¶ 10-11. In addition, Defendant attempted to collect
additional information about Plaintiff's claim. See id. at ¶¶
12-22. On August 26, 1998, Defendant wrote to Dr. Yuan, Plaintiff's
treating physician, requesting copies of his treatment notes and test
results and requesting that Dr. Yuan complete a "Physical Capacities
was enclosed with the letter. See id. at ¶ 13 and
Exhibit "A" at 68. Dr. Yuan returned the Physical Capacities Form on
September 14, 1998, but he did not complete the form and he did not
include copies of his medical records. See id. at 14.
Thereafter, by letter dated September 28, 1998, Defendant wrote to
Plaintiff, advising her, among other things, that Dr. Yuan had neither
provided copies of his medical records nor completed the Physical
Capacities Form. See id. at ¶ 15 and Exhibit "A" at 77-78.
Defendant also advised Plaintiff that it needed proof of her on-going
disability and that, if it did not receive that information within thirty
days, it would conclude that she was no longer pursuing disability
benefits and would close her claim. See id. at ¶ 15.
On October 29, 1998, Defendant's claim representative spoke with
Plaintiff about her current condition. See id. at ¶ 17.
Plaintiff told the claim representative that she had seen Dr. Yuan on
October 5, 1998, and that he had performed an MRI. See id. That
same day, Defendant wrote to Dr. Yuan requesting his office notes and
requesting that he complete the Physical Capacities Form. See
id. at ¶ 18 and Exhibit "A" at 88. Although Dr. Yuan provided a
copy of his notes, he did not complete the form. See id.,
Exhibit "A," at 97-100.
Thereafter, Eileen Mayo, RN CCM, reviewed Plaintiff's file for
Defendant. Ms. Mayo also called Dr. Yuan's office and received a return
call from Pat Lampert, a registered nurse practitioner in Dr. Yuan's
office. See id. at ¶ 20 and Exhibit "A" at 104-05. Ms.
Lampert advised Ms. Mayo that Dr. Yuan did not complete forms outlining
physical limitations and restrictions. See id.
On December 21, 1998, Ms. Mayo wrote to Dr. Yuan summarizing her
Based on review of the available information and
attempts to obtain further information from you,
we have concluded that Ms. Casey would minimally
be able to perform part-time work at a sedentary
level. It is reasonable that she would require the
ability to change positions, alternate sit/stand
every half hour or so. It is also reasonable that
she would be capable of a 20 hour/week at this
level. If you disagree with the above, please
forward your response within 14 days to my
attention. Please include specific restrictions
and limitations, and the basis for each. . . .
If I do not hear from you within 14 days of this
letter, I will assume you concur with our
conclusions of part-time sedentary work capacity.
See Dominick Decl., Exhibit "A," at 106-07.
Dr. Yuan did not respond to Ms. Mayo's letter. See id. at
¶ 22. Shortly thereafter, consistent with Defendant's review, which
found that Plaintiff was not disabled from her part-time occupation,
Defendant denied her benefits beyond January 13, 1999. Defendant sent
Plaintiff a letter setting forth the reasons for its decision. See
id., Exhibit "A," at 112-13. Defendant also advised Plaintiff that
she had the right to an ERISA review. See id. at ¶ 24 and
Exhibit "A" at 112. By letter dated January 28, 1999, Plaintiff exercised
that right. See id. at ¶ 25 and Exhibit "A" at 117.
The ERISA review consisted of a complete review of Plaintiff's file.
See Dominick Decl. at ¶¶ 26-21. During the course of
that review, Defendant received additional records from Dr. Yuan
concerning his March 30, 1999 office visit with Plaintiff. In his notes,
Dr. Yuan wrote
It is my opinion, with a degree of medical
certainty, that these are the limitations she has.
She continues to be totally disabled from going
back to any gainful employment of anybody that
will hire her. But, if we are going to qualify
limitations meaning that lifting 10 lbs, walking
15-20 minutes, sitting for 15-20 minutes,
interchanging positions with these degrees of
so-called limitations, the patient can be working
on a part time basis. If one pushes me to answer
those specifically, that is exactly what she has
been doing at home so based on those limitations
of function, that is
what she is doing so she can certainly
function at that level. This young lady at this
particular point does not have anything acute. If
she has anything acute, she will let me know.
See Dominick Decl., Exhibit "A," at 126.
Additionally, as part of the ERISA review, Defendant obtained the
opinions of Dr. Sharon Hogan, an internist, and Robert Violetta, a
vocational consultant. Dr. Hogan stated, "Dr. Yuan outlines specific R
& Ls [restrictions and limitations] in his 3/99 office visit which
appear to be consistent with part-time sedentary light work cap
[capacity] changes in position as needed every 15-20 min [minutes], no
lifting [greater than] 10 lbs. . . ." See id., Exhibit "A,"
at 150. In his report, Mr. Violetta stated that
According to the Dictionary Of Occupational
Titles, school secretary exists in the general
economy at a sedentary exertion
level primarily sitting with
standing/walking up to an occasional basis and
lifting up to 10 lbs. frequent, reaching, handling
and fingering are also required. The material
duties of this occupation and incumbent discretion
allow for change of position from sit to stand at
the intervals prescribed above.
With the restrictions and limitations identified
above, Ms. Casey would be able to perform her
school secretary occupation as it typically exists
in the general economy according to the Dictionary
Of Occupational Titles.
See id., Exhibit "A, "at 152.
Based upon this ERISA review, Defendant determined that Plaintiff was
not disabled from her part-time occupation and, therefore, upheld its
decision to deny benefits. See Dominick Decl. at ¶ 30. Upon
receiving Defendant's notification of its determination, Plaintiff
commenced the present action under ERISA. As noted, Defendant
subsequently moved for summary judgment.
In its previous Memorandum-Decision and Order addressing Defendant's
motion, the Court found that, based upon Defendant's ERISA review,
Defendant was not entitled to summary judgment because of several
inconsistencies in the administrative record. First, the Court noted that
the record was unclear as to whether Defendant relied upon the
appropriate definition of Plaintiff's "regular occupation" in determining
that she was not disabled and, therefore, not entitled to benefits.
Defendant's vocational consultant had relied upon the Dictionary of
Occupational Titles' definition of "School Secretary," even though
Plaintiff's job title was "administrative/accounting assistant." Second,
the Court expressed concern that Defendant took no steps to clear up the
confusion caused by the apparent inconsistency between Dr. Yuan's two
statements, i.e., that Plaintiff "continues to be totally disabled from
going back to any gainful employment of anybody that will hire her" and
that with certain limitations Plaintiff "can be working on a part time
basis." Third, the Court noted that "`an ERISA fiduciary such as a plan
administrator in [sic] under a duty to act solely in the interests of the
participants and that this includes a duty to investigate a claimant's
claim for benefits and develop reasonably available evidence.'"
See Memorandum-Decision and Order at 13 (quoting Janas,
1999 WL 31006, at *6 (citation omitted) (emphasis added)) (footnote
omitted). Fourth, the Court stated that it appeared that Defendant
virtually ignored Plaintiff's past objective medical evidence that she
suffered from a herniated disk. Finally, the Court noted that remand
would provide Defendant with the opportunity to compare Plaintiff's
limitations and restrictions with the material duties of her regular
occupation as an administrative/accounting assistant in a small school.
With regard to the last finding, the Court concluded that, based upon
the evidence in the administrative record, Defendant failed to consider a
number of relevant factors in arriving at its
determination that Plaintiff could perform "`each of the material
duties of [her] regular occupation.'" See id. (quoting
Martin, 999 F. Supp. at 422). Based upon all of these
inconsistencies in the administrative record, the Court denied the motion
and remanded the matter to Defendant with instructions to consider the
issues noted above, to apply the appropriate standards and to reach a
determination as to whether Plaintiff is, in fact, disabled within the
meaning of the Policy.
With this background in mind, the Court will now address the issues
that the parties raise in their present motions for summary judgment and
for judgment on the administrative record.
A. Standard of review
Plaintiff argues that the standard for reviewing Defendant's decision
should be de novo because Defendant was operating under a
conflict of interest in its role as both the adjudicator and payer of the
claims. To support this assertion, Plaintiff sets forth only conclusory
allegations, citing Defendant's "adversarial handling" of her claim and
the negative media attention Defendant has received. See
Plaintiff's Memorandum of Law at 21.
"In order to trigger de novo review of an administrator's
decision when the plan itself grants discretion to the administrator, a
plaintiff must show that `the administrator was in fact
influenced by the conflict of interest.'" Pulvers v. First UNUM Life
Ins. Co., 210 F.3d 89, 92 (2d Cir. 2000) (quoting Sullivan,
82 F.3d at 1256) (other citation omitted). The plaintiff bears the burden
of proving that a plan administrator was influenced by a conflict of
interest. See Sullivan v. LTV Aerospace & Defense Co.,
82 F.3d 1251, 1259 (2d Cir. 1996). The fact that a defendant
served as both plan administrator and plan insurer, although a
factor to be weighed in determining whether there has been an abuse of
discretion, is not sufficient to trigger de novo review. See
Pulvers, 210 F.3d at 92 (citations omitted).
In the present case, there is no evidence that Defendant was, in fact,
influenced by the conflict of interest inherent in its role as
adjudicator and payer of claims. Upon remand, Defendant conducted an
extensive investigation of Plaintiff's claim for benefits. Specifically,
Defendant hired a third vocational consultant, Mr. Byard, who reviewed
the matter and determined that, given Dr. Yuan's restrictions and
limitations, Plaintiff could perform her occupational duties. Defendant
also attempted to contact Plaintiff's physician, Dr. Yuan, but claims
Plaintiff's counsel prevented it from communicating with him,*fn1 and
Defendant opted not
to request that Plaintiff undergo an independent medical evaluation
because it would not determine whether Plaintiff was disabled on January
Based upon the above, the Court finds that Plaintiff has failed to
prove that Defendant was, in fact, influenced by a conflict of interest.
Accordingly, the Court will review Defendant's decision to deny Plaintiff
benefits using the "arbitrary and capricious" standard.
B. Defendant's decision regarding Plaintiff's disability
The Court reviews Defendant's denial of Plaintiff's disability benefits
under the "arbitrary and capricious" standard because, here, Defendant
has the discretionary authority to determine eligibility for benefits and
to construe the terms of the Policy. See Pagan v. NYNEX Pension
Plan, 52 F.3d 438, 441 (2d Cir. 1995) (citations omitted). This
standard of review "is limited to the administrative record," Miller
v. United Welfare Fund, 72 F.3d 1066, 1071 (2d Cir. 1995), and "is
highly deferential to a plan administrator." Martin v. E.I. DuPont de
Nemours & Co., 999 F. Supp. 416, 422 (W.D.N.Y. 1998). When
applying this standard, a court "may overturn a decision to deny benefits
only if it was `without reason, unsupported by substantial evidence or
erroneous as a matter of law.'" Pagan, 52 F.3d at 442 (quotation
and other citation omitted).
As a preliminary matter, the Court finds that Defendant complied with
the Court's Order
on remand. Specifically, Defendant's vocational consultant, Richard
Byard, concluded that, given Dr. Yuan's limitations and restrictions,
Plaintiff would be able to perform the material duties of her occupation.
Furthermore, Mr. Byard concluded that Plaintiff's material duties
consisted of a combination of the Personnel Clerk and Accounting Clerk,
and due to the variety of tasks required by these jobs, Plaintiff would
be able to change physical posture throughout the work day. Moreover,
having reviewed the administrative record, the Court concludes that there
is substantial evidence in that record to support these conclusions and,
thus, to support Defendant's decision to deny Plaintiff benefits.
Accordingly, the Court holds that Defendant's decision to deny Plaintiff
benefits was not arbitrary and capricious and, therefore, Defendant is
entitled to judgment on the administrative record.*fn2
After carefully considering the file in this matter, the parties'
submissions and the applicable law, and for the reasons stated herein,
the Court hereby
ORDERS that Defendant's motion for judgment on the
administrative record is GRANTED; and the Court further
ORDERS that Plaintiff's motion for summary judgment is
DENIED; and the Court further
ORDERS that the Clerk of the Court enter judgment in favor of
Defendant and close this case.
IT IS SO ORDERED.