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 ...