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HACHTEL v. CITIBANK

GEORGE HACHTEL, Plaintiff,
v.
THE CITIBANK, N.A., LONG TERM DISABILITY PLAN, THE CITIBANK, N.A., MEDICAL PLAN, THE CITIBANK, N.A., DENTAL PLAN, THE CITIBANK, N.A., LIFE INSURANCE PLAN, THE CITIBANK, N.A., ACCIDENT INSURANCE PLAN, THE CITIBANK, N.A., SAVINGS INCENTIVE PLAN Defendant(s).



The opinion of the court was delivered by: THOMAS PLATT, JR., Senior District Judge

MEMORANDUM AND ORDER

Before this Court are two motions:
1. Citibank Long Term Disability Plan (the "LTD Plan"), and Citibank Medical Plan, Citibank Flexible Benefits Plan, Citibank Dental Plan, Citibank Life Insurance Plan, Citibank Accident Insurance Plan, and Citibank Retirement Plan ("Non-LTD Plans"), (collectively "Defendants"), move for summary judgment pursuant Fed.R. Civ. P. 56(c); and,
2. George Hachtel ("Plaintiff" or "Hachtel") cross-moves for summary judgment pursuant to Fed.R.Civ. P. 56(c). For the following reasons, both Defendants' and Plaintiff's motions are DENIED.

  DISCUSSION

  A. Factual Background

  Prior to and including November 14, 1994, Plaintiff was employed as a Systems Programmer in the Information Management Systems at Citibank. (Defs. 3rd Amend. Rule 56.1 Statement at ¶¶ 23-4; Pl. 2nd Amend. Rule 56.1 Statement at ¶¶ 1-2). Plaintiff was a covered participant of the LTD Plan by virtue of his employment with Citibank. The LTD Plan is sponsored and funded by Citibank and administered by Aetna Life Insurance Company ("Aetna"). (Defs. 3rd Amend. Rule 56.1 Statement at ¶¶ 16-7; Green Aff., Exh. U). Aetna acts as the LTD Plan administrator and fiduciary. (Id.) Both the LTD and Non-LTD Plans are employee pension or welfare benefit plans subject to the Employee Retirement Income Security Act of 1974 ("ERISA"). (Defs. 3rd Amend. Rule 56.1 Statement at ¶¶ 1-8).

  Plaintiff alleges that on or about 1993, he developed a flu-like illness which caused him to suffer severe sore throat problems, extreme and debilitating exhaustion, lightheadedness and dizziness. (Montas Aff., Exh. A at 2). In December of 1993, Plaintiff sought medical treatment for these symptoms at his HMO medical center. Over the course of the next year, Plaintiff was seen by several different types of physicians in diverse areas of practice. (Montas Aff., Exh. A at 2).

  Plaintiff alleges that his condition subsequently worsened and he began to suffer from constant fatigue, weakness and severe cognitive impairments requiring him to sleep excessively and take several sick days. Plaintiff's doctors informed him that he could have chronic fatigue syndrome ("CFS") or major depression. (Id.) In November of 1994, Plaintiff joined a support group for CFS, wherein he learned about a specialist in this area by the name of Dr. Susan Levine ("Dr. Levine"). (Id.) Plaintiff consulted with Dr. Levine, and she diagnosed him with CFS and prescribed a treatment regimen of medications and vitamin injections. (Id.; Hachtel Dep. at 112, 114-5). Despite this treatment, Plaintiff's symptoms continued to increase in severity and on November 14, 1994, Plaintiff ceased working. (Montas Aff., Exh. A at 2; Hachtel Aff. at 77, 79-82, 126-7).

  On November 17, 1994, Plaintiff was evaluated at an HMO medical center by his own doctor, psychiatrist Dr. Deborah Pfeffer ("Dr. Pfeffer"). (Defs. 3rd Amend. Rule 56.1 Statement at ¶ 31; Bonner Aff. Exh. C). Dr. Pfeffer ruled out depression as the cause of Plaintiff's symptoms and found that Plaintiff had CFS and Adjustment Disorder mixed with "emotional feelings." (Id.)

  Plaintiff notified Aetna of his condition and his absence from work, indicating that he would first exhaust his sick days, then his vacation days, as required by the Short Term Disability Plan ("STD Plan") and the LTD Plan. The LTD Plan provides benefits to disabled employees beginning on the 181st day of disability, after the employee has received coverage under the STD Plan. Under the LTD Plan, "disability" is defined, in pertinent part, as:
a mental or physical condition which the Claims Administrator/Fiduciary determines: (i) prevents the Participant from performing each and every material duty pertaining to his or her regular occupation (and after 24 consecutive months of such condition prevents the Participant from engaging in each and every occupation or employment for wage or profit for which Employee is reasonably qualified by reason of education, training or experience or may reasonably become qualified)
(Green Aff., Exh. A, "LTD Plan").

  Likewise, the LTD Plan provides that a Claims Administrator/Fiduciary may require the employee to undergo an independent medical examination ("IME") by a doctor designated by the LTD Plan. (Id.)

  Aetna made a decision to deny certification of Plaintiff's disability pending an IME by a specialist in infectious diseases. (Defs. 3rd Amend. Rule 56.1 Statement at ¶¶ 26-7). Plaintiff underwent the IME in December 1994. (Id. at 27; Bonner Aff., Exh. B). Dr. Arthur Klein ("Dr. Klein"), who performed the IME, disagreed with the diagnosis of CFS, but found Plaintiff was disabled due to depression and headaches, secondary to chronic sinusitis. (Id. at 28). Dr. Klein then recommended that Aetna certify Plaintiff's disability pending evaluation by a neurologist and psychologist. (Id. at 29). Following this evaluation, Aetna informed Plaintiff that it would certify his disability until January 16, 1995. (Montas Aff., Exh. A at 4).

  In February 1995, pursuant to Aetna's instructions, Plaintiff was seen by a neurologist, Dr. Kristina Dahl ("Dr. Dahl"), who diagnosed Plaintiff again with CFS as well as symptoms associated with depression. (Bonner Aff., Exh. D). Dr. Dahl indicated that Plaintiff remained disabled due to his physical and cognitive disabilities. (Id.) The claim file contains notes from Aetna's Medical Director, Dr. Joseph Pascuzzo ("Dr. Pascuzzo"), which stated that no significant physical findings were noted in Dr. Dahl's report. (Defs. 3rd Amend. Rule 56.1 Statement at ¶ 34). Further, the cognitive defect could be on a medical or a psychiatric level. (Id.) Aetna notified Plaintiff that it would continue to certify his disability through March 3, 1995. (Id. at ¶ 33).

  On April 12, 1995, however, Aetna declined to certify additional disability time for Plaintiff until he underwent additional testing. (Id. at ¶ 45). Pursuant to this requirement, Plaintiff met with an Aetna rehabilitation nurse, Arlene Mackey ("Nurse Mackey"), so she could perform a Functional Capacity Evaluation ("FCE"). (Montas Aff., Exh. A at 7). Plaintiff, however, was too weak to perform the FCE and Nurse Mackey relayed to Aetna that Plaintiff was not capable of work due to his disability. (Id.) Aetna then scheduled a medical examination for Plaintiff with a neuropsychologist, Dr. Avraham Calev ("Dr. Calev"), in May 1995. (Bonner Aff., Exh. E). Dr. Calev also found that Plaintiff suffered from CFS and depression, although he made no finding with regard to Plaintiff's disability. (Id.)

  Plaintiff's entire file was then reviewed by one of Aetna's in-house physicians, Dr. David Erickson ("Dr. Erickson"), who recommended that Aetna certify the disability. (Montas Aff., Exh. A at 10-11). Aetna suggested that Plaintiff begin rehabilitation on June 16, 1995. (Defs. 3rd Amend. Rule 56.1 Statement at ¶ 46). Plaintiff began such rehabilitation three times per week, and Aetna again extended its certification until August 31, 1995. Plaintiff continued his rehabilitation, and Dr. ...


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