The opinion of the court was delivered by: Hurley, Senior District Judge
Plaintiff Janet Solnin ("Plaintiff") brings this action challenging the termination of long-term disability benefits under her employer's benefit plan. Defendants GE Group Life Assurance Company ("GE Group Life") and Phoenix Life Insurance Company ("Phoenix Life") (collectively, "Defendants") have moved for summary judgment pursuant to Federal Rule of Civil Procedure ("Rule") 56. For the reasons stated below, the motion is granted in part and denied in part, and the matter is remanded for proceedings consistent with this opinion.
The material facts, drawn from the Complaint and the parties' Local 56.1 Statements, are undisputed unless otherwise noted.
Plaintiff's Injury at Work
Plaintiff was employed as an Assistant Manager for Reliance Federal Savings Bank ("Reliance"). On November 18, 1998, Plaintiff suffered a back injury at work when she crawled underneath a table to fix a computer. On February 13, 1999, she filed a Notice of Claim for Disability Benefits under the disability insurance policy (the "Policy") provided by Reliance; her application was filed on July 26, 1999. The Policy was originally administered by Phoenix Life until April 2000, when GE Group Life acquired the group life and health operation of Phoenix Life and thereafter became the new Administrator.
A Group Policy and Long Term Disability Certificate were issued by Phoenix Life to Reliance which provided for long-term disability benefits. The Policy is an employee welfare benefit plan governed by the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001 et seq. The Policy defines "Total Disability" and "Totally Disabled" as:
1. During the Elimination Period and the following 24 months, you are unable to perform all the material and substantial duties of your regular occupation.
2. After the Elimination Period and the following 24 months, you are unable to perform the duties of Any Occupation.
Plaintiff's Application for Long-term Disability Benefits/The Medical Evidence
Plaintiff's application for benefits included a Health Care Provider's Statement executed by Barry G. Fisher, M..D. who noted a diagnosis of "Herniated Disc Lumbar Spine." On her application, Plaintiff noted that she would be receiving Worker's Compensation for the period February 5 through May 21, 1999, and that she had been unable to work because of her disability since February 5, 1999. The Attending Physician's Statement submitted with the application was signed by Thomas M. Mauri, M.D., Plaintiff's treating physician, who noted a diagnosis of thoracic disc herniations with spinal cord symptoms.
In a letter dated April 14, 1999, Dr. Mauri noted, inter alia, that Plaintiff immediately developed back pain following her injury and "over the ensuing weeks, developed significant lower extremity numbness and later weakness. On January 15, 1999, she had the first episode of shocks going down her left leg and then her left leg and foot collapsed under her and she fell. . . . . She walks better with a cane and especially using a shopping cart." (R. at 755.)*fn1
In the section entitled "Recommendations", Dr. Mauri noted that Plaintiff seemed to be progressing and had less pain and symptoms than she had a month earlier. He encouraged her to continue treatment, restart an anti-inflammatory and to continue therapy three times a week for at least another six to eight weeks. (Id.)
In a letter dated June 1, 1999, Dr. Mauri noted that Plaintiff continued to improve with less loss of sensation, that a neurological examination was normal, but noted that her thoracolumbar pain persisted. (Id. at 757.) He further stated that he did not think surgical intervention was necessary at this time but that she "continues to be totally disabled at this time because of her back pain. I am not sure that she will ever be able to return to work as a bank manager given the job description that she gave me." (Id.)
Phoenix Life also received a copy of a letter dated February 25, 1999 from Jeffrey Mallin, M.D., a neurologist, to Roger Gittelson, M.D., in which Dr. Mallin noted Plaintiff's complaints of numbness, tingling, and shivering in her legs. (Id. at 719.) Plaintiff complained that she had difficulty walking and that her left leg tended to buckle if she put too much weight on it. (Id.) Dr. Mallin concluded that Plaintiff was experiencing a "bona fide loss of motor strength" and that she "should be evaluated for possible neurosurgical intervention." (Id. at 720.) He noted that Plaintiff was taking several medications, including Valium, the latter of which he instructed her to reduce her dosage. (Id.)
Phoenix Life received a letter from Allen D. Efron, M.D., a nuerosurgeon, dated March 1, 1999, addressed to Dr. Mallin, who apparently referred Plaintiff to Dr. Efron. (Id. at 733.) Dr. Efron noted Plaintiff's complaints of pain and numbness and her alleged inability to walk for long periods without stopping to rest. (Id. at 734.) He concluded that he was "unsure as to what to attribute [Plaintiff's] symptoms" and that he did not think surgery was appropriate given the "lack of objective evidence of spinal cord compression, a lack of thoracic radicular findings and the minimal disc herniation." (Id.)
Office notes from Dr. Ralph Parisi dated March 25, May 4, June 29, and August 10, 1999 were also submitted to Phoenix. (Id. at 713-16.) On March 25, 1999, Dr. Parisi noted that Plaintiff was unable to return to work. (Id. at 716.) On May 4, 1999, Dr. Parisi noted that Plaintiff was improving and had less paresthesias.*fn2 (Id. at 715.) On June 29, 1999, Dr. Parisi noted that Plaintiff had chronic complaints of numbness in the left leg with difficulty walking but that there was "a paucity of objective findings." (Id. at 714.) Finally, on August 10, 1999, Dr. Parisi noted that Plaintiff's MRI showed a S1 nerve root problem, that Plaintiff's condition was "somewhat improved in terms of her strength but she continues to have persistent paresthesias down the left leg with a restriction of spine motion." (Id. at 713.)
Phoenix also received the notes and records of Dr. Melvin Holden. (Id. at 659-710.) Among other things, Dr, Holden noted that Plaintiff reported numbness in her legs and an unsteady gait. (Id. at 688.)
Records from Dr. Erik Entin, a neurologist, were also reviewed. (Id. at 647-59.) These records reflect the results of a MRI, noted on January 29, 1999, as an Impression of "T7-9 left paracentral disc herniation" (id. at 648), and the results of a MRI of the Cervical Spine, noted on February 11, 1999, which included an impression of "[m]inimual degenerative change," (id. at 649).
Plaintiff's Claim for Long-Term Disability Benefits is Approved
By letter dated August 31, 1999, Phoenix Life notified Plaintiff that her claim for long-term disability benefits had been approved. (R. at 641-43.) Plaintiff was advised that the benefits payable under the Policy were to be coordinated with certain other income benefits she was entitled to receive, including Social Security benefits and Workers' Compensation benefits. Plaintiff began receiving such benefits commencing with the period August 4 through August 31, 1999. (Id. at 613.)
Workers' Compensation Board Decision
On January 11, 2000, the Workers' Compensation Board issued a Memorandum and Decision awarding Plaintiff benefits of $320.51 per week beginning May 21, 1999. Pursuant to the Policy, Phoenix Life re-calculated the long-term disability benefits it had paid to offset the Workers' Compensation award.
Phoenix Life received updated medical records from Dr. Mauri in July 2000. (Id. at 526-546.) Among them was a report dated March 2, 2000, in which Dr. Mauri noted that Plaintiff "is going to suffer with the residual of her injuries to her thoracic spine for the rest of her life. I have discussed with her the possibility of having surgery for the thoracic disc herniation but she has chosen to continue suffering with the pain rather than take the risks of the surgery and certainly this is her option." (Id. at 544.) There also was a report dated June 1, 2000, in which he noted, inter alia, that Plaintiff still had restricted range of motion in the thoracic area, she continued to suffer with the effects of a thoracic herniated disc with spinal cord irritation, he recommended that she continue physical therapy three time per week, and that she remains totally disabled from any kind of work because of the severity of her injury. (Id. at 545.) Finally, there are multiple comments throughout his notes regarding Plaintiff's inability to walk more than a few minutes without weakness on her left side, her difficulty reaching, bending, and twisting, and that she continues to suffer significant left leg symptoms. (See generally id. at 526-46.)
Change in Eligibility for Benefits
By letter dated March 28, 2002, GE Group Life, which was now the Administrator of the Policy, advised Plaintiff that the definition of "Total Disability" had changed from the inability to perform her own occupation to the inability to perform any occupation because the 24-month disability period had expired. (Id. at 2566-2570.) Plaintiff was notified that additional medical information, not yet received from her, was required. In that regard, the letter noted that additional benefits could not be considered until the requested information was received and reviewed. (Id. at 2568-2570.)
That same day, GE Group Life received a Supplemental Statement of Disability from Plaintiff, an Attending Physician's Supplemental Statement from Dr. Mauri, and a medical report of Dr. Mauri, dated January 28, 2002. (Id. at 2558-2564.) In her Supplemental Statement dated March 14, 2002, Plaintiff stated that she "can't walk that much and at times [her] legs have no feeling and [she] fall[s]. [She] need[s] help around [her] home." (Id. at 2558.) She also stated that she leaves her home ...