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Shapiro v. Prudential Insurance Co. of America

June 13, 2008


The opinion of the court was delivered by: Kenneth M. Karas, District Judge


Plaintiff Helene Shapiro ("Plaintiff") brings this case challenging determinations denying her long-term disability ("LTD") benefits under a group employee benefit plan (the "Plan") offered by Defendant Prudential Insurance Company of America ("Defendant"). There is no dispute that Plaintiff was a covered employee of the Plan. Plaintiff's Complaint seeks relief under the Employment Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1132(a)(1)(B).

For the reasons stated in this Memorandum Order, Defendant's Motion for Summary Judgment is GRANTED.

Factual Background

Beginning in July 1994, Plaintiff was employed as a salesperson at Comsys Information Technology Services. (Pl.'s 56.1 ¶ 6; Decl. of Fred N. Knopf ("Knopf Decl."), Ex. I.)*fn1 Plaintiff claims to suffer from a severe case of cervical myofascitis and disc herniation, apparently arising from a 1996 car accident.*fn2 Plaintiff continued to work until November 1999, when she permanently left her job. (Pl.'s 56.1 ¶ 9.) She received short-term disability benefits from November 11, 1999, through February 2, 2000. (Id. ¶ 10.)

Standard of Review and Procedural Posture

Judge Colleen McMahon, to whom this case was initially assigned, issued an order on November 20, 2006, summarily deciding that the "denial of benefits will be reviewed de novo." (Dkt. No. 18.) The case was reassigned to this Court on August 6, 2007. The Court assumes without deciding that, as law of the case, de novo review is appropriate here. See Locher v. Unum Life Ins. Co. of Am., 389 F.3d 288, 296 (2d Cir. 2004) ("[U]pon de novo review, a district court may render a determination on a claim without deferring to an administrator's evaluation of the evidence."); see also Connors v. Conn. Gen. Life Ins. Co., 272 F.3d 127, 134-35 (2d Cir. 2001) ("[District Court is] free to evaluate [physician's] opinion in the context of any factors it considered relevant, such as the length and nature of the[] relationship [with the claimant], the level of the doctor's expertise, and the compatibility of the opinion with the other evidence.").

As to the ultimate burden, it is both common sense and settled law that "the insured has the burden of proving that a benefit is covered." Mario v. P & C Food Markets, Inc., 313 F.3d 758, 765 (2d Cir. 2002); see also Paese v. Hartford Life & Accident Ins. Co., 449 F.3d 435, 439-41 (2d Cir. 2006) (applying Mario where Plaintiff claimed to have injured neck, shoulders, back, and wrists in 1999 automobile accident, returned to work, then permanently left his job with short-term disability benefits); Morgan Stanley Group Inc. v. New England Ins. Co., 225 F.3d 270, 276 (2d Cir. 2000) ("It is well established under New York law that a policyholder bears the burden of showing that the insurance contract covers the loss.");.

In her papers opposing summary judgment, Plaintiff claimed that the matter was not ripe for summary judgment because of outstanding discovery. (Pl.'s Mem. of Law in Supp. of Pl.'s Opp'n to Defs.' Mot. for Summ. J. ("Pl.'s Mem. of Law") 10-11.) The Court held a conference addressing this issue on February 20, 2008, then ordered additional briefing of it and, by Order dated March 4, 2008, found Plaintiff's contention to be without merit.*fn3 Thus, the Court considers Defendant's Motion based on the evidence in the record.

The Court held oral argument on the Motion for Summary Judgment on June 4, 2008. The 2000 Application for Benefits At some unidentified point in 2000, an application for LTD benefits was submitted to Defendant. (Pl.'s 56.1 ¶ 11.)*fn4 Plaintiff highlights that this application included a "signed statement by Dr. [Leonard] Harrison, Plaintiff's physician, stating that Plaintiff was unable to work as of November 4, 1999, and would be able to perform usual work at an unknown future date." (Id.)

In a letter dated July 11, 2000, Defendant's representative explained that Defendant had reviewed Plaintiff's claim and determined that Plaintiff was not eligible for benefits. (Knopf Aff., Ex. J.) The letter began by stating the Plan's definition of disability. (Id.)*fn5 Next, the letter reviewed the evidence submitted by Plaintiff -- a letter from Dr. Harrison, medical records from Dr. Harrison, an MRI dated January 3, 2000, and physical therapy notes from Plaintiff's husband, Larry Shapiro. (Id.) The letter concluded: "We do not find that the available medical evidence submitted by your physician establishes a significant impairment that would warrant total disability. In addition, you worked for nearly three years from the time of the [1996 car accident] and the medical records received do not demonstrate that a significant change has occurred in your condition from the time you were working." (Id.) The letter also advised Plaintiff of her right to appeal the determination. (Id.)

Plaintiff now contends that "[d]espite ample medical records indicating the contrary, Defendants determined in July 2000 that Plaintiff was not totally disabled." (Pl.'s Mem of Law 18.) Plaintiff thus asks the Court to determine disability under the Plan principally based on Dr. Harrison's conclusion that Plaintiff "cannot work." (Id. 13.) First of all, there is no treating physician rule applicable to this case, as there would be in the Social Security context, commanding special deference to a treating physician. See Mood v. Prudential Ins. Co. of Am., 379 F. Supp. 2d 267, 281 (E.D.N.Y. 2005) (citing Black & Decker Disability Plan v. Nord, 538 U.S. 822, 831 (2003)); see also Connors, 272 F.3d at 135 n.4 ("We do not adopt for these purposes -- that is, when a district court reviews an ERISA administrator's decision under a de novo standard -- the 'treating physician rule' . . . ."). Second, even with the benefit of Dr. Harrison's interpretive letter dated June 6, 2006 -- a benefit the initial claim reviewer did not have -- Plaintiff's submission fails to convincingly show that Plaintiff was disabled, as defined by the Plan, as of November 1999. In his notes and his letter, Dr. Harrison says little more than that Plaintiff's pain became worse. His statement that it would prevent her from working in her then-current or any other job is abrupt, conclusory, and entirely without explanation for its suddenness. Any reasonable claim reviewer would want to understand the basis on which a claimant seeks LTD benefits, and Plaintiff's submission was and is insufficient to provide such an understanding.*fn6

Plaintiff also strenuously argues that Defendant's review of her application was defective because Defendant refused to consider treatment records submitted by Plaintiff's husband, Larry Shapiro. Plaintiff submits that Defendant's "thinly veiled accusations against Mr. Shapiro's character and refusal to consider his findings and review of Plaintiff's condition are preposterous." (Pl.'s Mem. of Law. 13 n.1.) To the contrary, it is curious that Plaintiff would expect Defendant to award LTD benefits relying substantially on Plaintiff's husband's representation about her medical condition. The Court makes no insinuation about Mr. Shapiro's professional competence or candor. Rather, the Court observes merely that Plaintiff's spouse stood and stands to gain financially from a benefits award from Defendant to Plaintiff, and therefore is subject to a structural bias that makes his medical representations of limited value. Cf. 81 Am. Jur. 2d Witnesses § 230 ("The traditional common-law rule . . . provides that neither party to a marriage can be a witness in favor of or against the other, in a suit to which the other is a party, or has a direct or immediate interest."). Moreover, Plaintiff was always free, and was invited, to augment the medical evidence in support of her LTD claim.

Beyond this, Plaintiff's successful effort to persuade Judge McMahon that de novo review applies here makes any failure by Defendant to consider the physical therapy records irrelevant. The records of Larry Shapiro submitted by Plaintiff include a one-page "Initial Evaluation" dated December 20, 1996, as well as notes apparently reflecting evaluations from March 3, 1999, through March 11, 2000. (Dkt. No. 37 at 23-31.) Unfortunately, the handwritten notes appeared illegible to the Court (at least to a person not familiar with Mr. Shapiro's handwriting), and Plaintiff's briefing fails to give any indication of what in the notes she believes supports her claim. Almost certainly, the initial claim reviewers faced ...

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