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Williams v. Delta Family-Care Disability and Survivorship Plan

January 6, 2009

CEE A.J. WILLIAMS, PLAINTIFF,
v.
THE DELTA FAMILY-CARE DISABILITY AND SURVIVORSHIP PLAN, THE DELTA FAMILY-CARE MEDICAL PLAN, THE DELTA FAMILY-CARE DENTAL PLAN, THE DELTA FAMILY-CARE LIFE INSURANCE PLAN, AND THE ADMINISTRATIVE COMMITTEE OF DELTA AIRLINES, INC., DEFENDANTS.



The opinion of the court was delivered by: Sifton, Senior Judge

MEMORANDUM OPINION AND ORDER

Plaintiff Cee A.J. Williams ("Plaintiff") brings this action against defendants the Delta Family-Care Disability and Survivorship Plan, the Delta Family-Care Medical Plan, the Delta Family-Care Dental Plan, the Delta Family-Care Life Insurance Plan, and the Administrative Committee of Delta Airlines, Inc. (the "Administrative Committee").*fn1 Plaintiff claims that defendants' termination of her disability income benefits, as well as her medical, dental and life insurance coverage, violated the terms of the various Delta employee benefit plans, and she seeks to recover these benefits pursuant to the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq. Presently before this Court are plaintiff's and defendants' cross motions for summary judgment pursuant to Rule 56 of the Federal Rules of Civil Procedure. For the reasons set forth below, defendants' motion is granted and plaintiff's cross-motion is denied.

BACKGROUND

The following facts are drawn from the parties' papers submitted in connection with this motion. Disputes are noted.

Plaintiff was employed by Delta Air Lines, Inc. ("Delta") for over 25 years, from October 28, 1968, to December 18, 1993, as a passenger or customer service agent.*fn2 Complaint filed December 21, 2007 ("Compl.") ¶¶ 12-13; Affirmation of Paul M. Kampfer, Esq. ("Kampfer Aff."), Ex. B at AJW00033, AJW00153.*fn3

Plaintiff's duties included providing a variety of personal services to airline passengers, including assisting elderly and minor passengers with intra-airport travel and baggage claim. Compl. ¶ 13; see also Plaintiff's Affidavit in Support of Her Motion for Summary Judgment ("Pl.'s Aff.") ¶ 6.

On December 18, 1993, plaintiff was driving to her place of work at John F. Kennedy International Airport in Queens, New York, when she swerved into oncoming traffic to avoid hitting a pedestrian. Pl.'s Aff. ¶¶ 16-17. Her car collided with another vehicle. Id. ¶ 17. The impact was so severe that plaintiff lost consciousness and had to be extracted by emergency response personnel. Id. ¶ 18. Plaintiff sustained injuries to the left side of her body, which was crushed, and suffered facial lacerations and lost teeth. The force of the impact caused plaintiff to bite off her lower lip. In addition, plaintiff sustained a lower back sprain, a crush injury of the left foot, internal derangement of both knees and a hernia to her left thigh. Id. ¶¶ 18-19. Between October of 1994 and December of 1997, plaintiff underwent at least six surgeries to address her injuries, including reconstruction of her lower lip and multiple operations on her knees. Id. ¶ 21.

Following the December 18, 1993 automobile accident, plaintiff applied for disability benefits under the Delta Family-Care Disability and Survivorship Plan (the "Disability Plan"). Id. ¶ 28. The Disability Plan is a non-contributory employee welfare benefit plan established and maintained pursuant to ERISA. Declaration of Suzanne Arpin ("Arpin Decl."), Ex. A at 86DP024, 86DP067.*fn4 The Disability Plan provides both short-and-long-term disability benefits to non-pilot Delta employees. 86DP039, 86DP043-44, 86DP048, 86DP055. Section 4.02 of the Disability Plan provides for short-term disability benefits when an eligible employee is "disabled as a result of a demonstrable injury . . . which prevents the Employee from engaging in the Employee's customary occupation." 86DP043. Section 4.03 provides for long-term disability benefits upon expiry of short-term benefits, if an eligible employee is "disabled at that time as a result of a demonstrable injury . . . which will continuously and totally prevent him [or her] from engaging in any occupation whatsoever for compensation or profit, including part-time work[.]" 86DP044. Section 4.01 sets forth additional eligibility criteria and states, in relevant part, that "[a]n Employee who is eligible for disability benefits under the Plan shall be eligible for such benefits only so long as [s]he is under the care of a physician or surgeon for the injury . . . which is the disabling condition." 86DP043. If an employee is receiving disability benefits under the Disability Plan, the employee is generally entitled to received medical and dental benefits as well as life insurance. Compl. ¶¶ 8, 88; Defendants' Response to Plaintiff's Rule 56.1 Statement at 3-4; Arpin Decl. ¶ 5.

Section 11.01 of the Disability Plan provides that the Administrative Committee shall be the named fiduciary of the Plan for purposes of the Plan's operation and administration, with the exception of responsibility for investment and control of Plan assets. 86DP070. Sections 11.01-02 also state that the Administrative Committee has the exclusive power to interpret the Plan and to carry out its provisions, including decisions relating to employee eligibility. 86DP070-72. According to Section 11.03, the Administrative Committee's decisions "as to interpretation and application of the Plan shall be final." 86DP072.

Delta does not directly contribute any monies to the Disability Plan. 86DP067-68. The only monies indirectly provided to the Disability Plan by Delta are placed into various related trust funds and insurance contracts (the "Benefit Fund"), which cannot revert back to Delta. Id. All contributions to the Benefit Fund must be used exclusively for the benefit of Disability Plan participants and reasonable Plan administration expenses. 86DP068. For the Plan year ended June 30, 2003, the Benefit Fund had over $377,576,000.00 in assets and paid out $49,048,000.00 in benefits. Arpin Decl. ¶ 6. At the time the benefit decision at issue here was made, the Administrative Committee had no responsibility or control over the Benefit Fund. Id. ¶ 7.

Plaintiff's application for short-term disability benefits under the Disability Plan was approved, and she received short- term benefits from the Plan for six months. Id. ¶ 29; AJW00451. Plaintiff's claim for long-term benefits was thereafter initially approved, and she received long-term benefits beginning on June 19, 1994. Pl.'s Aff. ¶ 30; AJW00449. On April 4, 1995, plaintiff was denied long-term disability benefits effective February 1, 1995, on the grounds that the Disability Plan had not received required documentation from plaintiff's treating physician. Pl.'s Aff. ¶ 31; AJW00446. Plaintiff appealed this decision in May of 1995, Pl.'s Aff. ¶ 31, AJW00442, and the denial was upheld by letter dated August 29, 1995 from the Administrative Subcommittee of the Disability Plan. AJW00437. Plaintiff appealed the Administrative Subcommittee's decision to the Administrative Committee in November of 1995, Pl.'s Aff ¶ 33, AJW00419, and by letter dated May 23, 1996, the Administrative Committee upheld the denial on the grounds that plaintiff's appeal was received outside the prescribed time period for appeals. Pl.'s Aff. ¶ 34, AJW00419.

On May 19, 1996, the United States Social Security Administration determined that plaintiff had become disabled under its rules on December 18, 1993. AJW00239-42. In its May 19, 1996 Notice of Award, the Social Security Administration granted monthly disability benefits to plaintiff beginning in January of 1995. Id.

Plaintiff thereafter instituted a lawsuit against the Disability Plan and the Administrative Committee in this Court, seeking reinstatement of benefits under the Disability Plan.

Pl.'s Aff. ¶ 35. The lawsuit was settled, and the Administrative Committee agreed to review plaintiff's appeal of the benefits denial. Id. ¶ 36. Following its review, by letter dated December 22, 2000, the Administrative Committee reversed the denial of benefits and conferred retroactive long-term disability benefits on plaintiff in the amount of $56,228.78, to cover the period from February 1, 1995 to May 31, 1999. Id. ¶ 37; AJW00233-34; AJW00252-53. The Administrative Committee conditioned approval of benefits post-May 1999 on receipt of medical documentation that claimant remained "completely and totally disabled" and "under the care of a physician for her condition." AJW00252.

On February 27, 2001 and on April 5, 2001, the Disability Plan wrote to counsel for plaintiff and plaintiff, respectively, stating that in order to avoid a denial of benefits effective June 1, 1999, it required medical reports from plaintiff's treating physician from that date forward. AJW00232-34. By letter dated May 3, 2001, plaintiff was denied disability benefits effective June 1, 1999 on the grounds that the Disability Plan had never received the required medical reports. AJW00228-29. Plaintiff requested review of this decision in a May 9, 2001 letter. AJW00206.

By letter dated August 24, 2001, plaintiff provided the Disability Plan with medical records from the physician treating plaintiff for the injuries causing her disability, Dr. Michael Soojian, M.D., an orthopedic surgeon. AJW00160-85; AJW00084. Plaintiff also provided medical records from Dr. Martin L. Schneider, who treated plaintiff for a lump in her breast in 2000, explaining that because plaintiff did not receive retroactive benefit payments from the Disability Plan until February of 2001, she could only afford to seek treatment from Dr. Schneider for the lump in her breast in 2000.

The records from Dr. Soojian, plaintiff's treating physician, included a December 27, 1999 Statement to the New York Office of Temporary and Disability Insurance and "office notes" dated February 1, 2001 and June 28, 2001. AJW00160-65. The December 27, 1999 Statement by Dr. Soojian contained the following conclusions:

Patient has great difficulty ambulating. R Knee ROM ["range of motion"] 0-100E. L Knee 0-120E with medial lateral joint line Pain. Patient is unable to walk continuously for more than 10 minutes. Patient cannot sit or stand continuously in excess of 10-15 min. Patient cannot lift or carry weight 5 lbs -- time 10 min. Patient remains with constant pain. Her prognosis is guarded. Patient is totally disabled. AJW000164. The office note dated February 1, 2001, contains the following observations: "Scar well healed. R Knee ROM 0-110  ["increased"] pain. L Knee ROM 0-120, medial joint line pain. Disabled." The office note dated June 28, 2001, contains the following observations: "R knee scar well healed. P -["Physical finding - "] crepatation. Plan to do (L) Total knee replacement. Vioxx 250 mg. Disabled." Plaintiff contends, and defendants dispute, that the office notes were recorded pursuant to contemporaneous in-office examinations of plaintiff by Dr. Soojian. Plaintiff's Memorandum of Law in Opposition to Defendant's Cross-Motion for Summary Judgment ("Pl's. Opp'n Memo.") at 9; Defendants' Memorandum of Law in Support of Defendants' Motion for Summary Judgment ("Def.'s Memo.") at 10. It is undisputed that on January 21, 2002, Dr. Soojian stated in a report that his last physical examination of plaintiff was on May 6, 1999. AJW00082.

By letter dated September 20, 2001, the Disability Plan informed plaintiff that it required an Independent Medical Evaluation ("IME") of her in order to assess her claim for disability benefits. AJW00157. On October 10, 2001, plaintiff was examined by Dr. Herman Ambris, M.D., a practitioner of physical medicine and rehabilitation, in the presence of Suzanne Bidart, a nurse employed by counsel for plaintiff. AJW00094-103; AJW00110-17. According to Dr. Ambris, the examination lasted one and a half hours, AJW00117, while according to Nurse Bidart, the examination lasted one hour. AJW00094. In his IME report, Dr. Ambris made the following observations:

Based on my objective findings and examination of the patient, I do believe that the patient is not totally disabled as defined by the criteria provided [by the Disability Plan]. I do believe that she is capable of performing some type of work, most appropriately not work related to prolonged standing or lifting; however, work such as light clerical duties or similar work that will permit the patient to sit most of the time or to move around only occasionally. There should be latitude for her being able to take frequent breaks after approximately two or three hours of constant work . . . [Patient] should be allowed a work station that lets her extend or flex the knees and an adjustable height chair, which would accommodate the pain in her back that she has reported. Her present physical findings do not preclude her from physical work. . . .

Ms. Williams has stated quite impressively that she is very interested in returning to work. Should she be able to manage, she ...


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