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O'Hara v. National Union Fire Insurance Company of Pittsburgh

March 23, 2010

PATRICIA O'HARA, PLAINTIFF,
v.
NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA, DEFENDANT.



The opinion of the court was delivered by: David G. Larimer United States District Judge

DECISION AND ORDER

Plaintiff Patricia O'Hara ("O'Hara") filed this action against National Union Fire Insurance Company of Pittsburgh, PA ("National Union"), seeking benefits pursuant to a National Union disability plan (the "Plan") offered by her former employer, ITT Flygt Corporation ("ITT"), in which O'Hara was a participant, and for which National Union acted as the Plan administrator. O'Hara alleges that National Union's decision to deny her disability benefits under the Plan was unsupported by sufficient evidence, inconsistent with the terms of the Plan, and in violation of the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1132(a)(1).

National Union now moves for summary judgment (Dkt. #12), arguing that O'Hara has failed to demonstrate that its determination was unsupported by sufficient evidence, and/or inconsistent with the terms of the Plan. For the reasons set forth below, that motion is granted.

I. Standard of Review

Where, as here, an ERISA plan does not give the plan administrator discretionary authority to determine eligibility for benefits or to construe the terms of the Plan (Dkt. #12-3, Exh. A), the Court's review of the denial is made under a de novo standard. Applying that standard, the Court will review "all aspects of [the] administrator's eligibility determination, including fact issues, de novo." Troy v. Unum Life Ins. Co. of Am., 2006 U.S. Dist. LEXIS 14965 at *22 (S.D.N.Y. 2006), citing Locher v. Unum Life Ins. Co. of Am., 389 F.3d 288, 293 (2d Cir. 2004). See also Sharkey v. Ultramar Energy, 70 F.3d 226, 230 (2d Cir. 1995); Heidgerd v. Olin Corp., 906 F.2d 903, 909 (2d. Cir. 1990).

The existence of conflicting evidence, even a conflicting opinion from a claimant's treating physician, is not dispositive of the matter.Courts undertaking the de novo review of an administrator's decision "continue[] to possess the authority to weigh competing physician opinions [themselves], and to make findings of fact based on [their] own consideration of the evidence." Troy, 2006 U.S. Dist. LEXIS 14965 at *24.

II. Plaintiff's Claims

A. O'Hara's Employment and Medical History

The Plan provides for disability coverage where, "as a result of injury and commencing within one year of the date of the accident an insured person is totally and permanently disabled and prevented from engaging in each and every occupation or employment for compensation or profit for which he is reasonably qualified by reason of his education, training or experience." (Dkt. #12-3, Exh. A at D00005). Written notice of disability claims must be provided to the employer within twenty days after the occurrence or commencement of the covered loss, or as soon thereafter as is reasonably possible. (Dkt. #12-3, Exh. A at D00009).

O'Hara was a Plan participant during her employment with ITT, from 1993 through August 2002. On March 15, 2001, while working as an office administrator in the Rochester, New York office of ITT, O'Hara slipped and fell, striking her head on the floor and sustaining a concussion. O'Hara was taken to the emergency room, where she was x-rayed and treated for headaches. O'Hara continued to work at ITT, and in or about July 2001, O'Hara's manager began to receive complaints from O'Hara's co-workers, alleging that O'Hara behaved unprofessionally and had difficulty maintaining satisfactory working relationships with colleagues. O'Hara's supervisor discussed the matter with her and changed her work assignment, but O'Hara's interpersonal relationships at ITT continued to deteriorate. On June 6, 2002, O'Hara's employment with ITT was terminated, on the grounds of interpersonal difficulties.

From the time of her fall onward, O'Hara was treated by neurologist Dr. Joseph Mann for headaches, and associated decreases in executive function, mood changes, and a sleep disorder. On July 10, 2002, Dr. Mann completed a report for O'Hara's use in seeking workers' compensation benefits, which stated simply that O'Hara was "completely disabled as of June 10, 2002 and unable to work at this time." (Dkt. #12-4, Exh. E at D00491). On December 12, 2002, Dr. Mann again stated that O'Hara was "totally disabled for the type of work that she was doing [as an administrative assistant at ITT], having suffered a head injury at work." (Dkt. #12-4, Exh. E at D00486). In June 2002, O'Hara began treating with Dr. Jaimala Thanik, a pain management specialist. In April 2003, Dr. Thanik concluded that although O'Hara had some functional limitations, she "may try going back to work doing half days with restrictions of no repetitive type work." (Dkt. #12-4, Exh. F at D00420).

On January 29, 2004, O'Hara submitted a claim for disability benefits under the Plan. The claim was processed by AIG Domestic Claims, Inc. ("AIG"), which reviewed O'Hara's medical records. AIG also reviewed medical examination reports from independent medical examiners Dr. Guy Corkhill, Dr. Thomas Letourneau, and Dr. David Marzulo. Dr. Corkhill, a neurosurgeon who examined O'Hara on multiple occasions beginning September 9, 2002, concluded on July 7, 2003 that O'Hara had a "mild partial temporary" disability arising from the accident. (Dkt. #12-5, Exh. G at D00334). Dr. Letourneau, a neurologist who examined O'Hara on March 24, 2003, indicated that although O'Hara was suffering from mild/moderate depression stemming from chronic pain, "[t]here is no psychiatric disability . . . [f]rom a psychiatric standpoint, [O'Hara] is able to return to work full-time." (Dkt. #12-5, Exh. H at D00315). Neurologist Dr. Marzulo, who examined O'Hara on September 12, 2005, felt that she was unable to perform her pre-injury occupation or work in a busy office setting requiring speedy recall and verbal skills, but nonetheless had only a "partial disability" and could perform a "low emotional stress job duty which would not necessitate a multitude of recall actions or marked responsibility . . . on a part time basis[,] up to 20 hours per week initially as a so-called testing ground." (Dkt. #12-5, Exh. I at D00106).

After reviewing the record, AIG denied O'Hara's claim for benefits on January 6, 2006, on the grounds that "while there is proof that [O'Hara was] disabled from [her] own job, there is [a] lack of objective medical evidence showing [disability] from any employment . . . neither proof of a generalized inability to work nor have any of [her] doctors actually opined that [her] disability is permanent, as required by the policy." (Dkt. #12-5, Exh. J at D00089). O'Hara appealed, and submitted additional medical evidence, including a June 28, 2006 letter from Dr. Mann, which employed the precise language of the Plan and stated that O'Hara was "totally disabled and prevented from engaging in each and every occupation or employment for compensation or profit that she was reasonably qualified for within 1 year of the March 15, 2001 fall." (Dkt. #12-5, Exh. M). On November 13, 2006, the ERISA Appeal Committee ...


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