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Baird v. Prudential Insurance Company of America

September 24, 2010

MONA BAIRD, PLAINTIFF,
v.
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA, DEFENDANT.



The opinion of the court was delivered by: Paul G. Gardephe, U.S.D.J.

MEMORANDUM OPINION AND ORDER

In this action, Plaintiff Mona Baird alleges that Defendant Prudential Insurance Company of America wrongfully terminated her employer-sponsored long term disability ("LTD") benefits.

Defendant now moves for summary judgment, arguing that "the administrative record . . . fully supports Prudential's decision [to discontinue Plaintiff's disability benefits] in that there is substantial evidence demonstrating that Plaintiff is capable of performing the material and substantial duties of her occupation." (Def. Br. 1) Because nothing in the administrative record suggests that Defendant acted in an arbitrary and capricious manner in deciding to terminate Plaintiff's LTD benefits, Defendant's motion to dismiss will be GRANTED.

BACKGROUND

Plaintiff is a participant in the Goldman, Sachs & Co. Class 1 Employees Long Term Disability Plan ("the Plan"), an ERISA-governed employee welfare benefit plan administered by Defendant. The Plan provides that a participant is disabled and thus entitled to benefits "when Prudential determines that" [the participant is] unable to perform the material and substantial duties of [her] regular occupation due to [her] sickness or injury; [the participant is] under the regular care of a doctor; and [the participant has] a 20% or more loss in . . . monthly earnings due to that sickness or injury. (Def. Rule 56.1 Stat. ¶ 1; Coppola Decl., Ex. 3 at D0800) (emphasis in original)*fn1 The Plan goes on to provide that "[m]aterial and substantial duties means duties that: are normally required for the performance of your regular occupation and cannot be reasonably omitted or modified"; that "[r]egular occupation means the occupation you are routinely performing when your disability begins"; and that "[i]njury means bodily injury that is the direct result of an accident, is not related to any cause other than the accident, and results in immediate disability." (Id. ¶¶2, 3; Coppola Decl., Ex. 3 at D0800-801)(emphasis in original, punctuation altered) The Plan requires that each claimant provide continuing proof of disability in order to receive ongoing benefits under the Plan. (Def. Rule 56.1 Stat. ¶ 4) The Plan further states that Prudential "as Claims Administrator has the sole discretion to interpret the terms of the Group Contract, to make factual findings, and to determine eligibility for benefits," and that "[t]he decision of the Claims Administrator shall not be overturned unless arbitrary and capricious." (Id. ¶ 5)

Plaintiff worked at Goldman Sachs as a manager of equity sales. (Id. ¶ 6) The parties disagree about the material duties of her position. (See Def. Rule 56.1 Stat. ¶ 7; Pltf. Rule 56.1 Stat. ¶ 7) Plaintiff's self-reported material duties included: (1) "working at a computer all day for 10-12 hours per day from 6 a.m. to 6 p.m. five days a week," (2) "sitting for 10-12 hours a day doing computer work," and (3) "writing and typing frequently." (Pltf. Rule 56.1 Stat. ¶ 7(a), (b), (e); Coppola Decl., Ex. 3 at D346, 351-52) Plaintiff was also required to occasionally push or pull up to 20 pounds and frequently up to 10 pounds, use her upper body for reaching or handling, and to "perform frequent fingering." (Def. Rule 56.1 Stat. ¶ 8)

On March 3, 2005, Plaintiff left work at Goldman because of bilateral carpal tunnel syndrome. (Id. ¶ 9) Plaintiff's average annual income from Goldman at that time was more than $1 million. (Hannan Decl., Ex. 1 at D0027) Plaintiff received disability benefits of $15,000 per month under the Plan from September 3, 2005 to April 1, 2008, when Prudential determined that she was able to perform the material and substantial duties of her own occupation as defined under the Plan. (Id. ¶ 10; Coppola Decl., Ex. 3 at D0766) Upon the termination of her benefits, Plaintiff filed first and second level appeals, both of which Defendant denied. (Id. ¶ 11)

I. PLAINTIFF'S CONDITION AND INITIAL TREATMENT

Baird began developing numbness, tingling, and weakness in her right hand in 2004. On July 16, 2004, she underwent right carpal tunnel release surgery. A second surgery was performed on March 3, 2005, after which Baird did not return to work. (Id. ¶¶ 13-14) Dr. Weiland, her treating physician and orthopedic surgeon, examined Baird on July 20, 2005 and noted that her right hand was improving "slowly and steadily." (Id. ¶¶ 15-16). Plaintiff complained of left wrist pain, but an electromyogram ("EMG") -- a nerve conduction study -- performed in January 2005 revealed no abnormalities in her left wrist. (Id. ¶ 17)

On September 7, 2005, Baird complained of continued pain in her wrists and told Dr. Weiland that she had "to make some life decisions with respect to her employment." (Id. ¶ 18) Dr. Weiland examined Plaintiff again on November 16, 2005, at which time improvement was noted. (See id. ¶ 19-21; Pltf. Rule 56.1 Stat. ¶¶19-21) At a July 5, 2006 visit, Baird complained that her right wrist was still not "back to baseline," and Dr. Weiland explained that "it would take 'another several months' to get back to baseline." (Def. Rule 56.1 Stat. ¶¶ 22-23)

Baird's next office visit was on December 7, 2007, when she reported "that her symptoms are the same as they were, however they have significantly improved from her pre-surgical level." Baird stated that she suffered from "occasional pain in the region of her [right] hand that goes in to her palm with some residual numbness which is unchanged," and that she continued to experience pain in her left hand. (Pltf. Rule 56.1 Stat. ¶¶ 25-26; see Coppola Decl., Ex. 3 at D148, 135)

Following her 2005 surgery, Baird received four months of physical therapy. The physical therapist's initial evaluation form notes that long term goals for Baird include regaining functional use of her right hand and returning to work. (Def. Rule 56.1 Stat. ¶¶ 28-29) Baird last received physical therapy on June 21, 2005. (Id. ¶ 30)

On January 24, 2008, neurologist Dr. Dexter Sun performed a nerve conduction study on Baird and reported "no neurophysiologic evidence of focal neuropathy on either side in the hand." Dr. Sun noted that this was the "second EMG study excluding carpal tunnel syndrome or any other neurologic sign in the hand." (Id. ¶¶ 31-32) Dr. Sun recommended that Plaintiff have an MRI of her cervical spine. (Id. ¶ 33)

The MRI was performed on April 29, 2008, and revealed minimal disc bulging and sponylosis but no disc herniation. (Id. ¶ 33) Plaintiff's new treating physician Dr. Edward Reich found that the MRI findings were insignificant. On May 27, 2008, Dr. Reich referred Baird to Dr. Martin Posner, an orthopedic surgeon who specializes in hand surgery. Dr. Reich explained to Dr. Posner that he suspected that Baird might suffer from pronator syndrome of the left arm, noting that she complained of paresthesias and numbness in her left hand. (Id. ¶¶ 34-36; Hannan Decl., Ex. 1 at D0277)

In a June 11, 2008 "To Whom It May Concern" letter, Dr. Reich stated that Baird suffered from pain in her forearm and wrists when engaged in prolonged writing and typing, and that his examination of her revealed evidence of entrapment of the median nerve as it passed through the pronator muscles. (Id. ¶¶ 38-40) Dr. Reich explained that Dr. Posner believed that surgery would only provide temporary relief and that due to "weakness" and "pain," Plaintiff "could not perform the tasks of her previous profession." (Id. ¶¶ 41-42; Hannan Decl., Ex. 1 at D0277)

Dr. Nahid Nainzadeh performed an EMG of Plaintiff's right upper extremity on February 24, 2009, and concluded that the test results were "highly suggestive of right ulnar nerve focal neuropathy at the elbow." (Id. ¶¶ 43-44) In a "To Whom It May Concern" letter dated May 1, 2009, Dr. Reich reported that he had examined Baird on April 14, 2009, in connection with her complaints of pain, tingling and numbness in her right hand. Dr. Reich stated that Baird has right ulnar nerve entrapment at the elbow but that surgery is not recommended, because the scar tissue formation Baird experienced after her carpal tunnel surgery suggests "a poor prognosis for ulnar nerve decompression." Because of Baird's tendency to develop scar tissue in response to surgery, ulnar nerve surgery might "result[] in more deficit and more disability than [Baird] is presently experiencing. For this reason, [surgery] is not being seriously considered by the surgeon unless the disability becomes so severe." (Id. ¶¶45-47; Hannan Decl., Ex. 1, D0099)

II. DEFENDANT'S REVIEW OF PLAINTIFF'S CLAIM

In connection with Baird's ongoing disability claim, Defendant arranged for an independent medical examination ("IME") of her on October 10, 2007. The IME was conducted by Dr. Neal Hochwald, a board-certified hand surgeon. (Id. ¶ 49) Baird reported that she had not received medical treatment for the pain and tingling in her hands or arms for at least a year. (Id. ¶ 52)

Dr. Hochwald found that Baird self-limited her range of motion due to subjective complaints of pain. During the examination, Dr. Hochwald found that Baird was fully able to passively flex and extend her wrists and that her fingers flexed into her palm with no limitation of motion. (Id. ¶¶ 53-55) Dr. Hochwald did not detect any muscle atrophy in Baird's hands or wrists, and found that she was able to maintain muscle function in both abduction and adduction of her fingers. (Id. ¶¶ 56-57) He reported that Baird, "self limits her own use of the right hand with no objective findings of muscle wasting or significant loss of sensation that can be objectively defined." (Id. ¶ 60) Dr. Hochwald likewise found no evidence of regional pain syndrome or of significant tendinitis, muscle atrophy, or swelling in Baird's hands or wrist. (Id. ¶¶ 61-62) Dr. Hochwald concluded that Baird's work activities should be limited as follows: limited lifting with the right hand to 20 pounds or less; no significant pressure directly on her palm; and limited use of vibrational tools. (Id. ¶¶ 63-64) He concluded that Baird could grip, grasp, and perform repetitive and fine motor skills with her hand, and that she might benefit from pain management, because she has a tendency to magnify her symptoms. (Id. ¶¶ 65-66)

On September 9, 2008, Defendant referred Plaintiff's file to Dr. Steve McIntire, an independent physician specializing in neurology, who reviewed the evidence submitted by Plaintiff, her counsel, and her healthcare providers. (Id. ¶¶ 67-68) Dr. McIntire contacted Baird's treating physician, Dr. Reich, who repeated his finding that Baird was disabled with pronator syndrome and was not a candidate for surgery. (Id. ¶ 69) Dr. McIntire found that Baird had a "mild degree of impairment" in her right hand due to her surgeries and "mild residual weakness." (Id. ¶ 70) Like Dr. Hochwald, Dr. McIntire concluded that Plaintiff was unable to use hand tools or vibratory tools and should not lift or carry more than 20 pounds. (Id. ¶ 71) He found, however, that she could engage in simple gripping and grasping functions and fine manipulation without restriction, and that there was no evidence of adverse side effects caused by medication. (Id. ¶ 72-73)

Dr. Richard Avioli, an independent physician specializing in orthopedic surgery, also reviewed Plaintiff's file for Defendant and found that the medical evidence did not demonstrate that Plaintiff's symptoms caused severe impairment. Dr. Avioli found only minor weakness in the left hand and no severe pain in either hand. (Id. ΒΆΒΆ 75- 76) Dr. Avioli reported that "[b]ased on the fact that the claimant has mild symptoms in both hands . . . reasonable restrictions and limitations . . . would include no push/pull, lift/carry greater than 20 pounds ...


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