The opinion of the court was delivered by: John T. Curtin United States District Judge
This action was commenced by the filing of a summons and verified complaint in Buffalo, New York, City Court on November 15, 2007, and was removed to this court pursuant to 28 U.S.C. § 1441 on the basis of original federal jurisdiction under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001, et seq. (see Item 1). Plaintiff Scott Trapp seeks damages in the amount of $7,500 from defendant, the Reliance Standard Life Insurance Company, for breach of a contract of insurance covering claims for short term disability benefits under an employer-sponsored plan, and defendant has moved for summary judgment (Item 10) dismissing the complaint.
For the reasons that follow, defendant's motion is granted.
The following facts, set forth in defendant's statement submitted pursuant to Rule 56.1(a) of the Local Rules of Civil Procedure for the Western District of New York (Item 10-3), have not been controverted by plaintiff and are therefore deemed admitted for the purpose of ruling on this motion.*fn1
Plaintiff was employed with CV Therapeutics, Inc. as a Cardiovascular
Account Specialist until January 12, 2007, when he stopped working due
to "stress, anxiety & depression . . . ." AR 96-97.*fn2
On or about January 17, 2007, plaintiff filed a claim for
short term disability benefits as a covered employee under policy
number G 100,001, issued by defendant Reliance Standard (see AR 4-19,
The policy defines the term "disabled" as "(1) unable to do the material duties of his/her job; and (2) not doing any work for payment; and (3) under the regular care of a physician." AR 10. The policy specifically excludes from coverage "any period of disability caused by . . . sickness which is covered by a Workers' Compensation Act, or other worker's disability law; or . . . injury which occurs out of or in the course of work for wage or profit." AR 16. The policy also provides that defendant, as "claims review fiduciary[,] has the discretionary authority to interpret the Plan and the insurance policy and to determine eligibility for benefits." AR 14.
Defendant initially approved plaintiff's claim for short term disability benefits, based on information in plaintiff's medical records indicating diagnosis and treatment for episodic symptoms of a mental health disorder (see AR 90). However, on June 13, 2007, defendant sent plaintiff a letter advising that an ongoing review of the records obtained from plaintiff's psychiatrist, Michael P. Hallett, M.D., revealed that plaintiff's condition was "due to a 'problem with [a] female supervisor (old co-worker),'" and therefore his claim was a work-related claim and excluded from coverage under the policy. AR 37. The letter specifically referenced Dr. Hallett's notes of plaintiff's office visits on April 2 and May 3, 2007, which reflected that plaintiff was "off since 1/12/07, had problem with his female supervisor (old co-worker, we never got along). Hired an attorney. Now on long term disability." AR 37, 61, 63. The letter also advised plaintiff of his right to administrative and judicial review of the denial of his claim (see AR 38).
On September 26, 2007, plaintiff sent defendant a letter (AR 29) requesting review of the denial, attaching a note from Dr. Hallett addressed "To Whom It May Concern" and stating that plaintiff's disability was "not due to work related cause" and was "not worker's compensation" (AR 31). Plaintiff also pointed out that he was awarded Social Security disability benefits by "NYS Disability" for the same period, and that his claim was not subject to the policy's Workers' Compensation exclusion because his request for Workers' Compensation benefits was denied (AR 29, 31).
By letter dated October 15, 2007 (AR 24-26), defendant notified plaintiff that it had conducted an independent review of his claim file and determined that the prior decision to deny short term disability benefits was appropriate. Defendant explained in the letter that, while it did not dispute plaintiff's mental health condition, the information in the file supported the conclusion that the condition was the result of "work-related discord" between plaintiff and a female supervisor barring coverage under the express exclusionary language in the policy (AR 25). With regard to Dr. Hallett's "To Whom It May Concern" note stating that plaintiff's condition was not work-related, defendant found that the statement did not provide substantial evidence to alter the prior determination because it was inconsistent with Dr. Hallett's actual treatment notes clearly indicating that plaintiff's stress, anxiety, and depression were caused by problems with his supervisor at work (id.). In addition, the independent review revealed that plaintiff's impairment was work-related at onset, and therefore the previous payment of $7,293.40 in short term disability benefits reflected an overpayment. However, defendant advised plaintiff that it was not seeking reimbursement (id.). With regard to plaintiff's contention that he should be found eligible for benefits under the policy because his Social Security disability claim was allowed by New York State, and because his Workers' Compensation claim was denied, defendant explained that because each entity employs different guidelines for determining eligibility for benefits, grant or denial by one entity does not guarantee grant or denial by another (id.).
As indicated above, plaintiff filed this lawsuit seeking judicial review of defendant's denial of benefits, and defendant seeks summary judgment dismissing the action. In support of its summary judgment motion, defendant contends that under the applicable standard of limited judicial review for challenging an administrator's determination regarding eligibility for disability benefits under an employee welfare benefit plan governed by ERISA, the undisputed facts outlined above, as reflected in the administrative record, demonstrate that plaintiff cannot meet his burden of establishing that defendant's denial of his claim for short term disability benefits was arbitrary and capricious. Plaintiff has not responded to defendant's motion (see footnote 1, infra).
Rule 56 of the Federal Rules of Civil Procedure, as amended effective December 1, 2010, now provides that "[t]he court shall grant summary judgment if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Fed. R. Civ. P. 56(a). Further:
If a party fails to properly . . . address another party's assertion of fact as required by Rule 56(c) [setting forth procedures for supporting and objecting to factual positions], the court may . . . grant summary judgment if the motion and supporting materials--including the ...