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Gary L. Katsanis v. Blue Cross and Blue Shield Association

March 23, 2011


The opinion of the court was delivered by: John T. Curtin United States District Judge


This is an action, brought pursuant to the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001, et seq., in which plaintiff seeks benefits under the long-term disability ("LTD") plan of his former employer, Excellus Health Plan ("Excellus"), a nonprofit independent licensee of defendant Blue Cross and Blue Shield Association ("BCBS"), the plan sponsor and administrator. The plan provides that a participant who is disabled primarily because of mental illness shall be limited to 24 months of LTD benefits. Plaintiff states that defendant improperly limited his benefits to a 24-month period after determining that he was disabled as a result of a mental condition. The case is currently before the court on the defendant's motion for summary judgment.


Plaintiff was employed by Excellus as a project manager from April 1992 until January 3, 2003 (AR 794, 132). On November 15, 2002, plaintiff applied for LTD benefits under the BCBS employee welfare benefit plan. The plan, governed by ERISA, is administered by the National Employee Benefits Committee ("NEBC") of BCBS, and the NEBC has delegated the day-to-day operation of the plan to the National Employee Benefits Administration ("NEBA") (Item 49, Att. 2, ¶¶ 5, 7, 8). The plan provides that a participant in the plan is entitled to benefits only "if he is found, on the basis of medical evidence satisfactory to the Committee, to be Disabled" (AR 873). The plan further provides that "a Participant who is Disabled primarily because of mental illness shall not receive a Disability Benefit for a period in excess of 24 months . . ." (AR 881).

Plaintiff's application for LTD benefits was based on "chronic fatigue and insomnia, depression, persistent pain, confusion and difficulty thinking and reasoning and remembering." (AR 792). He also disclosed that he was being treated for a herniated disc, gastroesophageal reflux disease ("GERD"), and post-thoracotomy*fn2 pain. Id. In a letter dated January 27, 2003, BCBS notified plaintiff that the Medical Review Committee ("MRC") had reviewed his application and found that he was disabled. The MRC approved his application for LTD benefits effective January 1, 2003 through March 31, 2003 and instructed plaintiff to provide additional medical documentation of his disability (AR 723, 725).

Over the following several months, plaintiff was advised that his benefits were to be extended through November 30, 2003 (AR 683), May 31, 2004 (AR 671), June 30, 2004 (AR 638), and August 31, 2004 (AR 633). In a letter dated June 24, 2004, plaintiff was advised that his LTD benefits were approved due to a "mental/nervous condition" and thus were subject to the 24-month limitation. Id. In a letter dated July 26, 2004, plaintiff was notified that his benefits were approved through December 31, 2004 (AR 593). He was again advised that the MRC had approved his disability due to a mental/nervous condition and that, in such a case, LTD benefits were limited to a maximum of 24 months. Id. Plaintiff was reminded that his "last month of entitlement to benefits will be December 2004." Id.

On December 29, 2004, defendant advised plaintiff that the MRC had reviewed the medical evidence submitted to support the claim for LTD benefits and determined that "the medical evidence shows you are disabled primarily because of mental illness" and, as such, the claim for benefits was denied as of December 31, 2004 (AR 327). Specifically, the MRC relied on:

1. An independent medical evaluation ("IME") by Dr. Pierre Tariot, a psychiatrist, from September 2004 in which he observed a "probable mixed personality disorder" and opined that plaintiff's "cognitive symptoms . . . represent a manifestation of the axis-2 disorder" (AR 373);

2. Neuropsychological evaluations by Dr. Mark Mapstone, PhD., a clinical psychologist, from 2002 and 2004. In a report dated October 14, 2004, Dr. Mapstone stated, "I continue to suspect that the etiology of [plaintiff's] cognitive complaints is mostly psychiatric rather than neurologic" (AR 58); and

3. The results of a sleep study which found no sleep apnea, just poor sleep hygiene (AR 381-82).

The MRC also noted the opinions of plaintiff's primary care physician, Dr. James Budd, and his treating psychiatrist, Dr. Melvin Pisetzner. In a report dated September 22, 2003, Dr. Budd stated that plaintiff suffers from a mood disorder and disorganized thinking, and that his "most intrusive problems are psychiatric" (AR 601). After an office visit on July 6, 2004, Dr. Budd stated that plaintiff has "disabling neuropsychiatric difficulties" which are likely "multifactorial," caused by medication side effects, sleep disorder, mood disorder, and "likely some organic brain syndrome, possibly of degenerative type" (AR 609). In a letter dated July 20, 2004, Dr Pisetzner stated that plaintiff was depressed and suffered from a "progressive decrease in cognitive functioning" (AR 463). Dr. Pisetzner opined that an "undiagnosed deteriorating illness exists" and that plaintiff's "depression is secondary to the underlying neurological condition" (AR 463, 465).

In a letter dated December 23, 2004, plaintiff notified BCBS that he wished to appeal the denial of his LTD benefits (AR 257). He acknowledged that "[m]ental health conditions affect my disability . . . [but] there is evidence that I have an additional medical problem, without a clear diagnosis, which is driving my disability." Id.

In March 2005, plaintiff was evaluated by Dr. Heidi Schwartz, who noted that "previous neuropsychological testing has not documented an organic cause" of plaintiff's cognitive decline (AR 39). She stated, "it remains unclear whether all of [plaintiff's] cognitive issues are psychiatric in nature (and if so, is this truly due to depression or an underlying personality disorder), or whether there is a component of organic decline." Id. In May 2005, Dr. Schwartz reported that plaintiff "continues to complain of cognitive decline, but the etiology remains unclear" (AR 247).

In May 2005, plaintiff was evaluated for mold sensitivity by Dr. John Condemi, a physician specializing in allergies and immunology. Plaintiff was found to have several allergies, but not toxic mold syndrome (AR 67). Dr. Condemi also stated that ...

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