The opinion of the court was delivered by: William M. Skretny Chief Judge United States District Court
In this action, Plaintiff Judith Baumer seeks to recover long term disability benefits under the Defendant Ingram Long Term Disability Plan ("the Plan"), issued by Defendant Continental Casualty Company*fn1 ("Continental"). Plaintiff asserts claims for benefits and declaratory relief pursuant to 29 U.S.C. § 1132(a)(1)(B), and for attorney's fees pursuant to 29 U.S.C. § 1132(g), which are both sections of the Employee Retirement Income Security Act of 1974 ("ERISA"). Presently before this Court is Defendants' Motion for Summary Judgment.*fn2 For the reasons that follow, Defendants' motion is denied.
On October 25, 1993, Plaintiff began working for Ingram Micro, a division of Ingram Industries, Inc. ("Ingram"), as a programmer/analyst. (Defendants' Statement of Facts ("Defs' State."), Docket No. 15, ¶ 10; AR 815.) During her employment, Plaintiff was covered under the Plan, which is a qualified pension plan governed by ERISA. (Defs' State., ¶ 11.) The Plan was insured through a Group Insurance Policy ("the Policy") that was issued to Ingram by Continental. (Id.)
The Policy provides long term disability benefits to employees of Ingram with "Total Disability." (Defs' State., ¶¶ 4, 11; Policy 9.) Pursuant to the Policy, an eligible employee who, because of injury or sickness, is continuously unable to perform the duties of her own occupation will be entitled to benefits for the Insured Employee Occupation Period*fn4 following the initial Elimination Period.*fn5 (Defs' State., ¶ 5; Policy 9.) To continue receiving long term disability benefits after expiration of the Elimination Period, the employee must then meet a different definition of "Total Disability," which provides, in relevant part, that the eligible employee, because of injury or sickness, is:
(1) continuously unable to engage in any occupation for which he is or becomes qualified by education, training or experience; and (2) under the regular care of a licensed physician other than himself. (Id.)
Plaintiff's last day of employment with Ingram was May 19, 1995, when she stopped working due to sickness with abdominal pain, gastroesophageal reflux disease ("GERD"), diarrhea, and vomiting. (Defs' State., ¶¶ 13,16; AR 815A.) Plaintiff submitted an initial claim report for long term disability benefits, which included an Attending Physician's Statement completed by her physician, Dr. Raymond J. Tuoti, dated October 13, 1995. (Defs' State., ¶ 19; AR 816, 816A.) Dr. Tuoti reported that Plaintiff (1) had been diagnosed with "IGA immune deficiency;" (2) had the subjective symptoms of abdominal pain and diarrhea; (3) had first visited him for treatment for this diagnosis on January 23, 1995; (4) had last visited him for treatment for this diagnosis on August 24, 1995; and (5) had been totally disabled from May 19, 1995, through the present date that he completed the statement. (Defs' State., ¶¶ 20, 21; AR 816, 816A.) Dr. Tuoti's prognosis as to Plaintiff's "[d]ates totally disabled" was "indefinite," he did not expect "a fundamental or marked change in the future," and his expectation of when she would "recover sufficiently to perform duties" was "unknown." (Id.)
By letter dated November 9, 1995, Ingram conveyed Plaintiff's long term disability claim documents to Continental on her behalf. (Defs' State., ¶ 14; AR 814.) By letter dated January 25, 1996, Continental approved Plaintiff's claim for long term disability benefits, retroactive to October 17, 1995, which was the conclusion of Plaintiff's Elimination Period pursuant to the Policy. (Defs' State., ¶ 23; AR 775--76.) Plaintiff then received long term disability benefits from Continental for nearly ten years. (Defs' State., ¶ 24.)
In June 2005, Continental advised Plaintiff by letter that, following its review of her claim for continued benefits, it had determined that she no longer met the definition of "Total Disability" under the Policy and was therefore no longer entitled to receive continued long term disability benefits. (AR 498--500A.) Continental advised Plaintiff that her claim for long term disability benefits had been terminated and that she had a right to appeal. (Id.)
In terminating Plaintiff's benefits, Continental relied, in part, on the opinion of Dr. Jerome Siegel, who reviewed Plaintiff's medical records upon Continental's request. (AR 500.) Dr. Siegel also spoke with Dr. Robert Hostoffer, one of Plaintiff's treating physicians. (Id.) Dr. Siegel determined that despite Plaintiff's diagnoses of "immunoglobulin deficiency, intermittent abdominal pain, and asthma," her gluten sensitivity, and her complaints of "chronic fatigue and intermittent headaches, which appear[ed] to be caused by receipt of [intravenous] immunoglobulin ("IVIG") therapy," Plaintiff's regular physical examinations and laboratory studies were reasonably normal, and therefore she was able to perform sedentary work activities on a full time basis, with a 20-pound lifting restriction, allowing for alternating between sitting and standing. (Id.)
By letter from her counsel dated December 16, 2005, Plaintiff appealed Continental's termination of her benefits. (Defs' State., ¶ 96; AR 269--71.) In support of her appeal, Plaintiff provided, among other documents, reports from five of her treating physicians and her intravenous therapy nurse, as well as medical records and letters. (Defs' State., ¶ 97.)
With respect to her treating physician reports, Plaintiff included the July 27, 2005 report from Dr. Hostoffer, wherein he opines that, due to her common variable immunodeficiency syndrome, which requires IVIG treatment, as well as her abdominal pain, occasional diarrhea, severe fatigue, and joint pains, Plaintiff is "unable to work" and, further, that he "would not be able to employ her in any position [in his office] due to her recurrent infections and probable absentee[ism] from work." (AR 272.)
Second, Plaintiff submitted the August 23, 2005 report from Dr. Carmen M. Todoro, which notes that Plaintiff "deserves long term disability," as she is "unable to perform normal daily activities due to [her] chronic disease states" and must "receive IVIG monthly" infusions ...