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Prabhakar v. Life Ins. Co. of North America

United States District Court, E.D. New York

August 16, 2013

RATNA PRABHAKAR, Plaintiff,
v.
LIFE INSURANCE COMPANY OF NORTH AMERICA, Defendant

Page 125

Ratna Prabhakar, Plaintiff, Pro se, Bayside, NY.

For Life Insurance Company of North America, subsidiary of Cigna Corporation, Defendant: Fred N. Knopf, LEAD ATTORNEY, Abigail Deborah Elrod, Emily Anna Hayes, Wilson, Elser, Moskowitz, Edelman & Dicker LLP, West Harrison, NY.

Page 126

MEMORANDUM & ORDER

PAMELA K. CHEN, United States District Judge.

On December 16, 2009, Plaintiff Ratna Prabhakar, acting pro se, filed her complaint alleging that Defendant Life Insurance Company of America (" LINA" ) had violated the terms of the Group Long Term Disability Income Policy (the " Policy" ) issued to State Farm Mutual Automobile Insurance Company (" State Farm" ). (Dkt. No. 45 (" Joint Pre-Trial Order" ), at 4.) The alleged violation occurred when LINA terminated Plaintiff's coverage under the Policy as a State Farm employee, and denied the payment of long term disability benefits to Plaintiff in December 2003. (Dkt No. 1 (" Compl." ) ¶ ¶ 6, 9, 15.)

On June 6, 2013, at a pre-trial conference in this action, this Court ruled that, although the administrative record constituting Plaintiff's claim history under the Policy would comprise the core evidence at trial, the parties would also be permitted to introduce extra-record evidence relating to, inter alia, (i) whether Plaintiff's copy of the Policy contained the provision notifying her of the three-year limitations period for filing this action, and (ii) the offset applied against Plaintiff's long term disability benefits based on a lump sum workers' compensation award. (Dkt. No. 47.)

On July 22, 2013, this Court conducted a one-day bench trial in this action. See Sullivan v. LTV Aerospace & Defense Co., 82 F.3d 1251, 1258-59 (2d Cir. 1996) (" [T]here is no right to a jury trial in a suit brought to recover ERISA benefits." ). Plaintiff presented her own testimony and that of her son, Sunil Prabhakar, and introduced three documents into evidence (Plaintiff's Exhibits (" Pl. Exs." ) A-C). LINA presented the testimony of Richard Lodi, one of its Senior Operations Representatives, and, through Mr. Lodi, introduced the administrative record into evidence

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(Defendant's Exhibit (" Def. Ex." ) 1).[1]

On July 29, 2013, this Court directed LINA to submit a sworn declaration, providing additional evidence relating to the three-year limitations period applicable to this action. (Dkt. No. 53.) LINA submitted a declaration from Mr. Lodi. (Dkt. No. 54 (" Lodi Decl." ).)

Based on the administrative record and other evidence received during and after trial, this Court finds that, even though this evidence demonstrates that LINA improperly denied Plaintiff's long term disability benefits in December 2003, she cannot recover such benefits, because this action is untimely. The limitations period applicable to this action is three years. The Policy contained a provision notifying State Farm employees of the three-year limitations period, and the evidence establishes that Plaintiff received at least one copy of the Policy containing this provision. Accordingly, this Court must dismiss this action with prejudice as being time-barred.

This Court's decision is based on the findings of fact and conclusions of law set forth below.

* * *

I. Findings of Fact

From June 20, 1988 to September 17, 1990, Plaintiff was employed by State Farm as a secretary and senior mail records clerk. (LINA 612, 731, 861; Tr. 49.)[2] On December 12, 1989, while at work, Plaintiff tripped and fell, resulting in injuries to her head and leg. (LINA 654, 862; see Joint Pre-Trial Order, at 4.)

A. LINA's Payment of Long Term Disability Benefits to Plaintiff

1. Plaintiff's Total Disability

As a State Farm employee, Plaintiff was covered by the Policy with LINA.[3] (Pl. Ex. A; LINA 6-47.) Within a week of the accident, Plaintiff began seeing a neurologist, Dr. Ira Casson, who diagnosed Plaintiff as suffering from post-concussion syndrome. (LINA 646, 654, 731-32, 859.) Dr. Casson also concluded that Plaintiff was totally disabled. (LINA 646, 834, 859-60.)

In the summer of 1990, despite her continuing total disability, Plaintiff returned to work at State Farm. (LINA 731, 802, 835-36.) On September 17, 1990, however, Plaintiff stopped working. (LINA 731, 858, 861.) She started receiving long term disability benefits as of March 17, 1991. (LINA 797-99.)

In September 1991, following a referral from Dr. Casson, Dr. Eugene Zanger, a psychologist, concluded, inter alia, that Plaintiff was suffering from an " organic mental syndrome" [4] and displaying symptoms

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of severe depression and anxiety. (LINA 652, 656.) Dr. Zanger also found that Plaintiff was " unable to function in almost any realm except the most routine behaviors." (LINA 653.)

On July 25, 1993, Dr. Casson provided a " Comprehensive Medical Report" summarizing in detail his treatment of Plaintiff since December 1989. The report concluded with Dr. Casson's findings that:

This patient is suffering from a severe post-concussion syndrome with headaches, vestibular dysfunction and severe cognitive and memory impairment. As a result of the severe post-concussion syndrome, she is also suffering from a [sic] severe anxiety and depression but this is clearly post-traumatic in origin. The fact that she may have had some mild depression prior to this injury in the past does not change the fact that the present illness clearly is causally related to the injuries sustained at work in December of 1989. This is not a pre-existing condition. The patient's severe headaches, vestibular dysfunction and cognitive and memory impairment all make it impossible for her to perform any type of work in any capacity whatsoever. At this point, more than four years following the injury, these conditions are permanent. There is no reason to ever expect any improvement in her situation. The patient is 100% impaired and will remain so permanently. There is no therapy, medication or any other type of treatment which will enable her to ever return to any type of work whatsoever .[5]

(LINA 657 (emphasis added); see also LINA 714 (handwritten note, dated May 4, 1993, indicating that Plaintiff was " totally and permanently disabled" and " unable to work at any occupation" ).) LINA requested but did not require Dr. Casson to submit treatment notes in support of this report.[6] (LINA 684, 722, 747-48.)

On April 8, 1994, a psychiatrist who had started seeing Plaintiff about a year prior, Dr. Kishore Saraf, prepared a letter, which was provided to LINA and indicated, inter alia, that, based on his examination and treatment of Plaintiff, he had diagnosed her with organic mental disorder " secondary to concussion" and organic mood disorder.[7] (LINA 619, 622.) Like Dr. Casson, Dr. Saraf concluded that Plaintiff was permanently disabled:

In view of the persistence of affective cognitive and neuropsychiatric deficits that the patient is still showing despite being medication free for six weeks, and my repeated observation upon examination,

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it leaves me to conclude that patient has suffered permanent Organic Mental Disorder secondary to the concussion and fully [sic] recovery to her preconcussion level seems impossible . In short, the patient is permanently disabled as a consequence of the head injury she suffered on December 12, 1989.

(LINA 622 (emphasis added).)

Dr. Saraf also submitted a response to the report of LINA's independent medical examiner, who had disagreed with Drs. Casson's, Zanger's, and Saraf's conclusions that Plaintiff was suffering from " organic" disorders as a result of her head injury. (LINA 600-601, 632-34.) In response, Dr. Saraf defended his diagnoses and additionally diagnosed Plaintiff with " Major Affective Disorder--AKA Manic depressive disorder, bipolar, depressed, nonpsychotic--precipitated by and directly attributable to stress caused by" Plaintiff's " Cognitive disorder NOS-post concussional disorder." [8] (LINA 601.) LINA did not require Dr. Saraf to submit treatment notes in support of these reports. (LINA 591, 606, 616.)

On May 17, 1995, LINA received a Supplementary Claim form (" Supplementary Claim form" ) completed by Dr. Saraf, verifying that Plaintiff remained totally disabled for any occupation due to her mental impairments. (LINA 580-82.) Dr. Saraf also verified that Plaintiff was not a suitable candidate for rehabilitation. (LINA 582.) LINA did not require Dr. Saraf to submit treatment notes in support of this form. (LINA 583-84.)

The following year, on March 28, 1996, Dr. Saraf submitted to LINA another Supplementary Claim form, again confirming Plaintiff's continuing total disability for any occupation and her unsuitability for rehabilitation. (LINA 564-65.) This time, LINA did require that Dr. Saraf submit treatment notes in support of this form. (LINA 472, 537, 552, 560-61.) Dr. Saraf faxed these notes to LINA on September 20, 1996. (LINA 461-68.) In an undated set of notes, Dr. Saraf indicated that " [m]y prognosis for this patient's return to work is poor because of her Neuro Psychiatric disability" and that " her current neuropsychiatric symptomatology in my opinion is . . . likely to continue indefinitely ." (LINA 463 (emphasis added).)

In September and November 1997, " for the continued management of [Plaintiff's] claim," LINA requested that Dr. Saraf provide updated medical proof that Plaintiff continued to be totally disabled, i.e., an Evaluation of Psychiatric Impairment form and treatment notes. (LINA 410, 414.) On February 10, 1998, because Dr. Saraf had failed to provide both the form and treatment notes, LINA temporarily denied Plaintiff's long term disability benefits. (LINA 400-401.) Shortly thereafter, LINA received an Evaluation of Psychiatric Impairment form completed by Dr. Saraf. (LINA 394-95.) LINA's medical consultant additionally reviewed the claim file, and concluded that Plaintiff's " medical docs support [her] psychiatric condition of Bipolar disorder, T/D [totally disabled] A/O [for any occupation]." (LINA 385, 388; Tr. 115.)[9] LINA reinstated Plaintiff's long term disability benefits without

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requiring Dr. Saraf's treatment notes. (LINA 382, 385; Tr. 115.)

On August 3, 1998, LINA received a Supplementary Claim form completed by Dr. Saraf, diagnosing Plaintiff with Bipolar Disorder and confirming her continuing total disability for any occupation. (LINA 365-66.) On this form, Dr. Saraf merely suggested that Plaintiff could " possibly" resume working in the future. (LINA 366.) LINA did not require Dr. Saraf to submit treatment notes in support of this form. (LINA 368, 371.)

On September 28, 1999, LINA received a Supplementary Claim form completed by a new psychiatrist, Dr. Ram Pardeshi, diagnosing Plaintiff with " Depression/Bipolar disorder." (LINA 352-54.) Unlike the prior versions of the Supplementary Claim form, the version that Dr. Pardeshi completed did not ask whether the claimant was totally disabled. (LINA 354.) Rather, in the section entitled " Extent of Disability," this version asked only " When was patient able to go to work?" with blanks for the pertinent dates. ( Id.) Dr. Pardeshi did not fill in those blanks and responded instead with " undetermined" and " manic episode followed by depressive episode." ( Id.) Like Dr. Saraf, Dr. Pardeshi indicated that Plaintiff was not a suitable candidate for rehabilitation. ( Id.) LINA did not require Dr. Pardeshi to submit treatment notes in support of this form. (LINA 357, 361; see also LINA 337 (stating, on October 25, 1999, that LINA was " [o]kay to continue" based on the form from Dr. Pardeshi).)

On June 15, 2001, LINA received a Disability Claim form completed by Dr. Pardeshi, which was substantively similar to Dr. Pardeshi's Supplementary Claim form. (LINA 166-67.) Dr. Pardeshi confirmed Plaintiff's diagnoses for bipolar disorder, depression, post-concussion syndrome, and anxiety disorder. (LINA 166.) Dr. Pardeshi also indicated that Plaintiff demonstrated, inter alia, severely impaired short and long term memory, severe confusion, moderate paranoia, and thought disorder. (LINA 167.) Finally, Dr. Pardeshi concluded that Plaintiff was " unable to function or work," incapable of performing any occupation, and unsuited for rehabilitation. ( Id.) The same day that LINA received this form, one of its reviewers recommended that Plaintiff's claim be considered for " MMI [maximum medical improvement] and SAM [stable and mature] tx [transfer]." [10] (LINA 163; Tr. 108-109, 114.) This time, LINA did require that Dr. Pardeshi submit treatment notes in support of this form. (LINA 161-62, 330, 340.) Dr. Pardeshi faxed these notes to LINA on August 31, 2001. (LINA 151-54.) In these notes, Dr. Pardeshi recited the above diagnoses, gave Plaintiff a Global Assessment of Functioning (" GAF" ) score of 40,[11] and concluded that " [d]ue to her severe illness which is of chronic nature[,] her disability should be continued." (LINA 152-53 (emphasis added).)

On July 17, 2003, LINA sent Plaintiff a letter requesting the completion and submission of a medical release form by Plaintiff,

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as well as a Psychiatric Functional Assessment (" PFA" ) form and treatment notes by Plaintiff's psychiatrist. (LINA 145-49.) On September 18, 2003, LINA received both forms, but no treatment notes. (LINA 139-43.) In the PFA form, Dr. Pardeshi confirmed Plaintiff's diagnoses for bipolar disorder and depression. (LINA 141.) Dr. Pardeshi also concluded that Plaintiff was " unable to function in work setting or in social ...


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