United States District Court, E.D. New York
LAW OFFICES OF DAVID L. TRUEMAN, P.C., By: David L. Trueman, Esq., New York, NY, Attorneys for Plaintiff.
BEGOS BROWN & GREEN, By: Patrick W. Begos, Esq., Southport, CT, Attorney for Defendants.
MEMORANDUM AND ORDER
LEONARD D. WEXLER, UNITED STATES DISTRICT JUDGE.
This is an action brought by Plaintiff Sandra Wilson (" Plaintiff" or " Wilson" ) against The Hartford (" Hartford" or " Defendant" ) and Emblem Health Services Company, LLC (" Emblem" ), pursuant to the Employee Retirement Income Securtiy Act of 1974 (" ERISA" ). Plaintiff seeks judicial review of the denial of her claim for long-term disability benefits under a policy issued by Hartford to Plaintiff's employer, Emblem. Presently before the Court are the parties cross-motions for summary judgment based upon the administrative record concerning the claim. For the reasons set forth below, Defendants'
motion for summary judgment is granted and Plaintiff's motion is denied.
I. Plaintiff's Employment and Policy
Plaintiff started working for Emblem in 1988 and continued until July 2010, when she left due to disability. Plaintiff had an office position, and on September 8, 2010, Emblem submitted to Hartford a Physical Demands Analysis, stating Wilson's position as a Claims Manager. It described the position as self-paced, in a cubicle at a computer, and one that permitted her to " alternate sitting and standing as needed." Administrative Record (" AR" ), at 508-509. The same description was provided in November 2010 to describe Plaintiff's position as a customer service representative. AR 267-268: Emblem's Physical Demands Analysis of 11/19/10, listing Wilson as Representative/Corresp., COB containing the same physical demands description. Plaintiff asserts she was a Managing Claims Adjuster, which is " more demanding" than a customer service representative, but does not challenge the physical demands analysis provided by her employer. See Plaintiff's Memorandum in Opposition to Defendants' Motion for Summary Judgment (" Pl. Mem. in Opp." ), at 18-20.
As an employee, Wilson was covered under a long-term disability plan (" LTD Plan" ) and a life insurance plan (" Life Plan" ). Under both the LTD Plan and the Life Plan, Hartford had " full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Policy." AR 323, 312 (LTD Plan): AR 379, 368 (Life Plan).
The LTD Plan defines disability as " [y]ou are prevented from performing one or more of the Essential Duties of...Your Occupation, for the 24 months following the Elimination Period..." " Essential Duty" is defined as " a duty that 1) is substantial, not incidental; 2) is fundamental or inherent to the occupation; and 3) cannot be reasonably omitted or changed." AR 312-313.
The Life Plan provides that a person who is " disabled" as defined in the Life Plan qualifies for a " Waiver of Premium," which is a provision permitting the disabled person to continue life insurance coverage without paying premium. Under the Life Plan, to be disabled means " You are prevented by injury or sickness from doing any work for wage or profit for which You are, or could become, qualified by: 1) education; 2) training; or 3) experience." AR 358-359.
II. Plaintiff's Disability Claim
In July 2010, Plaintiff submitted a claim for short-term disability benefits due to sciatica pain that prevented her from being able to sit for prolonged periods of time. Hartford approved Wilson's claim for short-term disability as of July 19, 2010, and informed her that it would be following up with her treating physicians and reviewing her claim for additional benefits beyond August 15, 2010. AR 432. The short-term disability benefits were extended through November 14, 2010, and in October 2010, Hartford informed Plaintiff it would begin investigating eligibility for
long-term benefits, which are not guaranteed by the receipt of short-term disability benefits. AR 426.
A. Plaintiff's Medical Treatment
In support of her claim, Plaintiff submitted records from her treating doctor, Dr. Mark Nelson, a neurologist. Included was Dr. Nelson's November 10, 2010 Attending Physician's Statement of Continued Disability (" APS" ), which is difficult to read, and lists a primary diagnosis of " left cerebral [illegible]" and a secondary diagnosis of " fibromyalgia." It notes that Plaintiff could only sit, stand or walk for 20 minutes at a time, and for a total of 3 hours per day of sitting and 2 hours a day of standing and walking. AR 252-253.
Plaintiff also submitted a report from a rheumatologist, Dr. Serina Chung, October 13, 2010. AR 275-281. Her report notes Plaintiff presented for an evaluation of numbness and tingling in her hands and feet " for about a year." Dr. Chung's office notes state Plaintiff had developed a severe headache with vomiting and photophobia and went to the emergency room. CT scan of her head was negative, and through Dr. Nelson, she had an MRI of her spine which was normal, and of her brain, which was negative. An EMG of her extremities was also normal. Results of an MRI of the brain with contrast were pending, and Plaintiff had not yet done labs which were ordered. Dr. Chung's assessment noted " multiple mild sensory and motor deficits of unclear etiology," and the need to await lab results to rule out possible conditions. On November 22, 2010, Dr. Chung submitted an APS to Hartford, which indicates a primary diagnosis of " migraine" and secondary diagnosis of " peripheral neuropathy," and restricted Plaintiff from " lifting, bending, squatting, standing or sitting for long periods of time." AR 274. There is nothing further in the record to indicate that Plaintiff ever followed up with Dr. Chung. In February 2011, Plaintiff reported to Dr. Nelson that Dr. Chung had told her that " everything was within normal limits." AR 235.
Plaintiff also submitted to Hartford an APS from her physical therapist, Daniel Bogart, who reported in December 2010 that Plaintiff's functionality was affected by her Plaintiff reported pain " with excessive ambulation" and " that sitting excessively increases bilateral leg pain. ...