DRACH v. SUN LIFE ASSURANCE COMPANY OF CANADA
Filing
26
OPINION. Signed by Judge Noel L. Hillman on 9/28/2016. (dmr)
UNITED STATES DISTRICT COURT
DISTRICT OF NEW JERSEY
_________________________________
DIANE DRACH,
Plaintiff,
Civil No. 15-5467 (NLH/KMW)
v.
OPINION
SUN LIFE ASSURANCE COMPANY
of CANADA,
Defendant.
__________________________________
APPEARANCES:
Thomas Joseph Hagner
Hagner & Zohlman, LLC
57 Kresson Road
Cherry Hill, NJ 08034
Attorney for Plaintiff
Peter J. Guffin
Pierce Atwood LLP
Merrill's Wharf
254 Commercial Street
Portland, ME 04101
Attorney for Defendant
HILLMAN, District Judge:
This matter comes before the Court on the summary judgment
motions of Plaintiff Diane Drach and Defendant Sun Life
Insurance Company of Canada.
The Court has considered the
parties’ submissions and decides this matter pursuant to Federal
Rule of Civil Procedure 78.
For the reasons to be discussed,
1
Plaintiff’s motion will be denied and Sun Life’s motion will be
granted.
I.
BACKGROUND
This case is about the denial of long term disability
benefits.
Plaintiff Diane Drach worked as a Programmer
Analyst/Network Administrator at Inolex Chemical Company from
1996 to 2010. (Def.’s Statement of Undisputed Materials Facts
(“Def.’s SMF”) ¶ 1 [Doc. No. 17-2]; Pl.’s Statement of
Undisputed Materials Facts (“Pl.’s SMF”) ¶ 6 [Doc. No. 18-2].)
As an Inolex employee, Plaintiff was a beneficiary of a group
insurance policy issued by Sun Life which included long term
disability coverage. (Def.’s SMF ¶ 2; Pl.’s SMF ¶ 1.)
Pursuant to the policy, before long term disability
benefits are payable, the employee must satisfy the 180-day
elimination period with the required days of “total disability,”
provide proof of total disability, and have regular and
continuing physician care. (Def.’s SMF ¶ 6 (citing
Administrative Record (“AR”) at 114, 78 [Doc. No. 17].))
“Totally disabled” is defined by the policy as “unable to
perform the Material and Substantial Duties of his [or her] Own
Occupation.” (Def.’s SMF ¶ 7 (citing AR at 90.))
After long
term disability payments have been paid for 36 months, the
employee continues to be “totally disabled” if he or she “is
unable to perform with reasonable continuity any Gainful
2
Occupation for which he is or becomes reasonably qualified for
by education, training or experience.” (Def.’s SMF ¶ 7 (citing
AR at 90.))
Beneficiaries must provide “proof” of their claim
to Sun Life, which “must include evidence demonstrating the
disability, including but not limited to, hospital records,
physician records, . . . x-rays, narrative reports, or other
diagnostic testing materials . . . .”
(Def.’s SMF ¶ 5.)
Plaintiff stopped working on April 9, 2010.
She submitted
a claim for long term disability benefits to Sun Life on October
25, 2010, claiming disability due to extreme fatigue, chronic
pain, muscle weakness, inability to concentrate and cognitive
problems. (Pl.’s SMF ¶ 9; Hagner Decl., Ex. B, Claim Packet at 4
of 12.)
To support her disability claim, Plaintiff submitted
the Attending Physician’s Statement (“APS”) 1 of Dr. Eileen
Moynihan who opined that Plaintiff could not perform “firm
grasping” due to psoriatic arthritis. (Def.’s SMF ¶ 18 (citing
AR at 145.))
By letter dated September 14, 2011, Sun Life notified
Plaintiff that it was unable to locate a copy of the denial
letter but that a decision to deny benefits was made. (Pl.’s SMF
¶ 11.)
Plaintiff submitted an appeal by letter dated February
7, 2012, which was supported by the medical records of Drs.
1
The APS is a form created by Sun Life.
3
David A. Bundens, M.D., Gerald Falasca, M.D., Eileen Moynihan,
M.D., and Michael DiMarino, M.D.
(Pl.’s SMF ¶ 14.)
Sun Life
denied Plaintiff’s appeal by letter dated May 9, 2012.
SMF ¶ 19.)
(Pl.’s
In response, Plaintiff instituted a lawsuit against
Sun Life on September 20, 2012. (Pl.’s SMF ¶ 22.)
The lawsuit
was resolved by way of a settlement agreement in which Sun Life
agreed to reconsider Plaintiff’s long term disability claim on
remand to determine whether she met her burden of proving she
was totally disabled as of April 9, 2010, when she stopped
working, and beyond. (Def.’s Response to Pl.’s SMF ¶ 23 (citing
AR at 421 (“Evaluation of Claim on Remand”) [Doc. No. 22].))
Plaintiff submitted a claim for further benefits on October
10, 2013. (Pl.’s SMF ¶ 24.)
To support her claim, Plaintiff
submitted a “Claimant Activity Questionnaire” which stated that
she had become numb, lost fine motor skills, was unable to make
a fist because her hands were swollen, and her psoriasis caused
her hands to crack and bleed. (Pl.’s SMF ¶¶ 24-25.)
Plaintiff
stated she had been diagnosed with psoriatic arthritis,
psoriasis, and bilateral carpel tunnel disease. (Pl.’s SMF ¶
26.)
Plaintiff submitted the records from her treating
physicians, Dr. Michael S. Rogers, M.D., Dr. Moynihan, Heartland
Rehabilitative Services, and Bannett Eye Centers. (Pl.’s SMF ¶
29.)
Plaintiff also submitted another APS from her treating
rheumatologist, Dr. Moynihan, which was completed on October 23,
4
2013. (Pl.’s SMF ¶ 30.)
Dr. Moynihan’s October 23, 2013 APS
opined that Plaintiff was unable to grasp or engage in fine
manipulation or keyboarding. (Pl.’s SMF ¶ 36.)
Plaintiff
additionally submitted a favorable decision for Social Security
Disability Income which stated that Plaintiff was disabled as of
April 2010 and suffered multiple impairments, including
bilateral carpel tunnel syndrome and psoriatic arthritis. (Pl.’s
SMF ¶ 27.)
The decision did not discuss Plaintiff’s ability to
use a keyboard. (Hagner Cert., Ex. K, SSDI Notice of Award.)
Plaintiff’s October 10, 2013 claim to Sun Life was denied
by letter dated July 17, 2014. (Pl.’s SMF ¶ 37.)
The letter
explained that the medical reports contained insufficient
information to support Plaintiff’s claim of psoriatic arthritis.
(Pl.’s SMF ¶ 38.)
The denial was based in part on a report by
medical consultant Dr. Tanya Lumpkins, M.D., a rheumatologist.
(Pl.’s SMF ¶ 41.)
Plaintiff submitted an administrative appeal of the July
17, 2014 denial on January 12, 2015. (Pl.’s SMF ¶ 48.)
Plaintiff’s appeal stated she was incapable of performing the
material and substantial duties of her occupation because it
required “fingering, keyboarding and near acuity” and that the
fact that she could not perform keyboarding was supported by Dr.
Moynihan’s findings. (Pl.’s SMF ¶ 49.)
contended she had vision problems.
5
Plaintiff further
(Id.)
The appeal contained
another APS from Dr. Moynihan and a vocational report by Dr.
Charles Kinkaid. (Pl.’s SMF ¶¶ 50-51.)
Plaintiff’s administrative appeal was denied by letter
dated March 20, 2015. (Pl.’s SMF ¶ 60.)
Sun Life’s decision was
supported, in part, by the medical reviews of: Dr. Lawrence J.
Albers, a psychiatrist and neurologist; Dr. Rajendra Marwah, a
rheumatologist; and Dr. Jose Perez, an internist. (Pl.’s SMF ¶
61.)
II. JURISDICTION
The Court has federal question subject matter jurisdiction
over this action pursuant to 28 U.S.C. § 1331.
Specifically,
this matter arises under the Employee Retirement Income Security
Act of 1974 (“ERISA”), 29 U.S.C. § 1001, et seq., as amended.
III. STANDARD OF REVIEW
Summary judgment is appropriate where the Court is
satisfied that “the pleadings, depositions, answers to
interrogatories, and admissions on file, together with the
affidavits, if any, show that there is no genuine issue as to
any material fact and that the moving party is entitled to a
judgment as a matter of law.”
Celotex Corp. v. Catrett, 477
U.S. 317, 322 (1986) (citing Fed. R. Civ. P. 56).
An issue is “genuine” if it is supported by evidence such
that a reasonable jury could return a verdict in the nonmoving
party's favor.
Anderson v. Liberty Lobby, Inc., 477 U.S. 242,
6
248 (1986).
A fact is “material” if, under the governing
substantive law, a dispute about the fact might affect the
outcome of the suit.
Id.
“In considering a motion for summary
judgment, a district court may not make credibility
determinations or engage in any weighing of the evidence;
instead, the nonmoving party's evidence ‘is to be believed and
all justifiable inferences are to be drawn in his favor.’”
Marino v. Indus. Crating Co., 358 F.3d 241, 247 (3d Cir. 2004)
(citing Anderson, 477 U.S. at 255).
Initially, the moving party bears the burden of
demonstrating the absence of a genuine issue of material fact.
Celotex, 477 U.S. at 323 (“[A] party seeking summary judgment
always bears the initial responsibility of informing the
district court of the basis for its motion, and identifying
those portions of ‘the pleadings, depositions, answers to
interrogatories, and admissions on file, together with the
affidavits, if any,’ which it believes demonstrate the absence
of a genuine issue of material fact.”) (citation omitted); see
also Singletary v. Pa. Dept. of Corr., 266 F.3d 186, 192 n.2 (3d
Cir. 2001) (“Although the initial burden is on the summary
judgment movant to show the absence of a genuine issue of
material fact, ‘the burden on the moving party may be discharged
by “showing” — that is, pointing out to the district court —
that there is an absence of evidence to support the nonmoving
7
party's case’ when the nonmoving party bears the ultimate burden
of proof.”)(citing Celotex, 477 U.S. at 325).
Once the moving party has met this burden, the nonmoving
party must identify, by affidavits or otherwise, specific facts
showing that there is a genuine issue for trial.
U.S. at 324.
Celotex, 477
A “party opposing summary judgment may not rest
upon the mere allegations or denials of the . . . pleading[s.]”
Saldana v. Kmart Corp., 260 F.3d 228, 232 (3d Cir. 2001)
(internal quotations omitted).
For “the non-moving party[ ] to
prevail, [that party] must ‘make a showing sufficient to
establish the existence of [every] element essential to that
party's case, and on which that party will bear the burden of
proof at trial.’”
Cooper v. Sniezek, 418 F. App'x 56, 58 (3d
Cir. 2011)(citing Celotex, 477 U.S. at 322).
Thus, to withstand
a properly supported motion for summary judgment, the nonmoving
party must identify specific facts and affirmative evidence that
contradict those offered by the moving party.
Anderson, 477
U.S. at 256–57.
IV. DISCUSSION
A. Standard of Review under ERISA
There is no dispute that the plan at issue qualifies as an
ERISA plan.
ERISA provides that a plan participant or
beneficiary may bring a suit “to recover benefits due to him [or
her] under the terms of his plan, to enforce his [or her] rights
8
under the terms of the plan, or to clarify his rights to future
benefits under the terms of the plan.” 29 U.S.C. §
1132(a)(1)(B).
The statute, however, does not specify a
standard of review for an action brought pursuant to §
1132(a)(1)(B). Firestone Tire & Rubber Co. v. Bruch, 489 U.S.
101, 109 (1989).
The Supreme Court clarified that “a denial of
benefits challenged under § 1132(a)(1)(B) is to be reviewed
under a de novo standard unless the benefit plan gives the
administrator or fiduciary discretionary authority to determine
eligibility for benefits or to construe the terms of the plan.”
Id. at 115.
When the plan affords the administrator with
discretionary authority, courts must review the benefit decision
for an abuse of discretion. Conkright v. Frommert, 559 U.S. 506,
512 (2010) (“[W]hen the terms of a plan grant discretionary
authority to the plan administrator, a deferential standard of
review remains appropriate even in the face of a conflict.”);
see Howley v. Mellon Fin. Corp., 625 F.3d 788, 793 n.6 (3d Cir.
2010)(explaining that courts in the Third Circuit have referred
to this standard of review as “abuse of discretion” or
“arbitrary and capricious” interchangeably).
The parties agree that the abuse of discretion/arbitrary
and capricious standard applies to this case because the plan at
issue gives the plan administrator discretionary authority to
decide eligibility benefits or interpret terms of the Plan.
9
B. Abuse of Discretion Analysis
Under the abuse of discretion standard of review, “the
Court's role is not to interpret ambiguous provisions de novo,
but rather to ‘analyze whether the plan administrator's
interpretation of the document is reasonable.’” Connor v.
Sedgwick Claims Management Services, Inc., 796 F. Supp. 2d 568,
580 (D.N.J. 2011) (quoting Bill Gray Enters. Inc. Employee and
Health Welfare Plan v. Gourley, 248 F.3d 206, 218 (3d Cir.
2001))(other citation omitted).
A decision is considered
arbitrary and capricious “if it is without reason, unsupported
by substantial evidence or erroneous as a matter of law.”
Miller v. Am. Airlines, Inc., 632 F.3d 837, 845 (3d Cir. 2011)
(further citation omitted).
To determine whether a plan administrator abused its
discretion, the Court must focus “on how the administrator
treated the particular claimant.” Id. (quoting Post v. Hartford
Ins. Co., 501 F.3d 154, 162 (3d Cir. 2007)).
“Specifically, in
considering the process that the administrator used in denying
benefits, we have considered numerous irregularities to
determine whether . . . the administrator has given the court
reason to doubt its fiduciary neutrality.” Id. (internal
quotations omitted).
This is accomplished “by taking account of
several different, often case-specific, factors, reaching a
result by weighing all together.” Id. (quoting Metropolitan Life
10
Ins. Co. v. Glenn, 554 U.S. 105, 117 (2008))(further citation
omitted).
The scope of a court's review is narrow, however, and the
court “is not free to substitute its own judgment for that of
the plan administrator in determining eligibility for plan
benefits.” Connor, 796 F. Supp. 2d at 580 (quotation omitted).
Thus, the plaintiff retains the burden to prove that he is
entitled to benefits, and that the plan administrator’s decision
was arbitrary and capricious.
Here, Sun Life is both the decider and payor of claims.
While that conflict of interest does not alter the standard of
review the Court applies, it is one factor to be considered in
evaluating whether Sun Life abused its discretion, the
significance of which depends on the facts of each case.
Conkright, 559 U.S. at 512; Metro. Life Ins., 554 U.S. at 108
(“The significance of the conflict of interest factor will
depend upon the circumstances of the particular case.”).
Additionally, another factor the Third Circuit considers
which can cause a heightened review is “demonstrated procedural
irregularity, bias, or unfairness in the review of the
claimant's application for benefits.” Kosiba v. Merck & Co., 384
F.3d 58, 66 (3d Cir. 2004).
Therefore, the Court considers the
structural conflict of interest and whether there is any
11
evidence of procedural irregularities, bias, or unfairness in
Sun Life’s review of Plaintiff’s claim.
C. Plaintiff's Motion for Summary Judgment
The Court finds that Plaintiff received a full and fair
review of the January 2015 administrative appeal of Sun Life’s
denial of her claim for long term disability benefits.
Plaintiff’s long term disability claim based on her psoriatic
arthritis and inability to use a keyboard was largely
unsupported by the medical evidence in the record.
The question
for the Court is whether Sun Life’s decision was “reasonable”
and supported by “substantial evidence.”
Fleisher v. Standard
Ins. Co., 679 F.3d 116, 121 (3d Cir. 2012).
The relevant
support for Plaintiff’s appeal consisted of APS statements
submitted by her rheumatologist, Dr. Moynihan, and an award for
Social Security Disability benefits.
Sun Life reviewed the
findings using eight board certified physicians, including three
board certified rheumatologists, to review all the medical proof
and comment on Plaintiff’s functional capacity over the course
of two independent appeals.
The overwhelming evidence suggested
Plaintiff was not disabled and could perform her own light
occupation.
After the previous settlement and remand, Sun Life referred
Plaintiff’s file to Behavioral Medical Institute, an independent
medical vendor, to obtain a rheumatologist’s opinion on
12
Plaintiff’s functional capacity. (Def.’s SMF ¶ 71.)
Behavioral
Medical Institute selected Dr. Lumpkins, who concluded there was
no evidence of impairment at any time based on her review of the
medical evidence, including Dr. Moynihan’s APS forms. (Def.’s
SMF ¶ 72 (citing AR 1106-07) (“Her psoriatic arthritis was never
documented to be of sufficient severity to preclude her from
performing the routine duties of a light occupation.”))
Plaintiff’s file was also reviewed by a psychologist, Dr. Price,
who concluded Plaintiff was not functionally impaired from a
psychiatric perspective from the time frame considered, April,
2010 to 2013. (Sun Life SMF at ¶ 70 (citing AR at 1032-33)).
Based on these reports, Plaintiff’s claim was denied.
Plaintiff
again appealed and provided a vocational report which concluded
that Plaintiff was “unemployable” because she could not perform
keyboarding.
Sun Life then referred Plaintiff’s file to Network Medical
Review, an independent medical vendor, who referred the review
to rheumatologist Dr. Rajendra Marwah, internist Dr. Jose Perez,
and psychiatrist Dr. Lawrence Albers.
All three doctors
concluded there was no evidence of impairment at any time.
SMF ¶¶ 99-103.)
(Sun
In whole, the administrative record contains
functionality or treatment records from eight rheumatologists
and a primary care physician: Drs. Adelizzi, Falasca, Moynihan,
Rogers, Payne, Laufer, Madhavi, Lumpkins, and Marwah.
13
Only one,
Dr. Moynihan, submitted information in support of Plaintiff’s
claim, which consists of only Dr. Moynihan’s previous APS forms.
Further, Dr. Moynihan did not test Plaintiff’s functionality and
did not review other physicians’ findings.
Sun Life briefly summarizes the medical record in support
of its claim denials as follows:
Date
02/22/2010
Medical Evidence
Plaintiff’s physician, Dr. Michael S. Rogers, finds
Drach had “[n]o recent arthralgias, myalgias, rash.”
(Id. at ¶ 74 (citing AR at 1192.))
04/09/2010
Drach stops working. (Id. at ¶ 14.)
05/20/2010
Dr. Rogers states: “No rashes seen.” (AR at 1164.)
06/07/2010 Dr. Moynihan finds that Drach’s psoriasis is
“confined mostly to her ears.” (AR at 172-73.)
08/13/2010
Dr. Rogers states: “No rashes seen.” (AR at 1153.)
05/07/2012
Rheumatology nurse Veronica Canino finds that
Drach’s hands were “without warmth or swelling,
synovitis, or significant hand deformities.”
(Def.’s SMF ¶ 52 (citing AR at 754.))
7/19/2012
Pain clinic nurse Stacey Eadie states that Drach’s
physical examination was normal including “[m]uscle
tone, bulk, and strength are normal, and power is 5/5
in all major muscle groups in lower extremities, such
as flexors and extensors of elbows, wrists, fingers,
hips, knees and ankles.” (AR at 749.) Her psoriasis
was in her ears. (AR at 751.)
14
07/31/2012
Rheumatologist Dr. Madhavi finds Drach had “no
tenderness or swelling” in her metacarpophalangeal
joints, “mild tenderness” over her distal
interphalangeal joint and proximal interphalangeal
joint and “scattered psoriatic rash over fingers of
both hands.” (AR at 857.)
08/27/2012
Dermatologist Hye Jin Chung states Drach’s
“psoriasis in skin is very mild and localized on
elbow, knee, ear, and hands.” (AR at 589.)
02/15/2013
04/22/2013
11/04/2013
Rheumatology nurse Canino states Drach had “few
psoriatic lesions” and hands “without warmth or
swelling.” (AR at 1270.)
Rheumatologist Dr. Terri Laufer states Drach had
“[v]ery mild psoriasis with no objective
evidence of inflammatory arthritis.” (Def.’s
SMF at ¶ 65 (citing AR at 1008.))
Dr. Rogers states Drach had “normal gait; grossly
normal muscle tone and muscle strength; full, painless
range of motion of all major muscle groups and joints”;
and “no ulcerations, lesions or rashes” of the skin.
(Def.’s SMF at ¶ 68 (citing AR at 965.))
Plaintiff argues that Sun Life’s denial of her claim for
long term disability benefits related to her January 2015
administrative appeal was arbitrary and capricious because: (1)
Sun Life ignored and failed to refute the evaluations of
Plaintiff’s vocational consultant and treating rheumatologist
(who opined Plaintiff could not use a keyboard); (2) the Social
Security award was dispositive; and (3) Plaintiff is unable to
perform the computer-based occupations Sun Life suggested.
15
The Court rejects Plaintiff’s argument that Sun Life was
required to rebut Dr. Moynihan’s APS forms and Dr. Kinkaid’s
vocational report.
Plaintiff bears the burden of proving that
she was totally disabled through the 180-day elimination period
which ended on October 7, 2010.
Even if Sun Life was required
to “refute” Dr. Moynihan’s opinion, there is ample evidence in
the record which does refute her findings.
For example, Dr.
Payne acknowledged that Dr. Moynihan diagnosed Plaintiff with
psoriatic arthritis but noted that her medical records did not
“clearly document inflammatory features in the historical data.”
(AR at 375.)
Dr. Payne concluded, “[a]lthough a diagnosis of
psoriatic arthritis is made and she is treated for the same with
the most recent treatment noted to be in October 2010, I can
find no objective evidence that this condition is active or
producing any impairment as no examiner reports any objective
features that are consistent with a degree of psoriatic
arthritis that would be producing restrictions or limitations on
activities.”
(Id. at 376.)
Additionally, Dr. Lumpkins concluded that Plaintiff’s
psoriatic arthritis did not change around April 2010 when she
stopped working and that at no time has her psoriatic arthritis
“documented to be of sufficient severity to preclude her from
performing the routine duties of a light occupation.” (AR at
1105-06.)
Similarly, Dr. Marwah stated that there were no
16
limitations for keyboarding. (AR at 1758.) 2
Plaintiff also
claims that Dr. Falasca diagnosed Plaintiff with psoriatic
arthritis, and Dr. Lumpkins found this diagnosis was supported.
However, Dr. Falasca also stated the psoriatic arthritis was
stable, not disabling, and further, diagnosis is not in and of
itself proof of disability.
Indeed, the medical evidence in the
records demonstrated it was not.
2
Plaintiff argues Dr. Marwah did not specifically make a finding
with regard to Plaintiff’s keyboarding abilities. Plaintiff
takes issue with Dr. Marwah’s allegedly ambiguous answer to the
following question:
3. From a physical functional perspective, does the
available medical treatment documentation provide
evidence that Ms. Drach was incapable of continuing to
perform full-time (i.e. 8 hours a day, 5 days a week)
Light Work duties beginning on or about April 10, 2010
through October 6, 2010 and continuing to the present?
Please discuss and note any specific medical
restrictions and limitations that were applicable
during this period of time. Specifically, please also
discuss Ms. Drach’s ability to keyboard and any
restrictions and limitations associated with her
ability to keyboard, finely manipulate and grasp with
her hands during these periods of time . . .
[Answer:] No. From a rheumatology perspective in
particular, there is no reason as to why Ms. Drach
could not perform Light Work duties beginning on or
about 04/10/10 through 10/06/10 and continuing to the
present. Based on the evidence provided and as
summarized above, Ms. Drach should be able to perform
these functions without any restrictions or
limitations.
The Court finds it was not arbitrary and capricious for Sun Life
to conclude that Dr. Marwah determined Plaintiff had the ability
to use a keyboard based on her response to the question posed.
17
Plaintiff claims Sun Life “shut its eyes” to Dr. Moynihan’s
APS forms.
ERISA does not require administrators to accord
special deference to Plaintiff’s treating physicians, “nor does
it impose a heightened burden of explanation on administrators
when they reject a treating physician’s opinion.” Baker v. The
Hartford Life Ins. Co., No. 08-6382, 2010 WL 2179150, at *14
(D.N.J. May 28, 2010), aff'd sub nom. Baker v. Hartford Life
Ins. Co., 440 F. App'x 66 (3d Cir. 2011)(citing Black & Decker
Disability Plan v. Nord, 538 U.S. 822, 834 (2003)); see also
Burk v. Broadspire Servs., Inc., 342 F. App’x 732, 737 (3d Cir.
2009)(“ERISA does not require that plan administrators give the
opinions of treating physicians special weight.”)(further
citation omitted).
Only one of Plaintiff’s doctors supported
her claim, and the conclusions of that report were undermined by
contemporaneous treatment records. Black & Decker Disability
Plan v. Nord, 538 U.S. 822, 823-24 (2003)("Courts have no
warrant to require administrators automatically to accord
special weight to the opinions of a claimant's physician; nor
may courts impose on plan administrators a discrete burden of
explanation when they credit reliable evidence that conflicts
with a treating physician's evaluation.”).
Plaintiff argues that like the administrator in Culley v.
Liberty Life Assur. Co. of Boston, 339 F. App’x 240 (3d Cir.
2009), Sun Life relied on its own consulting physician above
18
Plaintiff’s treating physician despite the inconsistencies in
its consultants’ reports.
distinguishable.
The instant facts are readily
In Culley, the weight of evidence was in the
plaintiff’s favor, while here, the substantial weight of the
evidence shows Plaintiff submitted inadequate proof of
disability.
Moreover, the only additional evidence Plaintiff provided
to Sun Life upon remand was notice that she was awarded Social
Security Disability benefits.
Plan administrators are not bound
by whether the claimant receives SSDI.
See Burk v. Broadspire
Servs., Inc., 342 F. App’x 732, 738 (3d Cir. 2009) (“[T]he
Social Security Administration’s determination of ‘disability’
is not binding in the instant case, where the determination is
governed by the plan terms rather than statute.”); see also
Menes v. Chubb & Son, 101 F. Supp. 3d 427, 436 (D.N.J. 2015)
(rejecting the plaintiff’s argument that MetLife failed to
consider a favorable Social Security Disability decision, noting
the “legal principles controlling the Social Security analysis
differ from those considered in an ERISA analysis”).
Further,
the SSDI decision did not discuss Plaintiff’s ability to
keyboard.
While the Court considers this as a factor, the SSDI
determination does not tip the scale in Plaintiff’s favor.
Additionally, Plaintiff argues that Sun Life ignored her
occupational limitations, suggesting she could perform six
19
occupations, all of which involved keyboarding, grasping, and
fine finger manipulation.
Plaintiff argues that a plan
fiduciary is required to “connect the medical evidence” to the
claimant’s “actual physical capacity,” otherwise, its
determination that the claimant can perform a given occupation
is arbitrary and capricious. (Pl.’s Br. at 12 (citing Dunn v.
Reed Group, Inc., 2009 WL 2848662, at *14-15 (D.N.J. September
2, 2009)).
Sun Life did connect the medical evidence, and it
showed that Plaintiff was not disabled.
This holds true even in
the consideration of the structural conflict of interest present
with Sun Life as the decider and payor.
Additionally, there is
no claim by Plaintiff of procedural irregularities, bias, or
unfairness, and the Court finds none.
Accordingly, summary
judgment on Plaintiff’s claim will be denied.
D. Defendant’s Motion for Summary Judgment
Sun Life argues Plaintiff failed to meet her burden of
proving her alleged disability.
More specifically, Sun Life
asserts that Plaintiff failed to submit proof satisfactory to
Sun Life that, due to injury or sickness, she was unable to
perform the Material and Substantial Duties of her own
occupation from April 10, 2010 and through the 180-day
Elimination Period. (Def.’s SMF at ¶¶ 5-7.) 3
3
Plaintiff appears to abandon her claim that she was disabled
due to psychological issues in her January 2015 appeal. Even if
20
Ability to find employment is only relevant if Plaintiff
first met her burden of proving she was unable to perform her
own occupation.
Plaintiff submitted a report by vocational
consultant Charles Kinkaid, who claimed that, as of January 9,
2015, Drach was “unemployable” because she could not perform
keyboarding (as per Dr. Moynihan’s October 2013 APS), she was of
“advanced work age,” and because her skills and experience were
obsolete, apparently because she was not trained in the most
current programming languages. (Hagner Cert., Ex. S.) 4
This
report, however, was premature until a finding that Plaintiff
was unable to perform her own occupation was made, which never
occurred.
Plaintiff also argues that her diagnosis of psoriatic
arthritis was supported by medical evidence and accepted by Dr.
Lumpkins. (AR at 1104.)
While it is true that Dr. Lumpkins
that claim is not abandoned, there is substantial medical
evidence that she was not disabled from a psychological
perspective as of April 10, 2010 and beyond. (Sun Life SMF ¶¶
39, 70.)
4
Further, this case is distinguishable from Shah v. Broadspire
Servs., Inc., No. 06-3106, 2007 WL 2248155, at *6 (D.N.J. Aug.
2, 2007), where the court found that a consultant made “no
effort” to determine if a person with the plaintiff’s physical
limitations could perform eight potential jobs. Here, however,
the overwhelming weight of the medical evidence in the record
showed Plaintiff did not have any physical limitations. Stated
more precisely, no other physician besides Dr. Moynihan opined
that Plaintiff’s hands were so cracked and swollen she could not
use a keyboard.
21
found sufficient medical evidence to agree with her diagnosis of
psoriatic arthritis in 2004, there are three critical holes in
Plaintiff’s argument.
First, the record does not explain why
Plaintiff was able to work with psoriatic arthritis in 2004 and
not in 2010.
disability.
Second, diagnosis alone is not proof of
Third, Dr. Lumpkins did not agree Plaintiff was
disabled based on psoriatic arthritis. (AR at 1105-06 (“The
medical record fails to demonstrate the exact clinical change
that occurred in the early part of 2010, necessitating the time
that the claimant stopped working . . . . Her psoriatic
arthritis was never documented to be of sufficient severity to
preclude her from performing the routine duties of a light duty
occupation.”))
Sun Life also asserts it is entitled to judgment on Count
II of Plaintiff’s complaint, which seeks a Life Waiver of
Premium benefits, which is a separate and distinct claim from
her long term benefits claim.
Sun Life argues this claim was
resolved in the parties’ August 2013 settlement. (Def.’s SMF ¶
43.)
Sun Life claims that Plaintiff waived this claim in the
parties’ prior settlement agreement.
Plaintiff does not oppose
this argument and the Court will grant summary judgment on Claim
II as well. (Pl.’s Response to Def.’s SMF ¶ 43.)
22
V. CONCLUSION
Summary judgment will be entered in favor of Sun Life.
Plaintiff’s motion will be denied.
An Order accompanying this
Opinion will be entered.
s/ Noel L. Hillman
NOEL L. HILLMAN, U.S.D.J.
Dated: September 28, 2016
At Camden, New Jersey
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