RODRIGUEZ v. RELIANCE STANDARD LIFE INSURANCE COMPANY

Filing 23

OPINION fld. Signed by Judge Dennis M. Cavanaugh on 1/31/14. (sr, )

NOT FOR PUBLICATION
UNITED STATES DISTRICT COURT
DISTRICT OF NEW JERSEY
SYLVIA RODRIGUEZ,
Plaintiff.

Hon. Dennis M, Cavanaugh
:

OPINION
Civil Action No. 2:12-cv-04810 (DMC) (JBC)

RELIANCE STANDARD LIFE
INSURANCE COMPANY,
Defendant.

DENNIS M. CAVANAUGI-i, U.S.D.J.:
This matter comes before the Court upon (1) Motion for Summary Judgment by Plainti
ff
Sylvia Rodriguez (Rodriguez” or P1aintiff’) (Pl.’s Mot. for Summ. J., May 24, 2013, ECF
No,
15), and (2) Motion for Summary Judgment by Reliance Standard Life Insurance Compa
ny
(Reiiance” or Defendant”) (Def.’s Mot. for Summ, J., May 24, 2013, ECF No.
16). Pursuant
to Fed, R. Civ. P 78, no oral argument was heard. Based on the following and
for the reasons
expressed herein, Plaintifis Motion for Summary Judgment is denied and Defend
ant’s Motion
br Summary Judgment is granted.
I.

1
BACKGROUND
Plaintiff was employed by GAF Materials Corporation as a Global Lead Analys
t. As an

employee benefit, Plaintiff was covered under Reliance’s standard long term disabil
ity insurance
policy. On or about July 26. 2008, Plaintiff asserts that she became disable
d as a result of the
effects of Chronic Fatigue Syndrome and related symptoms. On December
4, 2008, Plaintiff

I The facts set forth in this Opinion are taken from the parties’ respective pleadings
and moving

papers.

applied for long term disability benefits stating that she was no longer
able to work, Defendant
paid long term disability benefits to Plaintiff during the period from
January 22, 2009 to
To\emher ii, 2009 when it attempted to termin
ate payment. Plaintiff filed an appeal and
payments were reinstated on October 21, 2010. By letter dated Januar
y 21, 2011 (the

“Termination Letter”), Matrix Absence Management, Inc., acting on behalf
of Defendant.
informed Plaintiff that her long term disability benefits were being terminated.
As defined by the Policy, to qualify for disability during the initial 24mon
th period of
coverage, an Insured must demonstrate an inability to perform material duties
of her regular

occupation. To qualify for benefits after 24 months, a claimant must be unable
to perform the
duties of ‘any occupation” which is defined as an inability to perform the materi
al duties of any
occupation that her education, training or experience reasonably allow. In additio under
n,
the
Mental or Nervous 1)isorders Limitation. benefits are not payable beyond 24 month for
s
any
disability that is caused by or contributed to by a Mental Disorder, including anxiety
and
depression.
The Termination Letter includes the following language: “Based on the documentatio
n

provided, it appears that your Total Disability is caused by or contributed to by a Menta
l or
Nervous Disorder.” The Letter also makes reference to an Independent Medical Exam
showing

that Plaintiff did not meet the criteria for Fibromyalgia and that no findings were
made
demonstrating physical impairment from sedentary work. In addition. the Termin
ation Letter
explajned that the medical records received from Drs. Richard Podell and King
reflected
continued complaints of fatigue but did not provide sufficient medical eviden
ce to support

continued restrictions and limitations that would prevent less than sedentary work
capacity.
Plaintill appealed thL tLrmlnatlon ol hr benefits AItLI a

Dehndant sent

Plaintiff a letter, dated August 7, 2012 (the “Appeal Decisi
on Letter”), upholding the decision to
terminate benefits, The Appeal Decision Letter quotes from the
reports of five independent
physicians and concludes that Plaintiff is not sufficiently impair
ed from any of her physical
conditions to preclude her from doing sedentary work. The Appea
l Decision Letter also provides
that based on the evidence in the administrative record, ‘it is reason
able to conclude that her
primarY impairment is psychiatric in nature with somatic manifestation
s.” The Appeal Decision
Letter points to a note by one physician that Plaintiff was crying and
depressed during one of her
examinations and also notes that several of Plaintiffs own treatment
providers recommended
psychiatric medications to manage Plaintiffs symptoms. Essentially,
the Appeal Decision Letter
holds that there is sufficient evidence to deny Plaintiff benefit coverage beyond
24 months on
either of the two following grounds: (1) Plaintiff is not totally physically
disabled and is capable
of sedentary work or (2) a mental or nervous disorder contributes to Plaintiffs
disability.
On August 2,2012, Plaintiff filed suit in this Court, pursuant to Section 502(a)
(l)(B) of
ER1SA, 29 U.S.C. ii 32(a)(1)(B), seeking to recover the payment of long term
disability
insurance. Plaintiff argues that there is no evidence or diagnosis in the
record demonstrating that
Plaintiff has a mental or nervous disorder. Plaintiff further asserts that there
is no evidence in the
file that her stamina and other symptoms had improved to the point that
she could perform
sedentary duty type work, or even that her stamina had been tested. Finally, Plainti
ff argues that
Defendant violated federal regulations by failing to advise Plaintiff what
intorination she would
need to perfect her appeal.
STANDARD OF REVIEW
A. Summary Judgment
Summary judgment is granted only

it

all probative matenals ot record x iewed with all

inferences in favor of the nonmoving party, demonstrate that
there is no genuine issue of material
fact and that the movant is entitled to judgment as a matter of law.
See Celotex Corp. v. C atrett,
477 U.S. 317, 330 (1986); FED. R. Civ. P. 56(c). The movin
g party bears the burden of showing
that there is no genuine issue of fact, Id. “The burden has two
distinct components: an initial
burden of production, which shifts to the non-moving party if satisfie
d by the moving party; and
an ultimate burden of persuasion, which always remains on the movin
g party.” Id. The nonmoving party “may not rest upon the mere allegations or denials
of his pleading” to satisfy this
burden, but must produce sufficient evidence to
SLC

support a

jury verdict in his favor. Id. at 322:

also FED R Ci’v P 5 6(e), Matsushita Elec indus Co v icmth Radio
Corp 475 U S 574
,

586 (1986). “In determining whether there are any issues of material
fact. the Court must resolve
all doubts as to the existence of a material fact against the moving party
and draw all reasonable
inferences

-

including issues of credibility in favor of the non-moving party.” Newso
me v.
-

Admin. Office of the Courts of the State ofNJ., 103 F. Supp.2d 807. 815
(D.N.J. 2000). aff’d.
51 Fed. App’x 76 (3d Cir, 2002) (citing Watts v. Univ. of Del,. 622 F.2d
47, 50 (D.N.J. 1980)).
B. Standard of Review for Denial of Benefits Claim Under ERISA
A denial of a benefits claim brought pursuant to ERISA is typically
reviewed under a de
novo standard, “unless the plan grants discretionary authority to the
administrator or fiduciary to
determine eligibility for benefits or interpret the terms of the plan.”
Estate of Schwing v. The
LyjIea1fhPl, 562 F.3d 522, 525 (3d Cir. 2009) (citing Firestone Tire & Rubbe
r Co. v.
Bruch, 489 U.S. 101, 115 (1989). Where the plan grants the admini
strator discretionary
authority, as it does here, the court reviews the administrator’s exercis
e of that authority under an
“arbitrary and capricious standard.” Schwarzwaelder v. Merrill
Lynch & Co.. 606 F. Supp. 2cl.
546, 557 (W.D. Pa. 2009) (citing Firestone, 489 U.S. at 115). Under
the arbitrary and capricious

4

standard, ‘an administrator’s decision is 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) (quoting Abnathva v. HofTh
iann-La Roche. Inc.. 2 F.3d
40, 45 (3d Cii 1993)), See also Orxosh v Piogram of Gip Ins
toi Salaiicd Empics ol
Volkswagen of Am., Inc., 222 F.3d 123, 129 (3d Cir. 2000) (“[Aj plan
administrators decision
will he overturned only if it is clearly not supported by the evidence
in the record or the
administrator has failed to comply with the procedures required by
the plan.”). ‘To determine
whether the administrator’s decision is without reason, unsupported
by the evidence, or
erroneous as a matter of law,” the Court must look to the record as
a whole,’ which “consists ot
that evidence that was before the administrator when he made the decision being
reviewed.”
Mitchell v. Eastman Kodak Co., 113 F.3d 433. 440 (3d. Cir. 1997).
H.

DISCUSSION
The Court must

now examine

the administrative record and determine whether

Reliance’s decision to deny Plaintiff long term disability coverage beyond
24 months was
unreasonable, unsupported by evidence or erroneous as a matter of law.
According to
Defendant’s Termination and Appeal i)ecision Letters, Plaintiff was denied
benefit coverage
beyond 24 months because (1) Plaintiff was deemed capable of sedent
ary work and therefore not
‘totally disabled” and/or (2) a mental or nervous disorder was found to
contribute to Plaintifrs
disability. (AR0276-0278, 0286-029 1). Either ground would be sufficient
to deny Plaintiff
coverage

beyond 24 months under her employee benefit plan, The Court will addres
s each basis

in turn.
Under Plaintifrs Plan, to be eligible for long term disability benefits,
the insured must be
‘Totally Disabled” which is defined as the following: “for the first 24
months Ibr which a

Monthly Benefit is payable, an insured cannot perform the materi
al duties of his/her Regular
Occupation.” (AR0287). However, after a Monthly Benefit has
been paid for 24 months” to
meet the definition of “Totally Disabled,” the Insured must not be
able to “perform the material
duties of any occupation.” Id. “Any occupation” is defined as “one
that the insured’s education,
training or experience will reasonably allow.” Id. According to the
Termination Letter, Reliance
found insufficient “medical evidence to support continued restrictions
and limitations that would
prevent less than sedentary work capacity.” (AR0277).
Plaintiffs burden under the “any occupation” standard is an especia
lly heavy one. $eg
e.g.

542 F.3d 1213, 1219 (9th Cir, 2008) (the

language of the ‘any occupation’ standard is not demanding”); I3righa
m y,_un Life of
Canada, 317 F.3d72.. 86 ( st Cii’. 20(3) (“the hurdle plaintiff had to surmo
unt. establishing his
inability to perform any occupation lbr which he could he trained, was
a high one,” and under
the any occupation standard, the paraplegic claimant with severely limited
function who was
experiencing muscle pain was not totally disabled), in order to demonstrate
“lotal Disability”
under the “any occupation” standard, Plaintiff must show that she is not
capable of even
sedentary level work. Sedentary work is defined as “exerting up to 10
pounds of force
occasionally.. .and/or a negligible amount of force frequently.. .Seden
tary work involves sitting
most of the time, but may involve walking or standing for brief periods
of time.” (ARO2$9).
in its Appeal Decision Letter, Defendant cites to numerous reports from
Physicians to
support its determination that Plaintiff is capable of sedentary work and
therefore not Toiallv
Disabled. (AR0286-0291). For example, Dr. Jason Failer, a Board Certifi
ed Rheumatologist.
perlbrmed an independent medical examination and concluded that “So
far as her ability to
function in a workplace is concerned, there are no objective findings
to limit her functionality.”

6

(AR0289). Dr. Faller also completed a Physical Capacities Questi
onnaire in which he

determined Plaintiff to be capable of performing such activities as sedent
ary lifting, frequent
sitting and occasional standing and walking on a regular basis in an eight
(8) hour work day. Id.
In addition, after an independent evaluation on April 3, 2012, Dr.
Micha Abeles, also a Board
Certified Rheumatologist, made the following assessment:
Based on my examination, Ms. Rodriguez can sit. stand. walk, bend
at the waist. squat.
climb stairs, climb ladders, kneel, crawl, use foot controls and drive.,
.The Fibromyalgia
probably does not impact her and Fibromyalgia will not disallow her
to do all of’ the
above mentioned activities on a frequent to continuous basis. From
the diagnosis of
Fibromyalgia she can sit for 8 hours. She can stand and walk on and off
8 hours in an 8
hour day. She is not restricted from reaching at any level.. .Lifting and carryin
g of 10-20
pounds is not restricted. j4
The Appeal Decision Letter also cited to reports performed by I)r. Ihsan Plaque
, a Board
Certified Cardiologist, and Dr. David Foyt, a Board Certified Otolaryngolo
gist, to assess
Plaintiti s allegations of Postural Orthostatic Tachycardia Syndrome (‘POT
S”). Dr. Haque
concluded that “Standing should be limited to 20 minutes at a time every three
hours at most.
She can read, write and answer questions. use a keyboard, stretch, eat, drink and
walk.”
(AR0290). Dr. Haque also determined that The diagnosis of POTS is NOT
proven in the
record.” Id. Dr. Foyt opined that “From an otolaryngology perspective,
this claimant does have
full work capacity and is not restricted in any way on activities, including,
but not limited to,
sitting, standing, walking, reaching, lifting, carrying, and performing repetit
ive and fine motor
hand activities.” (ARO29I).
The Court finds the reports of the five independent physicians to be suffici
ent evidence to
support Defendant’s conclusion that Plaintiff was no longer fotally i)isable
d and its consequent
decision to deny Plaintiff coverage beyond the initial 24 month period.. The
Court finds it
reasonable for Defendant, in making its decision, to rely on assessments by
two

7

Rheumatologists, physicians qualified to evaluate Plaintiffs claims
of chronic fatigue syndrome:
two Otolaryngologists, physicians qualified to evaluate Plaintiffs
claims of lightheadedness and
imbalance; and one Cardiologist, a physician qualified to address the
claim that PlaintiiTsuft’ered
from POTS. As such, the Court finds that Defendant’s decision to termin
ate Plaintiff’s benefits
based on multiple physicians’ assessments that she was capable of sedent
ary work is not
arbitrary and capricious.
Under the Plan, “monthly benefits for total disability caused by or contrib
uted to by
Mental or Nervous Disorders will not be payable beyond an aggregate lifetim
e maximum
duration of twenty-four (24) months.” (AR0287). Mental or Nervous Disord
ers are defined to
include biopolar disorder, schizophrenia, delusional (paranoid) disorders. psycho
tic disorders.
depressive disorders, anxiety disorders. somatoform disorders (psychosomatic illness
),

eating

disorders and mental illness. (AR0287-0288). As explained in the Appeal Decisi
on Letter,
Defendant also terminated Plaintiffs benefits because it found that, based on the
administrative
record, her symptoms included anxiety/depression. (AR0288). Accordingly, Defend
ant
concluded that that Plaintiff’s benefits were subject to the twenty-four month maxim
um duration
for Mental or Nervous Disorders because “her psychiatric condition both ‘cause
d’ and
contributed to’ her overall impairment.” Id.
According the Appeal Decision Letter, Defendant concluded that Plaintiffs illness
was
psychiatric in nature” based on a note by Dr. Faller that Plaintiff was “crying
and depressed” as
well as the opinions of several other treatment providers who “recommende psychi
d
atric
medications to manage her symptoms.” (AR0291). In addition, according
to the record,
Plaintiff’s own physician, l)r. Podell, stated the impression that Plaintiff suffere
d from anxiety.
(AR854-855). Dr. Podell also attempted to treat Plaintiff with

8

anxiety

medication but Plaintiff

refused any va1ium type” medication because of her family’s
history of substance abuse.

(AR843-844, 856-858, 938-940).
The Court finds that the opinions of Dr. Faller and Dr. Podell as well
as the general
recommendations by Plaintiff’s treatment providers for Plaintiff to take
psychiatric medications
is sufficient evidence to support Defendant’s conclusion that a psychi
atric condition caused or
contributed to Plaintiffs impairment. Defendant’s decision to terminate
Plaintiff’s benefits on
the grounds that she had exhausted her twenty-four month coverage
•for a Mental or Nervous
Disorder was not without reason or erroneous as a matter of law and
should therefore be upheld.
Plaintiff also argues that Defendant’s denial letter failed to advise Plainti
ff what
intoimation was neLded to peifect her appeal as iequired by 29 C FR

2560 503 l(gXl )(ui)

Plaintiff asserts that the letter merely stated that she could send written comme
nts, records or
other information and provided no guidance on how to address the specific medica
l issues being
appealed. Based on relevant case law, the Court finds that Defendant’s appeal
letter was
sufficiently informative and complete. See çg Kao v. Aetna Life Ins. Co..
647 F. Supp. 2d. 397.
411 (D.N.J. 2009); Houser v. Alcoa. Inc.. CA no. 10-160. 2010 U.S. Dist. LEXIS
128281 (W.D.
Pa. Dec. 6. 20l0) Mazur v. Hartford Life & Accident Co., No. 06-1045,
2007 U.S. Dist. LEXIS
87477 (W.D. Pa. Nov. 28. 2007).
The denial letter in Kao advised the claimant that the record contained “insuff
icient
quantitative clinical findings” to support the claim and invited the claima
nt to, on appeal,
‘provide quantitative data and clinical evidence to support her appeal.”
647 F. Supp. 2d at 411412. The court deemed this sufficient to satisfy ERISA’s requirements,
noting ‘[t]here is
nothing cryptic about the meaning of [the] letter.” Id. at 412. Like the
letter at issue here, the
denial letter in Houser, quoted specific plan provisions on which the denial
was based, informed

9

plaintiff she could submit additional medical or vocational inform
ation and explained her appeal
rights. 2010 U.S. Dist. LEXIS 128281. It was deemed adequa
te. Id. Likewise, arguments of
inadequacy were rejected in Mazur, where the claimant was represe
nted by counsel, the
defendant provided access to the claim tile, and the defendant
told him that he could submit
additional information in support of the claim. 2007 WL 4233400.
The Court finds that Defendant’s denial letter was more than adequa
te in telling Plaintiff
why benefits were discontinued, The letter identified the policy
provisions that were relied on.
(AR0276-0277). The letter summarized the bases for the claim, includ
ing Plaintiffs complaints
of chronic fatigue and balance problems. (AR0277). The letter then
noted the lack of abnormal
findings that would support Plaintiffs claim of continuing disability. Id.
Specifically, the letter
addresses the records received from Plaintiffs treating physicians, Drs.
Podell and King, as well
as the results of independent medical examinations by a rheumatologist.
Dr. Faller and an
otolaryngologist, Dr. Freifeld. Id. After explaining the bases for its decisio
n, 1)efendant advised
Plaintiff of her right to appeal the decision. (AR277-278). This demonstrates
that Defendant’s
appeal letter gave Plaintiff sufficient information related to her appeal and
that ultimately
Plaintiff received a full and fair review.
fl

CONCLUSION
For the foregoing reasons, Plaintiffs Motion for Summary Judgment
is

Defendant’s Motion for Summary Judgment is

granted.

An appropriate

denied

and

(icr accompanies this

Opinion.
Denni’s M. Cavanaugh, U.S.
Date:
Original:
cc:

January
2014
Clerk’s Office
Hon. James B. Clark, U.S.M.J.
Counsel of Record, File
10