Filing 31

OPINION. Signed by Judge Jose L. Linares on 7/7/15. (DD, )

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NOT FOR PUBLICATION UNITED STATES DISTRICT COURT DISTRICT OF NEW JERSEY KAREN DUKES Civil Action No. 14-cv-00806 Plaintiff, V. LIBERTY LIFE ASSURANCE COMPANY OF BOSTON, et al., OPINION Defendants. JOSE L. LINARES, U.S.D.J. This matter comes before the Court upon cross motions for summary judgm ent. Plaintiff Karen Dukes (“Plaintiff’) moved for summary judgment on February 20, 2015. (ECF Nos. 14 and 15). On the same day, Defendants Liberty Life Assurance Company of Boston and Wells Fargo & Company Group Disability Policy (“Defendants”), also moved for summary judgment. (ECF No. 16). Pursuant to Rule 78 of the Federal Rules of Civil Procedure, no oral argument was heard. Upon consideration of the Parties’ submissions, and for the reasons stated below, Plaintiffs Amended Motion for Summary Judgment, (ECF No.15), is DENIED, and Defendants’ Motion for Summary Judgment, (ECF No. 16), is GRANTED. I. STATEMENT OF UNDISPUTED FACTS Defendant Liberty Life Assurance Company of Boston (“Liberty”) provides claim administrative services and acts as the insurer of benefits for a Group Disability Income Policy (LTD Policy) sponsored by Wells Fargo & Company. (Defendants’ Statement of Undisputed Material Facts (“SOUF”), ECF No. 16-2, 1). Plaintiff was employ ed as a Service Manager 1 ¶ for Wells Fargo & Company from December 21, 2010 until April 26, 2012. (Id. ¶ 5). Plaintiff’s job description states that her position required “seldom” lifting of up to ten pounds for thirty minutes or less within an eight hour workday. (Id. ¶ 8). Plaintiff left her employment on April 26, 2012 and began receiving short term disability benefits. (Id. ¶ 9). Plaintiff eventually exhausted short-term disability benefits and applied for long-term disability (LTD) benefits. (Id. ¶ 10). Liberty reviewed records from Plaintiff’s various physicians and treatment providers, and found evidence of degenerative disc disease and multilevel facet arthropathy. (Id. restrictions form. (id. ¶ 11-15). Liberty asked each medical provider to complete a ¶ 20). Liberty referred Plaintiff’s file to Raymond J. Chagnon, M.D. (Id. ¶ 30). Dr. Chagnon reviewed Plaintiff’s medical records, contacted Plaintiff’s physicians for peer-to-peer discussions, and furnished Liberty with a report on October 12, 2012. (Id. ¶ 31). Dr. Chagnon concluded that Plaintiff had lower back pain and radiation to her left leg, and that she had restrictions which would last three months. (Id. ¶ 37). On October 16, 2012, following a review of Plaintiffs claim documentation, Liberty determined that Plaintiff was eligible to received LTD benefits, effective that day. (Id. ¶ 40). Liberty advised Plaintiff that her claim would be reviewed periodically to determine ongoing eligibility. (Id. ¶ 41). In February 2013, Dr. Chagnon reviewed additional medical records and contacted Plaintiffs treatment providers again. (Id. ¶J 43-44). Based on his new findings, Dr. Chagnon reiterated the restrictions and limitations he had previously recommended, but also conclu ded that Plaintiff could return to full-time work within those restrictions. (Id. ¶IJ 54-55). Based on Dr. Chagnon’ s report and all other relevant information, Liberty sent Plaintiff a letter on February 22, 2013 to notify her that her LTD benefits would be discontinued becaus e she was no longer “disabled.” (Id. ¶ 56). Liberty concluded that the Plaintiff had not produced evidence 2 that she was precluded from performing the “Material and Substantial Duties” of her “Own Occupation.” (Id. ¶ 57). Liberty notified Plaintiff of her right to appeal its decision. (id. ¶ 58). Plaintiff, through counsel, formally appealed Liberty’s determination on August 16, 2013. (Id. ¶ 59). Plaintiff argued that she suffered from “unrelenting back pain, which prevents her from walking, standing, and sitting for [any] long-term period time,” and that this condition prevented her from performing her occupation. (Id. ¶J 60-6 1). Plaintiffs appeal mainly relied on two documents: a report from Dr. Daniel I. Richman, M.D., and a letter from Dr. Michael Coppola. (Id. ¶ 63). Dr. Richman determined that Plaintiff “cannot perform any type of employment that would require her to sit for any period of time, move around or stand for any period of time in particular to lift heavy objects have to bend at the waist.” (Id. disabled. (Id. more than 10 or 15 pounds where she would ¶ 66). Dr. Coppola, her chiropractor, stated that she was totally ¶ 70). Plaintiffs appeal was referred to an independent physician, Dr. Jamie L. Lewis, for review. (Id. ¶ 74). Dr. Lewis reviewed Plaintiffs medical records, Plaintiffs job description, and Liberty’s Occupational Analysis, and concluded that Plaintiff could perform her own occupation in a full-time capacity with appropriate restrictions and limitations. (Id. ¶J 76- 77). On October 28, 2013, Liberty upheld its decision to deny benefits after completing a thorough review of Plaintiffs entire claim file. (Id. ¶ 80). In light of the foregoing, Plaintiff commenced this action on February 7, 2014. (ECF No. 1). This Court’s jurisdiction is premised on federal question, 28 U.S.C. § 1331, as Plaintiffs claim arises from the Employee Retirement Security Act of 1974 (“ERISA”). (Cmp., ¶ 14). Both Parties moved for summary judgment on February 20, 2015 (ECF Nos. 15 and 16). 11. LEGAL STANDARD 3 Summary judgment is appropriate when, drawing all reasonable inferences in the non movant’s favor, there exists no “genuine dispute as to any material fact” and the movant is entitle d to judgment as a matter of law. See Fed. R. Civ. P. 56(a); Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 255 (1986). The moving party is entitled to judgment as a matter of law when the non-moving party fails to make “a sufficient showing on an essential element of her case with respect to which she has the burden of proof.” Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986). The Court must, however, consider all facts and their reasonable inferences in the light most favorable to the nonmoving party. See Pennsylvania Coal Ass’n v. Babbitt, 63 F.3d 231, 236 (3d Cir. 1995). If a reasonable juror could return a verdict for the non-moving party regarding material disputed factual issues, summary judgment is not appropriate. See Anderson, 477 U.S. at 242-43 (“At the summary judgment stage, the trial judge’s function is not himself to weigh the evidence and determine the truth of the matter but to determine whether there is a genuine issue for trial.”) . III. DISCUSSION A. Plaintiffs Amended Motion for Summary Judgment Plaintiff seeks summary judgment primarily because Liberty’s decision to terminate Plaintiffs LTD benefits was “arbitrary and capricious.” (Memorandum of Law in Suppo rt of Plaintiff’s Motion for Summary Judgment (“Pl.’s Brief’), ECF No. 15-1, at 19). Plainti ff first argues that Liberty’s decision was arbitrary and capricious because there was a structu ral conflict of interest given Liberty was “the sole adjudicator of all claims, as well as the sole payor of all benefits which might be due and owing to Plaintiff.” (Id. at 21). Plaintiff also argues that Liberty’s decision was arbitrary and capricious because Liberty “employed self-se rving 4 selectivity in the use of evidence, relied on self-serving paper reviews, and relied on the opinions of non-treating physicians without adequate explanation. . . .“ (Id. at 24). B. Defendants’ Motion for Summary Judgment Defendants seek summary judgment on similar grounds as the Plaintiff, focusin g on the standard of review and arguing that Liberty’s decision was not arbitrary and caprici ous. (Defendant’s Memorandum of Law in Support of their Motion for Summary Judgm ent (“Defs.’ Brief’), ECF No. 16-I, at 11). First, Defendants argue that Liberty’s decision to terminate LTD benefits was not arbitrary and capricious because the “determination concerning Plaintiff’s LTD claim was both reasonable and the result of a well-documented and procedurally fair review.” (Id. at 13). Next, Defendants argue that “[P]laintiff has neither alleged nor adduced any evidence whatsoever that Liberty’s decision was the result of bias or was tainted by any conflic t of interest.” (Id). Finally, Defendants argue that Plaintiff’s claims that she now suffers from additional medical issues are inappropriate, as “the sole question for this Court is whether Liberty reasonably concluded, based upon the administrative record before it, that plaintiff had not met her burden of proving she was Disabled, as that term is defined under the LTD Policy, during the administrative review period.” (Id. at 14). C. Arbitrary and Capricious Standard The Parties are in agreement that the correct legal standard to be applied to Liberty’s decision to terminate Plaintiff’s LTD benefits is whether the decision was “arbitr ary and capricious.” (Pl.’s Brief at 19; Defs.’ Brief at 11). The Parties, however, disagre e as to whether Liberty’s decision making process meets this standard of review. The Third Circuit recently held that “[a]n administrator’s decision is arbitrary and capricious if it is withou t reason, unsupported by substantial evidence or erroneous as a matter of law.” Miller v. Ameri can Airlines, inc., 632 5 F.3d 837, 844-845 (3d Cir. 2011) (citing Abnathya v. Hoffmann—La Roche, Inc., 2 F.3d 40, 45 (3d Cir. 1993). An administrator’s decision is supported by substantial evidence “if there is sufficient evidence for a reasonable person to agree with the decision.” Daniels v. Ancho r hocking Corp., 758 F. Supp. 326, 331 (W.D. Pa. 1991). The Court must look at a variety of factors when analyzing whether an ERISA decision was arbitrary and capricious, includ ing procedural concerns about the decision making process and structural concerns about conflicts of interest, but the factors will vary and are “case-specific.” Estate ofSchwing v. Lilly Health Plan, 562 F.3d 522, 526 (3d Circ. 2009) (citing Metropolitan Lfe Ins. Co. v. Glenn, 554 U.S. 105, 128 (2008)). Finally, this scope of review is narrow, and “[r]eview under this standa rd requires the challenged decisions to remain intact unless it is not rational.” Lucash v. Strick Corp., 602 F. Supp 430, 434 (E.D. Pa 1984) (quoting Federal Communications Commission v. Nation al Citizens Cominittee for Broadcasting, 436 U.S. 775, 803, (1978)). Accordingly, “deference should be given to the lion’s share of ERISA claims.” Shvartsman v. Long Term Disability Income Plan for Choices Eligible Employees ofJohnson & Johnson, No. 11-036 43, 2012 WL 2118126, at *9 (D.N.J. June 11, 2012) (citing Glenn, 554 U.S. at 116-17) (discus sing Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 111(1989))). D. Conifict of Interest Defendants concede that “a conflict of interest may arise where, as here, the plan administrator is responsible both for determining eligibility benefits and for paying those benefits out of its own funds,” (Defs.’ Brief at 12), but this is only one factor for the Court to review and is only important “where there is evidence that the benefits denial was motiva ted or affected by the administrator’s conflict.” Glenn, 554 U.S. at 120 (Roberts, C.J., concurring). This Court considered a factually analogous case just two years ago in Vander-Leeuw v. First Unum Life 6 Ins. Co., No. Civ. A. 11-5685, 2013 WL 3479433, at *8 (D.N.J. July 9, 2013). In that case, Plaintiff contended that the administrator’s discussions with a financial consul ting team constituted a conflict of interest. Id. The existence of a potential conflict of interes t was not enough to show the administrator’s decision was arbitrary and capricious, howev er, as this Court ruled that “Plaintiff does not point to any evidence that [the administrator] sought or followed the advice of financial consultants. . . Therefore, under the facts of this case, the Court finds that conflict of interest is not a significant factor.” Id. Similarly, in this case Plainti ff states “[t]here can be no dispute in this matter that Liberty Mutual was both the sole adjudi cator of all claims, as well as the sole payor of all benefits which might be due and owing to Plainti ff. . . Here, this factor weights in favor of granting Plaintiff’s Motion for Summary judgment.” (P1.’ s Brief at 21). Plaintiff merely points out the existence of a potential conflict of interes t, but does not proffer any evidence that Liberty’s decision to terminate Plaintiff’s LTD benefit s was influenced by this conflict or incentivized Liberty to deviate from their normal protocol. Accordingly, the Court finds that the potential conflict of interest is not a significant factor here. E. Liberty’s Procedure for Terminating Plaintiffs LTD Benefits The second critical dispute at issue in this case is whether Liberty’s review of Plaintiff’s claim was procedurally proper. Plaintiff claims that “Liberty Mutual employ ed self-serving selectivity in the use of evidence, relied on self-serving paper reviews, and relied on the opinions of non-treating physicians over treating physicians without adequate explan ation.” (Pl.’s Brief at 24). Defendants respond that “Liberty’s review of plaintiff’s claim was well-documented, procedurally fair, and free of taint,” and that “Liberty did not ignore the reports of plaintiffs treating physicians or her expert.” (Defs.’ Brief at 21). Both Parties acknow ledge that an administrator is not required to afford controlling weight to a Patient’s treating physicians, as set 7 out by the United States Supreme Court in Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003). Plaintiff contends, however, that Liberty’s decision was arbitrary and capricious because in that same case the United States Supreme Court also held that “[p]lan administrators, of course may not arbitrarily refuse to credit a claimant’s reliable evidence, including the opinions of a treating physician.” Id. Plaintiff relies on Culley v. Liberty Life Assurance Co., 339 Fed.Appx. 240 (3d Cir. 2009), where the Third Circui t stated “[wjhile Liberty Mutual may freely rely on its consultants, without giving special deference to the views of treating physicians, neither may it turn a blind eye to faults in the eviden ce supporting its consultants’ opinions.” Id. at 245. In Cuiley, the administrator’s consulting physician noted that he was missing some critical information that left him unable to render a clear opinion and a later review of the consulting physician’s findings by a case manager found incons istencies in his findings, yet Liberty stood by their termination of LTD Benefits. Id. at 244. Notably, in the present case, Plaintiff cannot point to inconsistencies in the findings of Dr. Chagnon or Dr. Lewis, but mainly challenges Liberty’s consultants based on the fact that “the consultants reported that the treating physicians allegedly made statem ents that are in direct conflict with their written statements.” (Pl.’s Brief at 24). These purpor ted discrepancies are do not rise to a level sufficient to cast doubt over the reasonableness of Liberty ’s decision, do not prove that Liberty’s decision was made without reliable evidence, and do not show that Liberty’s decision was incorrect as matter of law. Plaintiff may not agree with the findings of Liberty’s experts, but the experts clearly considered the entire administrative record before them as required. As such, Liberty’s decision was not arbitrary and caprici ous and cannot be overturned bythis Court. IV. CONCLUSION 8 For the reasons set forth above, Plaintiffs Amended Motion for Summary Judgm ent, (ECF No.15), is DENIED, and Defendants’ Motion for Summary Judgment, (ECF No. 16), is GRANTED. An appropriate Order accompanies this Opinion. Linares States District Judge Date: *,2Ol5 9

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