UQDAH v. UNUM LIFE INSURANCE COMPANY OF AMERICA
OPINION. Signed by Judge Susan D. Wigenton on 9/21/2015. (anr)
NOT FOR PUBLICATION
UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF NEW JERSEY
CYNTHIA MARIA UQDAH,
Civil Action No. 14-6367 (SDW) (SCM)
UNUM LIFE INSURANCE COMPANY OF
September 21, 2015
WIGENTON, District Judge.
Before this Court are Cynthia Maria Uqdah (“Plaintiff” or “Uqdah”) and Unum Life
Insurance Company of America’s (“Defendant” or “Unum”) Motions for Summary Judgment
pursuant to Federal Rule of Civil Procedure 56. Jurisdiction and venue are proper in this Court
under 28 U.S.C. § 1441 and 28 U.S.C. § 1391(b), respectively. This motion is decided without
oral argument as permitted under Federal Rule of Civil Procedure 78. For the reasons that follow,
this Court DENIES Plaintiff’s Motion for Summary Judgment and GRANTS Defendant’s Motion
for Summary Judgment.
FACTUAL AND PROCEDURAL BACKGROUND
Plaintiff resides in Oak Lawn, Illinois, and was employed by Ulmer & Berne, LLP
(“Employer”) as a legal secretary at all relevant times. (Am. Compl. ¶¶ 17–18.) Defendant is an
insurance company headquartered in New Jersey. (Id. ¶ 20.) Defendant issued a group disability
insurance policy to Plaintiff’s employer on October 1, 2005 under policy number 118962 001 (the
“Policy”). (See Hern Declaration (“Hern Decl.”) Ex. A).
On October 1, 2013, Plaintiff submitted a claim for total disability benefits under the Policy
due to “spinal stenosis” and specified her work end date as June 28, 2013. (Id.) Plaintiff claimed
that she could no longer perform her professional duties because she experienced “pain and
uncomfortability when walking [and] sitting” as well as overall weakness in her back and hips.
(Id.) According to Plaintiff’s employer, as a legal secretary, Plaintiff was required to file
documents, which generally requires “bending, kneeling or stooping[,]” and “lift[ing]/carry[ing]
files, books, reams of paper, 3-ring binders, etc. up to 10 pounds in weight.” (Id.)
Although Plaintiff visited the emergency room on July 5, 2013, about a week after she
stopped working, with complaints of nausea and dizziness, she first self-reported low back pain
radiating to both legs and pelvic pain on July 19, 2013, three weeks after she left work.
(Defendant’s Statement of Undisputed Facts (“Def.’s SUMF”) ¶ 26.)
Plaintiff’s initial claim form included a statement executed by her internist, Jerome Antony,
M.D. (“Dr. Antony”), on September 26, 2013. (Id.) Dr. Antony reported that while Plaintiff could
“occasionally” sit, stand, and walk, she could “never” climb, twist, bend, stoop, reach above
shoulder level, operate heavy machinery, or lift up to ten pounds. (Id.) Consequently, Dr. Antony
restricted Plaintiff from physical activity, sitting or walking for long periods of time, and lifting
and carrying heavy items. (Id.)
Under the Policy, a finding of disability results if there is evidence that the claimant is (1)
“limited from performing the material and substantial duties of [his or her] regular occupation due
to  sickness or injury;” and (2) has a “20% or more loss of [his or her] indexed monthly earnings
due to the same sickness or injury.” (Id.) “Material and substantial duties” are defined under the
Policy as those duties that “are normally required for the performance of your regular occupation
 [which] cannot be reasonably omitted or modified.” (Id.)
To facilitate its review of Plaintiff’s disability claim, Defendant requested and received
medical records from Plaintiff’s treating physicians. The following is a summary of those medical
Plaintiff’s internist, Dr. Antony noted that Plaintiff “self-reported nausea, weakness, and
dizziness commencing five days prior and lower abdominal pain” on July 5, 2013. (Id.) On July
19, 2013, Dr. Antony noted that Plaintiff self-reported “[l]ow back pain radiating to both legs [and
p]elvic pain.” (Id.) He also noted that Plaintiff showed symptoms of spinal stenosis, hypertension,
hypothyroidism, and hypercholesterolemia. He prescribed Norco and Flexeril. (Id.) On August 9,
2013, Dr. Antony prescribed Plaintiff an increased dosage of Synthroid for the treatment of
hypothyroidism. (Id.) Lastly, Dr. Antony’s notes from a September 24, 2013 office visit show that
Plaintiff complained of lumbar radicular pain. (Id.)
Plaintiff visited gynecologist, Dr. Cheryl Wolfe (“Dr. Wolfe”) on July 10, 2013. Treatment
notes from that visit show that Plaintiff complained that she had been experiencing pelvic pain for
two to three weeks. (Id.) Plaintiff told Dr. Wolfe that she learned she had an ovarian cyst during
an emergency room visit the prior weekend. (Id.) A July 12, 2013 MRI of Plaintiff’s pelvis
revealed a small non-enhancing left ovarian cyst, normal appearance of the uterus. (Id.) Dr. Wolfe
did not impose any restrictions or limitations on Plaintiff. (Id.)
Dr. Javad Hekmatpanah, M.D. FACS, FAAN (“Dr. Hekmatpanah”), a neurosurgeon,
examined Plaintiff and reported that:
On examination, [Plaintiff] is able to walk but does so cautiously.
[Plaintiff] is able to lie down on the examining table and turn from
side to side, but she does that with some discomfort. Leg raise is
limited on the right side. Unable to raise her leg straight but when
[Plaintiff] bends it she can. On the left side, [Plaintiff] could raise
her leg to about 90 degrees. The quadriceps muscles are strong on
both sides. The flexion and extension of the knees is strong. Flexion
and extension are strong. Reflexes are hypoactive. [Plaintiff] has
decreased sensation on the lateral side of her right leg and lateral
side of the thigh on the right side. The sensation on the buttocks is
normal. [Plaintiff] indicates pain in the lower lumbar area.
Dr. Hekmatpanah also noted that Plaintiff did not exhibit any palpable mass in her abdomen, had
normal skin color, and no swelling of the extremities. (Id.)
On November 22, 2013, Plaintiff’s total disability claim was reviewed by a multidisciplinary board of medical professionals including: Paula Newman (disability benefits
specialist), Kim S. Walker (vocational rehabilitation consultant), Allison Trelegan, RN, BSN
(clinical consultant), Dr. Collins (physician consultant), and Patty Holmquist (claims director).
(Id.). The review board recommended contacting Plaintiff’s primary physician, Dr. Antony, to
clarify his opinion regarding Plaintiff’s restrictions and limitations. (Id.)
Based on the review board’s recommendation, on December 6, 2013, Defendant’s
physician consultant, Dr. Edward T. Collins, DO (“Dr. Collins”), a board certified psychiatrist and
neurologist, contacted Dr. Antony. (Id.) In his correspondence to Dr. Antony, Dr. Collins stated
that he believed Plaintiff was capable of performing the full-time demands of her position as a
legal secretary. (Id.) Dr. Antony disagreed with Dr. Collins’s assessment and advised Defendant
to refer the questionnaire regarding Plaintiff’s functional capacity to Plaintiff’s neurosurgeon, Dr.
Hekmatpanah, which Dr. Collins did. (Id.) Dr. Hekmatpanah, however, did not respond to
Defendant’s request for his opinion, nor did he otherwise impose any restrictions and/or limitations
on Plaintiff. (SUMF ¶ 40.)
On January 2, 2014, Dr. Collins reviewed the administrative record and issued a report in
which he concluded that “[t]he medical records do not document evidence of physical findings,
diagnostic evaluations, treatment decisions, or other indicators that the claimant was precluded
from performing the use of up to 10 lbs of force occasionally, primarily seated with brief periods
of stand and/or walk from 7/1/13 through 9/28/13 and beyond.” (Id.)
Defendant referred the matter to Joseph Sentef, M.D., M.B.A. (“Dr. Sentef”), to assess the
conflicting opinions of Defendant’s reviewing physician, Dr. Collins, and Plaintiff’s attending
physician, Dr. Antony, and issue an independent analysis of the records. (Id.) Upon review of the
administrative file, Dr. Sentef concluded that Plaintiff “would be able [to] perform a full-time
sedentary occupation as documented by [Dr. Collins].” (Id.)
Plaintiff began a course of physical therapy on September 16, 2013 at Advocate Christ
Medical Center (“Medical Center”). (Id.) On February 11, 2014, Dr. Collins and Dr. Sentef
reviewed the Medical Center’s records regarding Plaintiff’s physical therapy and each prepared
addendum reports therefrom. Neither Dr. Collins nor Dr. Sentef changed their previous opinion
that Plaintiff was not disabled as defined by the Policy. (Id.) On February 13, 2014, Defendant’s
Quality Compliance Consultant, Bethany Emery, reviewed Plaintiff’s claim and the administrative
record, and concluded that Plaintiff would be able to sufficiently perform her occupation. (Id.)
Thereafter, on February 14, 2014, Defendant informed Plaintiff of its determination that she was
not disabled as defined by the Policy, and is therefore ineligible for long-term disability benefits.
Defendant cited the opinions of Dr. Collins, Dr. Sentef, and Bethany Emery as the basis for
denying Plaintiff’s claim. (Id.)
On April 23, 2014, Plaintiff, with the assistance of counsel, appealed Defendant’s initial
claim denial. (Id.) In support of her appeal, Plaintiff submitted an April 8, 2014 MRI of her lumbar
spine. (Id.) The MRI report indicated the following:
Multilevel degenerative disk disease resulting in severe central canal
stenosis at L4-5 and multilevel neural frontal narrowing. Severe
facet degenerative disease at L5-S1 with surrounding inflammation
demonstrated on sagittal STIR images.
On September 2, 2014, Nurse Angela Malan-Elzawahry, R.N. (“Nurse Malan-Elzawahry”)
issued a medical review report. (Id.) After detailing Plaintiff’s medical and treatment history,
Nurse Malan-Elzawahry reported that the conditions noted in Plaintiff’s medical history are “stable
with treatment and have not been noted in association with active symptoms or [restrictions and
limitations].” (Id.) Then, on September 3, 2014, neurological surgeon Charles Sternbergh, M.D.
(“Dr. Sternbergh”) issued a report in which he too concluded that Plaintiff could sufficiently
perform her occupational duties because it involves mostly sitting, “which is tolerated well by
most patients with lumbar stenosis.” (Id.) In addition to these two reports, Defendant sought the
opinion of G. Shannon O’Kelley, M. Ed., CRC, a senior vocational rehabilitation consultant.
O’Kelley concluded that Plaintiff can perform the “material and substantial duties of [her]
occupation . . . with the restrictions and limitations presented.” (Id.)
On September 12, 2014, Defendant issued its final determination denying Plaintiff’s appeal
claim for total disability benefits. (Id.) Defendant’s final determination letter identifies all of the
evidence presented in the administrative record. The letter also explains how the evidence was
reviewed and considered. (Id.) Through a motion for summary judgment, Plaintiff now seeks an
award of total disability benefits under the Policy from this Court pursuant to 29 U.S.C. § 1132.
(See ECF No. 11.) Defendant opposes the motion. Defendant also moves for summary judgment
on its denial of Plaintiff’s disability benefits claim. (See ECF No. 10.)
a. Summary Judgment
Summary judgment is appropriate “if the movant shows that there is no genuine dispute as
to any material fact and the movant is entitled to judgment as a matter of law.” Fed. R. Civ. P.
56(a). The “mere existence of some alleged factual dispute between the parties will not defeat an
otherwise properly supported motion for summary judgment; the requirement is that there be no
genuine issue of material fact.” Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 247-48 (1986). A
fact is only “material” for purposes of a summary judgment motion if a dispute over that fact
“might affect the outcome of the suit under the governing law.” Id. at 248. A dispute about a
material fact is “genuine” if “the evidence is such that a reasonable jury could return a verdict for
the nonmoving party.” Id. The dispute is not genuine if it merely involves “some metaphysical
doubt as to the material facts.” Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574,
Not every issue of fact will be sufficient to defeat a motion for summary judgment; issues
of fact are genuine “if the evidence is such that a reasonable jury could return a verdict for the
nonmoving party.” Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). Further, the
nonmoving party cannot rest upon mere allegations; he must present actual evidence that creates
a genuine issue of material fact. See Fed. R. Civ. P. 56(e); Anderson, 477 U.S. at 249 (citing First
Nat’l Bank v. Cities Serv. Co., 391 U.S. 253, 290 (1968)). In conducting a review of the facts, the
non-moving party is entitled to all reasonable inferences and the record is construed in the light
most favorable to that party. Hip Heightened Indep. & Progress, Inc. v. Port Auth. of New York &
New Jersey, 693 F.3d 345, 351 (3d Cir. 2012). Accordingly, it is not the Court’s role to make
findings of fact, but to analyze the facts presented and determine if a reasonable jury could return
a verdict for the nonmoving party. See Brooks, 204 F.3d at 105 n. 5 (citing Anderson, 477 U.S. at
249); Big Apple BMW v. BMW of N. Am., Inc., 974 F.2d 1358, 1363 (3d Cir. 1992).
b. Standard of Review for Denial of a Claim for Disability Benefits under ERISA
The denial of a claim for disability benefits, if challenged under 29 U.S.C. § 1132(a)(1)(B)
(“ERISA”), is reviewed de novo “unless the benefit plan gives the administrator or fiduciary
discretionary authority to determine eligibility for benefits or to construe the terms of the plan.”
Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). Where the ERISA policy terms
bestow discretionary authority upon the policy administrator to determine benefits eligibility, the
decision to deny benefits must be upheld unless it is “arbitrary and capricious.” Fleisher v.
Standard Ins. Co., 679 F.3d 116, 120–21 (3d Cir. 2012). “Likewise, when an administrator acts
pursuant to her authority to construe the terms of the plan . . . or to act as a finder of facts . . . [the
Court will] also apply the arbitrary and capricious standard when reviewing those interpretations
and factual findings.” Id. (citations omitted.) The Court may overrule an administrator’s decision
as arbitrary and capricious if it is without reason, unsupported by substantial evidence or erroneous
as a matter of law. Miller v. American Airlines, Inc., 632 F.3d 837, 845 (3d Cir. 2011) (quoting
Abnathya v. Hoffman-Law Roche, Inc., 2 F.3d 40, 45 (3d Cir. 1993)).
The Policy at issue explicitly states that “[w]hen making a benefit determination under the
[P]olicy, [Defendant] has discretionary authority to determine  eligibility for benefits and to
interpret the terms and provisions of the [P]olicy.” Hern Decl. Ex. A.
As earlier stated, where the ERISA policy leaves the determination of benefits eligibility
to the policy administrator’s sound discretion, the decision to deny benefits must be upheld unless
it is “arbitrary and capricious.” Fleisher, 679 F.3d at 120–21. An administrator’s decision will be
deemed arbitrary and capricious if it is without reason, unsupported by substantial evidence or
erroneous as a matter of law. Miller, 632 F.3d at 845.
In reviewing a policy administrator’s denial of benefits, the Court weighs both structural
and procedural factors. Estate of Schwing v. The Lilly Health Plan, 562 F.3d 522, 525–26 (3d Cir.
2009) (citing Metropolitan Life Ins. Co. v. Glenn, 54 U.S. 105 (2008)); Miller, 632 F.3d at 844–
45. The structural inquiry focuses on whether a conflict of interest existed. Id. (quoting Post v.
Hartford Ins. Co., 501 F.3d 154, 162 (3d Cir. 2007); Estate of Schwing, 562 F.3d at 526 (“[I]t is
clear that courts should take account of several different considerations of which a conflict of
interest is one, and reach a result by weighing all of those considerations.”). “The procedural
inquiry focuses on how the administrator treated the particular claimant.” Post, 501 F.3d at 162.
The parties agree that a conflict of interest exists here. See Defendant’s Motion for
Summary Judgment (“Def.’s Mot. Summ. J.”), p. 13; Plaintiff’s Motion for Summary Judgment
(“Pl.’s Mot. Summ. J.”), p. 9. In Glenn, the Supreme Court held that there is a presumed conflict
of interest where an insurance company both reviews claims and pays out benefits. 554 U.S. at
106. In the case at bar, because Defendant, an insurance company, issued the subject policy and
serves as its administrator, a conflict of interest exists. The existence of a conflict of interest,
however, is not dispositive. Estate of Schwing, 562 F.3d at 525–27. The significance of the conflict
of interest factor depends on the circumstances of each particular case; as such, a policy
administrator-insurance company may still be found to not have abused its discretion, even though
it issued the subject policy. Glenn, 554 U.S. at 106.
Next, the Court reviews various procedural factors present in the administrator’s decisionmaking process to determine if the conclusion was arbitrary and capricious. Miller, 632 F.3d at
845. “The procedural inquiry focuses on how the administrator treated the particular claimant.”
Post, 501 F.3d at 162. The factors to be weighed by the Court include:
a reversal of a benefits determination without additional
evidence, (2) a disregard of opinions previously relied upon, (3)
a self-serving selectivity in the use of evidence or reliance on
self-serving paper reviews of medical files, (4) a reliance on the
opinions of non-treating physicians over treating physicians
without explanation, (5) a reliance on inadequate information
or incomplete investigation, (6) failure to comply with the
notice requirements of Section 504 of ERISA, (7) failure to
analyze all relevant diagnoses, and (8) failure to consider
plaintiff’s ability to perform actual job requirements.
Kosiba v. Merck & Co., 2011 WL 843927, at *10 (D.N.J. March 7, 2011) (citing Miller, 632 F.3d
at 849–56); see generally Simon v. Prudential Ins. Co. of America, 2011 WL 2971203 (D.N.J. July
20, 2011). Here, despite the existence of a conflict of interest, this Court finds that Defendant’s
denial of Plaintiff’s total disability claim was neither arbitrary nor capricious.
The first of the procedural factors, whether Defendant reversed a benefits determination
without additional evidence, weighs in neither party’s favor as Plaintiff’s disability claim was
never approved in the first instance.
The second factor weighs in Defendant’s favor, as Defendant did not disregard in a later
review, an opinion it previously relied upon. In fact, throughout its review of Plaintiff’s disability
claim, Defendant steadfastly rejected Dr. Antony’s opinion regarding Plaintiff’s disability, which
is the sole medical opinion that unequivocally supports Plaintiff’s disability claim. By contrast,
Defendant obtained countervailing opinions from numerous medical professionals, some of whom
examined Plaintiff personally, to support its position. Critical to the evaluation of this factor, the
Supreme Court has held that:
Plan administrators, of course, may not arbitrarily refuse to credit a
claimant’s reliable evidence, including the opinions of a treating
physician. But, we hold, 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
Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003). Therefore, this factor weighs
in Defendant’s favor.
The third factor, whether Defendant placed undue reliance on self-serving paper reviews
of medical records, weighs in Defendant’s favor as there is ample evidence that Defendant relied
on opinions issued by both examining and consulting physicians in equal measure. Furthermore,
the Court is not mandated, nor are plan administrators required, to accord controlling weight to the
opinions of medical professionals who personally examined and treated Plaintiff. See generally
Black and Decker, 538 U.S. 822 (holding that ERISA does not require a Plan Administrator to per
se accord more weight to the opinion of a treating physician).
The fourth factor, which probes whether the Plan Administrator relied on the opinions of
non-treating physicians over treating physicians without explanation, skews in Defendant’s favor. 1
It is clear on the record that Defendant’s rejection of Dr. Antony’s opinion was adequately
explained and sufficiently supported with countervailing assessments and opinions of other
physicians who examined Plaintiff. For instance, in adjudicating Plaintiff’s appeal, Defendant
reviewed the analyses and conclusions of a nurse, a neurological surgeon, and a senior vocational
rehabilitation consultant. Each of these medically certified consultants independently concluded
that Plaintiff was able to perform her occupational duties and does not qualify for disability
Similarly, in reviewing Plaintiff’s initial claim, to resolve the conflicting opinions of
Plaintiff’s treating physician and Defendant’s physician consultant, Defendant referred the matter
Plaintiff does not address factors five through eight, namely, (5) reliance on inadequate information or incomplete
investigation, (6) failure to comply with the notice requirements of Section 504 of ERISA, (7) failure to analyze all
relevant diagnoses, and (8) failure to consider plaintiff’s ability to perform actual job requirements, nor does she
contend that they weigh in her favor. This Court does not find these factors probative to the resolution of this matter
and will not discuss them in further detail.
to Dr. Sentef for an independent review. Dr. Sentef determined that Plaintiff could perform her
occupational duties as a legal secretary. Notwithstanding, the Plan Administrator’s finding that
Dr. Antony’s opinion was unpersuasive in light of the totality of the medical evidence does not
necessarily imply that Defendant improperly valued the opinions of non-treating physicians over
that of Dr. Antony. See Stratton v. E.I. DuPont De Nemours & Co., 363 F.3d 250, 257–58 (3d Cir.
2004) (holding that where the professional disagreement between the review board’s consulting
physicians and claimant’s physicians appears grounded in differing conclusions based on a full
review of the medical record, there is no reason to give more weight to the treating physician’s
Lastly, Plaintiff’s reliance on Stith v. Prudential Ins. Co. of America is misplaced. 356
F.Supp.2d 431 (2005). In Stith, the defendant relied solely on the conclusion of one physician
consultant who disregarded the claimant’s medical records and the opinions of the claimant’s
treating physicians. Stith, 356 F.Supp.2d at 439–41. Here, Defendant based its decision upon the
substantiated conclusions of multiple physicians and consultants while Plaintiff relied upon the
opinion of one treating physician.
In view of Defendant’s full and fair review of Plaintiff’s initial disability claim and appeal
from the denial of that claim, this Court concludes that Defendant’s decision to deny Plaintiff’s
claim for disability benefits is supported by objective and credible medical evidence, and is neither
arbitrary nor capricious. See Bluman v. Plan Adm’r and Trustees for CAN’s Integrated Disability
Program, 491 Fed.Appx. 312, 315–16 (3d Cir. 2012). As such, Plaintiff’s motion for summary
judgment is DENIED and summary judgment is GRANTED in Defendant’s favor.
For the reasons discussed herein, Plaintiff’s motion for summary judgment (ECF No. 11)
is DENIED and Defendant’s motion for summary judgment (ECF No. 10) is GRANTED. An
appropriate order will be filed with this Opinion.
s/ Susan D. Wigenton
SUSAN D. WIGENTON
UNITED STATES DISTRICT JUDGE
Steven C. Mannion, U.S.M.J.
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