CONTI, District Judge.
Pending before the court are cross-motions for summary judgment filed by plaintiff
Haisley was born on April 13, 1951. (ECF No. 1 ¶ 7.) She was employed by PNC between May 3, 1971, and June 22, 2007. (Administrative Record ("AR") AR0034.) As of June 22, 2007, she was working as a Collections/Recovery Team Manager. (ECF No. 104 ¶ 1.) In this capacity, Haisley managed a team of adjustors responsible for collecting on accounts that had been delinquent for thirty days or more. (ECF No. 96 ¶ 2.) Her monthly salary was $4,708.33. (Id. ¶ 1.)
Haisley's mother died on June 28, 2007. (AR0027.) Haisley applied for short-term disability ("STD") benefits. (ECF No. 96 ¶ 18.) This request was based, at least in part, on depression and anxiety suffered by Haisley as a result of her mother's death. (Id.) At that time, Haisley was also suffering from peripheral neuropathy. (AR0027-29.) PNC approved Haisley's request for STD benefits for a full period commencing on July 5, 2007, and concluding on October 2, 2007. (ECF No. 96 ¶¶ 18-19.) She received STD benefits at the rate of 100% of her monthly salary. (Id. ¶ 19.)
The Plan provides full-time, salaried employees who are unable to work for more than ninety days with long-term disability ("LTD") benefits of up to 70% of their base salaries. (ECF No. 104 ¶ 2.) Haisley participated in the Plan because of her employment with PNC. (Id. ¶ 1.) PNC established a "Group Benefits Trust" to fund LTD disability payments made pursuant to the Plan. (AR0296-97.) As the Plan Administrator, PNC has the power "[t]o determine the eligibility and status of any [e]mployee with respect to Plan participation." (AR0233, AR0245.) PNC administers and funds the Plan as follows:
(Kerry A. Allen, Aff. Sept. 11, 2009, AR0334.)
(AR0234.) The Plan contains a "Mental Illness Limitation," which provides:
(AR0242.) The term "mental illness," as used in the language of the Plan, means "mental, nervous or emotional diseases or disorders of any type." (AR0243.)
At the conclusion of her STD period, Haisley believed that she was still incapable of performing the duties of her job. (ECF No. 96 ¶¶ 20-21.) She applied for LTD benefits on October 11, 2007. (AR0053-58.) On the application, Haisley indicated that she was disabled due to depression, anxiety and neuropathy. (AR0053.) She reported that she first noticed her symptoms on May 2, 2007, and that her last day of work was June 22, 2007. (Id.)
In support of her claim, Haisley submitted written reports which were supplied by her treating health-care providers. (ECF No. 96 ¶¶ 22-26.) Included with these reports were the results of nerve conduction studies which were conducted on August 15, 2007. (AR0075-76, AR0086-87.) These studies showed Haisley to be suffering from "diffuse peripheral neuropathy" that was deemed to be of "mild to moderate
In response to an inquiry from Graham dated October 19, 2007, Dr. Dushan Majkic, Haisley's primary care physician, reported that Haisley was suffering from both peripheral neuropathy and a relapse of major depression. (AR0084.) Dr. Majkic opined that Haisley was unable to concentrate because of the side effects of her medication, she could not sit or stand for prolonged periods of time, and her prognosis for returning to gainful employment was "undetermined." (Id.)
In a letter to Graham dated November 9, 2007, Dr. Sidney W. White, Haisley's clinical psychologist, stated that he began to treat Haisley on July 17, 2007. (AR0088.) According to Dr. White, the "immediate precipitant" of Haisley's symptoms was the death of her mother on June 28, 2007. (AR0089.) In the letter, Dr. White explained:
(AR0090.) Dr. White expressed his willingness to provide further information in connection with Haisley's LTD claim. (AR0091.)
On November 30, 2007, Graham sent Haisley a letter stating that Sedgwick approved her application for LTD benefits.
In a letter dated December 20, 2007, Graham informed Haisley that her claim for LTD benefits had been "formally suspended" as of December 1, 2007, due to "a lack of current treatment information on file supportive of continuing total disability." (AR0100.) In that letter Graham stated that Dr. White's report of November 9, 2007, had not been supported by treatment records or documentation concerning Haisley's medications. (AR0101.) Haisley was given until January 17, 2008, to provide Sedgwick with more detailed information about her treatment regimen. (Id.)
Haisley was experiencing discomfort in both her lower extremities. (AR0102.) On December 27, 2007, she was examined by Dr. Richard B. Kasdan, a neurologist. (Id.) Suspecting that Haisley's problems had a "lumbar source," Dr. Kasdan recommended that she undergo a magnetic resonance imaging ("MRI") scan. (Id.) Although the MRI scan revealed that Haisley had experienced "minor disc changes," it showed "nothing to explain her leg numbness." (AR0103.)
Dr. White responded to the suspension of Haisley's LTD benefits in a letter to Graham dated December 31, 2007. (AR0094-95.) He claimed that Graham "misrepresented" the contents of his earlier report. (AR0094.) After providing more specific information about Haisley's medication regimen, Dr. White wrote:
(AR0095.) Haisley provided Sedgwick with treatment records from Dr. Majkic and Dr. Kasdan. (ECF No. 96 ¶¶ 31-34.)
On February 29, 2008, Sedgwick denied Haisley's application for LTD benefits.
(AR0134.) In the letter Graham stated that Dr. Pemmaraju unsuccessfully attempted to conduct teleconferences with Dr. Kasdan on February 12, 2008, and February 14, 2008. (AR0135.) With respect to Dr. Pemmaraju's findings, Graham explained:
(AR0135.)
Since Sedgwick concluded Haisley had erroneously received LTD benefits for a period of time commencing on October 3, 2007, and ending on November 30, 2007, Haisley was instructed to reimburse PNC in the amount of $6,154.60 within thirty days. (Id.) Haisley was informed that she had 180 days to appeal Sedgwick's decision denying her application. (Id.) Haisley appealed Sedgwick's denial of her LTD claim by means of a letter authored by her counsel, Steven F. Kessler ("Kessler"), on May 7, 2008. (AR0142-44.) Enclosed with the appeal letter were additional documents that were supplied by Haisley's healthcare providers. (ECF No. 96 ¶ 50.) The submission included several pages of treatment notes from Dr. Majkic's office. (AR0146-79.) In a letter to Kessler dated March 27, 2008, Dr. Kasdan stated that Haisley was "still disabled from her job" due to "multifocal motor neuropathy." (AR0145.) Dr. Kasdan remarked that this condition was very difficult to diagnose, and explained why he had not previously made this diagnosis with respect to Haisley. (Id.) His opinion was based, at least in part, on nerve conduction studies of Haisley performed on February 7, 2008. (AR0182-83.) This information was forwarded to Sedgwick in connection with Haisley's appeal. (ECF No. 96 ¶ 50.) Sedgwick was provided with documentary evidence establishing that Haisley was awarded social security disability benefits on April 20, 2008. (Id.)
(ECF No. 63, Ex. K, BAH000378-79.) Dr. White concluded the letter by remarking that the denial of Haisley's claim only aggravated her condition, and a "positive resolution" was warranted. (ECF No. 63, Ex. K, BAH000379.) The parties vigorously dispute whether Dr. White's letter was forwarded to Sedgwick in connection with Haisley's appeal. (ECF No. 96 ¶¶ 51-69.) While Haisley contends that Kessler forwarded the letter to Sedgwick when the appeal was filed, Sedgwick maintains that the letter was not included within Haisley's submission. (Id. 151.)
Haisley's appeal was reviewed by Dr. Steven M. Arbit, a physiatrist, and Dr. Marcus J. Goldman, a psychiatrist. (ECF No. 63, Ex. K, BAH000193-200.) Dr. Arbit conducted teleconferences with Dr. Kasdan and Dr. Majkic respectively, on June 3, 2008, and June 4, 2008. (ECF No. 63, Ex. K, BAH000193.) Dr. Kasdan expressed the view that Haisley's neuropathy would inhibit her ability to work. (ECF No. 63, Ex. K, BAH000194.) In a written report dated June 6, 2008, Dr. Arbit described his teleconference with Dr. Majkic as follows:
On June 4, 2008, Dr. Goldman spoke with Dr. White. (ECF No. 63, Ex. K, BAH000197.) Dr. White claimed that Haisley "would not be able to perform the [] work duties associated with her prior job due to depression and fatigability." (Id.) After conferring with Dr. White, Dr. Goldman determined that Haisley's impairments would not preclude her return to work. (ECF No. 63, Ex. K, BAH000199.) He stated that Dr. White's treatment records did "not contain sufficient objective or observable data to establish significant psychopathology that would preclude worker functionality." (ECF No. 63, Ex. K, BAH000200.) Dr. Goldman noted that there was "no quantified data" to support a finding that Haisley suffered from "significant cognitive dysfunction." (Id.)
In a letter dated June 23, 2008, Sedgwick's appeals specialist Tim A. Prater ("Prater") informed Kessler that Sedgwick decided to uphold its prior decision denying Haisley's claim. (AR0220-23.) This determination was based primarily on the recommendations that had been made by Dr. Arbit and Dr. Goldman. (Id.) Prater's letter stated that no further information would be considered in connection with Haisley's claim, and that the administrative record involving that claim was closed. (AR0222.)
Haisley commenced this action on October 16, 2008, alleging violations of the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001 et seq. (ECF No. 1.) On July 7, 2010, the parties filed cross-motions for summary judgment pursuant to Federal Rule of Civil Procedure 56. (ECF Nos. 56 & 59.) These motions are the subject of this memorandum opinion.
Since Haisley argues that she was wrongfully denied "benefits due" to her under existing Plan provisions, her claims are properly grounded in 29 U.S.C. § 1132(a)(1)(B). Eichorn v. AT&T Corp., 484 F.3d 644, 651, 653 (3d Cir.2007). The standards applicable to claims arising under this statutory provision were articulated by the United States Supreme Court in Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989), Metropolitan Life Insurance Co. v. Glenn, 554 U.S. 105, 128 S.Ct. 2343, 171 L.Ed.2d 299 (2008), and Conkright v. Frommert, ___ U.S. ___, 130 S.Ct. 1640, 176 L.Ed.2d 469 (2010).
In Firestone Tire, the Supreme Court observed that the ERISA did not contain specific language establishing a judicial standard of review for claims arising under § 1132(a)(1)(B). Firestone Tire, 489 U.S. at 108-09, 109 S.Ct. 948. Turning to principles of trust law, the Supreme Court explained that while "a deferential standard of review" was appropriate when a trustee exercised "discretionary powers," de novo review of eligibility determinations was warranted when the particular plan at issue did not provide the relevant employer or administrator with "discretionary or final authority to construe uncertain terms." Id. at 110-13, 109 S.Ct. 948. It was determined that, in the absence of specific language according deference to determinations made by a plan administrator, the de novo standard of review would apply "regardless of whether the plan at issue [was] funded or unfunded and regardless of whether the administrator or fiduciary [was] operating under a possible or actual conflict of interest." Id. at 115,
In Glenn, the Supreme Court clarified that a "conflict of interest" exists where "a plan administrator both evaluates claims for benefits and pays benefits claims." Glenn, 554 U.S. at 112, 128 S.Ct. 2343. The existence of such a conflict, however, does not deprive a plan administrator of whatever discretionary authority that it may possess under Firestone Tire. Instead, the conflict is merely one factor relevant to a determination with respect to whether an abuse of discretion has occurred. Id. at 115-17, 128 S.Ct. 2343. The importance of a conflict as a factor depends upon whether the factual circumstances of the case at issue suggest that the conflict actually affected the challenged administrative decision, or upon whether the relevant plan administrator "has a history of biased claims administration." Id. at 117, 128 S.Ct. 2343. The Supreme Court opined that a conflict "should prove less important (perhaps to the vanishing point) where the administrator has taken active steps to reduce potential bias and to promote accuracy, for example, by walling off claims administrators from those interested in firm finances, or by imposing management checks that penalize inaccurate decisionmaking irrespective of whom the inaccuracy benefits." Id.
These principles were discussed further in Conkright, in which the Supreme Court declared that a single mistake by a plan administrator cannot serve as a basis for depriving that administrator of deference that would otherwise be warranted under Firestone Tire. Conkright, 130 S.Ct. at 1644-47. It was noted that deference to the findings of a plan administrator, where warranted under the terms of the plan in question, promoted the goals of "efficiency," "predictability" and "uniformity." Id. at 1649. Deference promotes efficiency by encouraging the resolution of benefits disputes by means of "internal grievance procedures," rather than by means of "costly litigation." Id. Predictability is ensured by standards allowing an employer to "rely on the expertise of the plan administrator rather than worry about unexpected and inaccurate plan interpretations that might result from de novo judicial review." Id. Uniformity is secured when an employer is able to "avoid a patchwork of different interpretations of a plan" that covers multiple employees in several different jurisdictions. Id. ERISA does not affirmatively require employers to establish employee benefit plans, nor does it mandate what types of benefits must be provided by employers who choose to create such plans. Lockheed Corp. v. Spink, 517 U.S. 882, 887, 116 S.Ct. 1783, 135 L.Ed.2d 153 (1996). It should not be construed in such a way as to "lead those employers with existing plans to reduce benefits," or to discourage employers without such plans from adopting them in the first place. Fort Halifax Packing Co. v. Coyne, 482 U.S. 1, 11, 107 S.Ct. 2211, 96 L.Ed.2d 1 (1987). Instead, it should be interpreted in light of its objectives of ensuring the enforcement of employees' rights under existing employee benefit plans and encouraging employers to create additional employee benefit plans. Aetna Health, Inc. v. Davila, 542 U.S. 200, 215, 124 S.Ct. 2488, 159 L.Ed.2d 312 (2004).
Haisley brings her claims pursuant to 29 U.S.C. § 1132(a)(1)(B), which permits
The statutory language most relevant to the court's analysis is codified at 29 U.S.C. § 1132(d), which provides:
29 U.S.C. § 1132(d). There is no question that, under this statutory language, the Plan is a proper defendant in this action. It is also clear that an entity or "person" other than a plan can be liable for a "money judgment" under certain circumstances.
Under the ERISA, a fiduciary who breaches a fiduciary duty in connection with a plan may "be personally liable to make good to such plan any losses to the plan resulting from each such breach, and to restore to such plan any profits of such
In this case, Haisley is seeking benefits solely from the assets of the Plan. (ECF No. 1 at 9-10.) She is not pursuing relief against Sedgwick and PNC in their individual capacities. Haisley's claims against Sedgwick and PNC are against them in their official capacities. Because a judgment in Haisley's favor would be enforceable only against the assets of the Plan itself, Sedgwick and PNC are only nominal defendants. Patrick v. Verizon Servs. Corp., Civil Action No. 07-766, 2009 WL 2043914, at *16 (W.D.Pa. July 8, 2009) (recognizing an official-capacity claim against a plan administrator as being "essentially a claim that is only nominally asserted against the plan administrator and is, for all practical purposes, a claim against the relevant plan itself").
The exercise of control over the administration of benefits is the "defining feature" of a proper defendant in an action brought under § 1132(a)(1)(B). Evans v. Emp. Benefit Plan, 311 Fed.Appx. 556, 558 (3d Cir.2009). It is undisputed that Sedgwick was responsible for denying Haisley's claim at both the initial and appellate stages of the administrative process. (AR0133-36, AR0220-23.) The plain language of the Plan designates PNC as the "Plan Administrator," thereby giving PNC the power "[t]o determine the eligibility and status of any [e]mployee with respect to Plan participation." (AR0233, AR0245.) As the Plan Administrator, PNC obviously plays some role in administering the Plan. Curcio v. John Hancock Mut. Life Ins. Co., 33 F.3d 226, 234 (3d Cir.1994). Consequently, Haisley can pursue official-capacity claims against both Sedgwick and PNC.
Haisley seeks both an order requiring the defendants to pay all LTD benefits owed to her under the terms of the Plan and a declaration clarifying her entitlement to future benefits under the Plan. (ECF No. 1 at 9-10.)
The first step in the court's analysis is to determine whether the decisions of Sedgwick and PNC are entitled to deference under the terms of the Plan. Firestone Tire, 489 U.S. at 115, 109 S.Ct. 948. As the Plan Administrator, PNC is accorded the powers "[t]o interpret the Plan" and "[t]o determine the eligibility and status of any [e]mployee with respect to Plan participation." (AR0233, AR0245.) The Plan expressly provides that "[t]he Administrator shall have complete and sole discretion with regard to each of [these] powers," and that "no decision of the Administrator shall be overturned unless the decision is arbitrary and capricious." (AR0245.) Pursuant to the terms of the Service Agreement, Sedgwick is "responsible for claims administration for any employee applying for LTD [benefits]" under the Plan. (AR0271.) Given the clear and unambiguous language of the Plan, the court cannot review the challenged determination de novo. Firestone Tire, 489 U.S. at 115, 109 S.Ct. 948. Instead, the dispositive inquiry is whether the decision denying Haisley's application for LTD benefits was "arbitrary and capricious."
Defendants argue that Haisley's claims are time-barred under the terms of the Plan. (ECF No. 84 at 16-18.) They base their argument on language stating that "[a]ny claim for benefits under the Plan must be filed with the Claims Administrator not later than 90 days following the date Total Disability begins." (AR0246.) Haisley applied for LTD benefits on October 11, 2007. She listed May 2, 2007, as the first day that she had noticed her symptoms and June 22, 2007, as the last day that she had worked. Her STD benefit period commenced on July 5, 2007. Defendants contend that Haisley's claims cannot proceed, since she did not apply for LTD benefits within 90 days of July 5, 2007.
Haisley points out that the Plan contains an ambiguity concerning the timeliness of her application. Under the heading "Notice of Claim," the Plan provides:
(AR0245-46.) Haisley argues that this language when read with the language creating the ninety-day limitations period relied upon by defendants created an ambiguity, and that this ambiguity should result in a construction of the Plan language that is favorable to her. She contends that defendants waived the defense of untimeliness by failing to assert it during the course of the administrative proceedings. (ECF No. 88 at 12-13.)
Under the doctrine of contra proferentem, ambiguous provisions of insurance policies are generally construed in favor of the insured and against the insurer. Royal Ins. Co. of Am. v. KSI Trading Corp., 563 F.3d 68, 74 (3d Cir.2009). "The policy rationale underlying strict application of the doctrine is that because most insurance agreements are drafted by the insurance industry, they are essentially contracts of adhesion." Pittston Co. Ultramar Am. Ltd. v. Allianz Ins. Co., 124 F.3d 508, 520 (3d Cir.1997). Because the insurance company is typically the drafter of the ambiguous contractual language at issue, it must suffer any negative consequences stemming from its own failure to draft clear and unambiguous language. In Kunin v. Benefit Trust Life Insurance Co., 910 F.2d 534 (9th Cir.1990), the United States Court of Appeals for the Ninth Circuit explained:
Kunin, 910 F.2d at 540. Alluding to the doctrine of contra proferentem, Haisley asserts that the ambiguous portions of the Plan should be read in a manner that does not unfairly disadvantage LTD claimants, and that protects the contractually-defined benefits established by the Plan.
In Heasley v. Belden & Blake Corp., 2 F.3d 1249, 1257-58 (3d Cir.1993), the United States Court of Appeals for the Third Circuit held that the doctrine of contra proferentem should be applied where the language of a plan is ambiguous about whether the plan administrator has the type of discretion that would warrant deference under Firestone Tire. In other words, an ambiguity about whether a plan accords discretion to a plan administrator should ordinarily result in a determination that de novo review of the plan administrator's findings is required under the ERISA. Heasley, 2 F.3d at 1257-58. In the aftermath of Heasley, district courts within this circuit have expressed differing views about whether contra proferentem should be utilized as a vehicle for interpreting other types of plan provisions. Some courts have indicated that the doctrine should be applied to ambiguous plan terms whenever the relevant ambiguity cannot otherwise be satisfactorily resolved. Erbe v. Connecticut Gen. Life Ins. Co., 695 F.Supp.2d 232, 248 (W.D.Pa.2010); Cohen v. Standard Ins. Co., 155 F.Supp.2d 346, 354 n. 7 (E.D.Pa.2001). Other courts have determined that the application of contra proferentem is inappropriate where a plan grants a plan administrator discretion to interpret plan provisions, given the tension between the doctrine's preference for a construction favoring the claimant and the deference owed to the findings of the plan administrator under Firestone Tire. Fahringer v. Paul Revere Ins. Co., 317 F.Supp.2d 504, 519 (D.N.J.2003); Murdock v. Unum Provident Corp., 265 F.Supp.2d 539, 542 (W.D.Pa.2002); Friends Hosp. v. MetraHealth Serv. Corp., 9 F.Supp.2d 528, 531 (E.D.Pa.1998).
In this case, there is no need for the court to determine whether contra proferentem should be applied, or to otherwise resolve the ambiguity created by the different limitations periods referenced in the language of the Plan. Even if it is assumed that judicial deference to the findings of Sedgwick and PNC is appropriate, the ninety-day limitations period was not relied upon as a basis for denying Haisley's claim during the course of the administrative proceedings. Sedgwick initially approved Haisley's application for LTD benefits in a letter from Graham dated November 30, 2007. When Haisley's claim was later "suspended" as of December 1, 2007, "a lack of current treatment information on file supportive of continuing total disability" was given as the reason for the suspension. (AR0100.) Haisley was given until January 17, 2008, to submit additional information in support of her claim. The claim was formally denied on February 29, 2008, based on the opinions of Dr. Givens and Dr. Pemmaraju. On June 23, 2008, Haisley was told that the prior denial of her claim had been
Since "benefits determinations arise in many different contexts and circumstances," the factors to be considered from one case to the next are "varied and case-specific." Estate of Schwing v. Lilly Health Plan, 562 F.3d 522, 526 (3d Cir. 2009). "[A]ny one factor will act as a tiebreaker when the other factors are closely balanced, the degree of closeness necessary depending upon the tiebreaking factor's inherent or case-specific importance." Glenn, 554 U.S. at 117, 128 S.Ct. 2343. The court will consider all factors relevant to this case to determine whether defendants' decision to deny Haisley's claim on the basis of the existing record was arbitrary and capricious.
In a letter dated November 30, 2007, Graham informed Haisley that Sedgwick had "approved" her application for LTD benefits. The letter stated that Haisley would receive a check in the amount of $6,154.54 for a period of disability commencing on October 3, 2007, and ending on November 30, 2007. In that letter, Graham stated:
(ECF No. 63, Ex. K, BAH000127.) Although Haisley was informed that her "ongoing eligibility for benefits" would need to be verified in order for her to receive "future benefits payments," she was not told that the information that she had already provided was insufficient to establish her initial entitlement to LTD benefits.
On December 20, 2007, Sedgwick informed Haisley that it "suspended" her claim as of December 1, 2007, due to "a lack of current treatment information on file supportive of continuing total disability."
Another factor weighing in favor of Haisley is that she was never asked to undergo an independent medical examination. The Plan unambiguously provides the Plan Administrator with the authority to have a claimant examined by a physician "as often as reasonably required." (AR0246.) Where the plan at issue specifically provides a plan administrator with the authority to request an independent medical examination, the failure of the plan administrator to procure such an examination before denying a particular claim may "raise questions about the thoroughness and accuracy of the benefits determination." Calvert v. Firstar Fin., Inc., 409 F.3d 286, 295 (6th Cir.2005). Although the ERISA does not require a plan administrator to request that a claimant undergo a medical examination before denying his or her claim, the failure to procure such an examination may be unreasonable where the specific impairments or limitations at issue are not amenable to consideration by means of a file review. See Elliott v. Metro. Life Ins. Co., 473 F.3d 613, 621 (6th Cir.2006); Lamanna v. Special Agents Mut. Benefits Ass'n, 546 F.Supp.2d 261, 296 (W.D.Pa.2008).
Dr. Majkic, Dr. White and Dr. Kasdan all believed Haisley to be disabled. Haisley was not examined by Dr. Givens, Dr. Pemmaraju, Dr. Arbit or Dr. Goldman. Because Haisley's claim was based on a confluence of mental and physical impairments, it weighs against defendants for Sedgwick to place considerable weight on opinions expressed by medical professionals who never examined her. See Schwarzwaelder v. Merrill Lynch & Co., Inc., 606 F.Supp.2d 546, 559-60 (W.D.Pa. 2009). Unlike types of physicians who can
In the letter dated November 30, 2007, Graham informed Haisley that she needed to apply for social security disability benefits in order to avoid a reduction in the amount of LTD benefits that she was receiving. Haisley was awarded disability insurance benefits under Title II of the SSA on April 20, 2008. Information about the award was forwarded to Sedgwick in connection with Haisley's appeal. Haisley's receipt of Social Security disability benefits was not addressed in Sedgwick's denial letter of June 23, 2008.
In Glenn, the Supreme Court remarked that a plan administrator's failure to address a claimant's award of social security disability benefits in denying a claim "suggested procedural unreasonableness" under circumstances in which the plan administrator had itself encouraged the claimant to apply for such benefits. Glenn, 554 U.S. at 118, 128 S.Ct. 2343. This is another factor which weighs in favor of Haisley's argument that Sedgwick's treatment of her claim was arbitrary and capricious. The court acknowledges that the standards applicable to social security disability benefits are not the same as those applicable to LTD benefits under the Plan. While a social security disability claim must be evaluated under "a uniform set of federal criteria," "employers have large leeway to design disability and other welfare plans as they see fit." Black & Decker Disability Plan v. Nord, 538 U.S. 822, 833, 123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003). The SSA's standard for establishing the existence of a statutory disability is demanding. Title II of the SSA defines the term "disability" as the "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months."
The Supreme Court has consistently recognized that a plan administrator's conflict of interest constitutes a factor relevant to whether a decision denying a claimant's application for benefits is arbitrary and capricious. Glenn, 554 U.S. at 111, 128 S.Ct. 2343; Firestone Tire, 489 U.S. at 115, 109 S.Ct. 948. In Glenn, the Supreme Court clarified that such a conflict exists where a plan administrator "both evaluates claims for benefits and pays benefits claims." Glenn, 554 U.S. at 112, 128 S.Ct. 2343. PNC established a "Group Benefits Trust" to fund LTD disability payments made pursuant to the Plan. As the Plan Administrator, PNC has the power "[t]o determine the eligibility and status of any [e]mployee with respect to Plan participation." (AR0233, AR0245.) The Service Agreement delegates to Sedgwick the responsibility for administering LTD claims under the Plan. While the parties dispute the extent to which PNC exercises control over LTD benefits determinations, the record contains a declaration from Kerry A. Allen ("Allen"), PNC's Vice President and Benefits Manager of Corporate Retirement Plans, explaining the manner in which PNC finances and administers the Plan. (AR0333-34.) In her declaration, which was signed on September 11, 2009, Allen explained:
(AR0334.) Haisley points to no evidence which directly contradicts Allen's declaration.
Since PNC both funds the Plan and serves as the Plan Administrator, a conflict of interest exists. Glenn, 554 U.S. at 115, 128 S.Ct. 2343. The significance of this conflict, however, is in dispute. Id. In Post v. Hartford Insurance Co., 501 F.3d 154 (3d Cir.2007), the United States Court of Appeals for the Third Circuit expressed "particular concern" about plans that are "funded on a case-by-case basis" and plans that are "funded and administered by an outside insurer." Post, 501 F.3d at 163. Where an administrator "pays claims out of its operating budget" on a case-by-case basis "rather than from segregated monies that the employer sets aside according to an actuarial formula," "each dollar paid out is a dollar out of the administrator's pocket," thereby giving the administrator "a financial incentive to deny claims." Id. "This concern is compounded when it is an outside insurer, rather than the employer, that funds and administers the plan," since an employer which is "a step removed from the process" is not likely to suffer "the full effects of employee dissatisfaction" resulting from poor claims handling. Id. at 163-64. Allen declared that PNC makes "fixed, periodic cash contributions" to the Group Benefits Trust, making it clear that LTD claims are not funded on a case-by-case basis. (AR0334.) She clarified that the Plan is not insured by a third party. (Id.) Thus, the specific concerns expressed by the court of appeals in Post are not present in this case.
In Glenn, the Supreme Court observed that a conflict of interest would be of minimal importance where a plan administrator "has taken active steps to reduce potential bias" and "promote accuracy" "by walling off claims administrators from those interested in firm finances, or by imposing management checks that penalize inaccurate decisionmaking irrespective of whom the inaccuracy benefits." Glenn, 554 U.S. at 117, 128 S.Ct. 2343. Under the Service Agreement, PNC is responsible for providing Sedgwick with sufficient funds to cover LTD claims, and Sedgwick is expressly relieved of the obligation to advance its own funds to cover such claims. (AR0273.) Hence, PNC has taken some steps to ensure that the administration of LTD claims is not influenced by collateral financial considerations.
Under the present circumstances, the presumed conflict of interest resulting from PNC's dual status as a Plan Administrator and a provider of funds is of minimal importance. Since the other factors are not closely balanced, however, the nature of PNC's conflict of interest is not dispositive in this case. Glenn, 554 U.S. at 117, 128 S.Ct. 2343. Because Sedgwick rendered inconsistent decisions during the initial stages of the application process, rejected the opinions of three treating health-care providers, relied on the opinions of four nonexamining physicians (even though Haisley's specific impairments were not amenable to evaluation by means of a file review), failed to request an independent medical examination, and ignored
The ERISA requires "every employee benefit plan" to "provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan has been denied, setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant. . . ." 29 U.S.C. § 1133(1). Regulations promulgated to implement this statutory mandate require a letter denying a claim to include, inter alia, "[a] description of any additional information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary. . . ." 29 C.F.R. § 2560.503-1(g)(iii). In her letter denying Haisley's claim on February 29, 2008, Graham referenced Dr. Givens' view that there was "no specific testing of cognitive functioning in the records but only subjective complaints of difficulty with concentration and memory." (AR0134.) The letter apparently placed Haisley on notice that she needed to submit objective evidence of her mental limitations in order to establish her entitlement to LTD benefits under the Plan. Haisley responded by securing Dr. White's letter of April 3, 2008, which expressly referenced "two objective mini-mental status exams" conducted on March 17, 2008, and March 25, 2008. (ECF No. 63, Ex. K, BAH000378.)
The parties vehemently dispute whether Dr. White's report of April 3, 2008, was submitted to Sedgwick in connection with Haisley's appeal. (ECF No. 96 ¶¶ 51-69.) Dr. White testified that he gave a hard copy of the report to Haisley, but did not send it directly to Sedgwick. (ECF No. 58-2 at 4.) Haisley testified that she delivered that same copy to Kessler's office, with the understanding that it would be forwarded to Sedgwick for consideration. (ECF No. 58-3 at 3.) When questioned about the report during his own deposition, Kessler stated that it was his practice to "send in everything." (ECF No. 1 at 6.) According to Prater, the "paper file" for Haisley's appeal was destroyed after being converted into an "electronic file," making it difficult to track a misplaced document that was never electronically recorded. (ECF No. 58-5 at 7-8.) Ericka McGrew ("McGrew"), an appeals manager employed by Sedgwick, acknowledged that only the contents of the electronic file was considered. (ECF No. 58-8 at 3.) Sedgwick's internal records indicate that Haisley's appellate submission, which was received on May 16, 2008, included a total of 54 pages.
While the parties dispute whether Dr. White's report was submitted to Sedgwick, they apparently agree that, for one reason or another, the report was never considered by Sedgwick. In the report, Dr. White referred to "two objective mini-mental status exams" conducted on March 17, 2008, and March 25, 2008. (ECF No. 63, Ex. K, BAH000378.) According to Dr. White, these examinations confirmed the accuracy of Haisley's "subjective complaints of difficulty with memory and concentration." (Id.) Kessler specifically referred to Dr. White's examination findings in the letter commencing Haisley's appeal. (AR0143.) When Dr. Goldman rendered his consultative opinion, he stated that Dr. White's letters did "not contain sufficient objective or observable data to establish significant psychopathology that would preclude worker functionality." (ECF No. 63, Ex. K, BAH000200.) A careful review of Dr. Goldman's report reveals that he read only Dr. White's letters dated November 9, 2007, and December 31, 2007, both of which predated the objective testing of March 17, 2008, and March 25, 2008. (ECF No. 63, Ex. K, BAH000198-99.) Dr. Goldman's report did not indicate he was aware of Dr. White's letter dated April 3, 2008, which described the nature of the objective testing that had been conducted in March 2008.
In his letter to Sedgwick, Kessler stated that Haisley's short-term memory problems had been "evidenced by clinical mental status examinations" conducted on March 17, 2008, and March 25, 2008. (AR0143.) Although the letter mentioned Dr. White's report dated November 9, 2007, it did not explicitly reference the report dated April 3, 2008. (Id.) It is arguable that Kessler's reference to the mental status examinations was sufficient to put Sedgwick on notice that important information may have been missing from the appellate record. (ECF No. 96 ¶ 54.) If it was, Sedgwick's failure to retrieve that information was unreasonable. The court need not confront that issue, since the actions of Sedgwick in this case already were found to be arbitrary and capricious for other reasons. For present purposes, it suffices to say that if the report had been properly considered by Sedgwick in the first instance, Haisley's administrative appeal may have been successful.
In determining whether to declare Haisley's entitlement to benefits under the Plan as a matter of law or remand the case to Sedgwick and PNC for further consideration, the court must consider the situation that Haisley was in before the arbitrary and capricious conduct of defendants took place. In Miller, the United States Court of Appeals for the Third Circuit explained:
Miller, 632 F.3d at 856-57 (3d Cir.2011). The reasoning employed by the court of appeals in Miller governs the fashioning of the remedy in this case.
Defendants contend that Haisley "automatically and conditionally began receiving LTD benefits" upon Sedgwick's receipt of her application, and that Sedgwick "expressly reserved the right to review and make a determination regarding her claim for LTD benefits." (ECF No. 96 ¶ 27.) This assertion, however, is contradicted by the documentary record. In a letter dated October 16, 2007, Graham acknowledged Sedgwick's receipt of Haisley's application for LTD benefits. (AR0032-33.) The letter stated that claim determinations were typically reached within an average of thirty days. (AR0032.) Graham's letter informing Haisley about the approval of her application was dated November 30, 2007, which was more than thirty days after the earlier letter. (ECF No. 63, Ex. K, BAH000125.) The letter dated November 30, 2007, informed Haisley that she would receive future benefit checks on the last business day of each ensuing month. (ECF No. 63, Ex. K, BAH000126.) Haisley was provided with a check in the amount of $6,154.54 covering the period commencing on October 3, 2007, and ending on November 30, 2007. (Id.) She was advised that Sedgwick would need to verify her "ongoing eligibility for benefits," and that any requested information needed to be "submitted on a timely basis to avoid any possible delay in [her] future benefit payments." (ECF No. 63, Ex. K, BAH000127 (emphasis added).) Graham's letter dated November 30, 2007, did not reflect a conditional approval of Haisley's
On December 20, 2007, Haisley was informed that her entitlement to LTD benefits was "formally suspended" as of December 1, 2007. She was instructed to submit additional evidence in support of her claim. When the claim was ultimately denied on February 29, 2008, Haisley was instructed to reimburse PNC for the payment that she had already received. Based upon the direction to reimburse PNC for the payment that she already received under the terms of the Plan, an argument could be made that Sedgwick's decision denying her claim constituted a "revocation" of its earlier decision to grant benefits, rather than simply a "termination" of continuing benefits. Whether called a revocation or termination of benefits the action was improper and a restoration of those benefits is necessary under these circumstances. Cf. Sanford v. Harvard Indus., Inc., 262 F.3d 590, 599 (6th Cir.2001).
As noted earlier, the Plan's definition of "total disability" becomes more restrictive after a claimant has received LTD benefits for a period of twenty-four months. Subject to certain exceptions, payments for a disability attributable to "mental illness" are limited to the first twenty-four months of a claimant's "total disability." (AR0242.) Graham's letter dated November 30, 2007, expressly stated that Haisley's entitlement to LTD benefits could not extend beyond October 2, 2009, given that her disability was mostly based on a mental impairment. (BAH000127.) Since the standards for determining whether Haisley was "totally disabled" under the terms of the Plan changed on October 3, 2009, she is entitled only to an award of benefits covering the period of time commencing on October 3, 2007, and ending on October 2, 2009.
On March 27, 2008, Dr. Kasdan opined that Haisley was "disabled" due to "multifocal motor neuropathy." (AR0145.) In his letter dated April 3, 2008, Dr. White stated that Haisley's disability was attributable to a "convergence" of physical and mental impairments, and not simply to "cognitive impairments." (ECF No. 63, Ex. K, BAH000378-79.) Dr. Majkic informed Dr. Arbit on June 4, 2008, that Haisley's neuropathy was adversely impacting her ability to sit, stand or walk for more than thirty minutes at a time. (ECF No. 63, Ex. K, BAH000193.) Hence, the record contains some evidence linking Haisley's disability to her physical impairments. This issue was not considered by Sedgwick or PNC and the case must be remanded to PNC and Sedgwick for a determination concerning Haisley's potential entitlement to LTD benefits under the terms of the Plan for the period of time postdating October 2, 2009. (ECF No. 56 ¶ 15.)
Although Haisley's three treating health-care providers consistently maintained
