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Johnson v. Guardian Life Insurance Co. of America

United States District Court, D. Connecticut

October 27, 2017

KIMBERLY JOHNSON Plaintiff,
v.
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA. Defendant.

          RULING ON CROSS-MOTIONS FOR SUMMARY JUDGMENT

          Michael P. Shea, U.S.D.J.

          Plaintiff Kimberly Johnson (“Plaintiff”) sued Defendant The Guardian Life Insurance Company of America (“Defendant”) under the Employment Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001, et seq., after Guardian terminated her long-term disability (“LTD”) benefits under an employee benefit plan. Plaintiff contends that Defendant's termination decision was arbitrary and capricious. The parties have filed cross motions for summary judgment. For the reasons set forth below, Plaintiff's motion is GRANTED and Defendant's motion is DENIED.

         I. Factual Background

         The following relevant facts, which are taken from the parties' Local Rule 56(a) Statements and the Administrative Record (“AR”), are undisputed unless otherwise indicated.

         A. Plaintiff's Claim for Benefits

         Plaintiff worked as a sales director for Greenfield Direct, LLC (“Greenfield”). (ECF No. 19 ¶ 1; AR 0006.) Greenfield provided LTD benefits to its employees, including Plaintiff, under an employee benefit plan (“the Plan”) administered by Defendant. (ECF No. 19 ¶ 2; AR 1780-1996.)

         On March 10, 2010, Plaintiff stopped working due to headaches, fatigue, vomiting, and nausea. (ECF No. 19 ¶ 6; AR 0006, 1596, 1999). Plaintiff filed an application for LTD benefits and Defendant approved her application. (ECF No. 19 ¶ 7; AR 0006, 1596, 1999.) Plaintiff began receiving LTD benefits from Defendant on June 13, 2010. (ECF No. 19 ¶ 8; AR 1599.)

         In July 2011, Defendant requested that Plaintiff file a disability claim with the U.S. Social Security Administration. (AR 1502.) In November 2011, Defendant informed Plaintiff that it had referred her file to a law firm, which Defendant selected, that specialized in Social Security law and could assist in pursuing Plaintiff's Social Security claim. (AR 1506-07.) Defendant noted that the representation would not result in any out-of-pocket cost to Plaintiff, and that it would pay the attorney. (AR 1507.)

         Defendant paid LTD benefits to Plaintiff for the first 24 months of Plaintiff's disability, from June 13, 2010, through June 13, 2012, and continued to pay benefits after June 13, 2012, based on periodic reviews through which Defendant concluded that Plaintiff remained eligible for benefits. (ECF No. 19 ¶¶ 9-10; ECF No. 16-2 ¶¶ 7-9, 11, 13; AR 1599, 2018.) Through these periodic reviews, Defendant concluded in March 2013, August 2013, December 2013, and August 2014 that Plaintiff remained eligible for LTD benefits due to her continued functional limitations. (ECF No. 16-2 ¶¶ 28-29; AR 2078, 2105.)

         On May 7, 2015, the Defendant denied Plaintiff's claim for LTD benefits, stating that Plaintiff was no longer disabled within the meaning of the Plan. (AR 896-900.) On October 28, 2015, Plaintiff initiated an appeal of the denial, after which Defendant reconsidered its decision. (AR 429-530; AR 2150.) On May 12, 2016, Defendant denied Plaintiff's appeal. (AR 3.)

         Plaintiff asserts that her disability is caused by a cervical spinal stenosis with severe occipital headaches and a history of a cervical fusion, a severe mid-thoracic disc protrusion deforming her spinal cord, Crohn's disease, a total colectomy which requires use of a colostomy bag, and sinus tachycardia. (ECF No. 16-2 ¶ 5.) Defendant contends that Plaintiff's only disabling diagnosis is her cervical spinal stenosis with severe headaches and cervical fusion, as the other conditions arose either before or after Plaintiff's date of disability, and Plaintiff did not claim to be disabled due to those conditions in her initial claim or appeal. (ECF No. 33 ¶ 5.)

         B. Plan Terms

         The Plan states, “Guardian is the Claims Fiduciary with discretionary authority to determine eligibility for benefits and to construe the terms of the plan with respect to claims.” (ECF No. 19 ¶ 4; AR 1847.) The Plan also contains the following relevant provisions with respect to LTD benefits:

Proof of Loss
. . . .
We require the items listed below as proof of loss:
(a)
. . . .
After the own occupation period, medical evidence in support of the limits on your ability to perform any gainful work.
. . . .
When Payments End Your benefits from this plan will end on the earliest of the dates shown below:
(a) The date you are no longer disabled.
(b) The date you earn, or are able to earn, the maximum earnings allowed while disabled under this plan.
(c) The date you are able to perform the major duties of your own occupation on a full-time basis with reasonable accommodation that an employer is willing to provide.
(d) After the own occupation period, the date you are able to perform the major duties of any gainful work on a full-time basis with reasonable accommodation that an employer is willing to provide.
. . .
(h) The date you fail to give us required current proof of loss. This includes taking part in any medical or vocational assessment we may require.
(i) The date you are no longer under the regular care of a doctor. . . .

(AR 1827.)

         The Plan provides the following relevant definitions:

Disability or Disabled These terms mean you have physical, mental or emotional limits caused by a current sickness or injury. And, due to these limits, you are not able to perform the major duties of your own occupation or any gainful work as shown below:
(1) During the elimination period and the own occupation period, you are not able to perform, on a full-time basis, the major duties of your own occupation.
(2) After the end of the own occupation period, you are not able to perform, on a full-time basis, the major duties of any gainful work.
. . . .
Gainful Occupation or Gainful Work
Work for which you are, or may become, qualified by: (a) training; (b) education; or (c) experience. When you are able to perform such work on a full-time basis, you can be expected to earn at least 60% of your indexed insured earnings, within 12 months of returning to work.

(AR 1839.) The Plan states that the “Own Occupation Period” is “[t]he first 24 months of benefit payments” from the Plan, and that the “Elimination Period” is 90 days. (AR 1822.)

         C. Administrative Record

         The Administrative Record before the Court is a 2, 198-page file containing the Plan, Defendant's files concerning Plaintiff's benefits, Plaintiff's medical records, and other documents submitted by Plaintiff as part of her administrative appeal. The relevant portions of the administrative record are summarized below.

         Medical notes indicate that Plaintiff has a history of Crohn's disease and uses a colostomy bag. (AR 1580.) Plaintiff underwent a cervical fusion (surgery that joins bones in the neck) in July 2012 and a cholecystectomy (gall bladder removal surgery) in August 2014. (ECF No. 19 ¶ 11; AR 0059, 0060.) Following these procedures, Plaintiff continued to complain of back pain and was under the care of several physicians, including an orthopedic spine surgeon, Dr. James Yue, and a pain management specialist, Dr. Dwight Ligham. (ECF No. 19 ¶ 12; AR 1004-1005, 1246, 2024-2127.)

         On August 30, 2012, Dr. Ligham provided Plaintiff, at the request of Plaintiff's Social Security attorney, with a written opinion regarding Plaintiff's functional capabilities, opining that Plaintiff was “very disabled requiring frequent rest breaks up to 10 minutes per hour and requiring changes in position several times per hour.” (AR 1182-83.) In December 2012, also at the request of her Social Security attorney, Dr. Ligham provided an updated opinion regarding Plaintiff's work capacity, writing that Plaintiff “continue[d] to be restricted from any work due to the limitations outlined in” the August 30 letter. (AR 1181.)

         On June 28, 2013, Plaintiff's treating neurologist Dr. Sanjay P. Rathi conducted a motor examination of Plaintiff and concluded that Plaintiff suffered from weakness in her upper extremities and had abnormal reflexes, warranting an MRI. (ECF No. 16-2 ¶ 18; AR 571-72.) The MRI results identified “a paracentral focal disc protrusion indenting the thecal sac and deforming the cord anterolaterally” and “severe left neuroforaminal stenosis.” (ECF No. 16-2 ¶¶ 19-20; AR 553-54.)[1] At the request of Plaintiff's Social Security counsel, Dr. Rathi provided Plaintiff with a medical opinion in which he concurred with Dr. Ligham's assessment. (ECF No. 16-2 ¶ 22; AR 1184.) Dr. Babu Kumar, Plaintiff's treating internist, also provided a medical opinion concurring with Dr. Ligham's assessment that Plaintiff was unable to work, also at the request of Plaintiff's Social Security counsel. (ECF No. 16-2 ¶ 23; AR 1185-1186.)

         In September 2013, as part of Plaintiff's Social Security case, Plaintiff submitted to the Social Security Administration an opinion of a Vocational Expert “for the purpose of convincing the SSA that [Plaintiff] was eligible for Social Security Disability Benefits.” (ECF No. 16-2 ¶ 24.) The expert's fees were paid by Defendant. (Id.; AR 1200-04.) The vocational expert opined that Plaintiff was “unable to return to any of her past relevant work, ” and that, “[p]hysically, the restrictions outlined by Dr. Ligham place[d] [Plaintiff] at less than the full range of sedentary work . . . . Moreover the limitations of interference with her ability to maintain concentration and complete tasks in a timely fashion precludes [Plaintiff] from maintaining sufficient concentration and pace to complete an 8 hour workday on a sustained basis.” (AR 1204.) On October 23, 2013, an Administrative Law Judge found Plaintiff to have been disabled as of March 10, 2010. (AR 1199.) Plaintiff's social security attorney informed Defendant of the outcome in Plaintiff's favor. (AR 1199.)

         On August 8, 2014, Defendant undertook a periodic review of Plaintiff's eligibility for benefits, concluding that Plaintiff remained eligible for LTD benefits, and suggesting that it would not ...


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