United States District Court, D. Connecticut
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.
following relevant facts, which are taken from the
parties' Local Rule 56(a) Statements and the
Administrative Record (“AR”), are undisputed
unless otherwise indicated.
Plaintiff's Claim for Benefits
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;
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
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.)
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.)
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.)
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.)
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
Proof of Loss
. . . .
We require the items listed below as proof of loss:
. . . .
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. . . .
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.)
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.
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.)
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.)
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.) 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.)
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.)
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 ...