Connors v. CT General Life Ins.

• Decision Date: 01 August 2001
• Docket Number: Docket No. 00-9288,PLAINTIFF-APPELLANT,DEFENDANT-APPELLEE
• Citation: 272 F.3d 127
• Parties: (2nd Cir. 2001) CLIFF CONNORS,v. CONNECTICUT GENERAL LIFE INSURANCE COMPANY,
• Court: U.S. Court of Appeals — Second Circuit

Page 127

272 F.3d 127 (2nd Cir. 2001)

CLIFF CONNORS, PLAINTIFF-APPELLANT v. CONNECTICUT GENERAL LIFE INSURANCE COMPANY, DEFENDANT-APPELLEE

Docket No. 00-9288

August Term, 2001

UNITED STATES COURT OF APPEALS FOR THE SECOND CIRCUIT

Argued: June 7, 2001

Decided: November 19, 2001

Appeal from a decision of the United States District Court for the Southern District of New York (John S. Martin, J.), upholding an ERISA insurance plan administrator's denial of disability benefits. Affirmed in part, and vacated and remanded in part. [Copyrighted Material Omitted] Evan S. Schwartz, of counsel, Quadrino & Schwartz, P.C., Garden City, NY (Eve-Lynn Gisonni, of counsel, on the brief), for Plaintiff-Appellant.

Kevin G. Horbatiuk, Russo, Keane & Toner, Llp, New York, Ny, for Defendant-Appellee.

Before: McLAUGHLIN and Cabranes, Circuit Judges, and Cote, District Judge.^*

Cote, District Judge

Defendant-appellee Connecticut General Life Insurance Company ("CGLIC" or "defendant") is the administrator of a group disability insurance policy for the former employer of plaintiff-appellant Cliff Connors ("Connors" or "plaintiff"). In 1995, CGLIC found that Connors was no longer "totally disabled" and thus not entitled to continued benefits under the policy. On de novo review of the administrative record, the United States District Court for the Southern District of New York concluded that CGLIC did not err in terminating Connors's benefits. Connors has appealed from the District Court's decision. For the reasons set forth below, we affirm in part, and vacate and remand in part the decision of the District Court.

BACKGROUND

On July 5, 1990, while making a sales call for his employer, Time Warner Cable, petitioner Connors was injured in a fall down a prospective customer's exterior stairs. Tests revealed that Connors suffered a herniated disk, nerve root compression, lumbosacral radiculopathy and a left knee injury in the fall.

As an employee of Time Warner Cable, which is apparently a subsidiary of American Television and Communications Corporation ("American"), Conners v. Conn. Gen. Life Ins. Co., No. 98-8522, 1999 WL 1211831, at *1 n.1 (S.D.N.Y. Dec. 16, 1999) ("Connors I"); Connors v. Conn. Gen. Life. Ins. Co., No. 98-8522, 2000 WL 1279790, at *1 (S.D.N.Y. Sept. 11, 2000) ("Connors II"), Connors was covered under the Group Long Term Disability Insurance Policy (the "Policy") issued by CGLIC for American. The Policy, administered by CGLIC,¹ provides monthly income benefits for eligible employees who become disabled while employed by Time Warner. Under the Policy, an employee is eligible for disability benefits for up to twenty-four months if he is "unable to perform the essential duties of [his] occupation." (Group Insurance Plan, American Television and Communications Corporation, Life, Long and Short Term Disability, at 33.) To continue receiving disability benefits after twenty-four months, the employee must be "unable to perform the essential duties of any occupation for which [he is] or may reasonably become qualified based on [his] education, training or experience." (Id.)

On September 24, 1993, Connors was retroactively awarded twenty-four months of disability benefits for the period of October 6, 1990 to October 5, 1992. Connors then received disability benefits under the second, more stringent definition of "total disability" for almost thirty additional months, i.e., from October 6, 1992 to March 31, 1995. On March 31, 1995, CGLIC terminated benefits on the ground that Connors was no longer "totally disabled" within the meaning of the Policy. Connors challenged this determination and submitted additional evidence of his disability to CGLIC. On November 28, 1995, CGLIC informed Connors that it had considered his additional evidence but that it declined to reverse its finding that he was no longer "totally disabled."

The Policy grants CGLIC the right to make certain deductions from an employee's benefits for amounts the employee receives from other sources. Under the Policy, an employee's benefits can be "reduced by the amount of all Other Benefits which [the employee] receive[s]" each month. (Id. at 8.) Other Benefits include "any amounts which [the employee] receive[s] because of disability under... any workers' compensation or similar law." (Id. at 9.) Connors received workers' compensation benefits concurrently with his disability benefits under the Policy. CGLIC reduced Connors's disability benefits by amounts equal to his workers' compensation benefits. In May 1996, Connors repaid the workers' compensation benefits he had received after he won a settlement award for the injuries he sustained in 1990. Connors contends that, as a result of this repayment, CGLIC owes him the amount it had previously deducted from his benefits.

A. Connors's Medical History Before the Administrator

The administrative record includes the following information regarding Connors's medical history following his accident. Dr. Surendranath K. Reddy, an orthopedist, first saw Connors in August of 1990. On every occasion on which Dr. Reddy saw Connors during the fall of 1990, he regarded Connors's condition as totally disabled. Seeing no improvement by November, Dr. Reddy recommended that Connors have a magnetic resonance image ("MRI") taken of his spine. This MRI revealed the existence of a herniated disk at L5-S1, located in Connors's lower spine, with displacement and compression of the right S1 nerve root, also in his lower spine.

Connors was treated by two other physicians in late 1990 and early 1991, Dr. Leo E. Batash and Dr. Bing H. Tang. Dr. Batash diagnosed Connors with lumbosacral radiculopathy at L5-S1 with S1 root involvement. Dr. Batash also documented Connors's complaints of pain and his limited range of movement, noting that Connors could "hardly bend his body to pick or lift up something from the floor." (Report of Leo E. Batash, M.D., on Clifford Connors of 12/10/90.) Dr. Tang, a neurologist, noted that Connors suffered from, inter alia, cervical strain/sprain, cervical radiculopathy, sciatic neuritis, knee intrasubstance degeneration and a herniated L5-S1 disk.

In early 1991, Dr. Reddy made arrangements for Connors to be hospitalized and placed in pelvic traction. Connors was hospitalized at LaGuardia Hospital from May 20 to 31, 1991. While there, he was put on a course of bedrest, pelvic traction and physical therapy. In a letter dated June 1991, Dr. Reddy described Connors's prognosis as "[g]uarded" and noted that Connors's injury was permanent. (Letter from Dr. Surendranath K. Reddy, M.D., to Harry I. Katz of 6/17/91, at 2.)

In March of 1992, Connors began a course of treatment with Dr. Donald K. Musaffi, a chiropractor.² In a letter dated February 4, 1993, Dr. Musaffi described his treatment of Connors since 1992, and noted that Connors suffered from, inter alia, acute severe lumbar disc syndrome, muscle spasms, sciatic radiculoneuropathy and a herniated lumbar disc. Dr. Mussafi noted that "Mr. Connors is able to work on a volunteer basis only due to the severity of his condition. It is my professional opinion that Mr. Connors work a maximum of three hours only." (Letter from Dr. Donald K. Musaffi to Whom It May Concern of 2/4/93 (emphasis in original).) On June 1, 1993, Dr. Musaffi noted that Connors suffered from radiating neck pains and headaches. Dr. Musaffi wrote that "Mr. Connors has been unable to perform the essential duties of any occupation since he has been under my care. He is unable to perform any lifting or bending. He cannot stand or walk for extended periods. He is also unable to perform sitting work tasks." (Letter from Dr. Donald K. Musaffi to Whom It May Concern of 6/1/93.)

Dr. Reddy again evaluated Connors as totally disabled in a report sent on August 9, 1993, and Connors underwent back surgery on August 24, 1993. The surgery, however, was unsuccessful. While Connors experienced some initial improvement the surgery failed to correct the herniated disk and Connors's pain returned. A March 1994 exam suggested that Connors suffered from L5-S1 radiculopathy or central nervous system pathology. A third MRI in April 1994, confirmed that Connors continued to suffer from a herniated disk at L5-S1.

In a letter dated February 15, 1994, Dr. Lawrence W. Shields, a neurologist who began treating Connors in June of 1993, documented Connors's limited range of motion and noted his complaints of constant back pain that radiated to his legs and neck pain that radiated to his right upper arm. Dr. Shields diagnosed Connors with, inter alia, a herniated disk at L5-S1 with displacement of the right S1 root, lumbrosacral radiculopathy, post traumatic stress disorder and cervical and lumbar myofascitis. Dr. Shields noted that Connors was taking a number of pain medications and described his prognosis as "guarded."

Dr. Reddy continued to treat Connors through 1995. In a January 1995 report, Dr. Reddy documented Connors's complaints of pain in the lumbar area; noted that he was undergoing chiropractic treatment and physical therapy and that Connors had been prescribed painkillers; and evaluated Connors as "totally disabled at present for any occupation." (Letter from Surendranath K. Reddy, M.D., to Gentlemen of 1/10/95.)

B. CGLIC's Denial of Benefits/Supplemental Administrative Record

CGLIC terminated Connors's benefits on March 31, 1995. In reaching this decision, CGLIC relied on information from a physician hired by CGLIC who examined Connors on one occasion, a CGLIC employee who performed an analysis of Connor's transferable skills, and an in-house CGLIC medical consultant who reviewed Connors's medical file.

In May of 1994, CGLIC retained Dr. Alan A. Mazurek, a neurologist, to evaluate Connors's physical condition. Following his examination of Connors, Dr. Mazurek confirmed that Connors was suffering from lumbosacral radiculopathy, that Connors had experienced "only temporary improvement" after the 1...