Doyle v. Nationwide Ins. Companies & Affiliates

• Citation: 240 F.Supp.2d 328
• Decision Date: 28 January 2003
• Docket Number: Civil Action No. 01-5768.
• Parties: Frank J. DOYLE, Plaintiff, v. NATIONWIDE INSURANCE COMPNIES & AFFILIATES EMPLOYEE HEALTH CARE PLAN, et al., Defendants.
• Court: U.S. District Court — Eastern District of Pennsylvania

240 F.Supp.2d 328

Frank J. DOYLE, Plaintiff, v. NATIONWIDE INSURANCE COMPNIES & AFFILIATES EMPLOYEE HEALTH CARE PLAN, et al., Defendants.

Civil Action No. 01-5768.

United States District Court, E.D. Pennsylvania.

January 28, 2003.

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Arnold Dranoff, Dranoff & Patrizio, P.C., Philadelphia, PA, for Plaintiff.

Curtis P. Cheyney, III, Brian K. Hanstein, Swartz, Campbell & Detweiler, Philadelphia, PA, Randolph C. Wiseman, Elizabeth A. Preston, Bricker & Eckler LLP, Columbus, OH, for Nationwide Ins. Companies & Affiliates Employee Health Care Plan.

Randolph C. Wiseman, Bricker & Eckler LLP, Columbus, OH, for Gates McDonald.

MEMORANDUM

RUFE, District Judge.

This is an action brought by Plaintiff Frank J. Doyle for disability benefits allegedly due under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001, et seq. Before the Court are Defendants' Motion for Summary Judgment and Plaintiffs Motion for Partial Summary Judgment. For the reasons set forth below, Plaintiffs Motion is granted, and Defendants' Motion is denied in part and granted in part.

I. FACTUAL AND PROCEDURAL BACKGROUND

Plaintiff Frank J. Doyle began working for Nationwide Insurance Company ("Nationwide") as a fraud investigator in July 1989. As a benefit of his employment, Plaintiff became a participant in the Nationwide Insurance Companies and Affiliates Employee Health Care Plan (the "Nationwide Plan"). The Nationwide Plan provides for long-term disability benefits for covered employees who are determined to be disabled under the terms of the Nationwide Plan. The entirety of the Nationwide Plan, including its amendments, was submitted to the Court and is attached to Defendants' Motion for Summary Judgment as Exhibits B and C.

Plaintiffs active employment with Nationwide continued until December 9, 1999, when he sought medical care for psychological difficulties. He first went to see his primary care physician, Dr. Sheldon Klein, who diagnosed Plaintiff with depression. See Administrative Record at Bates Stamp NW/Doyle 0071-0072, attached to Defendants' Motion for Summary Judgment at Ex. A (hereinafter "Admin. Rec. at NW —"). At that time, Plaintiff applied for, and began receiving disability benefits under the Nationwide Plan. He was initially entitled to twenty-five weeks of short-term disability benefits, after which he became eligible for long-term disability benefits.

Subsequently, Nationwide's Employee Assistance Program referred Plaintiff to a psychologist, Dr. Steven Gumerman. Dr. Gumerman first evaluated Plaintiff on December 15, 1999, and diagnosed him as of February 1, 2000 with "depression and anxiety" due to "excessive work demands." Admin. Rec. at NW 0068-0069. In a later diagnosis dated May 1, 2000, Dr. Gumerman diagnosed Plaintiff as depressed and concluded that Plaintiff "cannot RTW [return to work] at this time," and that while he showed "slight" improvement, he was "unable to work." In addition, Dr. Gumerman stated that Plaintiff was "totally disabled" from performing his job or any other job. Id. at NW 0062-0063. Plaintiff saw Dr. Gumerman weekly from December through February, then every other week after that. Id. at NW 0023, NW 0050.

About a month before he would become eligible for long term benefits, Plaintiff received a May 1, 2000 letter notifying him that he would be required to submit to an independent psychological examination "to determine whether you continue to meet the requirements to receive long-term disability benefits." Id. at NW 0051. Plaintiff met with Dr. Herbert M. Adler on June 2, 2000 for this independent evaluation, after which Dr. Adler drafted a report containing the following conclusions:

At the present time, I would conclude that Mr. Doyle is totally disabled from returning to his previous job full-time. However, there is a possibility that he could return to the previous job if it could be reduced to half-time, at first, so that he could gradually ease into it. It would also be the case that he could perform another job appropriate to his education.

Dr. Adler also recommended increasing Plaintiffs medication dosage. Id. at NW 0023.

On August 9, 2000, Dr. Gumerman completed a summary report on Plaintiffs mental health. See id. at NW 0053. On the pre-printed form, Dr. Gumerman evaluated Plaintiffs ability to deal with work stress as "Guarded/Poor." The form asked Dr. Gumerman about Plaintiffs "Return to Work Plan," and provided a place to check "Transitional," "Full Time," or "Never." Dr. Gumerman checked "Transitional," and wrote "we continue to discuss work as a potential future consideration." Under a space calling for Plaintiffs "Schedule" for returning to work, Dr. Gumerman writes, "if this becomes a possibility a graduated return would be essential." Id.

Under the Nationwide Plan, it is the responsibility of the "Plan Administrator" to construe and interpret the terms of the Nationwide Plan, including making determinations of eligibility for benefits. Id. at NW 0166-167. The Plan Administrator consists of a three person panel called the Benefits Administrative Committee. When a person submits a claim for benefits, the administrative review process is such that the first level of review is conducted by the "Disability Assessment Committee," and then appeals from this administrative level go to the Benefits Administrative Committee. There appears to be no legal or factual significance to the fact that the initial and appellate review committees have different names. Accordingly, the Court will refer to these committees collectively as the "Administrator," unless otherwise noted.

In an August 16, 2000 letter, the Administrator notified Plaintiff that it had reviewed his claim, and that "it has been determined that you no longer qualify for Long Term Disability benefits." Id. at NW 0035 (the "August Denial Letter"). The letter stated the definition of "disabled" under the Nationwide Plan, notified Plaintiff that his long term benefits would terminate on September 1, 2000, and set out the timing and procedure for appealing the decision. See id.

On August 31, 2000, Plaintiffs attorney, Arnold Dranoff, Esq., sent a notice of appeal to the Administrator, and requested additional information, including a copy of the independent medical examination report prepared by Dr. Adler, and sections of the Nationwide Plan relating to short and long term disability benefits. See id. at NW 0028-30. The Administrator responded in a September 21, 2000 letter, and enclosed the requested materials. See id. at NW 0021-24. In this letter, the Administrator notified Mr. Dranoff that he would have sixty days from the date of the letter to file his client's appeal for reinstatement of long term disability payments. Id. at 0021.

On October 13, 2000, Mr. Dranoff again wrote to the Administrator, and acknowledged receipt of Dr. Adler's report and portions of the Nationwide Plan. See id. at NW 0017-0019. In this letter, Mr. Dranoff complained that the materials provided failed to indicate the method of appellate review of Plaintiffs claim for benefits, "or the factors or materials to be taken into consideration when reviewing same." Id. at NW 0017. Mr. Dranoff requested such materials or information from the Administrator "so that I will be in a position to provide any materials needed or required by your company's administrative process." Id. His letter then restated Plaintiffs intention to appeal,¹ and proceeded to argue that Dr. Adler's report did not support a conclusion that Plaintiff was no longer disabled as that term is defined in the Nationwide Plan. Finally, Mr. Dranoff stated that he would be supplementing his letter with materials from Plaintiffs treating physician. See id. at NW 0018-0019.

The Administrator responded to Mr. Dranoff in an October 17, 2000 letter. See id. at NW 0020. In the letter, the Administrator explained that Plaintiffs appeal would be considered by the Benefits Administrative Committee, which would render a decision within sixty days. Regarding the merits of the decision, the letter stated that the committee "will review all medical documentation to make a determination of a claim for benefits, in accordance with the provisions of the [Nationwide Plan]." Id.

During October and November 2000, Plaintiff was evaluated on three separate occasions by Dr. Warren Jay Zalut, after which Dr. Zalut issued a report to Mr. Dranoff, dated November 17, 2000. See Exhibit B to Plaintiffs Motion for Partial Summary Judgment (the "Zalut Report"). In addition to meeting with and evaluating Plaintiff, Dr. Zalut reviewed Dr. Adler's report and the August Denial Letter. The Zalut Report concluded that Plaintiff was disabled from doing his prior job, and that he would be unable to return to his former job. However, it also concluded that Plaintiff "has been able to return to employment, but at a lower activity level and with less responsibility than he had while working at the Nationwide Insurance Company."

In reference to medication, Dr. Zalut noted that Plaintiffs treating physicians attempted to implement Dr. Adler's recommendation to increase Plaintiffs medication, but that the medication caused Plaintiff to suffer from tinnitus,² and that increasing the medication had increased the tinnitus. As a consequence, Dr. Zalut stopped medicating Plaintiff in order to evaluate the tinnitus. Without the medication, Dr. Zalut concluded, Plaintiffs "mental state is more fragile and he would be more susceptible to deterioration and regression, if placed in an environment that would place excessive amounts of stress on him." Id.

On December 11, 2000, the Administrator notified Plaintiff that his appeal had been denied. See Exhibit B to Plaintiffs Motion for Partial Summary Judgment, Bates-stamped NW 0011-0012 (the "December Denial Letter"). The December Denial Letter stated that the Administrator considered numerous items in making...