Foster v. Sedgwick Claims Mgmt. Servs., Inc.

• Decision Date: 28 August 2015
• Docket Number: Civil Action No. 14–1241 (JEB)
• Parties: Kelly Foster, Plaintiff, v. Sedgwick Claims Management Services, Inc., et al., Defendants.
• Court: U.S. District Court — District of Columbia

125 F.Supp.3d 200

Kelly Foster, Plaintiff,

v.Sedgwick Claims Management Services, Inc., et al., Defendants.

Civil Action No. 14–1241 (JEB)

United States District Court, District of Columbia.

Signed August 28, 2015

Denise Marie Clark, Clark Law Group, PLLC, Washington, DC, Scott Bertram Elkind, Elkind & Shea, Silver Spring, MD, for Plaintiff.

James Taylor Heidelbach, Gregory L. Arbogast, Gebhardt & Smith LLP, Baltimore, MD, for Defendants.

MEMORANDUM OPINION

JAMES E. BOASBERG, United States District Judge

Plaintiff Kelly Foster, a former employee of Sun Trust Bank, brought this action under the Employee Retirement Income Security Act of 1974, claiming that Defendants Sedgwick Claims Management Services, Inc. and the Bank's Short–Term and Long–Term Disability Plans improperly denied her disability benefits. She asserts that she submitted sufficient medical evidence of conditions—including fibromyalgia

, fatigue, and anxiety disorder—that render her "totally disabled" within the meaning of the Plans, and she further maintains that she has satisfied all of the Plans' other preconditions for receiving benefits.

Disagreeing with Foster's contentions, Defendants have filed a Motion for Summary Judgment. They first point out that the Short–Term Disability Plan is not even governed by ERISA. They also argue that the denial of long-term benefits was appropriate in light of the aggregate medical evidence and the eligibility requirements of the Plans.

Concluding that Defendants are entitled to judgment, the Court will grant their Motion.

I. Background

Sun Trust Bank automatically enrolls all of its employees in the company's Short–Term Disability (STD) and Long–Term Disability (STD) Benefits Plans after six months of employment. See Mot., Exh. 2 (STD Benefits Handbook) at 1. Plaintiff, formerly a Mortgage Loan Closer at Sun Trust, was enrolled in both Plans. See Mot., Exh. 5 (STD Claim File) at 1. Sun Trust retains Sedgwick as the claims administrator for both of its Disability Benefits Plans. See Mot., Exh. 4 (Affidavit of Anna M. Grant) at 1. The claims administrator "make[s] a determination regarding whether your medically-documented claim entitles you to a Long–Term Disability [or Short–Term Disability] benefit." Mot., Exh. 3 (LTD Plan) at 11.

Enrolled employees are eligible for STD benefits if the claims administrator determines that for more than five consecutive business days, the employee is "not able, solely because of disease or injury, to perform the material duties of their own occupation and are under the regular care of a physician." STD Benefits Handbook at 2. This determination is to be based on "[o]bjective medical documentation supporting the employee's claim.' " Id. at 1.

An employee is eligible for LTD benefits, conversely, if, after 180 consecutive calendar days of total disability, he or she remains disabled. See LTD Plan at 4. During the entirety of this 180–day "waiting period," the employee must be entitled to STD benefits or Workers Compensation, see id., the latter of which is not at issue here. The waiting period commences on the first day the employee is absent from work as a result of his or her disability, and it is broken (and must be restarted) if the employee returns to work for more than 30 days. Id. These requirements are laid out in the Plan documents and are discussed in more detail in the Analysis.See infra Section III.B.1.

According to Foster, she suffers from a series of disabling conditions, including fibromyalgia

and fatigue. See STD Claim File at 1, 23. She filed her first claim for disability benefits under Sun Trust's STD Plan in January 2012. See Mot., Exh. 7 (Claim Log I) at 36. Sedgwick conditionally approved Plaintiff's claim but later discontinued her benefits the following month, after she failed to provide medical support for a continuing disability. See Mot., Exh. 8 (Letter Discontinuing Temporary Benefits) at 1.

Foster then filed another STD benefits claim—the claim at issue in this action—on August 20, 2012. See STD Claim File at 1. On two occasions after the filing of this claim, Sedgwick notified Plaintiff that she had to file medical documentation in support of her claim before September 7, 2012. See id. at 4, 15. After Foster failed to do so, Sedgwick denied her claim on September 10, 2012. See id. at 18. Five days after the deadline, Dr. Robert Mayfield submitted an Attending Physician Statement in support of Plaintiff's claim, in which he reported that she suffered from fibromyalgia

, dry eyes, and anxiety. See id. at 20–22 (Statement of Dr. Mayfield). His diagnosis cited an MRI performed in 2011, and he noted that further objective findings would require additional testing. See id. at 23. Finding that this Statement did not constitute "satisfactory" objective medical documentation of Plaintiff's disability, Sedgwick again denied her STD claim on September 13, 2012. See Mot., Exh. 13 (Claim Log II) at 46–47; STD Claim File at 26–27.

On September 25, 2012, Sun Trust terminated Foster's employment as a result of her absence from work. See Grant Aff. ¶ 4. On that same day, a second physician, Dr. James Sutherland, submitted an Attending Physician Statement on her behalf. See Mot., Exh. 14 (Statement of Dr. Sutherland). Although this Statement confirmed many of Dr. Mayfield's diagnoses, it also indicated that Plaintiff's physical condition did not functionally limit her activities of daily living and did not merit driving restrictions. See id. at 2.

Plaintiff, through counsel, formally appealed the denial of her claim for STD benefits, which she was permitted to do even after her termination. See STD Claim File at 28. After additional review, including consultation with independent physicians, Sedgwick upheld this denial on March 29, 2013. See Mot., Exh. 16 (STD Appeal Denial).

Plaintiff next filed a claim for benefits under Sun Trust's LTD Plan on October 31, 2013. See Claim Log II at 4. Sedgwick denied this claim on November 8, on the basis that Foster had not established that she was entitled to STD benefits or Workers' Compensation for the duration of the 180–day waiting period. Mot., Exh. 17 (LTD Denial Letter). Plaintiff appealed the denial of her claim for LTD benefits on January 10, 2014, but Sedgwick upheld it on January 27. See Claim Log II at 2.

Foster then filed this action on July 21, 2014, seeking to clarify and enforce her rights under the benefits plans, as permitted by ERISA. See 29 U.S.C. § 1132(a).

II. Legal Standard

"There is a divide among the circuit courts of appeal ... as to whether Fed.R.Civ.P. 56 is necessarily the appropriate mechanism to resolve a § 1132(a)(1)(B) ERISA claim for denial of benefits." Horton v. Life Ins. Co. of N. Am., No. 14–3, 2015 WL 1469196, at *12 (D.Md. Mar. 30, 2015). Because the D.C. Circuit has not ruled on the question and because both parties endorse the use of Rule 56, the Court will proceed under that framework. It notes that its decision would be the same under Rule 56 (no material dispute of fact regarding whether Sedgwick abused its discretion) as under Rule 52 (no abuse of discretion).

Summary judgment is appropriate when "the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Fed.R.Civ.P. 56(a) ; see also Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 247–48, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986). "A fact is material if it ‘might affect the outcome of the suit under the governing law,’ and a dispute about a material fact is genuine ‘if the evidence is such that a reasonable jury could return a verdict for the nonmoving party.’ " Steele v. Schafer, 535 F.3d 689, 692 (D.C.Cir.2008) (quoting Anderson, 477 U.S. at 248, 106 S.Ct. 2505 ).

Although the Court must view all of the facts in the light most favorable to the non-moving party, the non-moving party's opposition must consist of more than mere unsupported allegations or denials, and it must be supported by affidavits, declarations, or other competent evidence setting forth specific facts showing that there is a genuine issue for trial. See Fed.R.Civ.P. 56(e) ; see also Celotex Corp. v. Catrett, 477 U.S. 317, 324, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986). The non-moving party is required to provide evidence that would permit a reasonable factfinder to find in her favor. Laningham v. United States Navy, 813 F.2d 1236, 1242 (D.C.Cir.1987). A "mere ... scintilla of evidence" in support of the non-movant's position is insufficient to defeat a motion for summary judgment. Anderson, 477 U.S. at 252, 106 S.Ct. 2505. And if the non-movant's evidence is "merely colorable" or "not significantly probative," summary judgment may be granted. Liberty Lobby, Inc., 477 U.S. at 249–50, 106 S.Ct. 2505 ; see Scott v. Harris, 550 U.S. 372, 380, 127 S.Ct. 1769, 167 L.Ed.2d 686 (2007) ("[W]here the record taken as a whole could not lead a rational trier of fact to find for the non-moving party, there is ‘no genuine issue for trial.’ ") (quoting Matsushita Electric Industrial Co. v. Zenith Radio Corp., 475 U.S. 574, 587, 106 S.Ct. 1348, 89 L.Ed.2d 538 (1986) ).

III. Analysis

ERISA was enacted to protect "the interests of participants in employee benefit plans and their beneficiaries."

29 U.S.C. § 1001(b). Under § 502(a) of the Act, "[i]f a participant or beneficiary believes that benefits promised to him under the terms of the plan are not provided, he can bring suit seeking provision of those benefits .... [or] to ‘enforce his rights' under the plan, or to clarify any of his rights to future benefits." Aetna Health Inc. v. Davila, 542 U.S. 200, 210, 124 S.Ct. 2488, 159 L.Ed.2d 312 (2004) (quoting 29 U.S.C. § 1132(a)(1)(B) ). Plaintiff invokes this section, asserting that she is entitled to past and future benefits under Sun Trust's STD and LTD Benefits Plans. The Court will address each Plan in turn.

A. Short–Term Disability Benefits

As a threshold matter, Defendants contend that this Court cannot even assess the merits of...