Logan v. The Prudential Ins. Co. of Am.
| Decision Date | 09 November 2022 |
| Docket Number | 2:20-cv-01742-KJM-JDP |
| Parties | Tammy Logan, Plaintiff, v. The Prudential Insurance Company of America, et al., Defendants. |
| Court | U.S. District Court — Eastern District of California |
Plaintiff Tammy Logan challenges defendant Prudential Insurance Company of America's denial of her claim for long-term disability benefits under the Employee Retirement Income Security Act (ERISA). As explained in this order, Prudential incorrectly denied her claim for benefits for the period between June 19 2019 and July 2, 2021.
Logan began working for Sentry Insurance in 2016. AR 7. In 2018 she was a senior claims representative. Id. According to the job description, senior claims representatives investigate, evaluate, and make decisions about claims for insurance. See AR 129-30, 1588. They consult with customers, create claims files, and attend mediations, settlement conferences, and trials. Id. They might also collect evidence, such as by taking recorded statements and obtaining police and medical reports or appraisals. AR 129-30. Most of Logan's days were spent sitting, working at a computer, and in meetings or calls. AR 1588. She worked eight to ten hours a day, sometimes more, and sometimes also on the weekend. See AR 1588-89.
In late December 2018, Logan fell from a ladder and fractured her ankle. AR 7, 254. She went to the hospital. AR 742. The next day, she saw Dr. Stephen Barad, an orthopedic surgeon, who performed an operation to stabilize and heal her ankle through a procedure known as an open reduction and internal fixation. AR 742, 762. She was discharged two days later, and her doctors advised her not to work while she was recovering. AR 18, 29, 742. Dr. Barad instructed her specifically not to spend time sitting, standing, using a keyboard, or rotating and flexing her wrists. AR 29-30.
A few weeks later, an x-ray of her ankle showed a “stable alignment” and no “definite hardware loosening or fracture,” but there was a “faintly seen” fracture line, “suggesting incomplete healing.” AR 1459. Logan saw Dr. Barad for a follow-up visit. AR 254. He wrote that she was “doing well.” Id. He described the alignment of her ankle as “perfect” and the mortise “well maintained.” Id. His plan was for Logan to gradually increase the amount of weight her ankle could bear using a boot. Id. He scheduled a follow-up visit in four to six weeks and created a therapy program. Id.
Despite these initially positive signs, Logan's recovery stalled. In March, she still had swelling and discomfort in her ankle. AR 1459. She could not sit for long periods of time. Id. An MRI showed tears in the soft tissues in her knee. AR 1459, 253. Dr. Barad thought her ankle was recovering well, and he thought she was “just about ready” to begin physical therapy, but he had concerns about a possible injury in her knee. AR 253. He decided to wait and watch her progress and see her again in six weeks. Id. He thought surgery might eventually be necessary. Id.
Before six weeks had passed, however, Logan was back in Dr. Barad's office. AR 252. As before, her ankle was getting stronger, but her knee was in pain. Id. X-rays and an MRI suggested the anterior cruciate ligament (ACL) in her left knee was stretched or torn. Id. Dr. Barad prescribed physical therapy, anti-inflammatory medication, and exercise. Id. He did not think surgery was necessary yet. Id. But by the next month, in April, the swelling and pain in Logan's ankle was subsiding, but her knee was still in pain. AR 253. Dr. Barad reviewed the benefits and risks of a diagnostic surgery with Logan, and she told him she wanted to move forward with that plan before she went back to work. Id. Dr. Barad instructed her not to spend time sitting, standing, walking, driving, climbing, or working, but he did not impose restrictions against using a keyboard or rotating her wrists. AR 32. In May, a surgery was scheduled. AR 9. Logan told Sentry, and it submitted a claim for long-term disability insurance coverage to Prudential on her behalf. AR 7-8.
Dr. Barad performed the surgery later the same month. AR 437-38. Afterward, he told Sentry that Logan would not be able to work again until June, if not later. AR 233-34. He instructed her again not to spend time sitting, standing, walking, and driving, among other things, but he did not impose limits on her use of a keyboard. AR 233.
Unfortunately, Logan's condition did not significantly change for the better. She described her symptoms in detail in a statement she later submitted with a claim for long-term disability insurance. She could not “sit or stand for long periods of time.” AR 323. She had “chronic pain in her left ankle with stiffness, swelling & popping,” “stabbing pain” in her left heel and foot, “chronic” pain and “tightness” in her knee, headaches, and pain in her left leg, hip, arm, shoulder and neck.” Id. She could not walk without assistance. Id. She could not focus or concentrate. Id.
Prudential requested medical records from Dr. Barad and asked him to fill out a questionnaire. AR 243-50. He gave her diagnoses using ICD10 codes: “M23.009,” which indicates “cystic meniscus, unspecified meniscus, unspecified knee,” and “S82.91xA,” for “unspecified fracture of right lower leg, initial encounter for closed fracture.”[1] AR 248. He estimated Logan would be able to return to work full time by the end of August. AR 249-50.
Although he checked “no” in response to the question, “Are you opining any restrictions and limitations for this patient?” he responded later on that Logan could not spend any time standing, walking, sitting, climbing stairs, climbing ladders, stooping, kneeling, reaching overhead, or lifting and carrying more than 10 pounds. AR 247, 249. He did not impose limits on her use of a computer mouse or keyboard. AR 249. Logan also spoke to a Prudential employee on the phone during this time. She described similar problems. See AR 282-83.
In another follow-up visit in July 2019, Dr. Barad saw some swelling in Logan's knee, but only a “little bit.” AR 1673. Her ankle had also swelled, but she had a good range of motion. Id. He recommended “bracing and activity as tolerated.” Id. In a report to Prudential, he noted restrictions against prolonged standing, walking, sitting, climbing, and heavy lifting, among other things, but not keyboarding. AR 1417. He gave her a three-month prognosis to return to work. AR 1416, 1418. At about the same time, a different doctor, Paramjit Takhar, diagnosed Logan with a pinched nerve in her neck, namely radiculopathy in the cervical region. AR 1661.
Prudential was reviewing Logan's long-term disability insurance claim at about this same time. Logan would be entitled to long-term disability benefits if she had a “disability.” AR 69. For Logan's claim, the policy defines “disability” using three criteria. First, employees must be “unable to perform the material and substantial duties” of their “regular occupation” due to “sickness or injury.” AR 81 (emphasis omitted). “Material and substantial duties means duties that: are normally required for the performance of your regular occupation; and cannot be reasonably omitted or modified.” Id. (emphasis omitted). Second, employees must be under “regular care of a doctor.” Id. (emphasis omitted). Third, employees must have sustained a loss in monthly earnings of 20 percent or more due to that sickness or injury. Id. (emphasis omitted).
Heidi Garcia, a nurse employed by Prudential, reviewed Logan's claim and medical records. In Garcia's opinion, it would be reasonable to expect someone in Logan's situation to have no capacity for about three months after her first surgery, then limited capacity for the next two months. See AR 1457-61. Garcia also believed it would be reasonable to expect Logan to have no capacity to work for two to four weeks after her second surgery in late May. AR 1461. Beyond that, however, Garcia thought it would be reasonable to expect Logan to return to work. Id. A vocational expert also decided Logan's position, her “regular occupation,” was “sedentary.” AR 1484-86.
Prudential determined Logan did not meet the policy's definition of “disability,” so it denied her claim. AR 1486. Based on its review of her medical records, it was “unclear” to Prudential why Logan was “not released to full time return to work 2-4 weeks” after her second surgery. AR 1485. According to a call log, Prudential informed Logan “[i]t doesn't appear your condition would prevent you from performing the material and substantial duties of your regular occupation beyond that.” AR 1504.
In its letter, Prudential recognized that the Social Security Administration had approved Logan's claim for Social Security Disability benefits. AR 1486. That approval did not change Prudential's decision to deny benefits. Id. Its explanation was unenlightening. Id. “[T]he Social Security Administration (SSA) must make their determinations based on the information available to them and their rules and guidelines,” Prudential wrote, “and we must render our decisions based on the information available in your . . . file and the provisions of the . . . Plan.” Id.
After Prudential denied Logan's claim, she saw another doctor Phong Le, a physical therapist. AR 1676. He diagnosed her with “painful hardware in the left ankle and mild ankle OA,” i.e., osteoarthritis. AR 1678. He spent more than 45 minutes speaking with her about her file and treatment options. See id. She decided to “undergo elective surgery for hardware removal.” Id. In a later visit, she had not yet undergone this surgery, and Dr. Le described her condition as “temporarily disabled.” AR 1681. In his words, she had an “orthopedic device screw that is too long and interfering with her joint (ankle) and bone which...
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