Miller v. PNC Fin. Servs. Grp., Inc.

• Decision Date: 02 October 2017
• Docket Number: Case No. 1:16–cv–25142–KMM
• Citation: 278 F.Supp.3d 1333
• Parties: Wendy MILLER, Plaintiff, v. The PNC FINANCIAL SERVICES GROUP, INC., The PNC Financial Services Group, Inc. and Affiliates Long Term Disability Plan, an ERISA Benefit Plan, Defendants.
• Court: U.S. District Court — Southern District of Florida

278 F.Supp.3d 1333

Wendy MILLER, Plaintiff,

v.The PNC FINANCIAL SERVICES GROUP, INC., The PNC Financial Services Group, Inc. and Affiliates Long Term Disability Plan, an ERISA Benefit Plan, Defendants.

Case No. 1:16–cv–25142–KMM

United States District Court, S.D. Florida.

Signed October 2, 2017

Carter Meader Sox, Edward Philip Dabdoub, Dabdoub Law Firm, P.A., Coral Gables, FL, for Plaintiff.

Sherril May Colombo, Littler Mendelson, P.C., Miami, FL, for Defendant.

ORDER ON CROSS–MOTIONS FOR SUMMARY JUDGMENT

K. MICHAEL MOORE, CHIEF UNITED STATES DISTRICT JUDGE

THIS CAUSE came before the Court upon Plaintiff's Motion for Summary Judgment ("Plaintiff's Motion") (ECF No. 27) and Defendants' Motion for Summary Judgment ("Defendants' Motion") (ECF No. 30). The motions are now ripe for review.¹ The Court, having considered the parties' submissions, the administrative record and relevant case law, and being fully advised in the premises, grants Plaintiff's Motion for Summary Judgment and denies Defendants' Motion for Summary Judgment.

I. BACKGROUND²

This action seeks reversal of Liberty Life Assurance Company's decision, as the Claims Administrator for an employee welfare benefit plan, pursuant to the Employee Retirement Income Security Act of 1974 ("ERISA"), § 502 (a)(1)(B), 29 U.S.C. § 1132(a)(1)(B), to terminate the long-term disability ("LTD") benefits of Wendy Miller ("Plaintiff").

A. The Plaintiff and the Plan

Plaintiff worked as a Branch Manager II at The PNC Financial Services Group, Inc. ("PNC"). See Pl.'s 56.1 ¶¶ 1, 5; Defs.' 56.1 ¶ 1; see also Defs.' Opp. 56.1 ¶ 5. By virtue of her employment at PNC, Plaintiff participated in an employee welfare benefit plan known as The PNC Financial Services Group, Inc. and Affiliates Long Term Disability Plan (the "Plan"). Pl.'s 56.1 ¶¶ 1–2; Defs.' 56.1 ¶ 1–2. The Plan is governed the ERISA. Defs.' 56.1 ¶ 2. The terms of the Plan are written in a Summary Plan Description booklet ("SPD"), which serves as both the plan document and summary plan description for the Plan. Pl.'s 56.1 ¶ 2.

The Plan provides full-time, salaried employees, who are out of work for longer than ninety-one (91) days (the "Elimination Period") with LTD benefits of up to 60% of their base salary. Defs.' 56.1 ¶ 2. The Plan allows employees to purchase an additional 10% of LTD coverage for a total benefit of 70%. Id. Plaintiff participated in the Plan at the 70% level. Id.

The SPD explains that the "claims administrator determines whether [a participant's] disability meets" the definition of an LTD. Pl.'s 56.1 ¶ 3; Defs.' 56.1 ¶ 6. The SPD also provides the following definition for an LTD:

For disabilities that extend beyond 91 consecutive calendar days and are considered long term, the definition of disability is as follows:

• For the first 24 months [from the date LTD benefits begin]: you are disabled if your disability makes you unable to perform the material or essential duties of your own occupation as it is normally performed in the national economy.

• After you have been disabled for 24 months: you are disabled if your disability makes you unable to perform the material duties of any occupation for which you are or can become qualified to perform by education, training or experience.

Pl.'s 56.1 ¶ 3; Defs.' 56.1 ¶ 6. The SPD also provides that "[a]s a condition of receiving benefits under the Plan, any person may be required to submit whatever proof the Plan Administrator may require (either directly to the Plan Administrator or to any person delegated by it)." Defs.' 56.1 ¶ 7. The Plan is "fully self-funded" and the benefits are paid out of a trust, the funds of which "must be used at all times for the exclusive benefit of Participants or Beneficiaries" of the Plan. Defs.' 56.1 ¶ 3.³

The SPD lists PNC as the Plan Sponsor and Plan Administrator and lists Liberty Life Assurance Company ("Liberty") as the Claims Administrator. Defs.' 56.1 ¶ 4. As Plan Administrator, PNC was authorized to delegate its responsibility under the Plan. Defs.' 56.1 ¶ 5; see also AR 2679–2681.⁴ PNC and Liberty entered into an Administrative Services Only Agreement ("ASA"), in which Liberty was vested with some authority to construe and interpret the terms of the Plan and to evaluate and decide questions of eligibility and/or entitlement to LTD benefits under the Plan. Id.

The SPD contains a clause providing that decisions made by the Plan may only be overturned by a court if the decision is found to have been arbitrary and capricious. Id. The ASA similarly provides that Liberty is deemed to have properly exercised its authority, unless it has abused its authority by acting arbitrarily and capriciously. Id.

B. The Claim and the Review

Plaintiff suffers from a degenerative disc disease causing chronic back pain that radiates into her hips and legs (known as radiculopathy ). Pl.'s 56.1 ¶ 6. Since 2009, Plaintiff has undergone five surgical procedures in an attempt to alleviate her chronic pain and radiculopathy. Pl.'s 56.1 ¶¶ 7–12. In April 2015, Plaintiff underwent the last of these surgical procedures, in which she had a neurostimulator implanted. Id. ¶ 11. After this implant, Plaintiff was unable to return to work and filed a claim for LTD benefits. Id. ¶ 13.

By letter dated August 5, 2015, Liberty informed Plaintiff that it had determined that she was eligible to receive LTD benefits, but that her claim would be reviewed periodically and that "approval at this time does not guarantee payments through the maximum benefits duration." Defs.' 56.1 ¶ 9; Pl.'s 56.1 ¶ 14.

Months later, Liberty reviewed Plaintiff's continuing eligibility. Pl.'s 56.1 ¶ 16. In the course of its review, Liberty's vocational consultant, Patricia Thal, completed an occupational analysis, which determined that Plaintiff's occupation as Bank Manager could be completed both at a sedentary and at a light level. Pl.'s 56.1 ¶ 16. Thal also found that there were employment opportunities in the national economy existing at both levels. Defs.' 56.1 ¶ 14.

While investigating Plaintiff's claim, Liberty also consulted with an independent physician Board Certified in Physical Medicine & Rehabilitation, Dr. Negin Gohari, who reviewed the medical evidence in Plaintiff's file. Defs.' 56.1 ¶ 10. Dr. Gohari found in his December 12, 2015 report ("Gohari's Initial Report") that Plaintiff's "[d]iagnosis of post-laminectomy syndrome, status post spinal cord stimulator is supported by the medical evidence in this file." Id. Dr. Gohari concluded that Plaintiff had full-time capacity to work at a sedentary level and found, inter alia , that Plaintiff "can sit up to a half-hour at one time up to three hours per 8 hour day." Id. ¶ 11; Pl.'s 56.1 ¶ 18.

Upon receipt of Dr. Gohari's report, Liberty's LTD Disability Case Manager sent an e-mail to Dr. Gohari, informing him that "[p]er vocational guidelines, sedentary would mean she is sitting most if not all of the day," and requesting a clarification from him because Dr. Gohari indicated that Plaintiff could work at a "sedentary level" but that Plaintiff "can sit up to a half-hour at one time up to three hours per 8 hour day." Defs.' 56.1 ¶ 11–12; Pl.'s 56.1 ¶ 19; AR 2351.

Dr. Gohari amended his report on January 5, 2016 ("Gohari's Amended Report") to set forth revised restrictions. Defs.' 56.1 ¶ 13. Dr. Gohari's Amended Report indicated that Plaintiff "can sit for two hours at a time for a total of 7 hours per 8–hour day." Defs.' 56.1 ¶ 13.

In the course of its review, Liberty also requested that Plaintiff's physical therapist, Brian Schuman, fill out a form indicating Plaintiff's restrictions. Pl.'s 56.1 ¶ 16. On November 5, 2015, Schuman filled out this form (the "Restrictions Form") and indicated that Plaintiff had a "class 5" impairment with severe limitations of functional capacity. Defs.' Opp. 56.1 ¶ 17. Schuman also checked a box indicating that she is capable of performing "sedentary" work. Pl.'s 56.1 ¶ 17. This form contains instructions to "check one that indicates what your patient is capable of performing," and contains four other potential check-boxes—all of which entail greater forms of exertion than "sedentary." See AR 2397 (For example, "sedentary" involves "lifting/carrying up to 10 pounds occasionally," whereas "light" involves "lifting/carrying up to 20 pounds occasionally").

C. The Termination and the Administrative Appeal

By letter dated January 12, 2016, Liberty terminated Plaintiff's benefits. Pl.'s 56.1 ¶ 21; Defs.' 56.1 ¶ 15. The letter stated, in part: "Based on the medical information in relation to your occupation requirements, the consulting physician's findings and the occupational analysis, you no longer meet your Plan's definition of disability, and we must close your claim. Benefits will be paid through January 12, 2016 and your claim will be closed." Defs.' 56.1 ¶ 17. In the letter, Liberty noted (a) the applicable definition of LTD, (b) medical documentation on file from Dr. Daniel Laich (Neurosurgery ), Physical Therapist Brian Schuman, and Dr. Joel See (Physiatry and Pain Management), (c) Thal's occupational analysis, and (d) Gohari's Amended Report. Defs.' 56.1 ¶ 16; Pl.'s 56.1 ¶ 22. The letter made no mention of the restrictions set forth in Dr. Gohari's Initial Report. Pl.'s 56.1 ¶ 22. The termination letter also cited Schuman's Restrictions Form for the proposition that Schuman "note[d] [Plaintiff's] ability to perform at a sedentary level," but omitted any reference of Schuman's stated restrictions or limitations, or his opinion that she is severely functionally impaired. Id. ¶ 23.

By letter dated June 29, 2016, Plaintiff informed Liberty that she had recently retained counsel and requested an extension of 60 days to submit an appeal. Pl.'s 56.1 ¶ 24.⁵ After conferring with PNC, Liberty denied the requested extension by letter dated July 7, 2016—the day before her appeal due date. Pl.'s 56.1 ¶¶ 25–27.

Plaintiff submitted an appeal on July 8, 2016 and requested that Liberty toll its review while Plaintiff gathered...