Pettaway v. Teachers Ins.

• Decision Date: 15 July 2011
• Docket Number: No. 10–7062.,10–7062.
• Citation: 396 U.S.App.D.C. 40,644 F.3d 427
• Parties: Sonya PETTAWAY, Appellantv.TEACHERS INSURANCE AND ANNUITY ASSOCIATION OF AMERICA, et al., Appellees.
• Court: U.S. Court of Appeals — District of Columbia Circuit

644 F.3d 427

396 U.S.App.D.C. 40

Sonya PETTAWAY, Appellant

v.TEACHERS INSURANCE AND ANNUITY ASSOCIATION OF AMERICA, et al., Appellees.

No. 10–7062.

United States Court of Appeals, District of Columbia Circuit.

Argued May 12, 2011.Decided July 15, 2011.

Appeal from the United States District Court for the District of Columbia (No. 1:07–cv–01721).Denise M. Clark argued the cause and filed the briefs for appellant.Andrew M. Altschul argued the cause and filed the brief for appellees Teachers Insurance and Annuity Association and Standard Benefit Administrators.Karla Grossenbacher was on the brief for appellee National Academy of Sciences Group Total Disability Insurance Plan.Before: SENTELLE, Chief Judge, GINSBURG and GARLAND, Circuit Judges.Opinion for the Court filed by Chief Judge SENTELLE.SENTELLE, Chief Judge:

After injuring her back in a car accident, Sonya Pettaway filed for and received long-term-disability benefits from the insurance plan sponsored by her employer. After providing benefits to Pettaway for several years, the claims administrator of that plan determined that Pettaway no longer qualified under the plan and terminated her benefits. Pettaway brought suit pursuant to the Employee Retirement Income Security Act of 1974 against her employer and the administrators and underwriters of her employer-sponsored long-term-benefit disability insurance policy. Finding no violation of law, the district court granted the defendants' motion for summary judgment, and Pettaway appealed. Because the district court properly granted summary judgment, we affirm the district court's decision.

I.

Plaintiff-appellant Sonya Pettaway was employed by the National Academy of Sciences (“the Academy”) for seven years and participated in the National Academy of Sciences Group Total Disability Insurance Plan (“the Plan”), provided as a benefit for employees by the Academy. The Academy Plan was created pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et seq., and was governed by three separate documents. The first document was the Academy Total Disability Insurance Plan description (the “Plan Document”), a document created by the Academy which outlined general aspects of the Academy Plan. The second document was the Total Disability Insurance Plan Summary (the “Summary Plan Description”), a plain language summary of the participants' rights and obligations under the Academy Plan. The last document was the Group Total Disability Insurance Certificate (the “Policy Document”), a document created by Teachers Insurance and Annuity Association (“TIAA”), the Academy Plan's underwriter and claims administrator, which described the main features of the insurance under the group policy that TIAA issued to the Academy. At some time in or around the year 2003 (the record is unclear as to the exact date), Standard Benefit Administrators took over administration on behalf of TIAA. As there appears to be no legal distinction between the two entities relevant to this litigation, we will refer to TIAA and Standard jointly and separately as “TIAA.”

The Academy Plan provided disability benefits to eligible participants who qualified as “totally disabled” under the terms of the plan. The plan employed two different definitions of totally disabled, one concerning the first twenty-four months during which a participant received benefits and a more rigorous definition after that twenty-four month period. During the initial two-year period, the Academy Plan defined totally disabled as “being completely unable due to sickness, bodily injury, or pregnancy to perform the material and substantial duties of [the participant's] Normal Occupation.” Policy Document at 8.1. To continue to qualify as totally disabled after the initial period, the Academy Plan required participants to be unable “to perform the material and substantial duties of any occupation for which [the participant is] reasonably qualified by education, training, or experience.” Id. (emphasis added). During both periods, the plan also required that participants be under the “Regular Care” of a physician, defined as “regular in-person visits with [the participant's] Physician as frequently as required under standard medical practice to effectively manage and treat [the participant's] disabling sickness or injury.” Id. “Regular Care” also required participating in “a reasonable program of care and treatment that is, in accordance with accepted medical practice, expected to enhance your ability to work....” Id. In accordance with ERISA's statutory requirements, the Academy Plan provided participants with the opportunity for a “full and fair” internal administrative review of any denial of participant benefit claims.

In January of 2000, while employed by the Academy and while participating in the Academy Plan, Pettaway suffered a back injury in an automobile accident. The injury, which required back surgery, prevented Pettaway from performing her usual duties, so Pettaway filed the total disability claim underlying the present litigation. Agreeing that Pettaway qualified as “totally disabled” as defined by the Academy Plan for the first twenty-four months, TIAA approved Pettaway's claim and began providing disability benefits effective August 1, 2000. In September 2001, in preparation for the end of the initial two-year benefits period, TIAA began reviewing Pettaway's file and requesting additional medical information from Pettaway to determine if she would qualify for benefits under the Academy Plan's more rigorous definition of total disability. After performing an independent medical examination and assessing Pettaway's medical record, TIAA concluded that Pettaway did not qualify for benefits beyond the initial twenty-four month period and notified her that it would cease paying benefits after December 2002.

Pursuant to the Academy Plan's administrative review provisions, Pettaway requested an internal review of TIAA's decision to terminate her benefits. Pettaway failed, however, to provide TIAA with any new evidence to support her total disability claim. Noting that it had “no diagnostics or physical exam findings on file” to support Pettaway's complaint, TIAA affirmed its decision to cease paying benefits after December 2002. Letter from Iserdai Burston, Group Benefits Analyst, TIAA, to Sonya Pettaway (Jan. 14, 2003). TIAA notified Pettaway of the results of the administrative review, informed her that she still had 180 days to submit another written request for further review, and recommended that any future request should be accompanied by relevant medical documentation that would support her disability claim.

Over the course of the next six months, a series of events caused TIAA to reconsider its decision to cancel Pettaway's benefits. First, Pettaway returned to the “Regular Care” of her back surgeon, whom she had not seen for over two years. This was significant because, as discussed above, by resuming medical treatment and monitoring of her disability by her physician, Pettaway satisfied a significant condition of her long-term-disability policy. Furthermore, Pettaway aggravated her back injury twice, once during a slip-and-fall accident in January 2003 and again during a second car accident in April 2003. As a result of the additional injuries, Pettaway's back surgeon recommended that Pettaway undergo a second back surgery. In light of Pettaway's new injuries, her pending back surgery, and her return to the “Regular Care” of her surgeon, TIAA reinstated Pettaway's long term disability benefits in August 2003, requesting that she provide TIAA with an update of her medical condition after her back surgery.

Beginning in November 2003, TIAA began requesting from Pettaway updates on her medical status. In January 2004, Pettaway's back surgeon sent TIAA a brief letter stating his opinion that Pettaway could not “return to any type of gainful employment.” Letter from Bernard Stopak to Whom It May Concern (Jan. 23, 2004). In June 2004, Pettaway's surgeon, Doctor Stopak, sent a brief report to TIAA in which he explained that Pettaway had not yet undergone her second back surgery and that she was unable to “return to any type of work whatsoever at [that] time.” Bernard Stopak, Supplemental Neurological Report (June 24, 2004). The surgeon did not provide TIAA with any medical data or test results with either the letter or the report. Hoping to obtain objective medical data, TIAA scheduled an independent medical examination and a functional capacity examination for Pettaway, but she did not attend either test. On August 12, 2004, lacking “objective medical documentation to support [Pettaway's] inability to perform any occupation,” TIAA terminated Pettaway's benefits effective August 31, 2004. Letter from Carmen Lourensz, Senior Disability Benefits Analyst, Standard Benefit Administrators, to Sonya Pettaway (Aug. 12, 2004). As before, TIAA informed Pettaway that she had 180 days to request an internal administrative review of the termination decision and suggested that she include any new medical evidence with her request for review.

Pettaway wrote to TIAA in October 2004 requesting an administrative review of its decision to terminate her disability benefits. In response to TIAA's statement that it lacked independent medical evidence to support Pettaway's disability claim, Pettaway included with her request two additional medical reports from her surgeon. TIAA forwarded Pettaway's file and the new medical reports to its Quality Assurance Unit, a separate in-house group that, according to TIAA, exists specifically to assure that each claim receives a fair and objective review by individuals who were not involved in the original determination. In addition to reviewing Pettaway's existing file, the Quality Assurance Unit took several actions to develop its own evidence. First, it offered Pettaway another opportunity to attend...