Pettaway v. Teachers Ins.

• Decision Date: 30 March 2010
• Docket Number: Civil Action No. 07-1721 (RBW).
• Citation: 699 F.Supp.2d 185
• Parties: Sonya PETTAWAY, Plaintiff, v. TEACHERS INSURANCE AND ANNUITY ASSOCIATION OF AMERICA, et al., Defendants.
• Court: U.S. District Court — District of Columbia

699 F.Supp.2d 185

Sonya PETTAWAY, Plaintiff,

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

Civil Action No. 07-1721 (RBW).

United States District Court,District of Columbia.

March 30, 2010.

COPYRIGHT MATERIAL OMITTED.

Denise Marie Clark, Washington, DC, for Plaintiff.

Elisabeth Moriarty-Ambrozaitis, Karla Grossenbacher, Seyfarth Shaw, LLP, Washington, DC, Andrew Altschul, Buchanan Angeli Altschul LLP, Portland, OR, for Defendants.

MEMORANDUM OPINION

REGGIE B. WALTON, District Judge.

The plaintiff, Sonya Pettaway, brings this action under the Employee Retirement Income Security Act of 1974 (the “ERISA”), 29 U.S.C. §§ 1132(a)(1)(B), (a)(3), and 1133 (2006), against the Teachers Insurance and Annuity Association of America (the “Teachers' Association”), Standard Benefit Administrators (the “SB Administrators”), and the National Academy of Sciences Group Total Disability Insurance Plan (the “Academy Plan” or “Plan”) (collectively the “defendants”) alleging that the defendants violated the ERISA by wrongfully terminating her benefit coverage and by not following proper procedures in the course of administering her claim. See Complaint (“Compl.”) ¶¶ 1, 13, 16-17. The defendants deny the allegations. See Answer of the National Academy of Sciences Group Total Disability Insurance Plan (“Def. Acad.'s Answer”) ¶¶ 1, 16-20; Answer of the Teachers' Association and the SB Administrators (“Defs. Teachers'/Adm'or's Answer”) ¶¶ 16-19. The Court previously ruled that the plaintiff's claims were not time-barred under the doctrine of equitable tolling, Pettaway v. Teachers Ins. & Annuity Ass'n of America, 547 F.Supp.2d 1, 7-8 (D.D.C.2008) (Walton, J.), and currently before the Court are the parties' cross-motions for summary judgment. ¹ Upon consideration of the parties written submissions and the administrative record in this case, for the reasons set forth below the Court must deny the plaintiff's motion and grant summary judgment to the defendants.

I. BACKGROUND

A. The Academy Plan

During the time period relevant to this litigation, the plaintiff was employed by the National Academy of Sciences (the “Academy”) and enrolled in the disability plan it sponsored as a benefit for its employees. Compl. ¶ 6; Def. Acad.'s Answer ¶ 6. See generally Def. Acad.'s Mem., Attach. A to Declaration (“Decl.”) of Sheila Wright (National Academy of Sciences Total Disability Insurance Plan). The Academy Plan is accompanied by a Summary Plan Description. See generally Def. Acad.'s Mem., Attach. B to Decl. of Sheila Wright (Total Disability Insurance Plan Summary Plan Description) (the “Plan Description”). ² The Academy Plan was created pursuant to the ERISA as an employee benefit plan, it is underwritten by the Teachers' Association, ³ Compl. ¶¶ 4, 7; Defs. Teachers'/Adm'or's Answer ¶ 7, and the SB Administrators serve as the administrator of the Academy Plan, ⁴ Compl. ¶ 5; Pl.'s Stmt. ¶ 6; Defs. Teachers'/Adm'or's Answer ¶ 5.

The Academy Plan states that participants “shall be entitled to benefits under the Plan as set forth in the Policy,” Acad. Plan at 4. 1, which is identified as “the Group Policy [number] D1129 issued by the [Teachers' Association],” id. at 1.6. See generally Def. Acad.'s Mem., Attach. C to Decl. of Sheila Wright, (D-1129 Group Total Disability Insurance Certificate) (the “Policy”) at A.R. 26-169. ⁵ If a participant qualifies, she receives benefits in the form of monthly payments equal to sixty percent of her basic monthly salary, up to a certain amount, as well as annuity premium benefits to compensate for lost retirement contributions. Id., at A.R. 164-65.

According to the Policy, benefits are awarded to participants who are “totally disabled” or have a “total disability.” Id., at A.R. 165. The terms are used interchangeably and are defined as follows:

(1) for the Elimination Period shown in Part I, and for the next 24 months, being completely unable due to sickness,

bodily injury, or pregnancy to perform the material and substantial duties of your Normal Occupation; and

(2) after those 24 months, being unable due to sickness, bodily injury, or pregnancy to perform the material and substantial duties of any occupation for which you are reasonably qualified by education, training, or experience.

You must be under the Regular Care of a Physician, other than yourself or a member of your family.

Id., at A.R. 143. ⁶ The Elimination Period applicable to the plaintiff's claim is six months, meaning that after receiving benefits for twenty four months, the definition of total disability shifts from the first definition to the second. See id., at A.R. 165 (providing the two definitions of the Elimination Period). In other words, and relevant to the dispute in this case, in order to receive benefits after the first twenty four months of payments, participants must be under the “Regular Care of a Physician” and demonstrate they are “unable due to sickness, bodily injury, or pregnancy to perform the material and substantial duties of any occupation for which [they] are reasonably qualified by education, training, or experience.” Id., at A.R. 143.

In order to demonstrate their entitlement to benefits, participants must provide “proof of [their] Total Disability” to the Teachers' Association. Id., at A.R. 146. According to the Policy, examples of the kinds of proof required are “statements of treating physicians; copies of test reports or examinations; x-rays; hospital records; medical examinations by impartial specialists at [the Teachers' Association's] expense; investigations conducted by [the Teachers' Association] or outside agencies.” Id., at A.R. 146. The Plan Description adds that the “insurance carrier may require a medical exam.” Def. Acad.'s Mem., Attach. B to Decl. of Sheila Wright (Plan Description) at 8. The Policy also states that “[w]ritten proof of continued Total Disability is required at reasonable intervals to be determined by [the Teachers' Association],” and further indicates that “[a]ll proof must be satisfactory to [the Teachers' Association].” Def. Acad.'s Mem., Attach. C to Decl. of Sheila Wright at A.R. 146.

With respect to the Teachers' Association's role in administering claims, it is given that authority from two sources. Def. Acad.'s Mem., Attach. B to Decl. of Sheila Wright (Plan Description) at 3, 8. The first source for this authority is found in the Plan Description under the section entitled “Total Disability,” which provides that “the determination of your total disability is made solely by the insurance carrier[,]” id., Plan Description at 3, and the Teachers' Association is listed as the insurer for the Academy Plan in a later section of the Plan Description titled “Summary of ERISA Information,” id., Plan Description at 12. The second source for the authority, also found in the Plan Description under the heading “Claims Procedures,” states that the “[Teachers' Association] has full power and discretionary authority under the group policy to control and manage the operation and administration of the group policy, subject only to the participant's rights of review and appeal under the group policy.” Id., Plan Description at 8. The same section declares that the

[Teachers' Association] has all the powers necessary to accomplish these purposes in accordance with the terms of the group policy including, but not limited to, the following: (1) determining the benefits and amounts payable therefor[e] to any participant or beneficiary; (2) establishing and administering a claims review and appeal process; and (3) interpreting, applying, and administering the provisions of the group policy.

Id., Plan Description at 8.

If the Teachers' Association denies an application for benefits, the Policy states that the Teachers' Association must send a written denial to the claimant “specify[ing] the reason(s) for the denial, the provisions of the contract on which the denial is based, and how to ask for a review.” Def. Acad.'s Mem., Attach. C to Decl. of Sheila Wright at A.R. 147. Participants therefore have the right to appeal a denial of an application for benefits. Id.

B. The Plaintiff's Medical Condition

The plaintiff, who is college educated, was employed as a technical trainer at the Academy and was enrolled in the Academy Plan when she injured her back in an automobile accident on January 10, 2000. Pl.'s Stmt. ¶¶ 1, 3; Def. Acad.'s Stmt. ¶¶ 1, 13. She did not report to work the next day and remained on leave until she eventually underwent back surgery in September 2000. Pl.'s Stmt. ¶¶ 3-4; Def. Acad.'s Stmt. ¶ 13. On October 5, 2000, the plaintiff was approved for long term disability benefits. Def. Acad.'s Stmt. ¶ 13.

About a year later, in November 2001, the Teachers/Administrator started contacting the plaintiff requesting updates regarding her condition. Id. ¶ 17. In January 2002, the plaintiff provided to the Teachers/Administrator records from her treating physician, Dr. Bernard Stopak, a neurosurgeon. Pl.'s Stmt. ¶¶ 10, 13; Def. Acad.'s Stmt. ¶ 19. Dr. Stopak's records reflected that he had not seen the plaintiff in about a year, and he later advised the Teachers/Administrator that he did not have proper authorization to conduct further diagnostic studies of her condition. Def. Acad.'s Stmt. ¶ 19. In light of this information, the Teachers/Administrator asked the plaintiff to undergo an Independent Medical Examination (“IM Examination”) to assess her current condition. Id. ¶ 20.

After some scheduling difficulties, ⁷ the plaintiff underwent the IM Examination on August 28, 2002. Pl.'s Stmt. ¶ 11. Dr. Arthur Kobrine, the examining physician, reported that the plaintiff was a “healthy appearing female who gets up easily from the chair[,] ... walks in a normal fashion [,]” and walks “equally well on heels and toes.” Defs. Teachers'/Adm'or's Mem., Ex. A to Decl. of Andrew M. Altschul at A.R. 321. Examination of her lower extremities showed “normal...