Pfifer v. Sedgwick Claims Mgmt. Servs. Inc.

• Court: U.S. District Court — Southern District of Texas
• Writing for the Court: Kenneth M. Hoyt, United States District Judge
• Citation: Pfifer v. Sedgwick Claims Mgmt. Servs. Inc., 414 F.Supp.3d 1024 (S.D. Tex. 2019)
• Decision Date: 30 September 2019
• Docket Number: Civil Action No. 4:18-CV-1296
• Parties: Allison PFIFER, Plaintiff, v. SEDGWICK CLAIMS MANAGEMENT SERVICES INC., Defendant.

414 F.Supp.3d 1024

Allison PFIFER, Plaintiff,

v.SEDGWICK CLAIMS MANAGEMENT SERVICES INC., Defendant.

Civil Action No. 4:18-CV-1296

United States District Court, S.D. Texas, Houston Division.

Signed September 30, 2019

Madison Tate Donaldson, Marc Stanley Whitehead, Marc Whitehead Assoc., Houston, TX, for Plaintiff.

Esteban Shardonofsky, Seyfarth Shaw LLP, Houston, TX, Nathan P. Lusignan, Christopher M. Busey, Seyfarth Shaw LLP, Chicago, IL, for Defendant.

MEMORANDUM OPINION AND ORDER

Kenneth M. Hoyt, United States District Judge

I. INTRODUCTION

The plaintiff, Allison Pfifer ("Pfifer" or "the plaintiff"), commenced the instant action against the defendant, Sedgwick Claims Management Services, Inc. ("Sedgwick"), pursuant to the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1132 (a)(1)(B),¹ alleging that Sedgwick, the Claims Administrator, wrongfully denied her claims for short-term disability ("STD") benefits pursuant to the 3M Short Term Disability Plan and long-term disability ("LTD") benefits pursuant to the 3M Long Term Disability Plan. Both plans are sponsored by 3M Company ("3M") and governed by ERISA. The plaintiff seeks compensation for denied benefits, interest and attorneys' fees and costs.

Pending before the Court are Sedgwick's motion for summary judgment and memorandum of law in support thereof (Dkt. No. 21), the plaintiff's response in opposition to Sedgwick's motion for summary judgment (Dkt. No. 24), Sedgwick's reply (Dkt. No. 25), the plaintiff's cross-motion for summary judgment (Dkt. No. 22) and Sedgwick's response in opposition to the plaintiff's cross-motion for summary judgment (Dkt. No. 23). After having carefully considered the motions, responses, reply, the record and the applicable law, the Court determines that Sedgwick's motion for summary judgment should be GRANTED ; and the plaintiff's cross-motion for summary judgment should be DENIED .

II. FACTUAL BACKGROUND

The plaintiff, Pfifer, is a 64-year old female who worked as a "Lead Proposal Writer² " for 3M. During the relevant time, the plaintiff participated in a 3M-sponsored Short Term Disability Plan ("STD Plan") and Long Term Disability Plan ("LTD Plan") for eligible employees, effective January 1, 2016. Pursuant to the specific terms of the STD Plan and the LTD Plan, 3M's Director, Total Rewards Program Management, is designated as the Plan Administrator with the authority to delegate "its full and final discretionary power and authority with respect to benefit determinations to the Claims Administrator." (Dkt. No. 21, App. 3 at 3M00001479; App. 4 at 3M00001446.). Sedgwick is identified as the Claims Administrator with the discretionary authority to interpret the Plans' terms and decide questions of eligibility for coverage. (Id. at 3M00001482, 3M00001449).

An employee participant's eligibility for benefits under the STD Plan is determined as follows:

Eligibility for Benefits

You are eligible to receive [STD] benefits under the Plan only if the Claims Administrator determines that:

• You are eligible and covered under the Plan;

• You meet the Plan's definition of Disabled (including providing Objective Medical Evidence of your disability, when requested by the Claims Administrator);

• Your disability is not one excluded from coverage under the Plan; and

• You satisfy all other eligibility requirements under the Plan.

To be eligible for STD benefits, you must provide sufficient Objective Medical Evidence of your disability. The Claims Administrator determines whether you have provided sufficient Objective Medical Evidence of your disability and may require more than one examination. You may be required to provide the Claims Administrator with continuing proof of your disability and prove that you are under the regular care of a physician. You must provide this proof at your own expense and within the timeframe required by the Claims Administrator. Failure to comply with the Claims Administrator's requests may impact your eligibility for and payment of benefits.

(Id. at 3M00001461.). The term "disabled" is defined under the STD Plan as follows:

Disabled Defined

You are considered Disabled for purposes of the Plan only if the Claims Administrator determines that due to an illness, injury, pregnancy or other medical condition you are unable to perform the material duties of:

• Your regular and customary occupation at 3M; or

• Any other appropriate job offered by 3M.

In addition, you must be under the regular and continuous care of a licensed Health Care Provider, unless such treatment is not medically necessary given the nature of your disability.

...

The Claims Administrator determines whether or not you are Disabled on the basis of Objective Medical Evidence and any other relevant evidence.

Please Note : Social Security's decision is not considered when determining your eligibility for STD benefits. Therefore, if the Social Security Administration approves you for disability benefits, it doesn't mean you are eligible for 3M STD benefits.

(Id. ).

An employee participant's eligibility for benefits under the LTD Plan is determined as follows:

Eligibility for Benefits

You are eligible to receive [LTD] benefits under the Plan only if the Claims Administrator determines that:

• You are eligible and covered under the Plan;

• You meet the Plan's definition of Disabled (including providing Objective Medical Evidence of your disability, when requested by the Claims Administrator);

• Your disability is not one excluded from coverage under the Plan;

• You have exhausted your 3M STD benefits; and

• You satisfy all other eligibility requirements under the Plan.

To be eligible for LTD benefits, you must provide sufficient Objective Medical Evidence of your disability. The Claims Administrator determines whether you have provided sufficient Objective Medical Evidence of your disability and may require more than one examination. You may be required to provide the Claims Administrator with continuing proof of your disability and prove that you are under the regular care of a physician. You must provide this proof at your own expense and within the timeframe required by the Claims Administrator. Failure to comply with the Claims Administrator's requests may impact your eligibility for and payment of benefits.

(Id. at 3M00001428.). The term "disabled" is defined under the LTD Plan as follows:

Disabled Defined

You are considered Disabled for purposes of the [LTD] Plan only if the Claims Administrator determines the following:

• During the First 18 Months of LTD Benefit Payments: Due to an illness, injury, pregnancy or other medical condition you are unable to perform the material duties of:

• Your regular and customary occupation at 3M; or

• Any other appropriate job offered by 3M.

In addition, you must be under the regular and continuous care of a licensed Health Care Provider, unless such treatment is not medically necessary given the nature of your disability.

• After the First 18 Months of LTD Benefit Payments:

• You are totally Disabled;

• You are unable to perform the material duties of any occupation or employment for which you are, or may become, reasonably qualified by training, education or experience; and

• You are unable to earn 70% or more of your Planned Total Cash Compensation (as defined under the "Planned Total Cash Compensation Defined" topic under this section) while working in any occupation or employment.

In addition, you must be under the regular and continuous care of a licensed Health Care Provider, unless such treatment is not medically necessary given the nature of your disability.

Please Note : Social Security's decision is not considered when determining your eligibility for LTD benefits. Therefore, if the Social Security Administration approves you for disability benefits, it doesn't mean you are eligible for 3M LTD benefits.

(Id. ).

On May 11, 2016, the plaintiff ceased actively working for 3M due to severe pain in her right knee, including "swelling, stiffness, a decreased range of motion, changed gait and multiple falls." (Dkt. No. 1 at ¶ 24.). The plaintiff alleges that she became "disabled" on May 11, 2016 and, as such, filed a claim for STD benefits through 3M's STD Plan administered by Sedgwick. Pursuant to a letter dated May 12, 2016, Sedgwick sent the plaintiff necessary forms to be executed and returned to it by May 27, 2016, as support for her claim of disability. The letter further advised the plaintiff as follows: "Failure to meet the eligibility requirements for Short Term Disability Benefits or failure to timely submit the required forms will result in delay or denial of benefits ." (Dkt. No. 21, App. 1 at 3M0000234).

On May 27, 2016, personnel from one of the plaintiff's treating physicians' offices contacted Sedgwick and left a message indicating that it would not be able to complete the necessary forms on time. By letter dated May 31, 2016, Sedgwick denied the plaintiff's claim for STD benefits, informing her that "due to the failure or refusal to submit objective medical evidence, there is insufficient information to support that you are unable to perform the material duties of your regular and customary occupation at 3M, or any other appropriate job offered by 3M, due to an illness, injury, pregnancy, or other medical condition." (Id. at 3M0000140 - 42). Sedgwick's letter further informed the plaintiff of her right to seek review of its decision, submit additional evidence or obtain a reasonable accommodation. (Id. ).

On June 3, 2016, the plaintiff filed a request for an appeal of Sedgwick's decision to deny her claim for STD benefits. As support for her appeal, she included office notes from Dr. Xinmin Tang, her treating physician, dated May 24, May 31, June 2 and June 3, 2016, along with a radiology report from Dr. Jonathan Squires dated May 28, 2016. (Id. at 3M0000119 - 27). An Attending Provider Statement executed by Dr. Tang was also encompassed amongst the medical documentation submitted by the plaintiff in support of...