Ringwald v. the Prudential Ins. Co. of Am.

• Decision Date: 14 December 2010
• Docket Number: No. 4:08CV801–DJS.,4:08CV801–DJS.
• Citation: Ringwald v. the Prudential Ins. Co. of Am., 754 F.Supp.2d 1047 (E.D. Mo. 2010)
• Parties: Eric S. RINGWALD, Plaintiff,v.The PRUDENTIAL INSURANCE COMPANY OF AMERICA, Defendant.
• Court: U.S. District Court — Eastern District of Missouri

754 F.Supp.2d 1047

Eric S. RINGWALD, Plaintiff,

v.The PRUDENTIAL INSURANCE COMPANY OF AMERICA, Defendant.

No. 4:08CV801–DJS.

United States District Court, E.D. Missouri, Eastern Division.

Dec. 14, 2010.

Deborah A. Arbogast, Attorney at Law, Clayton, MO, Gregory A. Oliphant, Law Office of Gregory A. Oliphant, St. Louis, MO, Sophie Woodworth, Holman Schiavone, LLC, Kansas City, MO, for Plaintiff.Richard J. Pautler, Thompson Coburn, LLP, St. Louis, MO, for Defendant.

ORDER

DONALD J. STOHR, District Judge.

Plaintiff Eric S. Ringwald challenges the discontinuation of his long-term disability benefits under a group insurance plan (“the Plan”) in which he participated through his employer, Harrah's Casino. The Plan, identified as “Harrah's Operating Company, Inc. Short Term Disability–Grade 17 and below/Long Term Disability–Grade 22 and below,” is governed by the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001. Now before the Court is defendant The Prudential Insurance Company of America's motion for summary judgment [Doc. # 41]. The motion has been fully briefed by the parties and is now ripe for disposition.

Summary Judgment Standard

In determining whether summary judgment should issue, the facts and inferences from these facts are viewed in the light most favorable to the non-moving party, and the burden is placed on the movant to establish both the absence of a genuine issue of material fact and that it is entitled to judgment as a matter of law. Fed.R.Civ.P. 56(c); Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 586–87, 106 S.Ct. 1348, 89 L.Ed.2d 538 (1986); Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 247, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986); Celotex Corp. v. Catrett, 477 U.S. 317, 322, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986). A fact is “material” if it is a legal element of a claim under applicable law that might affect the outcome of the case. Anderson, 477 U.S. at 248, 106 S.Ct. 2505. An issue of fact is “genuine” if the evidence is such that a reasonable fact finder could find for the non-moving party. Id. Once the movant has met its burden, the non-moving party may not rest on the allegations in its pleadings but by affidavit and other evidence must set forth specific facts showing that a genuine issue of material fact exists. Fed.R.Civ.P. 56(e).

Facts

The following facts are undisputed for purposes of the instant motion. In April 2004, plaintiff was a Table Game Dealer at Harrah's. At that time, plaintiff was a participant in the Plan within the meaning of ERISA § 3(7). The Plan, which was issued to Harrah's by defendant, is an employee welfare benefit plan within the meaning of ERISA § 3(1). In relevant part, the long-term disability coverage provides as follows:

BENEFIT INFORMATION

How Does Prudential Define Disability?

You are disabled when Prudential determines that:

• you are unable to perform the material and substantial duties of your regular occupation due to your sickness or injury; and

• you have a 20% or more loss in your indexed monthly earnings due to that sickness or injury.

After 24 months of payments you are disabled when Prudential determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.

* * *

What Disabilities Have a Limited Pay Period Under Your Plan?

Disabilities, which, as determined by Prudential, are due in whole or part to mental illness have a limited pay period during your lifetime.

The limited pay period for mental illness is 24 months during your lifetime.

* * *

Mental illness means a psychiatric or psychological condition regardless of cause. Mental illness includes but is not limited to schizophrenia, depression, manic depressive or bipolar illness, anxiety, somatization, substance related disorders and/or adjustment disorders or other conditions. These conditions are usually treated by a mental health provider or other qualified provider using psychotherapy, psychotropic drugs, or other similar methods of treatment as standardly accepted in the practice of medicine.

Doc. # 9–1, p. 24, 32–33.

In October 2005, plaintiff submitted a claim to defendant for long-term disability benefits, claiming he had been disabled since April 16, 2004. He claimed to be unable to work because of depression and HIV. Defendant initially denied the claim, but after reconsidering it through the established appeals process, concluded that plaintiff was disabled by his mental illness. Defendant then paid plaintiff long-term disability benefits for 24 months from July 17, 2004 through July 16, 2006. Defendant denied long-term benefits beyond 24 months, citing the limitation on benefits for disabilities caused in whole or part by mental illness. Plaintiff was regularly treated by a psychiatrist, Dr. Kevin Miller, and a psychologist, Dr. Alice Vliestra, ¹ and since 2004, plaintiff has been diagnosed by numerous doctors with depression and bipolar disorder, and prescribed Lamictal, Zoloft, and Lexapro for these illnesses.

Administrative Record

The administrative record in this case consists of nearly 500 pages of medical reports, medical records, and correspondence. The Court chronologically summarizes the relevant portions of the record below.

In 2005, plaintiff was examined by Dr. Kenneth Bohm, a clinical psychologist, as part of a custody proceeding in state court to determine whether plaintiff was fit to serve as a parent to his child. Dr. Bohm noted that plaintiff was prescribed Zoloft as an antidepressant. He suggested that plaintiff be prescribed mood stabilizing or antipsychotic medication. Dr. Bohm's diagnosis of plaintiff included schizoaffective disorder and personality disorder.

On May 5, 2006, Dr. Morton Singer, one of plaintiff's treating physicians, wrote to defendant's claim representative “to appeal the denial of Mr. Ringwald's disability claim.” Doc. # 10, p. 230. He stated that:

This patient was experiencing progressively symptomatic HIV disease from December 2003 through July 2004 when he resumed antiretroviral therapy. He was not receiving medication for his HIV infection due to adverse effects he had experienced in the past.

In addition to the HIV related thrombocytopenia which developed in 2002 and persisted until resuming treatment in July 2004, he was also experiencing HIV related wasting syndrome. He sustained a 20 pound weight loss or greater than 10% loss body weight in the preceding 12 months. His weight declined from 171 pounds to 151 pounds in March 2004 which is documented in his medical records. This meets criteria for CDC defined HIV Wasting Syndrome.

During this same time period off of antiretroviral therapy, his CD4 lymphocyte count declined from 520 to 280 and his HIV viral load increased from 22000 to 60000. The HIV infection had become more active with increased viral burden, immunodeficiency, wasting and weight loss as well as progressive fatigue. This was responsible for Mr. Ringwald's disability.

He may also have a sleep disorder for which he was taking Valium at that time, but I do not believe his use of Valium at bedtime was causing his fatigue, weight loss, wasting, and progressive immunodeficiency. In fact, when Mr. Ringwald restarted antiretroviral therapy in July 2004, his CD4 lymphocyte count increased to 490 and HIV viral load declined to undetectable levels. His weight increased to 172 pounds within six months and his fatigue improved.

His disability in March 2004 was due to his HIV disease and improved with treatment starting in July 2004. Please reconsider your denial of his claim.

Id. at 230–31.

On May 23, 2006, Dr. Vliestra wrote a letter on plaintiff's behalf concerning his treatment. The letter was addressed “To Whom It May Concern” and appears to be written in regards to plaintiff's parenting abilities. Dr. Vliestra noted that their “counseling sessions focused on assessing his depression, parenting capacities, and family support, and then focused on a treatment plan for establishing healthier relationships.” Id. at 157. Her letter concluded:

He currently is on medication which has improved his ability to focus and concentrate. His original depression has improved significantly. He informs me that he is fully cooperating and complying with all court requests in order to be a parent for [his minor child]. I believe he is capable of parenting a child.

Id.

On May 30, 2006, defendant's claims representative responded to Dr. Singer regarding his May 5, 2006, assessment of plaintiff's condition. Defendant's representative noted that Dr. Singer's assessment indicated that “with treatment, Mr. Ringwald's CD4 count increased, his viral load decreased, his weight increased to 172 within 6 months, and his fatigue improved.” Id. at 468. Defendant's representative asked Dr. Singer to “[p]lease advise our office if, given these improvements, you believe that Mr. Ringwald remained unable to work after July, 2004. If so, please advise for what period(s) he remained disabled and how he was impaired.” Id.

In June 2006, Dr. Singer responded to defendant's representative's request for additional information concerning plaintiff's disability claim. He stated that plaintiff:

has remained disabled since 2004 despite improvement in his immune function. He has had persistent depression since 2004 causing impairment in his cognitive function and his ability to work. His ability to concentrate has been severely compromised as well as his ability to function socially. He has been seen by several psychiatrists and neurologist [sic] in the past two years and most recently has been started on Lexapro and Risperdal. His disability remains ongoing.

Id. at 225.

At the end of July, 2006, Dr. Vliestra wrote a letter to plaintiff responding to his request for a statement concerning their counseling. Dr. Vliestra stated that plaintiff “has been in counseling with me since May 2005 to the...