Shatto v. Liberty Life Assurance Co. of Bos., CIVIL ACTION NO. 14-5653
| Decision Date | 26 September 2016 |
| Docket Number | CIVIL ACTION NO. 14-5653 |
| Parties | CALVIN SHATTO, Plaintiff, v. LIBERTY LIFE ASSURANCE COMPANY OF BOSTON, Defendant. |
| Court | U.S. District Court — Eastern District of Pennsylvania |
Currently pending before the Court are the Motion for Summary Judgment by Plaintiff Calvin Shatto ("Plaintiff") and the Motion for Summary Judgment by Defendant Liberty Life Assurance Company of Boston ("Defendant"). For the following reasons, Plaintiff's Motion for Summary Judgment is denied, and Defendant's Motion for Summary Judgment is granted.
Defendant provides long-term disability insurance to employees of Estes Express pursuant to a group disability income policy ("the Policy"). (Def.'s Statement of Material Facts ("DSMF") ¶ 1.)2 Plaintiff was covered under the Policy through his employment as a truck driver with Estes Express. (Id.)
On May 30, 2012, Defendant received notice of Plaintiff's claim for benefits under the Policy. (Id. ¶ 2.) Plaintiff began medical leave from his employment on May 28, 2012 after being involved in a motorcycle accident. (Id.) As a result of the accident, Plaintiff suffered multiple injuries, including a head injury, injuries to his back and hip, and a closed pelvic fracture. (Id. ¶ 3.)
Shortly before Plaintiff exhausted his short-term disability benefits, Defendant began investigating his eligibility for long-term disability benefits under the Policy. (Id. ¶ 4.) Based on Plaintiff's date of disability, and taking into account the Policy's 180-day elimination period for long-term benefits, Plaintiff was potentially eligible for long-term disability benefits effective November 26, 2012. (Id.) In order to be eligible for long-term disability benefits under the Policy, Plaintiff's conditions must prevent him from performing the material duties of his own occupation during the elimination period as well as the first twelve months of disability. (Id. ¶ 5.) Subsequent to that period of time, Plaintiff's conditions must prevent him from performing the material and substantial duties of any occupation. (Id.) The Policy defines "any occupation" as "any occupation that the Covered Person is or becomes reasonably fitted by training, education, experience, age, physical and mental capacity."
As part of Defendant's investigation of Plaintiff's eligibility for long-term disability benefits, Defendant received records from Dr. Carol Copeland, an orthopedic surgeon who had performed various surgeries on Plaintiff following the motorcycle accident. (Id. ¶ 6.) Defendant also received information regarding the job duties associated with Plaintiff's occupation as a truck driver. (Id.) Defendant approved Plaintiff's claim for long-term disability benefits underthe Policy based on Plaintiff's medical records and the job duties information, and notified Plaintiff of its approval of his claim in a letter dated October 23, 2012. (Id. ¶ 7.) Defendant continued to request updated medical records from Plaintiff's treating physicians and medical providers, and, based upon those records, Plaintiff continued receiving long-term disability benefits under the Policy. (Id. ¶ 8.)
On May 29, 2013, Defendant sent Plaintiff a letter reminding him of the Policy's change in definition of "disability" that would occur on November 26, 2013, at which time Plaintiff would have received twelve months of long-term disability benefits. (Id. ¶ 9.) In the letter, Defendant advised Plaintiff that it was gathering information to assess his continued eligibility for benefits following the change in definition of disability. (Id.) Defendant received various records from some of Plaintiff's treating providers in response to its September 2013 requests for updated medical records, including information from Dr. Copeland, Plaintiff's treating orthopedic surgeon, which indicated that she had not seen or treated him since May 23, 2013. (Id. ¶ 10 (citing LL-0555.) Based on that information, and the absence of any significant medical data from any other treating physicians, Defendant informed Plaintiff that, effective November 25, 2013, his benefits were discontinued due to the change in definition of disability under the Policy and the absence of any clinical evidence to support a finding that he was unable to perform the duties of any occupation, as defined in the Policy. (Id.) In response to the November 25, 2013 letter, Plaintiff submitted an administrative appeal along with updated medical records from Dr. Copeland and other treating physicians. (Id. ¶ 11.) On February 19, 2014, Defendant informed Plaintiff that his benefits were being reinstated pending its completion of an administrative review of the additional medical records and an assessment of his eligibility for benefits under the "any occupation" definition of disability. (Id.) Defendant also informedPlaintiff in the February 19, 2014 letter that, while he would continue to receive benefits during its review under the "any occupation" standard, payment of those benefits as well as the payment of any future benefits should not be interpreted as an admission of present or ongoing liability. (Id.)
Following receipt of the updated medical records, Defendant requested a review of the records by an independent physician who was board certified in Physical Medicine and Rehabilitation ("PM&R"). (Id. ¶ 13.) On March 7, 2014, Defendant received a peer review report completed by Dr. Philippe Chemaly, who is certified in PM&R. (Id. ¶ 14.) In his report, Dr. Chemaly summarized the various medical records he had reviewed and expressed an overall opinion that Plaintiff was capable of sustaining full-time work with restrictions and limitations consistent with a sedentary work capacity. (Id.) Dr. Chemaly's report included the following:
Based on my review of the medical documentation, the medical diagnosis noted [in this report], in combination, particularly neck and right hip pain noted with activities, including prolonged sitting, standing, walking and lifting and carrying and reaching, along with mildly antalgic gait, with documentation noting that he does not need any gait aides and is moving and was able to go up and down stairs carrying things, doing work around the house, and getting ready to move and is not taking any more pain medicines, other than occasional Oxycodone[,] with mildly restricted range of motion of the right hip and would translate to the following restrictions and limitations: allowance for symptom-relieving position breaks every hour for 5 to 10 minutes from sitting, standing or walking position; six hours of sitting in an eight hour day; up to two hours a day of standing and walking, but not consecutive; stair climbing occasionally and, again, 5 to 10 minute break between one hour of walking and standing for a total of two hours in an eight hour day. Lifting, carrying, pushing and pulling would be limited to 20 lbs occasionally with no repetitive lifting, carrying, pushing or pulling. Reaching below waist and above shoulder would be limited to occasionally. Reaching between waist and shoulder would be unrestricted. Squatting, bending and stooping would be limited to occasionally. Fine motor activities, including grasping, gripping and typing would be unrestricted. Lifting above shoulder would be limited to 5 lbs occasionally with,again, lifting, carrying, pushing and pulling limited to 20 lbs occasionally below shoulder and 5 lbs occasionally above shoulder and based on my review of the medical documentation, these restrictions and limitations would be applicable for the one year, as the claimant is continuing to improve and the medical file can be re-evaluated at that time.
(Id. ¶ 15 (quoting McGee Decl., Ex. B, Administrative Record at LL-0365-LL-0366).)3
After receiving Dr. Chemaly's March 7, 2014 report, Defendant forwarded Plaintiff's file to its vocational rehabilitation department for completion of a transferrable skills analysis and labor market study. (Id. ¶ 16.) On March 13, 2014, Melissa Michuda, a case manager in Defendant's vocational rehabilitation department, prepared a report which was premised on the physical restrictions identified in Dr. Chemaly's March 7, 2014 peer review report, as well as information Plaintiff provided on a training, education, and experience form he submitted as part of the administrative process. (Id. ¶¶ 16-17.) Ms. Michuda identified a number of alternative occupations consistent with the physical restrictions described in Dr. Chemaly's report, including scale house operator, documentation billing clerk, assembler (bench), and inspector (bench). (Id. ¶ 17.) Plaintiff maintains that the occupations Ms. Michuda identified were not within Dr. Chemaly's restrictions and limitations because they were not actually sedentary occupations. (Pl.'s Resp. to DSMF ¶17.)
On March 20, 2014, Defendant received a restrictions form from Dr. Copeland which she had completed on March 13, 2014. (DSMF ¶ 18.) Dr. Copeland checked boxes on the form indicating her opinion that, notwithstanding his physical conditions, Plaintiff was capable of performing full-time work at a sedentary level, with lifting and carrying up to ten pounds occasionally; sitting over fifty percent of the time, and standing/walking occasionally. (LL-0313.) Dr. Copeland's opinion regarding Plaintiff's capabilities was consistent with the restrictions which were listed in Dr. Chemaly's March 7, 2014 report. (DSMF ¶ 18.)
On March 26, 2014, Defendant issued a determination letter informing Plaintiff that, effective January 26, 2014, it was discontinuing his receipt of long-term disability benefits under the Policy. (Id. ¶ 19.) In that letter, Defendant discussed the evidence that was reviewed and received during the course of its administrative review, including the results of Dr. Chemaly's peer review and Dr. Copeland's March...
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