Simmons v. Prudential Ins. Co. of America

• Decision Date: 15 May 2008
• Docket Number: No. 4:06-CV-212-D.,4:06-CV-212-D.
• Citation: 564 F.Supp.2d 515
• Court: U.S. District Court — Eastern District of North Carolina
• Parties: Oscar SIMMONS, Plaintiff, v. PRUDENTIAL INSURANCE COMPANY OF AMERICA, Defendant

564 F.Supp.2d 515

Oscar SIMMONS, Plaintiff, v. PRUDENTIAL INSURANCE COMPANY OF AMERICA, Defendant

No. 4:06-CV-212-D.

United States District Court, E.D. North Carolina, Eastern Division.

May 15, 2008.

COPYRIGHT MATERIAL OMITTED

David J. Ward, The Ward Law Firm, Raleigh, NC, Diane Baysinger, Cary, NC, for Plaintiff.

Stephen A. Dunn, James M. Mason, Emanuel & Dunn, PLLC, Raleigh, NC, for Defendant.

ORDER

JAMES C. DEVER III, District Judge.

Oscar Simmons ("plaintiff or "Simmons") seeks continuation of his group life insurance coverage under the Extended Death Benefit During Total Disability provision ("Extended Death Benefits" or "Benefits") of Group Contract No. G-41800 ("the Plan"). The Plan is an employee welfare benefit plan regulated by the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001 et seq., that defendant The Prudential Insurance Company of America ("defendant" or "Prudential") issued.¹ Acting in its capacity as Claims Administrator of the Plan, Prudential denied Simmons' claim for Extended Death Benefits on May 12, 2006. Simmons filed suit alleging a cause of action under ERISA.² On December 6, 2007, Prudential moved for summary judgment. On December 9, 2007, Simmons also moved for summary judgment. As explained below, Prudential's motion for summary judgment is granted, and Simmons' motion for summary judgment is denied.

I.

On April 30, 2004, plaintiff ceased working for Hatteras Yachts, a ship-building facility in New Bern, North Carolina, alleging disability. R. at A072.³ Shortly thereafter, plaintiff filed for Long-Term Disability ("LTD") Benefits under the Plan, which provides coverage for qualified employees of Hatteras Yachts. See id. at B067-74. Prudential is Claims Administrator of the Plan, and is granted discretionary authority to interpret the terms of the Plan and to determine eligibility for Plan benefits. Aff. of Edith Ewing Ex. A, p. 55. As a result of Simmons' LTD Benefits claim, Prudential also considered plaintiffs eligibility for Extended Death Benefits under the Plan. R. at A027. To qualify for Extended Death Benefits, the covered party must be "Totally Disabled," which the Plan defines as:

(1) You are not working at any job for wage or profit; and

(2) Due to Sickness, Injury, or both, you are not able to perform for wage or profit the material and substantial duties of any job for which you are reasonably fitted by your education, training, or experience.

Id at A003-A004.

In considering plaintiffs Extended Death Benefits claim, Prudential reviewed the information in Simmons' LTD Benefits claim file, which included: (1) hospitalization records for a lumbar laminectomy and fusion performed on May 6, 2004, see R. at A051-62; (2) an attending physician statement dated June 4, 2004, from plaintiffs neurosurgeon, Dr. Michael K. Rosner, see id. at A059-61; and (3) an updated attending physician statement dated March 16, 2005, from Dr. Rosner, see id. at A062-64.⁴ In the June 4, 2004 statement, Dr. Rosner opined that plaintiff could return to light duty in three to six months. Id at A060. By checking the "light" box for plaintiffs functional abilities, Dr. Rosner indicated that when plaintiff returned to work, plaintiff would be able to lift up to 10 pounds frequently, up to 20 pounds occasionally, walk and stand frequently, and push or pull constantly. Id. at A059. In the updated attending physician statement dated March 16, 2005, Dr. Rosner revised his prior restrictions and limited plaintiff to sitting no more than 15 minutes, standing no more than 15 to 30 minutes, long distance driving no more than 60 minutes, and heavy lifting no more than 10 pounds. Id. at A063. As of March 16, 2005, the date of Dr. Rosner's updated statement, plaintiff had not yet returned to work. Id. Dr. Rosner did not anticipate Simmons' return to work over the next six months and noted that plaintiff had minimal tolerance for even sedentary work. Id. at A062-63.

On October 5, 2005, Prudential denied plaintiffs Extended Death Benefits claim. In discussing the medical information, the denial letter stated:

You stopped working due to spondylolisthesis and lumbago. We reviewed medical information from your LTD file. Information in [the] file indicates you had a lumbar laminectomy in October 2002 and a fusion on May 6, 2004. We reviewed an Attending Physician Statement from Dr. Michael Rosner dated March 16, 2005. Dr. Rosner noted you were restricted from prolonged sitting more than 15 minutes or standing more than 15 to 30 minutes. Dr. Rosner also recommended no long distance driving more than one hour and no heavy lifting greater than 10 pounds. There is no medical information on file documenting a loss in function that would render you totally disabled from any occupation. Accordingly, we are not able to approve your claim on the basis of the information supplied.

Id. at A026-27; see id. at A003-A004 (defining "Totally Disabled").

On October 17, 2005, plaintiff appealed Prudential's decision. Id. at A028-29. On October 27, 2005, Prudential advised Simmons of its unsuccessful efforts to obtain additional medical records from Dr. Rosner and reiterated its request for medical records for all treatment since January 2005 to further evaluate Simmons' Extended Death Benefits claim. Id. at A030. Prudential also stated that "a narrative or letter from a treating physician cannot substitute for actual office visit notes, treatment notes, diagnostic testing results and any other objective medical documentation." Id. In response, plaintiff submitted an operative report of surgery dated May 6, 2004, see id. at A035-36, an addendum to the operative report dated September 19, 2005, see id. at A037, and an abbreviated medical record of an overnight hospitalization for observation of a syncopal episode on October 25, 2005, see id. at A032-34. The September 19, 2005 addendum indicated that X-rays showed good alignment and a solid fusion mass with no movement on flexion and extension. Id. at A037. However, plaintiff continued to experience pain, and Dr. Rosner noted that plaintiff had not subjectively improved. Id. Plaintiff also submitted a copy of a Social Security Administration Request for Hearing by Administrative Law Judge form dated December 6, 2004. See id. at A031.

On December 2, 2005, following review of the newly submitted medical records and Social Security Administration hearing request form dated December 6, 2004, Prudential upheld its initial decision to deny plaintiffs Extended Death Benefits claim. Id. at A044-46. On January 24, 2005, plaintiff appealed. Id. at A047. On February 22, 2006, Prudential requested medical records for all treatment since October 2005 to support plaintiff's claim. Id. at A048. Plaintiff did not provide additional medical records. See id. at A049. Plaintiff did, however, provide a decision from the Veterans Administration finding plaintiff totally disabled and noted that a hearing on plaintiffs alleged disability was pending at the Social Security Administration. See id. at A075. Prudential conducted its final review of plaintiffs claim under the Plan. By letters dated May 12 and May 23, 2006, Prudential denied Simmons' Extended Death Benefits claim because he failed to demonstrate that he was "Totally Disabled" as defined in the Plan. Id. at A078-80, A082-84; see id. at A003-A004 (defining "Totally Disabled").

On August 30, 2006, Simmons filed a complaint in Craven County Superior Court asserting state law remedies with respect to Prudential's denial of his Extended Death Benefits claim. On September 29, 2006, Prudential removed the action to this court and argued that ERISA preempted plaintiffs state law claims. On February 7, 2007, plaintiff amended his complaint to allege a cause of action under ERISA. Both Prudential and Simmons now move for summary judgment.

II.

Summary judgment is appropriate when no genuine issue of material fact exists and the moving party is entitled to judgment as a matter of law. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 247, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986); Fed.R.Civ.P. 56(c). The party seeking summary judgment initially must demonstrate the absence of a genuine issue of material fact. Celotex Corp. v. Catrett, 477 U.S. 317, 325, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986). Once the moving party has met its burden, the non-moving party may not rest on the allegations or denials in its pleading, Anderson, 477 U.S. at 248, 106 S.Ct. 2505, but "must come forward with specific facts showing that there is a genuine issue for trial." Matsushita Elec. Indus. Co., Ltd. v. Zenith Radio Corp., 475 U.S. 574, 587, 106 S.Ct. 1348, 89 L.Ed.2d 538 (1986) (quotation omitted & emphasis removed). A trial court reviewing a motion for summary judgment should determine whether a genuine issue of material fact exists for trial. Anderson, 477 U.S. at 249, 106 S.Ct. 2505. In making this determination, the court must view the evidence and the inferences drawn from the evidence in the light most favorable to the non-moving party. United States v. Diebold, Inc., 369 U.S. 654, 655, 82 S.Ct. 993, 8 L.Ed.2d 176 (1962) (per curiam). When considering cross-motions for summary judgment, a court evaluates each motion separately using the standard set forth above. See, e.g., Local 2-1971 of Pace Int'l Union v. Cooper, 364 F.Supp.2d 546, 554 (W.D.N.C. 2005).

A.

In reviewing a motion for summary judgment, the trial court must also consider the non-moving party's ultimate evidentiary burden at trial and the applicable standard of review. Anderson, 477 U.S. at 255,106 S.Ct. 2505. In order to determine whether the ERISA plan confers discretionary authority on an administrator, courts interpret ERISA plans de novo "by looking to the terms of the plan and other manifestations of the parties' intent." Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 113, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989); Bynum v. Cigna Healthcare of North Carolina,...