Wade v. Life Ins. Co. of North America
| Decision Date | 03 June 2003 |
| Docket Number | No. 02-CV-105-B-S.,02-CV-105-B-S. |
| Citation | 271 F.Supp.2d 307 |
| Parties | Nancy P. WADE, Plaintiff v. LIFE INSURANCE COMPANY OF NORTH AMERICA, Defendant |
| Court | U.S. District Court — District of Maine |
Jon Holder, Holder & Grover, ME, Portland, for Nancy P. Wade.
John J. Aromando, Mark E. Porada, Pierce, Atwood, Portland, ME, for Life Insurance Company of North America.
A former participant in an employee benefit plan alleges that her long term disability insurer improperly terminated her coverage, in violation of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. §§ 1001-1461. Presently before the Court is Defendant's Motion for Judgment on the Administrative Record (Docket # 30). For the following reasons, the Court GRANTS Defendant's motion.
Plaintiff Nancy Wade was employed as a claim service assistant by State Farm Insurance Company ("State Farm"). State Farm maintained a group long term disability plan (the "Plan") for eligible employees. Wade was insured under a Group Long Term Disability Income Policy (the "Policy") issued by Defendant Life Insurance Company of North America ("LINA") to the Plan in 1997.
The Policy provides payment to employees in the event of disability. Under the Policy:
An Employee will be considered Disabled if because of Injury or Sickness, he is unable to perform all essential duties of his occupation.1
After Monthly Benefits have been payable for 24 months, an Employee will be considered Disabled only if he cannot actively work in any "substantially gainful occupation" for which he is qualified or may reasonably become qualified by reason of his education, training or experience.2
"Substantially gainful occupation" means one which provides the income required to support the standard of living reasonably approximating the standard maintained prior to the disability.
The Policy further defines "injury" as an "accidental bodily injury" and "sickness" as "a physical or mental illness." The Summary Plan Description ("SPD") vests LINA with:
the power to make all reasonable rules and regulations required in the administration of the Plan and for the conduct of its affairs, to make all determinations that the Plan requires for its administration, and to construe and interpret the Plan whenever necessary to carry out its intent and purpose and to facilitate its administration.
(Decl. of Counsel at Ex. B (Docket # 15).) Any determinations, interpretations or constructions by LINA are "binding upon the Policyholder [and] all Employees ...."
Early in 1996, Wade began complaining of pain in both hands and on January 22, 1997, stopped working after being diagnosed with Carpal Tunnel Syndrome ("CTS").3 She submitted a claim for disability benefits to LINA on September 5, 1997. On November 12, 1997, LINA determined that Wade was disabled within the meaning of the "own occupation" prong of the Policy and approved the payment of long term disability benefits retroactive to July 21, 1997. However, on February 19, 2002, LINA denied Wade further disability benefits under the "any occupation" provision of the Policy. Wade presently disputes this determination.
Although uncontested, LINA's initial disability determination forms part of the administrative record and informed LINA's subsequent eligibility determination under the "any occupation" prong of the Policy. Therefore, the Court recounts the relevant portions of the earlier record.
On September 5, 1997, State Farm submitted a disability claim to LINA on behalf of Wade. Included in the application for benefits was an initial employee questionnaire. Wade provided the names of her attending physician, Dr. John Archambault, M.D., and her orthopedic hand specialist, Dr. P. Gregory Askins, M.D., as well as brief descriptions of her treatments, medications and past work experience. Drs. Archambault and Askins also included physician's statements. Dr. Archambault diagnosed Wade's condition as bilateral CTS with pain, numbness and weakness in both wrists and hands. He indicated that Wade had limited functional capacity, but retained the ability to occasionally lift or carry no more than ten pounds. He further noted that Wade's pushing, pulling and climbing abilities were limited. In Dr. Archambault's opinion, Wade was not capable of performing her job with State Farm or any other occupation.
As part of its initial determination, LINA also requested that Dr. Archambault complete a Physical Ability Assessment ("PAA") and submit any medical records for Wade. Dr. Archambault's PAA again indicated that Wade experienced considerable pain and numbness in her wrists when using a computer and was therefore unable to work. His treatment notes from the preceding period largely concur with this assessment.
In his statement, Dr. Askins diagnosed Wade's condition as ongoing bilateral upper extremity limb pain and tenosynovitis.4 Subjective symptoms, according to Dr. Askins, included numbness in the thumb, ring finger and little finger with discomfort along the outside of the palm. He indicated that Wade's restrictions included lifting or carrying no more than ten pounds, standing or walking four to six hours per day and sitting four to six hours a day. Dr. Askins indicated that Wade could perform unlimited bending and stooping. Although Dr. Askins noted that Wade was not capable of performing her occupation, he did not address the question regarding Wade's ability to perform other occupations. Additionally, the Doctor remarked that Wade should avoid repetitive grasping and manipulation, sustained grasping and push/pull activities. He further noted that keyboarding and writing should be limited to less than ten minutes an hour. Dr. Askin's PAA, dated October 9, 1997, indicated largely the same limitations and restrictions as his earlier physician statement. The Doctor's treatment notes suggested similar restrictions.
Wade supplemented her application for benefits with a completed disability questionnaire on September 21, 1997. The form indicated that pain, numbness and weakness in both wrists due to CTS prevented Wade from continuing to work as a claim service assistant. She further wrote that she could not write or type for more than ten minutes per hour, could not lift anything over five to ten pounds, or bend her arms for an extended period of time. Wade was able to perform all of her own personal care functions, light cooking and cleaning, shopping and laundry with the assistance of her spouse. Wade indicated that due to her physical restrictions she did not anticipate returning to work in any capacity. The application also included a description of Wade's educational background and her entire work history.
LINA approved Wade's claim for long term disability benefits on November 12, 1997 retroactive to July 21, 1997. However, the approval letter cautioned that after the first twenty-four months of benefits, Wade "must be unable to engage in the essential duties of any occupation to qualify for [continued] benefits."
After approving initial benefits, LINA received a completed "Estimated Functional Capacities Form" from Dr. Askins, dated November 6, 1997. The capacities form indicated that Wade could sit, stand or walk four hours over the course of an eight hour work day. Dr. Askins also noted that Wade could occasionally lift or carry up to ten pounds, push and pull objects and reach above shoulder height. Although Wade could not perform repetitive grasping or gripping actions, she could employ her hands for fine manipulation. Again, Dr. Askins limited keyboarding to ten minutes per hour.
Dr. Askins subsequently reaffirmed Wade's capacities in a May 5, 1998 supplemental form.5 Using the restrictions suggested by Dr. Askins, LINA commissioned a transferable skills analysis ("TSA") to determine whether Wade's disability permitted work in any other occupation. This was the first of five such TSAs commissioned by LINA. Although the vocational assessment, dated June 6, 1998, determined that three jobs consistent with Wade's education and work history fell within her medical restrictions, none of the positions offered comparable earnings.
On December 12, 1998, Dr. Archambault submitted a supplemental claim form indicating that Wade's diagnosis was still bilateral CTS. Dr. Archambault's objective findings included positive Tinel's and Phalen's signs as well as grip weakness in both wrists.6 He further noted that Wade had severely limited functional capacity and was incapable of even minimal activity. The Doctor indicated that Wade was not a candidate for further rehabilitation or vocational counseling and retraining.
By letter dated March 9, 1999, LINA provided Wade with notice that after the passage of twenty-four months, she would no longer be considered disabled under the Policy if she could work in any substantially gainful occupation. LINA requested that Wade complete another disability questionnaire to facilitate the new determination Similarly, the insurer requested that Dr. Archambault submit a "comprehensive medical narrative report," an additional PAA and a complete copy of his records dating from March 1, 1998.
Wade's response on March 16 echoed earlier questionnaires. Wade indicated that she cooked and cleaned in limited capacities daily as well as shopped and did the laundry with the aid of her husband. Wade noted that she attended therapy twice a week at her doctor's instruction. Additionally, she stated that she was not interested in retraining for another occupation, that she did not anticipate...
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