Wedge v. Shawmut Design & Constr. Grp. Long Term Disability Ins. Plan
| Decision Date | 02 June 2014 |
| Docket Number | No. 12 Civ. 5645KPF.,12 Civ. 5645KPF. |
| Parties | William WEDGE, Plaintiff, v. The SHAWMUT DESIGN AND CONSTRUCTION GROUP LONG TERM DISABILITY INSURANCE PLAN and Reliance Standard Life Insurance Company, Defendants. |
| Court | U.S. District Court — Southern District of New York |
Mark Peter Scherzer, The Law Office of Mark Scherzer, New York, NY, for Plaintiff.
Emily Anna Hayes, Wilson, Elser, Moskowitz, Edelman & Dicker, White Plains, NY, Joshua Bachrach, Heather Janene Austin, Wilson, Elser, Moskowitz, Edelman & Dicker LLP, Philadelphia, PA, for Defendants.
On July 24, 2012, Plaintiff William Wedge commenced this litigation under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001 –1191c, 1202 –1242, 1301 –1461, against Defendants Shawmut Design and Construction Group Long Term Disability Insurance Plan (the “Shawmut Plan” or “Plan”) and Reliance Standard Life Insurance Company (“RSLI”) to contest a denial of benefits by RSLI. Plaintiff, who has a disability that inhibits visual capacity in his right eye, was denied extended Long Term Disability Benefits from RSLI upon its determination that Plaintiff did not establish that he was “Totally Disabled,” as defined under the Plan. Because RSLI's decision to deny Plaintiff the benefits sought was not arbitrary and capricious, Plaintiff's motion for summary judgment is denied, and Defendants' motion for summary judgment is granted.
Plaintiff is a former employee of Shawmut Design and Construction Group (“Shawmut”), a construction management firm. (56.1 Statement ¶ 2; AR 336–37). During the relevant time period, Plaintiff was a Senior Project Manager at Shawmut, whose responsibilities included overseeing construction operations for large-scale projects that required an advanced level of construction expertise; these projects included the construction and/or renovation of luxury and premier specialty retail stores, health clubs, spas, and fitness centers. (AR 328–29). Plaintiff's job required him, among other things, to travel via car and airplane; drive; walk; ascend and descend stairs, ladders, and scaffolding; conduct extended construction-site visual inspections; read and work with construction drawings, plans, and hard-copy and computer-based documents; and partake in financial and strategy meetings. (Id. at 331).
Shawmut established and maintained the Shawmut Plan, a benefit plan for its employees. (See AR 1–31). The Shawmut Plan, in turn, purchased Group Long Term Disability Policy No. 114007 (the “Policy”) from Defendant RSLI to provide long term disability (“LTD”) benefits to Shawmut Plan beneficiaries. (See 56.1 Statement ¶ 4). Under this arrangement, Shawmut was the Plan's Administrator, and RSLI was the claim review fiduciary with respect to the Policy and the Plan. (Id. at ¶¶ 5–6). In this role, RSLI had “the discretionary authority to interpret the Plan and the insurance policy and to determine eligibility for benefits.” (Id. at ¶ 6).
As a Shawmut employee, Plaintiff was a participant in, and received coverage under, the Shawmut Plan. (56.1 Statement ¶ 3). Based on Plaintiff's rate of earning, he was classified as a Class 2 employee under the Policy. (Id. at ¶ 7). For such employees, the Policy defines disability, in relevant part, as follows:
“Totally Disabled” and “Total Disability” mean that, as a result of an Injury or Sickness: (1) during the Elimination Period and for the first 24 months for which a Monthly Benefit is payable, an Insured cannot perform the material duties of his/her Regular Occupation ... (2) after a Monthly Benefit has been paid for 24 months, an Insured cannot perform the material duties of any occupation. Any occupation is one that the insured's education, training or experience will reasonably allow ...
(AR 10). The Policy also includes a provision that requires the offset of benefits received from what it termed Other Income Benefits, including any award of individual or family Social Security Disability benefits. (See id. at 18).
On February 23, 2009, while Plaintiff was employed by Shawmut, he was examined by Dr. Guarang Trivedi for a gray spot in the center of Plaintiff's field of vision in his right eye that had manifested two weeks earlier. (AR 300–01). In his medical report, Dr. Trivedi noted his impression that Plaintiff may have central serous chorioretinopathy
(“CSCR”) (id. at 300–01), which is also referred to as central serous retinopathy (56.1 Statement ¶ 11).2 Dr. Trivedi referred Plaintiff to Dr. Howard Charles for a retinal examination. (AR 301). Plaintiff was examined by Dr. Charles on February 25, 2009, during which Dr. Charles diagnosed Plaintiff with Type 1 CSCR. (Id. at 311). Dr. Charles explained, in a letter to Dr. Trivedi summarizing his examination of Plaintiff, that CSCR “tend[s] to resolve over weeks to months.” (Id. ).3
Based on the prognosis received from Dr. Charles, on March 26, 2009, Plaintiff informed Shawmut that he was unable to perform the regular functions of his employment due to his CSCR. (AR 328). Plaintiff ceased working for Shawmut as of that day, and submitted a claim for benefits under Shawmut's short term disability plan. (See id. ). A few months later, in July 2009, Plaintiff's condition had not improved, and he applied for LTD benefits under the Policy. (Id. at 340–46).
RSLI granted Plaintiff's application for LTD benefits by letter dated April 8, 2010. (AR 257–58). In so doing, RSLI determined that Plaintiff became totally disabled from his Regular Occupation, as defined by the Policy, on March 27, 2009, and that benefits to him under the Plan were payable as of June 25, 2009, after the Elimination Period was satisfied. (Id. ). In that same letter, RSLI suggested that Plaintiff apply for Social Security Disability (“SSD”) benefits. More importantly for the instant litigation, RSLI informed Plaintiff that in order to qualify for LTD benefits beyond 24 months, Plaintiff must demonstrate that he is “totally disabled from performing the material duties of Any Occupation” as defined under the Policy. (Id. ).
Plaintiff heeded RSLI's suggestion and applied for SSD benefits. In connection with that application, Plaintiff was initially represented by counsel suggested by RSLI. (See AR 214–15). In December 2010, however, Plaintiff informed Shawmut that the appointed counsel intended to withdraw from representing him in the SSD benefits proceeding “based on an assessment that [Plaintiff's] claim ha[d] no merit.” (Id. ).
In connection with his SSD application, Plaintiff was examined by Dr. Martin Bernstein, the SSA's independent ophthalmologist. (AR 1536–41). Dr. Bernstein's examination revealed that Plaintiff had peripheral count finger vision and no near vision acuity in his right eye. (Id. at 1538).4 The examination further recounted that Plaintiff had informed Dr. Bernstein that any reading caused him “severe temporal headaches and eye aches and a tremendous feeling of tension, stress and some nausea.” (Id. at 1537). Notably, Dr. Bernstein discerned an inconsistency between Plaintiff's subjective complaints and the objective tests, and related in his report that he (Dr. Bernstein) could not explain, and the objective tests did not indicate, why Plaintiff's “central scotoma
[was] so obviously much larger than the actual diameter of the pathology in the macula.” (Id. at 1540).5
The SSA initially denied Plaintiff's request for benefits. Subsequently, in January 2012, U.S. Administrative Law Judge Roberto Lebron awarded Plaintiff SSD benefits. (AR 1494–99). In reaching this determination, Judge Lebron noted that he gave “great weight” to the opinions of Dr. Charles and of Dr. David Robbins, Plaintiff's psychiatrist. (Id. at 1498).
After providing Plaintiff with LTD benefits for 24 months under the Policy on account of his demonstrated inability to perform the material duties of his Regular Occupation, RSLI informed Plaintiff by letter dated June 3, 2011, that he no longer qualified for LTD benefits because he had not demonstrated an inability to perform the material duties of any occupation, and thus had not satisfied the definition of “Totally Disabled” under the Policy. (AR 277–79). RSLI explained that although Plaintiff was unable to work in his prior occupation, he “appear[ed] capable of sedentary work activity.” (Id. at 278).
To reach this determination, RSLI reviewed all of the information in Plaintiff's file, including medical records provided by Dr. Alphonso Aversa, Plaintiff's general physician; Dr. Seth Shifrin, who saw Plaintiff for an injury to his right thumb; Dr. Robbins; and Dr. Charles. (Id. ). As relevant to Plaintiff's eye condition, Dr. Aversa, who saw Plaintiff for a comprehensive physical on May 18, 2010, indicated that Plaintiff's “visual loss has been unchanged,” and that he was “followed regularly by ophthalmology.” (Id. at 732). Dr. Charles indicated in a January 6, 2010 letter submitted in support of Plaintiff's initial claim for LTD benefits that Plaintiff complained of headaches “when having to do extended reading of the sorts he was required to do,” a complaint that the doctor found consistent with the reported symptoms of CSCR. (Id. at 500). Subsequently, in the record of an examination of Plaintiff conducted on May 26, 2010, however, Dr. Charles stated that Plaintiff's “level of vision is not consistent with the macular findings,” thereby echoing Dr. Bernstein's observation of the disparity between Plaintiff's illness and his reported symptoms. He suggested that Plaintiff would “benefit from an updated refraction [test],” and related that he had asked Plaintiff to schedule such a test. (I...
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Wedge v. Shawmut Design & Constr. Grp. Long Term Disability Ins. Plan & Reliance Standard Life Ins. Co., 12 Civ. 5645(KPF).
...23 F.Supp.3d 320William WEDGE, Plaintiff,v.The SHAWMUT DESIGN AND CONSTRUCTION GROUP LONG TERM DISABILITY INSURANCE PLAN and Reliance Standard Life Insurance Company, Defendants.No. 12 Civ. 5645(KPF).United States District Court, S.D. New York.Signed June 2, Administrator's motion granted; ......