Winters v. Liberty Life Assurance Co. of Bos.

• Decision Date: 07 October 2022
• Docket Number: C. A. 20-11937-MLW
• Parties: EDWARD J. WINTERS, III, Plaintiff, v. LIBERTY LIFE ASSURANCE COMPANY OF BOSTON N/K/A LINCOLN LIFE ASSURANCE COMPANY OF BOSTON, Defendant.
• Court: U.S. District Court — District of Massachusetts

EDWARD J. WINTERS, III, Plaintiff, v. LIBERTY LIFE ASSURANCE COMPANY OF BOSTON N/K/A LINCOLN LIFE ASSURANCE COMPANY OF BOSTON, Defendant.

C. A. No. 20-11937-MLW

United States District Court, D. Massachusetts

October 7, 2022

MEMORANDUM AND ORDER

WOLF D.J.

I. INTRODUCTION

Plaintiff Edward J. Winters, III has sued defendant Liberty Life Assurance Company of Boston ("Liberty")^[1] to recover benefits denied to him under §502 of the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §1132(a)(1)(B). Winters filed a motion for summary judgment, and Liberty filed a motion for judgment on the administrative record. Winters also filed a motion to strike two exhibits that Liberty submitted in support of its statement of material facts.

As explained below, the motion to strike is not meritorious. The court finds that the exhibits do not impermissibly expand the administrative record because they include a summary of information included in the record and a declaration necessitated by Winters' claim of procedural bias.

The court has reviewed Liberty's decision to terminate Winters' long-term disability benefits under the arbitrary and capricious standard. This standard is not altered by state law or Winters' claims of procedural error. To the extent, if any, that Liberty committed any procedural error, Winters has failed to prove any resulting prejudice. Under the arbitrary and capricious standard, the court finds that Liberty's decision to terminate benefits was based on substantial evidence but was unreasonable based on the record before it because Liberty did not complete an assessment of whether Winters was able to carry out all of the Material and Substantial Duties of his Own Occupation as defined by the relevant disability plan. Rather, Liberty made a determination that Winters could perform sedentary or light physical work.

Therefore the court is denying Winters' motion to strike, denying Winters' motion for summary judgment, denying Liberty's motion for judgment on the administrative record, and remanding the case to Liberty for further consideration.

II. BACKGROUND

Winters was a mortgage consultant at Wells Fargo & Company ("Wells Fargo"). See Compl. (Dkt. No. 1) ¶6. As an employee, he participated in Wells Fargo's Long-Term Disability Plan (the "LTD Plan"), which was administered by Liberty. Id. ¶¶2, 7. The LTD Plan is an ERISA-governed welfare-benefit plan. Id. ¶2.

Information concerning the LTD Plan is in the more than 4,400-page administrative record filed under seal at Dkt. Nos. 22-24. The LTD Plan defines "Disability" or "Disabled" to mean:

i. that during the Elimination Period and the next 24 months of Disability the Covered Person, as a result of Injury or Sickness, is unable to perform the Material and Substantial Duties of his Own Occupation; and

ii. thereafter, the Covered Person is unable to perform, with reasonable continuity, the Material and Substantial Duties of Any Occupation.

Administrative Record ("AR") at 4345. The Elimination Period is 26 weeks and begins on the first day of Disability. AR at 4341, 4346. "Sickness" is defined as "illness, disease, pregnancy or complications of pregnancy." AR at 4352. "Material and Substantial Duties" are "responsibilities that are normally required to perform the Covered Person's Own Occupation, or any other occupation, and cannot be reasonably eliminated or modified. AR at 4348. "Own Occupation" means "the Covered Person's occupation that he was performing when his Disability or Partial Disability began . . . as it is normally performed in the local economy." AR at 4349.

Winters' date of disability was January 24, 2018. AR at 59. He satisfied the 26-week Elimination Period on July 25, 2018. Id. Twenty-four months following the Elimination Period was July 25, 2020. Winters' benefits were terminated on October 29, 2019. AR at 3005-18. Therefore, Winters was within the first 24 months of Disability at the time his benefits were terminated. Accordingly, the relevant question is whether he was able to perform the Material and Substantial Duties of his Own Occupation. See AR at 4345.

The LTD Plan provides that "Liberty shall possess the authority to construe the terms of this policy and to determine benefit eligibility hereunder." AR at 4375. For long term disability coverage, "Proof that a Covered Person is Disabled due to Injury or Sickness and requires the Regular Attendance of a Physician . . . must be given upon Liberty's request and at the Covered Person's expense." AR at 4359. The covered person must also provide proof of continued "Appropriate Available Treatment. Id. The LTD Plan provides that "[i]n determining whether the Covered Person is Disabled, Liberty will not consider employment factors including, but not limited to, interpersonal conflict in the workplace, recession, job obsolescence, paycuts, job sharing and loss of a professional or occupational license or certification." Id. The LTD Plan is governed by Minnesota law. AR at 4338.

The LTD Plan became effective on January 1, 2010. AR at 4385. It has been amended several times, most recently and most pertinently by Amendment No. 4 in September 2016. AR at 1990-94. Amendment No. 4 revises the Survivor Benefit for Disabilities and Partial Disabilities which start on or after its effective date, January 1, 2016. AR at 1990. It states that "[t]his policy's terms and provisions will apply other than as stated in this amendment." Id.

In early 2018, while still employed at Wells Fargo, Winters stopped working because of "headaches, dizziness, tremor, low back pain, knee pain, joint pain, fatigue, soreness, and cervical and lumbar pain." Compl. ¶15. Winters asserted that he suffered from Lyme disease, see, e. g., id., although he has never been given that diagnosis, see, e.g., AR at 413-16. Winters claims that his work capacity is also limited by difficulty driving and looking at computer screens. See, e.g., AR at 1867. The administrative record also makes references to Winters' cognitive complaints, such as memory loss, anxiety, and reactive emotions. See, e.g., AR at 90, 1167.

Winters filed a claim for short-term disability benefits on January 10, 2018. See AR at 2, 50. Winters' request for short-term disability benefits was approved, AR at 2065, and benefits were extended through July 24, 2018, AR at 3988, 3992, 4070, 4186. Winters applied for and initially received long-term disability benefits based on a determination that he was "disabled by symptoms of headaches, dizzines [sic], joint pain, and fatigue" and unable to perform the duties of his occupation. AR at 3520-23.

On October 29, 2019, Liberty terminated Winters' long-term disability benefits because it determined that Winters had sedentary work capacity. AR at 3005-18. This decision was based on medical peer reviews of Winters' medical records performed by four physicians, an independent medical examination ("IME") of Winters, and an occupational analysis performed by a vocational counselor. See id.

The IME was performed by physiatrist Dr. Neil Patel who found that Winters "does have sustained sedentary work capacity to perform his own occupation as a Mortgage Consultant and is able to meet the demand levels outlined in the job description provided."^[2] AR at 3174-84. Liberty sent this assessment to Winters' treating physicians, including his primary care physician Dr. Joseph DeLuca. See AR at 3033-35. In response to a letter dated October 3, 2019, Dr. DeLuca checked the line that stated that he agreed with Dr. Patel's "assessment and findings," including the conclusion that "[t]he claimant does have sustained sedentary work capacity to perform his own occupation as a Mortgage Consultant and is able to meet the demand levels outlined in the job description provided." Id. Winters' rheumatologist Dr. Betty Hsiao responded that she could not comment because she only saw Winters once. AR at 3063-64. His neurologist Dr. Sirisha Sanamandra did not respond. See AR at 2982.

Winters had 180 days, until at least April 27, 2020,^[3] to appeal Liberty's decision. See AR at 4429. On March 25, 2020, Winters requested a 90-day extension because of difficulties gathering medical records as a result of the COVID-19 pandemic. AR at 1959-60. In a letter dated April 18, 2020, Liberty granted a 45-day extension, until June 10, 2020. AR at 2968. Winters states that he did not receive the letter until May 11, 2020, see Compl. ¶42, and filed an appeal of the termination on April 20, 2020, see AR 1961-70.

Winters' claim of disability is chiefly supported by Dr. DeLuca. Dr. DeLuca opined in 2018 that Winters was "unable to work." AR at 3727. On December 9, 2019, after agreeing with Dr. Patel that Winters could perform the functions of a Mortgage Consultant, Dr. DeLuca stated that Winters "is currently not able to drive for work" and "is thoroughly disabled." AR at 1876. On March 3, 2020, Dr. DeLuca wrote that he did not "believe [Winters] should be driving or working as he is [sic] steadily deteriorated over this period of time." AR at 1867.

Although Dr. DeLuca does not explain why he initially agreed with Dr Patel that Winters could perform the functions of a Mortgage Consultant and reversed his opinion two months later, it appears that Dr. DeLuca was relying, at least in part, on his opinion that Winters could not drive. AR at 1867, 1876. However, a September 2020 labor market survey commissioned by Liberty and conducted by Paradigm Complex Care Solutions ("Paradigm") found that the duties of a Mortgage Consultant do not include driving. See AR at 74-77. More specifically, Paradigm surveyed 10 local employers, and found that 80 percent of jobs in the occupation of "Sales Representative, Financial Services"^[4] were sedentary,...