Opinion
Case No. 1:02cv113 AS
December 10, 2002
MEMORANDUM AND ORDER
This matter is before this Court on Defendants' motion for summary judgment. This case arises out of Plaintiff's claim for continued long-term disability benefits under an employee welfare benefit plan ("Plan") established by her employer, Wal-Mart Stores, Inc. ("Wal-Mart"), through its purchase of group insurance issued by Hartford Life and Accident Insurance Company, incorrectly named herein as Hartford Life, Benefit Management Services, ("Hartford").
Plaintiff received $11, 469.72 in long-term disability benefits from June 20, 2000 through June 19, 2001. The Defendants argue that since June 20, 2001, Plaintiff has been capable of performing the essential duties of a telephone solicitor, which is a sedentary occupation for which Plaintiff is, according to the Plan's terms "qualified by education, training, or experience."
Therefore, they claim Plaintiff is not entitled to the continued long-term disability benefits she seeks in this case. For these reasons, the Plan and Hartford now move for summary judgment in their favor and against Plaintiff on Plaintiff's complaint. No response was filed by Plaintiff.
I. BACKGROUND
The Plan, to which Plaintiff is a part of, affords Hartford "full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Group Insurance Policy." The Plan defines "Total Disability" as follows:
Total Disability or Totally Disabled means that:
1) during the Elimination Period; and
2) for the next 12 months; you are prevented by:
a) accidental bodily injury;
b) sickness;
c) Mental Illness
d) substance abuse; or
e) pregnancy,
from performing the essential duties of your occupation, and are under the continuous care of a Physician and as a result you are earning less that 20% of your Pre-disability Earnings, unless engaged in a program of Rehabilitative Employment approved by us And after that you must be so prevented from performing the essential duties of any occupation for which you are qualified by education, training, or experience.
The Plan also states as follows:
That Hartford will pay benefits until the first to occur of:
1) the date you are no longer disabled;
2) the date you fail to furnish proof that you are continuously disabled.
Furthermore the Plan provides that Hartford reserves the right to determine if proof of loss is satisfactory.
Plaintiff received $11,469.72 in long-term disability benefits under the Plan from June 20, 2000 through June 19, 2001. In February 2001, Hartford initiated an internal review to determine whether Plaintiff qualified for long-term disability benefits after June 19, 2001. On June 7, 2001, one of Plaintiff's treating physicians, Oldrich J. Kolar, M.D., Ph.D., conducted a Physical Capacities Evaluation regarding Plaintiff and her abilities. Dr. Kolar noted that Plaintiff was able to: sit for eight hours; stand for fewer than two hours; walk for fewer than two hours; lift up to 10 lbs.; reach above her shoulder at waist level occasionally; reach below waist level frequently; perform fingering frequently; and perform feeling constantly. On June 28, 2001, Marvin Bryant, MS, CRC, completed an Employability Analysis Report for Plaintiff. The report analyzed Plaintiff's work history, as well as a statement submitted by Dr. Kolar regarding his previous evaluation of Plaintiff. The report suggested the following functional capacities and limitations:
1. Sitting unlimited,
2. Can stand for 6-8 hours of the day with frequent breaks every 30 minutes,
3. Reaching, working overhead, pushing-pulling limited in intensity and duration,
4. Performance is expected to fluctuate due to fatigue,
5. Frequently reach at waist level, below waist level,
6. Limitations noted for keyboarding, but extent of limitation not specified,
7. Ability tot climb a 3-step ladder without incident,
8. Sustain functional tasks in reaching and lifting tasks of 5-10 pounds,
9. Duration of activities appear to be limited by fatigue
10. Dr. Kolar's statement did recommend drivers evaluation
11. Per Dr. Kolar's evaluation, claimant has significant weakness in pelvic and lower extremity making stooping, squatting and bending difficult.
Using a computerized job matching system, an analysis was performed which resulted in a conclusion that Plaintiff could perform in the sedentary level category. Two specific occupations were identified for which Plaintiff had transferrable skills: escort vehicle driver and telephone solicitor. The report eliminated escort vehicle driver since Plaintiff's driving capacity had not yet been evaluated as recommended. However, the report concluded that Plaintiff possessed the transferrable skills to perform the occupation of telephone solicitor. On July 5, 2001, based on the Plan language and a review of all of the documents in Plaintiff's claim file, Hartford determined that Plaintiff was qualified to perform the essential duties of a telephone solicitor and thus, no longer met the definition of "total disability" under the Plan. And was therefore not entitled to long-term disability benefits after June 19, 2001.
On July 30, 2001, Plaintiff returned to work as an escort driver. She was involved in a car accident that same day while driving as an escort driver for her new employer. On September 3, 2001, Plaintiff's counsel requested an appeal of the July 5, 2001 decision. Plaintiff's counsel disagreed that the Plaintiff could perform the occupation of telephone solicitor. Hartford upheld its July 5, 2001 decision after reviewing Plaintiff's complete file. Hartford explained in a September 25, 2001 letter that no long-term disability benefits were payable to Plaintiff for a new injury after June 19, 2001, which occurred while Plaintiff was working for an employer other than Wal-Mart. On November 21, 2001, Plaintiff's counsel requested a review of Hartford's September 25, 2001 decision. Hartford referred the claim to the Appeals Unit for a complete review. On January 30, 2002, a Hartford specialist notified Plaintiff's counsel that Hartford upheld its previous decisions. Hartford made its final determination that Plaintiff was no longer "totally disabled" after June 19, 2001, under the Plan. Plaintiff filed this present action on April 1, 2002.
II. SUMMARY JUDGMENT STANDARD
Summary judgment is to be granted "forthwith" when, after an adequate period for discovery one party is unable to show a genuine issue as to a material fact on which that party will bear the burden of proof at trial, so long as judgment against that party is appropriate as a matter of law. Department of Commerce v. U.S. House of Representatives, 525 U.S. 316, 327 (1999); Celotex Corp. v. Catrett, 477 U.S. 317, 322 (1986). When there are no genuine issues of material fact, contract interpretation is particularly well-suited for summary judgment. Anstett v. Eagle-Picher Industries, 203 F.3d 501 (7th Cir. 2000).
III. STANDARD OF REVIEW
In Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101 (1989) the Supreme Court set out the applicable standard of review for a decision made by a plan administrator in an ERISA case. A de novo standard of review is not applied in cases where a benefit plan gives the administrator or fiduciary discretionary authority to construe the terms of the plan. Id. at 115. In situations where the administrator is given discretionary authority courts apply an arbitrary or capricious standard in reviewing the administrator's decision. Russo v. Health, Welfare Pension Fund, 984 F.2d 762, 765-766 (7th Cir. 1993); Exbom v. Central States, Southeast and Southwest Areas Health and Welfare Fund, 900 F.2d 1138 (7th Cir. 1990).
IV. DISCUSSION
The issue before this Court is whether Hartford's decision that Plaintiff is not "totally disabled" and therefore not entitled to long-term disability benefits beyond June 19, 2001, is reasonable and must be upheld. The Plan expressly grants Hartford full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Group Insurance Policy. The Seventh Circuit has held that cases involving the challenge of a denial of benefits under ERISA, where it is undisputed that the plan expressly gives the administrator discretion to construe the terms of the plan, may only be reversed by the court if the denial of benefits was arbitrary and capricious. See, Chojnacki v. Georgia Pacific Corp., 108 F.3d 810, 814 (7th Cir. 1997). According to Perlman v. Swiss Bank Comprehensive Disability Protection Plan, 195 F.3d 975, 982 (7th Cir. 1999), a court's review of a plan administrator's decision is strictly limited to the evidence in the administrative record. There must be sufficient evidence to support the plan administrator's decision, otherwise it may be deemed arbitrary and capricious.
A. Background of ERISA
In 1974, Congress enacted the Employee Retirement Income Security Act or ERISA in response to wide disuniformity among various state laws as they applied to employee benefit plans. 29 U.S.C. § 1144 (West 1998). The purpose of the Act was to afford employers with a uniform set of administrative procedures rather than trying to comply with a different set of procedures for creating health plans in each state. Fort Halifax Packing Co. Inc., v. Coyne 482 U.S. 1 (1987). With this point in mind, Federal Courts are quick to establish that ERISA's concern is with the administration of the benefits plan and not the actual design or contents of the plan. The actual terms and conditions of the plan are left to the discretion of the various employers who create the plan. Hickey v. A.E. Staley Mfg., 995 F.2d 1385, 1388 (7th Cir. 1993). ("Decisions of this Circuit have recognized that plan providers have great latitude in determining whom to include in a plan and the scope of the plan."); See Also; Nazay v. Miller, 949 F.2d 1323, 1329 (3rd Cir. 1990).
In enacting ERISA, congress felt that a body of federal common law should be developed in order to establish uniformity in applying various concepts of law to areas not addressed specifically by the benefits plan. See; Franchise Tax Bd. v. Construction Laborers Vacation Trust, 463 U.S. 1, 24 n. 26 (1983) (quoting 120 Cong.Rec. 29942 (1974) (remarks of Senator Javits)); see also Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 110 (1989); Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 56 (1987). However, various legal principles recognized under federal common law may not be employed by a Court where there exists specific language in a plan to the contrary. Cutting v. Jerome Foods, Inc. 993 F.2d 1293, 1297 (7th Cir.) cert denied, 510 U.S. 916 (1993). Trustmark Life Ins. Co. v. University of Chicago Hosp., 207 F.3d 876, 884 (7th Cir. 2000).
The principles of contract interpretation require this Court to interpret the terms of this ERISA plan in an ordinary and popular sense as would a person of average intelligence and experience. Swaback v. American Info. Techs. Corp., 103 F.3d 535, 540-541 (7th Cir. 1996). "Extrinsic evidence should not be used where the contract is unambiguous." Id. at 541; GCIU Employer Retirement Fund v. Chicago Tribune Co., 66 F.3d 862, 865 (7th Cir. 1995) (citing Bidlack v. Wheelabrator Corp., 993 F.2d 603, 608 (7th Cir.), cert. denied, 510 U.S. 909, 114 S.Ct. 291, 126 L.Ed.2d 240 (1993)).
B. Hartford's Decision
Plaintiff received $11,469.72 in long-term disability benefits under the Plan from June 20, 2000 to June19, 2001 because she was unable to perform the essential duties of her job as a stocker for Wal-Mart. However, according to the Plan, in order for Plaintiff to have received benefits after June 19, 2001, she must have been unable, per the definition of "total disability" to perform the essential duties of any occupation for which she is qualified. Hartford conducted a routine review in determining whether Plaintiff would be qualified for long-term disability benefits after June 19, 2001.
As part of the review, Hartford relied on the reports referred to earlier that were prepared by Marvin Bryant and Dr. Kolar. Plaintiff's work history, various skills, and work functions were also considered by Hartford. Hartford relied on the computerized matching system analysis conducted by Mr. Bryant which revealed that Plaintiff was capable of performing the occupation of a telephone solicitor. Hartford reasonably relied on this analysis in determining that Plaintiff was qualified by education, training, or experience to perform the essential duties of this job, and therefore no longer within the Plan's definition of "total disability" after June 19, 2001.
Furthermore, Hartford conducted a reasonable inquiry into Plaintiff's medical condition as well as her vocational skills and potential, relying on the report by Mr. Bryant as well as input from one of Plaintiff's treating physicians, Dr. Kolar.
Hartford reviewed Plaintiff's entire claim file, including additional information that her counsel sent with his request for an appeal. Hartford also referred Plaintiff's case to an Appeals Unit, which similarly reviewed Plaintiff's complete claim file. The fact of the matter is, Plaintiff was not even covered under the Plan when her injury, that resulted from the accident on July 30, 2001, occurred. And even if Plaintiff were so covered, Dr. Jenkinson, who treated Plaintiff, stated that the only disabling effect would be a limit to how much Plaintiff would be able to lift. The occupation of telephone solicitor does not involve any lifting, so regardless, Plaintiff would not have been prevented from performing that occupation. Hartford's decision that Plaintiff was qualified to perform the essential duties of a telephone solicitor, and therefore no longer met the Plan's definition of "total disability" after June 19, 2001, was in accordance with the terms of the Plan and was supported by sufficient evidence.
V. CONCLUSION
For the foregoing reasons, Defendants' motion for summary judgment pursuant to Rule 56 of the Federal Rules of Civil Procedure is now GRANTED. The clerk shall enter judgment accordingly.
IT IS SO ORDERED.