The opinion of the court was delivered by: Anita B. Brody, District Judge.
Before me is defendant's motion for summary judgment. For the
reasons set forth below, defendant's motion will be denied
Plaintiff Mary Friess brought this action against the
defendant, Reliance Standard Life Insurance Company ("Reliance")
following Reliance's denial of her claim for long-term disability
("LTD") benefits. Because the insurance policy at issue is an
employee benefit plan, this action is governed by the Employee
Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001
et seq. Removal was proper as ERISA provides that a civil
action may be brought in federal court by a plan participant "to
recover benefits due to him under the terms of the plan. . . ."
29 U.S.C. § 1132(a)(1)(B). ERISA preempts all state claims that
"relate to any employee benefit plan." 29 U.S.C. § 1144(a).
Woodward and Lothrop established and maintained a benefit plan
offering LTD benefits to its employees. As an employee of
Woodward and Lothrop,*fn2 Friess participated in the plan. Her
coverage under the plan became effective in 1989.*fn3
Woodward and Lothrop's plan was insured under a group LTD
policy ("the Policy") issued and administered by Reliance. The
Policy states that Reliance will pay a monthly benefit if an
(1) is Totally Disabled as the result of a Sickness
or Injury covered by this Policy; (2) is under the
regular care of a Physician; (3) has completed the
Elimination Period; and (4) submits satisfactory
proof of Total Disability to us.
Defendant's Motion for Summary Judgment, Exhibit B, p. 7.0.
According to the Policy, an employee is "Totally Disabled" when
"during the Eliminator Period and thereafter 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." Id. at 2.1. An insured who
is "Partially Disabled" — capable of performing the material
duties of any occupation on a part-time basis or some of the
material duties on a full-time basis — will be considered Totally
Disabled, the definition continues, except during the
"Elimination Period." The "Elimination Period" is defined as a
period of 90 consecutive days of Total Disability for which no
benefit is payable, and begins on the first day of Total
Disability. Id. at 1.0-2.0.
On January 19, 1996, Friess submitted a claim for LTD benefits
under the Policy. Friess maintained that she had become totally
disabled on May 25, 1994, when she fell from a platform at work
and broke her left ankle. In her motion, plaintiff indicates that
she had expected the injury to heal, allowing her to return to
work. However, her doctors eventually determined that the ankle
injury was permanent, as her severe pain and difficulty walking
and standing did not subside. Following the determination that
the injury was permanent, Friess filed her claim with Reliance in
January of 1996.*fn4
After receiving Friess's claim in January of 1996, Reliance
opened a file on Friess and began obtaining medical records from
her treating physicians. At Reliance's request, Friess provided
the necessary medical releases and authorizations, and also
provided Reliance with contact information concerning the doctors
she had seen after the ankle injury. Based on the information
provided by Friess, Reliance undertook to contact those doctors
to obtain necessary records and evaluations.
The compiled medical records document problems with Friess's
left ankle and foot dating from November 28, 1994, when William
Markmann, M.D. began treating Friess for those problems.*fn5
However, Friess maintains that her medical treatment began
immediately following her fall on May 25, 1994. On the day of the
fall, she was taken to the emergency room at Nazareth Hospital
and treated for an ankle injury. On the next day, May 26, 1994,
Friess saw Dr. Thomas Peff for treatment. Dr. Peff treated Friess
over the next several months. During that time, Dr. Peff put a
cast on the ankle and had Friess perform physical therapy.
In November of 1994, Dr. Markmann's practice assumed care for
Friess. The record of his November 28, 1994 evaluation*fn6
indicates that Friess described her earlier treatment under Dr.
Peff to Dr. Markmann. Friess also provided Dr. Markmann with
x-rays she brought with her from Dr. Peff's office. Friess
complained to Dr. Markmann of persistent pain in her left ankle
and foot that made
walking and standing difficult. Dr. Markmann ordered an MRI*fn7
scan of her ankle and foot and also an EMG*fn8 of her back and
left leg. On December 20, 1994, Markmann prescribed Percodan in
response to Friess's request for pain relief.
On December 28, 1994, I.M. Solanki, M.D. conducted the
MRI.*fn9 The records of both Dr. Solanki and Dr. Markmann
indicate that the MRI study was normal.
In January of 1995, Dr. John Beight, another doctor in the same
practice group as Dr. Markmann, examined Friess.*fn10 His
records indicate that Friess continued to complain of persistent
pain in her foot. He agreed with Dr. Markmann that she should
have an EMG. In notes dated January 20, 1995, Dr. Beight wrote
that he believed Friess could work in a seated position. However,
Friess's attempt to resume work in late January 1995 intensified
her pain. On January 27, ...