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Lightner v. Liberty Life Assurance Co. of Boston

March 31, 2006


The opinion of the court was delivered by: Judge Conner


Presently before the court are cross-motions for summary judgment (Docs. 12, 14) with respect to the claim of plaintiff, Julie Lightner ("Lightner"), to recover disability benefits allegedly owed to her by defendant, Liberty Life Assurance Company of Boston ("Liberty"), under an employee benefit plan subject to the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. §§ 1001-1401. Lightner argues that Liberty, administrator of the plan, improperly refused and then terminated her disability benefits. Liberty disagrees, and contends that the evidence before it was insufficient for a finding that Lightner was unable to perform her job, and that Lightner's own physician approved her return to work. After a thorough review of the record, and for the reasons that follow, the court will grant Liberty's motion for summary judgment and deny Lightner's motion for summary judgment.

I. Statement of Facts*fn1

Lightner is employed by the Milton S. Hershey Medical Center ("HMC") as a patient billing assistant. (Doc. 15 ¶¶ 1,2; Doc. 25 ¶¶ 1,2; Doc. 17 at LL-0197.) Her job description requires that she perform basic accounting duties, such as preparing and reconciling daily bank deposits, resolving credit balances, and downloading and resolving lockbox deposits. (Doc. 17 at LL-0197.) As an HMC employee Lightner is eligible for long-term benefits through a group disability policy with Liberty. (Doc. 15 ¶¶ 1,2; Doc. 25 ¶¶ 1,2.) The terms of the disability policy provide, in pertinent part, as follows:

When Liberty receives Proof that a Covered Person is Disabled due to Injury or Sickness and requires the Regular Attendance of a Physician, Liberty will pay the Covered person a Monthly Benefit after the end of the Elimination Period . . . . The benefit will be paid for the period of Disability if the Covered Person gives to Liberty Proof of continued:

1. Disability;

2. Regular Attendance of a Physician; and

3. Appropriate Available Treatment.

(Doc. 17 at LL-0017.) "Proof" of a disability includes an attending physician's statement attesting to the disability, as well as the physician's "standard of diagnosis, chart notes, lab findings, test results, x-rays and[/]or other forms of objective medical evidence." (Doc. 17 at LL-0097.) These submissions must demonstrate that, as a result of injury or sickness, the individual covered by the policy is "unable to perform the [m]aterial and [s]ubstantial [d]uties" of his or her occupation for a minimum period of 180 days after the onset of the disability. (Doc. 17 at LL-0006; see also id. at LL-0008 (defining "material and substantial duties").) It is only after this 180 day "elimination period" that benefits will begin to accrue. (Doc. 17 at LL-0007.)

On February 17, 2004, Lightner submitted a claim to Liberty under its disability policy. (Doc. 17 at LL-0193-94.) The claim stated that Lightner was involved in an automobile accident on September 18, 2003, resulting in a "head injury," "nerve damage in the head," and "severe pain in the head." (Doc. 15 ¶ 1; Doc. 25 ¶ 1; Doc. 17 at LL-0193.) Lightner also submitted a copy of her job description (Doc. 15 ¶ 4; Doc. 25 ¶ 4; Doc. 17 at LL-0197), a form completed by HMC setting forth Lightner's job title and hours of employment (Doc. 17 at LL-0192), and an "attending phsyician's statement," completed by James P. Argires, M.D. ("Dr. Argires") of Lancaster Neuroscience and Spine Associates. (Doc. 17 at LL-0195-196.) According to the physician's statement, Lightner suffered from headaches as a result of "post concussion syndrome." (Doc. 17 at LL-0195.) Dr. Argires prescribed various medications for Lightner, ordered an MRI, and referred her to Stephen C. Ross, M.D. ("Dr. Ross"), a neurologist at HMC, for further testing. (Doc. 17 at LL-0196.) The physician's statement identified various categories of limitations. The categories of "mental/nervous impairment" and "cardiac impairments" were noted inapplicable, but, under the category of "physical impairment," a box was checked indicating "[s]evere limitation of functional capacity; incapable of minimum activity." (Doc. 17 at LL-0196.)

After its initial review of Lightner's claim, Liberty requested additional information from Lightner and her physicians. (Doc. 15 ¶ 6; Doc. 25 ¶ 6.) Thereafter, Liberty received a "physician's special report" (Doc. 17 at LL-0214), the results of an MRI and a CAT scan (Doc. 17 at LL-0206, 0212), correspondence written by Dr. Argires to Lightner's family physician, Stanley Godshall, M.D. ("Dr. Godshall") of Norlanco Medical Associates ("Norlanco") (Doc. 15 ¶ 6; Doc. 25 ¶ 6; Doc. 17 at LL-0201, 0203, 0205, 0207, 0209, 0210), a referral letter to Dr. Ross (Doc. 17 at LL-0199-200), and copies of several excuse slips written by Dr. Argires (Doc. 17 at LL-0202, 0204).

The "physician's special report," dated October 28, 2003, indicated that Lightner was being treated with medication for post-concussion syndrome, and that she "could not return to work" at that time. (Doc. 17 at LL-0214.) The MRI results, with the exception of a notation that Lightner suffered from "minimal sinus disease," were normal. (Doc. 17 at LL-0166, 0206.) The CAT scan results were also normal, indicating that Lightner's "ventricles and extra-axial spaces" were "normal in size and shape," her "bony structures" were intact, her parenchyma "demonstrate[d] no foci of abnormal attenuation," and that there was "no evidence of an intracranial hemorrhage or mass lesion." (Doc. 17 at LL-0158, 0212.)

The correspondence submitted by Lightner consisted of several letters from Dr. Argires to Dr. Godhsall, and one letter from Dr. Argires to Dr. Ross. The first letter to Dr. Godshall reflects that Lightner was examined on October 28, 2003 for a headache. (Doc. 17 at LL-0170, 0173, 0214.) Lightner complained of "left-sided headache patterns" that were "sharp and lancinating at times," spreading on occasion to the right side of her head. (Doc. 17 at LL-0127, 0211.) Although she was not experiencing any nausea or vision problems, she was experiencing anxiety and having "difficulty with concentration and memory." (Doc. 17 at LL-0127, 0211.) Her medical evaluation was "remarkable for fatigue, dizziness, shortness of breath and headaches." (Doc. 17 at LL-0127, 0211.)

Another letter to Dr. Godshall, dated November 11, 2003, advises that Lightner's neurological examination is normal. (Doc. 17 at LL-0126, 0208, 0209.) Dr. Argires did not believe that there was a "strong element of post traumatic stress," but he indicated that Lightner was "[not] quite ready to return to gainful employment." (Doc. 17 at LL-0126, 0208, 0209.)

A third letter to Dr. Godshall, dated November 25, 2003, relates that Lightner complains of "lightening-like pains across the right frontal area" of her head. (Doc. 17 at LL-0125, 0207.) In this letter, Dr. Argires observes that the results of a neurological examination are still normal, but notes that Lightner is suffering from a "considerable amount of anxiety." (Doc. 17 at LL-0125, 0207.)

The fourth letter to Dr. Godshall is dated December 9, 2003. (Doc. 17 at LL-0124, 0205.) Dr. Argires indicates again that Lightner's neurological examination is normal. (Doc. 17 at LL-0124, 0205.) However, he observes that medication prescribed is not providing any relief. (Doc. 17 at LL-0124, 0205.) Dr. Argires examined Lightner again less than three weeks later, and wrote to Dr. Godshall, describing Lightner's pain as a "dull ache from time to time." (Doc. 17 at LL-0123, 0203.) Notably, he observed that it "switched" from the left side of her head to the right side, and that prescription medications were providing "no relief." (Doc. 17 at LL-0123, 0203.) Dr. Argires indicated that Lightner's CAT scan and MRI results did not reflect any "postconcussion problem[s]," and that Lightner's condition "may just be post-traumatic stress." (Doc. 17 at LL-0123, 0203.)

The final letter to Dr. Godshall submitted by Lightner is dated January 7, 2004. (Doc. 17 at LL-0122, 0201.) In it, Dr. Argires states that several medications are not affording Lightner any relief, that her problem is likely "a traumatized supraorbital nerve," and that Lightner will be referred to another physician for a second opinion. (Doc. 17 at LL-0122, 0201.)

The correspondence from Dr. Argires to Dr. Ross is a referral letter dated January 20, 2004. (Doc. 17 at LL-0120, 0199.) In this letter, Dr. Argires describes Lightner's symptoms and course of treatment, and relays that one medication is providing relief. (Doc. 17 at LL-0120, 0199.) Dr. Argires states that he is unsure whether Lightner had a "contused supra-orbital nerve," but that it "might be the answer" to her complaints. (Doc. 17 at LL-0120, 0199.)

The excuse slips submitted by Lightner to Liberty were prepared by Dr. Argires. These slips are dated December 9, 2003, and January 7, 2004. (Doc. 17 at LL-0202, 0204.) The December slip notes that Lightner was "under [Lancaster Neuroscience and Spine Associates'] care" and that she "continues to be disabled until further notice due to [a] medical condition." (Doc. 17 at LL-0138, 0168, 0204.) The January slip requests that Lightner be excused from work "[u]ntil further notice," and states that Lightner is "being treated for post traumatic stress syndrome, and supra orbital neuropathy." (Doc. 17 at LL-0202.)

On March 18, 2004, a nurse at Liberty reviewed all of the documents submitted by Lightner. (Doc. 15 ¶ 7; Doc. 25 ¶ 7; Doc. 17 at LL-0185-86.) The nurse drafted a memorandum, in which she listed the injuries sustained by Lightner following her accident. (Doc. 17 at LL-0185.) The memorandum indicates that Lightner complained of sharp headaches on the left side of her head and had difficulty with her memory and concentration at times, and that Lightner was being treated by Drs. Argires and Godshall. (Doc. 17 at LL-0185.) The nurse also reviewed the medications prescribed to Lightner, the results of the CAT scan, MRI, and neurological examinations, and Dr. Argires' assessment that Lightner may be suffering from post traumatic stress disorder, and may have contused the frontal branches of her supra-orbital nerve. (Doc. 17 at LL-0185.)

In her memorandum, the nurse expressed several concerns with the medical records. For example, Lightner's position as a patient billing assistant was "sedentary" work, and any limitations with respect to that position were not adequately documented. (Doc. 17 at LL-0186.) Further, the medical evidence appeared to be inconsistent with Dr. Argires' diagnosis of post concussion syndrome. The nurse opined that "[p]ost concussion syndrome-PCS-is a specific set of neuropsychological thinking, behavioral, and emotional disorders caused by traumatic brain injury, aka concussion. PCS results from actual, physical damage, or injury to the brain caused by an external force." (Doc. 17 at LL-0185.) However, Lightner's complaints of memory and concentration had not been objectively tested, her CAT scan and neurological examinations were normal, her MRI reflected only minimal sinus disease, and Dr. Argires had found that Lightner did not suffer from a mental nervous impairment. (Doc. 17 at LL-0186-87.) The nurse concluded that "[Lightner] may need to have more extensive testing done-or [a] [seco]nd opinion-overall [Lightner's] symptoms are self reported[.]" (Doc. 17 at LL-0185.)

Following the nurse's review, on March 23, 2004, Liberty sent to Lightner correspondence denying her disability benefits. (Doc. 17 at LL-0182-83.) The letter stated that Lightner's occupation as a patient billing assistant required sedentary activity, and that the information provided by Lightner was insufficient to demonstrate that she could no longer perform that position. (Doc. 17 at LL-0183.) The letter noted that Lightner complained of post concussion syndrome and headaches, but that the results of her CAT scan and MRI were normal. (Doc. 17 at LL-0182.) The letter also stated that Lightner's memory and concentration problems were not objectively tested, and that the results of her neurological examination were normal. (Doc. 17 at LL-0182.) Although Lightner was diagnosed as suffering from post traumatic stress syndrome, the letter observed that other medical records were inconsistent with this diagnosis and specifically indicated that Lightner did not have a mental nervous impairment. ...

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