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Humble v. Liberty Life Assurance Company of Boston

June 9, 2008


The opinion of the court was delivered by: Judge Munley


Before the court are the parties' motions for summary judgment. Having been fully briefed and argued, the matter is ripe for disposition.


This case arises from plaintiff's appeal of defendant's termination of her long-term disability benefits pursuant to the Employee Retirement Income Security Act (ERISA). Plaintiff, who was employed as Operations Manager by Geisinger Health System, made a claim for such benefits after she became disabled due to a kidney transplant and polycystic kidney disease. (Statement of Material Facts in Support of Plaintiff's Motion for Summary Judgment (Doc. 16) (hereinafter "Plaintiff's Statement") at ¶ 2; Statement of Undisputed Material Facts of Defendant (Doc. 18) (hereinafter "Defendant's Statement) at ¶¶ 2-3).*fn1 Defendant Liberty Life provided Geisinger with coverage; under the plan, if found disabled, plaintiff was entitled to 66.67% of her weekly salary from the time she was forced to stop working, less any social security benefits she received. (Plaintiff's Statement at ¶ 4).

Plaintiff underwent kidney transplant surgery on March 16, 2004. (Defendant's Statement at ¶ 4). She took a medical leave from her position at Geisinger on that date. (Id.). Plaintiff submitted an application for long-term disability benefits to defendant in August 2004. (Plaintiff's Statement at ¶ 3). To be eligible for such benefits, plaintiff had to show that she was unable to perform her job for 180 days (an "elimination period") after she commenced leave from work for her disability. (Defendant's Statement at ¶ 5). Plaintiff thus became eligible for long-term disability benefits under defendant's policy on September 12, 2004. (Id.). Plaintiff was eligible for twenty-four months of benefits under this policy. (Id. at ¶ 6). During this period, the plan defined plaintiff as disabled if she had to show that "as a result of Injury or Sickness, [she was] unable to perform the Material and Substantial Duties of [her] Own Occupation." (Disability Insurance File of Liberty Life Insurance Company for Rita Humble (Doc. 13) (hereinafter "R.") at LL-0006). To be eligible for disability after this initial twenty-four-month period, plaintiff had to show that she was "unable to perform the Material and Substantial Duties of Any Occupation" for which she was "or becomes reasonably fitted by training, education, experience, age physical and mental capacity." (R. at LL-0005-6).

In connection with plaintiff's application for these benefits, defendant requested plaintiff's medical records and other information about her condition. (Defendant's Statement at ¶ 7). The records received from this request included information from Dr. Nicole Alu which confirmed that plaintiff's kidney transplant and continuing health problems made it impossible to return to her nursing position. (Id.). Dr. Alu found that the high stress of the job and danger of exposure to infection made return to the hospital inappropriate. (Id.). Based on this information, defendant approved disability payments for plaintiff on September 8, 2004. (Id. at ¶ 8).

As part of normal procedure under the long-term disability policy, defendant continued to monitor plaintiff's condition after this initial determination. (Id. at ¶ 9). Liberty received updated medical reports on plaintiff's condition. In April 2005, Dr. Mark Finger, a board-certified doctor in internal medicine and nephrology, examined plaintiff's medical records. (Id. at ¶ 10). He confirmed that her condition presented a continued high risk of infection, and found that plaintiff remained unable to return to her previous employment because of the dangers of patient contact. (Id.). Defendant made further investigation into the conditions of plaintiff's work and found that she indeed came into frequent contact with patients. (Id.). Accordingly, the defendant determined that plaintiff remained disabled under the terms of the policy and continued her disability coverage. (Id.).

Liberty Life continued to request and receive medical information from the plaintiff during 2005 and early 2006. Plaintiff completed an "activities questionnaire" for defendant on December 9, 2005. (See R. at LL-0722-24). She related that she could sit for two hours and stand and walk for an unlimited period of time. (Id. at LL-722). Plaintiff spent three hours a day sitting, eight hours standing and an hour walking. (Id.). Plaintiff frequently left the house each week, was able to walk outside at least three times a week, and worked in her garden wearing gloves. (Id.). She could not wash her car or work on her house. (Id.). Plaintiff performed many household tasks, such as grocery shopping, cooking, vacuuming and doing laundry. (Id. at LL-0723). She could also care for her personal hygiene. (Id.). Plaintiff related that her condition and the dangers of infection it posed prevented her from engaging in the patient care required in her profession of nursing. (Id. at LL-0724).

The Defendant wrote plaintiff on August 21, 2006 to inform her that her disability status would change on September 11, 2006. (Defendant's Statement at ¶ 15). Plaintiff would no longer be covered by the policy that recognized her as disabled if she could not work the position in which she was employed at the onset of her disability. (Id.). In order to continue receiving benefits, plaintiff would have to demonstrate that she suffered from a medical condition that prevented her from working altogether. (Id.). The company warned that it was collecting information to determine whether she was eligible for the policy benefits, and that a determination that she was not eligible could come at any time after September 11. (Id.).

Plaintiff underwent a nephrectomy, removing her right kidney, on June 30, 2006. On December 1, 2006, Liberty also wrote to plaintiff's treating physicians, asking them to assess the company's determination that plaintiff could return to work in sedentary positions. Two of plaintiff's doctors, Dr. Bart Fulmer and Dr. Santosh Potdar, agreed that she could return to this sort of work. (See R. at LL-0367; LL-0041). A third doctor's repose was somewhat ambiguous, but did not state that plaintiff could not return to work in a sedentary capacity. Dr. Alu disagreed, stating that plaintiff "has not been trained to work in a 'sedentary capacity.' I do not feel this is appropriate and that she continues to be disabled from her regular work activities."

On September 15, 2006, plaintiff completed another "activities questionnaire" for defendant. (See R. at LL-0540-42). Plaintiff related that she had her right kidney removed on June 30, 2006. (Id. at LL-0542). She left the house daily, went outside for walks daily unless the weather was bad, and worked in the garden. (Id. at LL-0540-41). Plaintiff could not, however, work on the house or wash her car. (Id. at LL-0540). With the help of her husband, plaintiff shopped for groceries. (Id. at LL-0541). Her husband carried their groceries, and plaintiff and her husband put them away at home. While plaintiff cooked the meals, she and her husband worked together to clean up afterwards. (Id.). Plaintiff did other work around the house, such as cleaning bathrooms (with her husband), vacuuming and doing laundry. (Id.). Plaintiff could take care of all her personal grooming needs. (Id.). In that document, plaintiff related that she could sit for 1 1/2 to two hours, stand for two hours, and walk for 45 minutes. (Id. at LL-0540). Plaintiff reported that her problems with immunity prevented her from working at her previous occupation, and that joint pain prevented her from doing any other work. (Id. at LL-0542).

Defendant used experts to determine plaintiff's capacity to work. Dr. Amy Hopkins, certified in internal and occupational and environmental medicine, examined plaintiff's medical records in March 2006. (See R. at LL-0361-65). Hopkins issued a report on March 16, 2006. (Id. at LL-0361). Dr. Hopkins found that because of plaintiff's "permanent immunocompromised status, she is permanently restricted from working in direct patient care or in environments with high likelihoods of infectious disease exposure." (Id.). This limitation, however, would "Not preclude her from working in ordinary office environments." (Id.). Pain experienced by plaintiff due to enlarged kidneys also meant that she should be confined to "sedentary or light level work." (Id.). In the event that plaintiff required removal of a kidney, "she will have a postoperative recovery period during which time she will be unable to work at all." (Id.). Hopkins found that plaintiff suffered from "musculoskeletal complaints" caused by various physical ailments meant that "she should probably be restricted to light work so as not to aggravate the pain with heavy lifting." (Id.). Plaintiff summarized the medical evidence provided by plaintiff's doctors, as well as the activities questionnaire provided by plaintiff to support her conclusions about plaintiff's work capabilities. (Id. at LL-0634-35).

On March 22, 2006, Patricia Thal, a vocational expert employed by the defendant examined the plaintiff's records and prepared a "transferable skills analysis and labor market information" report. (See R. at LL-0628-29). Thal reviewed the claim file and consulted "standard vocational resources," but made no contact with plaintiff. (Id. at LL-0628). In evaluating plaintiff's medical status and functional capacity, Thal adopted Dr. Hopkins's recommendation that plaintiff be restricted to "sedentary or light level work." (Id.). Thal also found that plaintiff could no longer work in "direct patient care" because of the risks of exposure to infectious diseases, though she could work in an "ordinary office." (Id.). Thal noted that plaintiff was a high school graduate who possessed a nursing diploma. (Id.). She was employed as a registered nurse and supervisor for more than thirty years, the last twenty-three at the Geisinger Wyoming Valley Medical Center. (Id.). Based on this experience, Thal found that plaintiff possessed a set of "transferable skills," which included "oral and written communication; analytical skills; patient care; knowledge of medial terminology; medical record maintenance; assessment of patient health problems and needs; [and] management skills." (Id.). Thal proposed three occupations that plaintiff could perform, given her training and physical limitations: "Telephonic Advice Nurse, e.g. Ask-a-Nurse; Precertification Nurse; and Utilization Review Nurse." (Id. at LL-0369).

On February 20, 2007, the defendant determined that plaintiff was no longer eligible for total disability payments, notifying her by correspondence dated February 23, 2007. (Plaintiff's Statement at ¶ 7). In its letter to plaintiff, defendant informed her that her disability insurance was terminated on February 20, 2007 because she had "not continued to meet the Geisinger System Services Group Disability Income Policy requirements," which required that after the first twenty-four months of disability coverage she show that she is "unable to perform, with reasonable continuity, the Material and Substantial Duties of Any Occupation." (R. at LL-0114). The defendant defined "'any occupation'" as "any occupation that the Covered Person is or becomes reasonably fitted by training, education, experience, age, physical and mental capacity." (Id.). After listing contacts with various of plaintiff's doctors about restrictions on her daily activities and describing the review process undertaken by Liberty physicians and vocational experts, the defendant informed plaintiff that it had determined she could work as a "Telephonic Advice Nurse, Precertification Nurse, and Utilization Review Nurse." (Id. at LL-0115). Since "[a] review of [plaintiff's] claim has determined that [she has] no restrictions or limitation which would preclude work in a sedentary occupation in an office setting," defendant determined that plaintiff's claim should be denied. (Id.).

Plaintiff appealed this decision, writing defendant to explain the reasons for her appeal. Two factors, plaintiff argued, supported her claim for long-term disability benefits. First, she continued to suffer from a compromised immune system. (See letter from Rita Humble to Elizabeth Kiernan, dated March 16, 2007, R. at LL-0353). This condition meant that plaintiff suffered frequent minor illnesses such sore throats and coughs and colds. (Id.). If forced to return to work, these illnesses would mean that plaintiff would have to take sick days regularly. (Id.). Second, plaintiff found that the jobs which the company suggested she was capable of performing were ones she had "no experience in or knowledge of." (Id. at LL-0354). Her career as a nurse had centered around patient care, and she had no interest or experience with "insurance and payor practices." (Id.). Further, plaintiff had worked for Geisinger Health Systems for more than twenty years, and would "not look ...

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