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Dolfi v. Disability Reinsurance Management Services

August 21, 2008


The opinion of the court was delivered by: Judge Vanaskie


Nearly five and one-half years after she allegedly became disabled due to a work-related injury, Plaintiff Brenda Dolfi filed a claim for disability benefits with Defendant United States Life Insurance Company ("U.S. Life"),*fn1 the disability insurance carrier that issued a policy to her employer. Despite the significant passage of time, Defendant Disability Reinsurance Management Services, Inc. ("DRMS"), the claims administrator, undertook a comprehensive investigation and review of Ms. Dolfi's claim.*fn2 DRMS concluded that the evidence did not support Ms. Dolfi's claim that she was disabled by her physical injuries, but, however, it determined that the evidence established she was disabled due to a mental, nervous, or emotional disorder, and awarded benefits for a closed period. Dissatisfied with this outcome, Ms. Dolfi commenced this action under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001-1461, to recover disability benefits.*fn3 (Dkt. Entry 1.)*fn4

Before the Court are Cross-Motions for Summary Judgment. (Dkt. Entries 20 & 35.) Having carefully examined the administrative record of the benefits decision under the arbitrary and capricious standard, the Court concludes that the decision must be sustained.


A. The Plan and Claim Administration Process

Ms. Dolfi was employed by Luzerne County Community College ("LCCC"), the policyholder of a group insurance plan issued by U.S. Life that provided LCCC's full-time employees long-term disability benefits ("Plan"). (Admin. R. ("AR"), at 1-19 (Plan).)*fn5 The Plan provides that if an employee, "while insured, . . . become[s] disabled and continue[s] to be so disabled past the waiting period, [U.S. Life] will pay to you [long-term disability] benefits." (Id. at 10.) Disability means total or partial disability. (Id.) As defined by the Plan, "total disability" means during the waiting period and thereafter, your complete inability to perform the material duties of your regular job. "Your regular job" is that which you were performing on the day before total disability began.

The total disability must be a result of an injury or sickness. To be considered totally disabled, you must also be under the regular care of a physician. (Id.)*fn6

An employee totally disabled is entitled to benefits as determined by the Plan's Schedule of Benefits. Generally, an employee will receive a monthly benefit of seventy percent (70%) of the employee's basic monthly pay, up to a monthly maximum of $5,000. (Id. at 5.) That benefit is reduced, however, by the amount of income received from other sources, such as social security disability benefits and workers' compensation benefits. (Id. at 12.) Benefits are paid until the earlier of the date that the disability ends or the maximum benefit period ends. (Id. at 11.) The maximum benefit period varies depending on the employee's age at the onset of total disability. For employees disabled due to alcoholism, drug addiction, or mental, nervous, or emotional disorder, the maximum benefit period is twenty-four months. (Id. at 11.)

To file a claim for benefits, an employee must complete and submit a proof of claim form. (Id. at 18.) Proof of claim forms may be available from the employer, but if not, the employee must send written notice of the claim to U.S. Life within twenty days of the date of loss. (Id.) Upon receipt of notice, U.S. Life will mail to the employee a proof of claim form. (Id.) The proof of claim form, whether obtained from the employer or U.S. Life, must be completed by both the employer and employee, with additional proof attached if required, and sent to U.S. Life within thirty days after the waiting period. (Id.) Late submission of a proof of claim will not result in denial or reduction of benefits "if . . . proof was sent as soon as possible." (Id.) The employee is subject to examination, at U.S. Life's expense, as often as necessary to process a claim. (Id.) Moreover, "[U.S. Life ] may require more proof as often as needed to verify disability." (Id.)

Although a reading of the Plan suggests U.S. Life is the administrator, (see id.), the Plan is actually administered by DRMS pursuant to an "Agreement for Group Long Term Disability Claims Adjudication effective August 1, 2000." (Knutsen Decl., Dkt. Entry 25, ¶ 2.) DRMS administered Ms. Dolfi's claim. (Id. ¶ 3.)

DRMS handles all aspects of the claim administration process, from initial review to final administrative appeal. Following the initial review, DRMS sends a letter to the employee advising her of the benefits decision and, if the claim is denied, stating the specific reasons for the denial. (AR at 173.) An employee denied benefits has 180 days from receipt of the adverse decision to file an appeal. (Id.) On appeal, DRMS reconsiders and reevaluates the employee's entire claim file and will also consider any new information submitted by the employee. (Id. at 1393.) "The appeal review will not be conducted by an individual who made the original adverse determination; nor will they be a subordinate of that decision-maker." (Id. at 1392.) The employee will receive from DRMS another decision letter stating the specific reasons for DRMS's determination. (Id.) If the appeal results in a decision adverse to the employee, the employee has the option of requesting a second appeal review or filing a lawsuit under ERISA to recover benefits. Electing the former requires the employee to file an appeal within 60 days of receipt of the adverse decision. (Id.) Like the first appeal, this review involves a complete reconsideration and reevaluation of the claim file (along with any new information submitted by the employee) and is not "conducted by an individual who made the original adverse determination or conducted the first appeal review; nor will they be a subordinate of either of the prior decision-makers." (Id. at 1392, 1974.) Should the employee disagree with the determination made following the second appeal, the employee's recourse is an ERISA lawsuit. (Id. at 2041.)

If, on the other hand, DRMS determines on initial or appellate review that an employee is disabled and entitled to benefits under the plan, DRMS itself issues the employee a benefit check. (See id. at 1975 ("Under separate cover we will issue a benefit check . . . .").) There is nothing in the record indicating that decisions favorable to an employee must be approved by U.S. Life prior to the issuance of a benefit check.

B. Ms. Dolfi's Employment with LCCC

Ms. Dolfi worked as a job placement coordinator with LCCC from January 5, 1998, to May 24, 1999. (Id. at 145.) Working full-time, she was an insured employee under the Plan. (See id. at 7.) Among other duties, she was responsible for devising and implementing gender equity programs, providing "nontraditional career awareness and vocational assessment," facilitating student support activities, and teaching students "employability and coping skills." (Id. at 170.) The position was not physically demanding. In this regard, an eight-hour workday entailed two to four hours of standing, zero to two hours of walking, and four to six hours of sitting. (Id. at 171.) Occasionally she was required to lift or carry zero to ten pounds. (Id.) She was not required, however, to use her hands for grasping, pushing or pulling, or "fine manipulation," nor was she expected to bend, squat, climb, crawl, twist/turn, or reach above her shoulder. (Id.)

C. Ms. Dolfi's Work Injury and Medical Treatment

On April 26, 1999, Ms. Dolfi was injured at work when she attempted to prevent a filing cabinet from falling onto a nearby secretary. Observing the toppling cabinet, she rushed over and thrust her shoulder against the cabinet, wrapped her arms around the secretary, and, in a twisting motion, pulled her from the cabinet, which crashed to the floor. (Id. at 600-599.) Ms. Dolfi felt two cracks in her back as she pivoted away from the cabinet. (Id. at 599.) Immediately she experienced pain along the right side of her body, particularly in her back, shoulder, and neck. (Id.) She also had a headache and later felt nauseous. (Id.)*fn7

After being evaluated by an LCCC nurse, Ms. Dolfi sought treatment at the Wilkes Barre General Hospital. She related the incident at work, noting a burning sensation in her low back after she pivoted away from the cabinet, and complained of a headache, right neck pain, right shoulder pain, and low back pain that ran through her buttocks into her right thigh. (Id. at 1615.) A physical examination revealed tenderness primarily in the right shoulder and cervical, thoracic, and lumbar spines, with limited range of motion in those regions. (Id. at 1612.) X-rays were taken of the right shoulder and cervical and lumbar spines; other than slight straightening of the cervical spine possibly due to muscle spasm, X-rays were negative for abnormalities. (Id. at 1610-1608.) Diagnosed with cervical strain, lumbar strain, and right shoulder pain, Ms. Dolfi was directed to take Norflex and Motrin, and released. (Id. at 1615, 1611.)

Several days later Ms. Dolfi returned to work. She experienced increased pain in her neck, right shoulder, and back, with pain radiating down her right leg, and more intense headaches. Ms. Dolfi was referred to Peter Feinstein, M.D., whom she first saw May 7, 1999. Dr. Feinstein examined Ms. Dolfi and noted bilateral tenderness in the "paracervical musculature," greater on the right side; slightly positive straight leg raising in the right leg, although no "motor deficits"; and "slight diminution of sensation in the right lateral calf," but otherwise normal sensation. (Id. at 1622.) Dr. Feinstein diagnosed "[m]yofascial or whiplash injury to the cervical spine and lumbar spine with possible discogenic irritation in the cervical and lumbar spine. Bruise of the left shoulder, resolved." (Id. at 1623.)*fn8 He prescribed Dolobid, an anti-inflammatory medication, Flexeril, a muscle relaxant, and physical therapy. (Id. at 1622.) Her prognosis was fair, and she was permitted to return to her pre-injury job without restriction. (Id.)

Ms. Dolfi was next seen by Dr. Feinstein on May 17, 1999, presenting similar complaints of pain and difficulty sleeping. (Id. at 1625.) She had negative straight leg raising and walked without limping. (Id. at 1624.) Dr. Feinstein advised Ms. Dolfi to see a neurosurgeon to evaluate her headaches. (Id. at 1625.) He also prescribed Darvocet and advised her not to return to work, though he recommended that she continue her normal routine and walk for exercise. (Id. at 1625-1624.)

On May 20, 1999, MRIs were obtained of Ms. Dolfi's cervical and lumbar spines. Other than a "[h]emangioma of bone in the T2 vertebral body," the MRI of the cervical spine was "unremarkable," and there was no evidence of disc herniation or spinal stenosis.*fn9 (Id. at 1652.) The MRI of the lumbar spine demonstrated "[m]ild disc degeneration at L3-4 associated with posterior disc bulge [lateralizing] slightly to the right of midline," but there was no evidence of disc herniation or spinal stenosis. (Id. at 1651.) At L4-5, the MRI depicted mild disc degeneration with abnormal soft tissue along right posterolateral aspect of L4-5, suggesting possible disc herniation. (Id. at 1651-1650.) Significantly, there was no evidence of spinal stenosis or of "mass effect on the exiting nerve root." (Id.)

Dr. Feinstein noted the MRI results at Ms. Dolfi's next appointment, June 1, 1999. (Id. at 1626.) Along with her usual complaints, Ms. Dolfi presented swelling and pain in her left knee and ankle. (Id. at 1627.) A physical examination, however, was negative for pain and other abnormalities. (Id. at 1626.) Dr. Feinstein recommended physical therapy, suggested epidural injections may be necessary, and provided a note to remain out of work. (Id. at 1627-1626.)

On June 3, 1999, Ms. Dolfi was evaluated by A.R. Samii, M.D., a board-certified psychiatrist and neurologist. On examination, he observed questionable decreased senses in the right foot and hand and tenderness in the right side of neck and paracervical area, but otherwise the examination was unremarkable. (Id. at 1512-1511.) Dr. Samii reviewed the recent MRIs of the cervical and lumbar spines, noting there was no evidence of compression of the root area at the lumbar spine. (Id. at 1511.) He diagnosed Ms. Dolfi as having sustained a cervical sprain, which contributed to her daily headaches, and a low back sprain. Acknowledging Ms. Dolfi's complaint of radicular pain to the right leg, he thought this was possibly related to "L4-L5 root compression. However, this was not seen in MRI reports." (Id.) To investigate further, Dr. Samii ordered an electromyogram, or "EMG," of Ms. Dolfi's right extremities. (Id.; see id. at 1510-1503.) After reviewing the results, Dr. Samii concluded there was "[m]ild degree right carpel tunnel syndrome [but] no electrophysiological evidence of radiculopathy."*fn10 (Id. at 1510.)

Ms. Dolfi saw Dr. Feinstein again on June 15 and July 1, 1999. At the June appointment, she was "visibly teary and upset" and was contemplating consulting a counselor for her emotional problems. (Id. at 1629.) Dr. Feinstein encouraged her to contact a psychologist because of her anxiety and depression. (Id. at 322, 1628.) On July 1, Dr. Feinstein reviewed a job description forwarded to him and concluded Ms. Dolfi was unable to perform that job, or any other work activity, at the present time.*fn11 (Id. at 1631.) He altered Ms. Dolfi's prognosis from "fair" to "guarded," (id. at 1630), reasoning that Ms. Dolfi "continued to remain symptomatic in a significant way, despite having tried the really extensive variety of therapeutic interventions that weren't helping her." (Id. at 319.)

July 1 was also Ms. Dolfi's first counseling session at the Psych Center of Northeast Pennsylvania. She treated there until April 20, 2000, primarily with Michael A. Youron, M.A., a licensed psychologist, and at times with Drs. Cupple and Sanjay S. Chandragiri, staff psychiatrists. (See id. at 1521-1533.) Mr. Youron's observations and conclusions are best summarized in an August 20, 1999, letter to Guard's Rocko Pierantoni (See id. at 454-453.) Following the accident at work, Ms. Dolfi reported feeling depressed and anxious, having trouble sleeping, and suffering panic attacks. (Id. at 454.) She also presented agoraphobia-like symptoms. (Id.)*fn12 The accident impeded her ability to cope with stress and resurrected traumatic events previously experienced in her life. (Id.) For instance, her stepson recently committed suicide. (Id.) And, though not referred to in the letter, Ms. Dolfi confided to Mr. Youron that she was abused sexually as a child. (Id. at 1523.) Mr. Youron concluded Ms. Dolfi was suffering from Post-Traumatic Stress Disorder ("PTSD"), the traumatic event being the injury at work. (Id. at 454.) Her perceived vulnerability after the accident triggered depression, a sense of hopelessness, nightmares, and diminished interest in socialization. (Id.) Further aggravating her condition was the revival of previous trauma experienced in her life. (Id. at 453.) Mr. Youron wrote that Buspar might be an appropriate psychopharmacological treatment to alleviate Ms. Dolfi's symptoms. (Id.) He was optimistic that psychotherapy would enable Ms. Dolfi to regain her self-worth and alleviate her symptoms. (Id.) Treatment continued thereafter with Mr. Youron, and his office notes indicate Ms. Dolfi's condition varied little from this assessment. (See id. at 1521-1533.)

On July 16, 1999, Ms. Dolfi was examined by a second neurologist, V.D. Dhaduk, M.D. Along with her usual symptoms, she complained of pain radiating into both upper extremities. (Id. at 1515.) Dr. Dhaduk examined Ms. Dolfi and reviewed the MRIs of her brain and cervical and lumbar spines. (Id. at 1514-1513.) He diagnosed Ms. Dolfi's work-related injury as "severe post-traumatic tension vascular headache," "cervical radiculopathy with paraspinal muscle spasm," and "degenerative and herniated disc with lumbar radiculopathy mainly at L5-S1 level." (Id. at 1513.) Several treatment options were recommended regarding medication, exercise, and diet. (Id.)

Ms. Dolfi was seen again by Dr. Feinstein on July 22, August 23, and September 21, 1999. Her complaints and physical examination were essentially unchanged, although Dr. Feinstein observed positive right straight leg raising at the August and September visits. (Id. at 1636, 1640.) He also noted during the August visit that Ms. Dolfi exhibited anxiety symptomotology.*fn13 (Id. at 1636.) Ms. Dolfi was encouraged to walk and be active physically as much as possible and to continue treatment with the other providers. (Id. at 1633, 1636, 1641.)

On August 17, 1999, Ms. Dolfi had her first appointment with pain management specialist Asit P. Patel, M.D. Upon examination, Dr. Patel found tenderness and positive straight leg raising. He and reviewed her lumbar MRI, which he noted revealed "mild disc degeneration at L3-4 with posterior disc bulge lateralizing slightly to the right." (Id. at 1536-1535.) Assessing her back and right leg pain as "probable neuropathic pain" and her neck pain as "mostly musculoskeletal in nature with component of occipital neuralgia," Dr. Patel administered a lumbar epidural steroid injection and recommended future trigger point injections in cervical paravertebral region and occipital nerve block. (Id. at 1535.)

A third neurologist, Dorothy A. Farrell, M.D., evaluated Ms. Dolfi on September 8, 1999. Ms. Dolfi complained of persistent neck pain, low back pain radiating down her right leg, and daily headaches, and reported difficulty sleeping, anxiety, nightmares, and personality change. (Id. at 1552-1551.) Dr. Farrell examined Ms. Dolfi and reviewed several diagnostic studies. (Id. at 1550.) Concluding Ms. Dolfi presented a "mixed picture," Dr. Farrell diagnosed her condition as cervical strain, myofascial pain, headaches ("mixed with muscle contraction and migraines"), and lumbar disc. (Id.) She prescribed medications to alleviate the pain and the migraine headaches. (Id.) Additionally, Dr. Farrell recommended Ms. Dolfi continue the steroid injection therapy from Dr. Patel and the "ongoing psychiatric care for anxiety and depression which is significant in her symptoms." (Id.)

A second MRI of Ms. Dolfi's lumbar spine was obtained September 21, 1999. The image was essentially unchanged from the May 20 MRI. (Id. at 1676.) At L3-4, there was mild diffuse disc bulge, but "no evidence of compromise of the spinal canal or exiting nerve roots." (Id. at 1677; see also id. at 1676 (noting disc bulge "does not contribute to compromise of the spinal canal or exiting nerve roots").) No additional herniations or bulges were observed. (Id. at 1676.) At both L4-5 and L5-S1, there was no evidence of disc protrusion or extrusion or of "compromise of the spinal canal or exiting nerve roots." (Id. at 1677-1676.) The report concluded that "[Ms. Dolfi's] given history of lower extremity radiculopathy are not explained on this MRI." (Id. at 1676.)

Ms. Dolfi returned to Dr. Patel on September 30, 1999. Dr. Patel reviewed the recent MRI of the lumbar spine and remarked that it was unchanged from the previous MRI. (Id. at 1538.) He now attributed her back and right leg pain to "[p]ossible SI arthropathy" and ruled out, inter alia, lumbar radiculopathy. (Id.) A right S1 joint injection and trigger point injection were administered along the cervical and thoracic muscles. (Id. at 1537.) These injections provided pain relief, Ms. Dolfi reported at her next visit on November 8, 1999, especially the trigger point injections that alleviated significantly her neck and upper back pain and headaches. (Id. at 1540.) Dr. Patel administered lumbar facet injections at bilateral L4-5 and L5-S1. (Id. at 1539.) He also modified his impression of Ms. Dolfi's back and right leg pain, this time characterizing it as musculoskeletal pain. (Id. at 1540.)

Following a visit with Dr. Farrell on October 12, 1999, (id. at 1554-1553), Ms. Dolfi saw Dr. Feinstein again on November 1, 1999, and December 13, 1999. Her complaints of pain varied little from previous examinations. (Id. at 1671, 781.) Dr. Feinstein agreed that the MRI of the lumbar spine obtained in September was unchanged from the MRI obtained in May. (Id. at 1670.) The December office note indicates that some time prior to the visit Ms. Dolfi returned to work for four hours, but her migraine headaches and other symptoms ...

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