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Farina v. Temple University Health System Long Term Disability Plan

April 27, 2009

CHRISTINA FARINA, PLAINTIFF,
v.
TEMPLE UNIVERSITY HEALTH SYSTEM LONG TERM DISABILITY PLAN, ET. AL, DEFENDANTS.



The opinion of the court was delivered by: Schiller, J.

MEMORANDUM

Plaintiff Christina Farina brings this action, pursuant to the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132(a)(1)(b), against Defendants Temple University Health System Long Term Disability Plan (the "Plan") and the Life Insurance Company of North America ("LINA"), the Plan's claims administrator, challenging LINA's denial of her claim for long term disability benefits. Currently before the Court are the parties' cross-motions for summary judgment. When an individual suffers from a chronic, disabling condition that waxes and wanes, as does Plaintiff, an insurance company may not discontinue benefits based on a brief window during which the condition improved despite evidence that the improvement was merely ephemeral. Because LINA improperly denied Plaintiff's benefits on this basis, Plaintiff's motion is granted and Defendants' motion is denied.

I. BACKGROUND

A. Plaintiff is Diagnosed with RSD and Begins Receiving Long Term Disability Benefits

Plaintiff was a senior endoscopy technician employed by Temple University Health System in Philadelphia. (Compl. ¶ 9; Ans. ¶ 9.) On August 22, 2003, Plaintiff injured her left knee when she tripped over a baby gate; she was later diagnosed with Reflex Sympathetic Dystrophy ("RSD") in connection with that injury. (Defs.' Mot. for Summ. J. [hereinafter "Defs.' Mot."] Ex. E [Administrative R. Excerpt] at LINA00044.) RSD, also known as Complex Regional Pain Syndrome, is a chronic neurological syndrome best described as a nerve or soft tissue injury that does not heal normally. See Reflex Sympathetic Dystrophy Syndrome Association, "What is CRPS?," available at http://www.rsds.org/2/what_is_rsd_crps/index.html (last visited Apr. 15, 2009). Those with RSD often suffer from "continuous, intense pain out of proportion to the severity of the injury, which gets worse rather than better over time." National Institute of Neurological Disorders and Stroke, "Complex Regional Pain Syndrome Fact Sheet," available at http://www.ninds.nih.gov/disorders/reflex_sympathetic_dystrophy/detail_reflex_sympathetic_dy strophy.htm (last visited Apr. 16, 2009). This pain is often accompanied by a burning sensation, increased skin sensitivity, changes in skin temperature (warmer or cooler compared to the opposite extremity), blotchy or purple skin, changes in skin texture (shiny and thin, and sometimes excessively sweaty), changes in nail and hair growth patterns, swelling and stiffness in affected joints and motor disability. Id. Although some individuals with RSD experience spontaneous remission, others experience "unremitting pain and crippling, irreversible changes in spite of treatment." Id.

Although Plaintiff returned to work, she reinjured her knee on the job when she walked into an x-ray arm on February 4, 2004. (Defs.' Mot. Ex. E at LINA00044 & Ex. F [Administrative R. Excerpt] at LINA00150.) She was diagnosed with "recurrent RSD." (Defs.' Mot. Ex. E at LINA00044.) Plaintiff stopped working on April 14, 2004 and continued to receive treatment for her pain. (Defs.' Mot. Ex. J [Nov. 19, 2004 Letter to Pl. Approving Claim for Benefits] at LINA01224.)

On July 15, 2004, Plaintiff filed for long term disability benefits. (Defs.' Mot. Ex. H [Application for Benefits] at LINA01300.) Pursuant to the Plan's policy, a participant is considered disabled, and therefore entitled to disability benefits, if due to injury or sickness he or she is unable "to perform all the material duties of his or her regular occupation," or "to earn more than 80% of his or her Indexed Covered Earnings." (Defs.' Mot. Ex. B [LINA Policy] at 3.) This definition of disability is referred to as the "own occupation" standard, since a participant meets this standard when he or she cannot perform the duties of his or her own occupation. After disability benefits are paid under the Plan policy for two years, a Plan participant must then satisfy a different standard - the "any occupation" standard - to continue receiving benefits. This standard is met when, due to injury or sickness, a Plan participant "is unable to perform all the material duties of any occupation for which he or she may reasonably become qualified based on education, training or experience" or "is unable to earn more than 80% of his or her Indexed Covered Earnings." (Id.) Per the policy, "[s]atisfactory proof of Disability must be provided to [LINA] . . . before benefits will be paid." (Id. at 18.)

LINA approved Plaintiff's claim for benefits and she received disability benefits of $50.00 per month under the Plan from October 13, 2004 through October 12, 2006.*fn1 (Pl.'s Mot. for Summ. J. [hereinafter Pl.'s Mot.] ¶ 7; Defs.' Mot. Ex. J.) As of October 12, 2006, to continue receiving benefits, Plaintiff was required to establish that she was disabled under the Plan's "any occupation" standard.

B. Plaintiff's Medical History

Since her reinjury in February, 2004, Plaintiff was seen by several doctors, including Drs. James Tweedy and Milton Soiferman, her primary care physicians; Dr. Alan Carr, a pain management specialist; Dr. Steven Mandel, a neurologist; and Dr. Philip Getson. (Defs.' Mot. Ex. G [Dr. Topper's Review] at LINA00181-185 (summarizing Plaintiff's medical history); Pl.'s Mot. Ex. A [Administrative R. Excerpts] at LINA00415.) She underwent various treatments including medication, physical therapy, epidurals, nerve blocks, and topical creams, often with little success. (Defs.' Mot. Ex. G at LINA00181-185.) Dr. Evan Frank, the pain management specialist who treated Plaintiff prior to Dr. Carr, noted on March 7, 2005 that, despite these treatments, Plaintiff was still experiencing pain and, unless she sought to pursue alternative therapies, she reached her maximum medical improvement. (Id.)

On December 15, 2005, LINA requested from Drs. Soiferman and Tweedy's office Plaintiff's records from September 10, 2005 through the present and asked for an estimated return to work date. (Pl.'s Mot. Ex. A at LINA00619.) On March 23, 2006, Dr. Tweedy responded that Plaintiff was still being treated for her RSD and that it would be "impossible to determine a return to work date" because "[Plaintiff] cannot work in any capacity." (Id.) Dr. Tweedy also completed a Physical Ability Assessment ("PAA") for Plaintiff, which he forwarded to LINA. (Id. at LINA00620.) The PAA listed activities, such as sitting, standing, and walking, and provided options for indicating Plaintiff's capability for tolerating those activities throughout an eight-hour workday. (Id.) The options were: (1) occasionally (1-33%) (< 2.5="" hrs);="" (2)="" frequently="" (34-66%)="" (2.5="" -="" 5.5="" hrs);="" (3)="" continuously="" (67-100%)="" (5.5="" hrs);="" or="" (4)="" not="" applicable="" to="" diagnosis(es).="" dr.="" tweedy="" noted="" on="" the="" form="" that="" plaintiff="" could="" sit="" and="" stand="" for="" less="" than="" fifteen="" minutes="" and="" that="" she="" could="" walk="" for="" less="" than="" ten="" minutes.="" (id.)="" she="" could="" frequently="" reach="" (overhead,="" at="" desk="" level="" and="" below="" her="" waist)="" and="" manipulate="" and="" grasp="" with="" her="" right="" and="" left="" hands.="" (id.)="" however,="" she="" could="" not="" lift="" or="" carry="" ten="" pounds,="" push="" or="" pull,="" climb,="" balance,="" stoop,="" kneel,="" crouch,="" crawl="" or="" tolerate="" exposures="" to="" extreme="" temperatures="" or="" vibration.="" (id.)="" he="" specifically="" noted="" her="" inability="" to="" use="" foot="" controls.="" (id.)="" he="" added="" that="" "significant="" [rsd]="" precludes="" virtually="" all="" of="" the="" above="" activities."="">

On April 22, 2006, Plaintiff completed a form entitled "Disability Questionnaire & Activities of Daily Living," in which she indicated that she could drive for ten to twenty-five minutes. (Pl.'s Mot. Ex. A at LINA00412.) She noted that her regular activities included cooking for one hour a day, four days a week; doing laundry for one hour a day, two days a week; and reading and watching TV on a daily basis. (Id.) She also noted that she was capable of walking one to two blocks "not often." (Id.)

Unfortunately, Plaintiff was in a car accident on July 13, 2006, while en route to an appointment with Dr. Carr to follow up on a nerve block treatment. (Pl.'s Mot. Ex. A at LINA00442.) Dr. Carr next met with Plaintiff on July 18th and reported that her pain was "back to its baseline," despite some pain relief following the prior nerve block. (Id.) On examination, Plaintiff exhibited allodynia and hyperesthesiae in her left leg and was wearing "very loose clothing" because of the pain.*fn2 (Id.) Dr. Carr noted that the pain in Plaintiff's left leg was unrelated to the accident, but that she "had some restriction in range of motion of the right shoulder" as a result of the accident. (Id.) She was underwent another nerve block with Dr. Carr on August 23, 2006. (Id. at LINA00443, LINA00447.)

In a September 5, 2006 letter, LINA informed Plaintiff that, as of October 12, 2006, she would have to satisfy the "any occupation" standard in order to continue receiving benefits and that LINA was awaiting medical records from Plaintiff's treating physicians. (Defs.' Mot. Ex. K [Sept. 5, 2006 Letter to Pl.].) On September 6, 2006, Dr. Carr completed a PAA identical to that completed earlier by Dr. Tweedy. (Defs.' Mot. Ex. L [Carr Sept. 6, 2006 PAA].) Dr. Carr indicated that Plaintiff could continuously sit and reach overhead, at desk level and below waist level, but that she could only occasionally stand, walk, lift or carry up to twenty pounds, and balance.*fn3 (Id.)

Drs. Soiferman and Tweedy's office sent LINA notes documenting Plaintiff's five visits between April 21, 2006 and September 8, 2006. (Pl.'s Ex. A at LINA00404-409.) The notes indicate that Plaintiff continued to complain of pain and that she received constant treatment for her RSD. (Id.) Additionally, a September 8, 2006 note from Dr. Getson regarding Plaintiff's visit on that date indicated that Plaintiff reported that her condition was "20% worse." (Id. at LINA00382.) Plaintiff was "having difficulty walking," was "doing poorly," her RSD "was progressing," and she was exhibiting "spastic motor movement dysfunction." (Id.)

In an October 2, 2006 report of a September 29, 2006 consultation with Plaintiff, Dr. Carr reported that "[a]t this time, [Plaintiff] is having a lot of pain down through the left leg and into the right arm, as well." (Defs.' Mot. Ex. M [Oct. 2, 2006 Intermediate Consultation Report] at LINA00220.) Upon examination, Plaintiff exhibited allodynia and hyperesthesiae of her left leg and her skin was shiny and discolored. (Id.) The doctor ultimately scheduled Plaintiff for another sympathetic nerve block. (Id. at LINA00221.) In this report, Dr. Carr also responded to an IME, conducted by a Dr. Levin, which Dr. Carr had reviewed, explaining that:*fn4

I do agree with [Dr. Levin] that the patient does not have RSD, at this time. She has had distinctive signs of RSD in the past and also one must recall that she has had appropriate responses to the sympathetic nerve blocks. Her response to the sympathetic nerve block coupled with her other diagnostic studies including the thermogram and her characteristic findings on examination, not only by this physician, but by multiple physicians, clearly rules in the elements of RSD. It is quite easy for a physician who sees the patient on a single visit not to fully appreciate the full complexity of the syndrome. Certainly, during the examination not all of the signs and symptoms may be present all the time, and not only due to the fact that she has been under continuous care for her symptoms. (Id.)

Plaintiff also saw Dr. Mandel, her neurologist, on September 29, 2006. (Pl.'s Mot. Ex. A at LINA00222.) Dr. Mandel's report of that visit explained that he knew Plaintiff to have a diagnosis of RSD in her left leg, but that he was treating her at that time in connection with the July 13, 2006 car accident, which affected her upper extremities. (Defs.' Mot. Ex. N [Oct. 10, 2006 Letter from Mandel to Soiferman].) The doctor reported that Plaintiff did not have RSD in her right arm, but opined that she should undergo nerve blocks to prevent her RSD from spreading from the left leg to the right arm. (Id.) The report did not discuss the status of Plaintiff's left leg.

Since the "any occupation" date was approaching, LINA requested that Vince Engel, a Rehabilitation Specialist, perform a "Transferable Skills Analysis" in order to determine whether Plaintiff was capable of performing occupations other than her own. (Defs.' Statement of Undisputed Facts ¶ 24; Defs.' Mot. Ex. O [Transferable Skills Analysis].) The October 12, 2006 report, which was based on Dr. Carr's PAA, characterized Plaintiff as "functioning in the sedentary to light level of physical demand." (Defs.' Mot. Ex. O at LINA00461.) Mr. Engel identified six possible occupations that Plaintiff could perform that satisfied her wage requirement under the Plan: holter scanning technician, protective-signal operator, surveillance-system monitor, service clerk, claims clerk I, civil service clerk. (Id. at LINA00461-62.)

C. LINA's First Denial of Benefits

On October 13, 2006, LINA informed Plaintiff that it was terminating her benefits. (Defs.' Mot. Ex. P [Oct. 13, 2006 Letter to Plaintiff].) In a letter to Plaintiff, LINA explained its process in evaluating Plaintiff's claim and the reasons for its termination of her benefits. LINA had sought information from five doctors - Drs. Soiferman, Tweedy, Mandel, Carr and Getson - in evaluating Plaintiff's claim. (Id. at LINA00456.) However, the letter indicated that LINA did not have the most current information regarding Plaintiff's treatment from any of these doctors.

LINA's letter to Plaintiff explained that it was terminating Plaintiff's benefits primarily because Dr. Carr's PAA indicated that Plaintiff was capable of performing sedentary work:

After reviewing information submitted by your treating providers we find that medical received no longer supports your claim to be open. Dr. Mandel's last submitted note from January 11, 2006 indicates you continue to have problems but does not note any physical examination findings or plans for future treatments. Dr. Mandel's office did notify us that you last treated on September 29, 2006, unfortunately this note has not been received. Dr. Carr's office submitted information from July 19, 2006 with notification of physical examination findings from a previous visit, but nothing recent. Dr. Carr did complete Physical Abilities Assessment form that provided restrictions that fall within a sedentary occupation.

Dr. Soiferman and Dr. Tweedy [sic] office submitted recent documentation from September 08, 2006. These notes indicate you have complaints of pain, anxiety, and depression but they do not present any physical examination findings regarding your condition. Dr. Getson did not submit and [sic] recent medical documentation and you are no longer treating with Dr. Frank. (Id. at LINA00458.) LINA explained that, based on these records, Plaintiff did not meet the "any occupation" standard because she was capable of performing ...


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