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Patrick v. Verizon Services Corp.

July 8, 2009


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


Before the Court for disposition are the Stipulation Concerning Contents of Administrative Record and Evidentiary Appendix Filed in Connection with Cross-Motions for Summary Judgment (Document No. 36), the Appendix to the Stipulation (Document No. 37), the Defendants' MOTION FOR SUMMARY JUDGMENT (Document No. 38), the Defendants' Memorandum in Support of Motion for Summary Judgment (Document No. 39), the Defendants' Concise Statement of Material Facts in Support of Motion for Summary Judgment (Document No. 40), the Plaintiff's MOTION FOR SUMMARY JUDGMENT (Document No. 41), the Plaintiff's Brief in Support of Motion for Summary Judgment (Document No. 42), the Plaintiff's Concise Statement of Material Facts (Document No. 43), the Plaintiff's Supplement to Brief in Support of Motion for Summary Judgment (Document No. 44), the Plaintiff's Errata Sheet to Brief in Support of Motion for Summary Judgment and Concise Statement of Material Facts (Document No. 47), the Plaintiff's Response to Motion for Summary Judgment (Document No. 50), the Plaintiff's Response to Concise Statement of Material Facts and Counterstatement (Document No. 51), the Plaintiff's Brief in Response to Motion for Summary Judgment (Document No. 52), the Defendants' Memorandum in Opposition to Motion for Summary Judgment (Document No. 53), and the Defendants' Response to Concise Statement of Material Facts (Document No. 54). For the reasons that follow, the Defendants' Motion for Summary Judgment (Document No. 38) will be granted in part and denied in part, and the Plaintiff's Motion for Summary Judgment (Document No. 41) will be granted in part and denied in part.


Plaintiff Patricia Patrick ("Patrick") was born on February 6, 1953, making her 56 years of age at the present time. Doc. No. 54 at ¶ 2. On October 31, 1983, at the age of 30, Patrick was hired by AT&T and Bell Atlantic Corporation ("Bell Atlantic"). Id. at ¶ 1. Bell Atlantic later merged with GTE*fn1 to form Verizon Services Corporation ("Verizon"), a wholly owned subsidiary of Verizon Communications, Inc. ("Verizon Communications"). Id. at ¶ 3. Verizon Communications sponsored a health and welfare plan which provided for long-term disability ("LTD") benefits. Id. at ¶ 4. It was known as the Verizon Long-Term Disability Plan for Mid-Atlantic Associates, PN 516 (the "Plan"). Id. Verizon was a participating member of the Plan. Id. at ¶ 6.

At all times relevant to this case, Patrick was a participant or beneficiary under the Plan. Id. at ¶ 7. The Plan was funded by the general assets of the participating companies. Id. at ¶ 8. Under the Plan's definitions, Verizon Plan 553 includes both LTD benefits and the Verizon Sickness and Accident Disability Benefit Plan for Mid-Atlantic Associates (the "SADBP"). Id. at ¶ 10. The Summary Plan Description ("SPD") includes the following language concerning LTD benefits:

LTD benefits may begin after you have received 52 weeks of Sickness Disability Benefits. To receive benefits you must meet one of the following conditions:

* You must be unable to work in any occupation or employment for which you are or may become reasonably qualified by training, education, or experience.

* As a result of your disability, you are only able to work at a job that pays less than half of your basic pay rate at the time you became disabled.

* In addition, you must be under the care of a qualified physician who must provide appropriate documentation of your disability. You must take proper care of yourself and receive proper medical treatment. Otherwise, you will not be eligible for benefits.

Id. at ¶ 11. The Plan defines the term "disability" as "[t]he inability, due to sickness or injury documented by objective medical evidence, of the Participant to (i) perform any occupation or employment for which the Participant is (or may reasonably become) qualified by reason of education, training or experience, or (ii) to perform any job that pays (on a full-time basis) 50% or more of the Participant's Base Pay at the time the Participant is disabled." Doc. No. 37-3, pg. 2; Appendix Tab B, V-0006. Neither the Plan nor the SPD defines the term "objective medical evidence." Doc. No. 54 at ¶ 13. The Plan permits a participant to receive LTD benefits until he or she either dies or ceases to be disabled. Id. at ¶ 14.

The Verizon Employee Benefits Committee ("VEBC") and the Verizon Claims Review Committee ("VCRC"), and the chairs of each, have discretion to designate claims and appeals administrators for each benefit. Id. at ¶ 18. Verizon's sickness and accident benefits, or short-term disability ("STD") benefits, are administered by a company known as CORE, Inc. ("CORE"). Id. at ¶ 15. Verizon's LTD benefits are administered by the Metropolitan Life Insurance Company ("MetLife"). Id. at ¶ 17. The VCRC has the authority to designate itself as the final appeals administrator under the Plan, either in place of the existing appeals process or as an additional level of appeal beyond that process. Id. at ¶ 19. In Patrick's case, the VCRC entertained an appeal beyond the existing process. Id. at ¶ 20. The VCRC had the final and sole authority to review and resolve her final appeal. Id. at ¶ 21. Before the VCRC was designated as the final appeals administrator for Patrick's claim, this authority had been with MetLife.*fn2 Id. at ¶ 22. The VCRC is comprised of individuals employed by Verizon Communications and its affiliates. Id. at ¶ 24.

Patrick was involved in an automobile accident in October 1993. Id. at ¶ 26. In February 1994, she fell on a patch of ice while walking to work. Id. at ¶ 27. These accidents apparently caused the condition of her back to deteriorate. Id. She underwent rotator cuff surgery on August 9, 1999. During the course of Patrick's employment at Verizon, CORE accumulated medical records which documented her injuries. Id. at ¶ 29. Patrick apparently suffered from chronic back problems. Id.

Patrick's primary care physician is Dr. Dawna Woodyear ("Dr. Woodyear"). Id. at ¶ 31. Patrick sought treatment from Dr. Woodyear for pain in her lower back, osteoarthritis, and back motion difficulty. Id. On April 2, 2001, Dr. Woodyear determined that Patrick was capable of working for only half-days. Id. At that time, Patrick was working as a service representative for Verizon. Id. at ¶ 33. She was examined by Dr. William Donaldson ("Dr. Donaldson"), an orthopedic surgeon, on July 3, 2001. Id. at ¶ 34. On July 7, 2001, she underwent a magnetic resonance imaging ("MRI") scan. Id. at ¶ 35. This MRI scan yielded the following findings:

The L1-2 and L2-3 levels are within normal limits.

At L3-4 level, there is desiccated disc. There is minimal facet arthrosis and ligamentum flavum hypertrophy resulting in mild canal stenosis.

At the L4-5 level, there is diffuse disc bulge slightly more prominent on the right than on the left with mild desiccation of the L4-5 disc. There is bilateral facet arthrosis and ligamentum flavus hypertrophy resulting in moderate canal stenosis. The neural foramina do not appear to be narrowed.

The L5-S1 level is normal.

Doc. No. 37-24, pg. 12; Appendix Tab F, PP00023. Because of these findings, surgery was required.

On August 28, 2001, Patrick worked her last day for Verizon. Doc. No. 54 at ¶ 32. Three days later, on August 31, 2001, she underwent surgery on her lumbar spine. Id. at ¶ 36. Dr. Donaldson performed the surgery. Metal rods were inserted into her spine. Id. Unable to work, Patrick began to receive STD benefits. Id. at ¶ 37. The SADBP provides that an employee receiving STD benefits may sometimes be required to undergo an independent medical examination ("IME") for the purpose of assessing his or her medical condition and continued eligibility for benefits. Doc. No. 37-5, pg. 17; Appendix Tab D, V-0079. At CORE's request, Patrick underwent an IME on April 11, 2002. Doc. No. 54 at ¶ 38. The examining physician was Dr. David Frame ("Dr. Frame"), an orthopedic surgeon. Id. In a written report dated April 16, 2002, Dr. Frame stated that Patrick's prospective return-to-work date was "undetermined." Doc. No. 37-9, pgs. 7-8; Appendix Tab E, V-0182-V-0183. After Dr. Frame's examination, no physician examined Patrick on behalf of Verizon, Verizon Communications or MetLife. Doc. No. 54 at ¶ 46.

Around April or May of 2002, Patrick received a packet of materials needed to apply for LTD benefits under the Plan. Id. at ¶ 47. Patrick formally applied for LTD benefits on May 7, 2002. Id. at ¶ 50. That same day, Dr. Donaldson examined Patrick. In a treatment note, he recorded the following observations:

She still has back and leg pain with limited sitting and standing tolerance. I have recommended that she return in July, and I put her on Ultram and Neurontin, 300 mg. po bid. We will increase to 600 po bid if she does not get relief. In July, she will need to consider going back to work in August, or she most likely will lose her job, and I do not think that she is a candidate for Social Security disability.

Doc. No. 37-14, pg. 21; Appendix Tab E, V-0331. On July 9, 2002, Dr. Donaldson examined Patrick again. Doc. No. 54 at ¶ 53. He completed a functional capacity assessment form indicating that Patrick was totally disabled. Id. at ¶ 55. He also completed a form requesting that Patrick's STD benefits be extended because of her inability to sit or stand for prolonged periods of time. Doc. No. 37-9, pg. 10; Appendix Tab E, V-0185. Patrick was instructed to return to Dr. Donaldson's office for a follow-up appointment in January 2003. Id. In the meantime, Dr. Donaldson listed Patrick's return-to-work date as "undetermined." Id.

MetLife requested additional information from Patrick on August 9, 2002. Doc. No. 54 at ¶ 59. Patrick was informed that she needed to apply for Social Security disability benefits, and that LTD benefits under the Plan, even if approved, could not be paid to her beyond a period of six months in the absence of an application for Social Security disability benefits. Doc. No. 37-13, pg. 4; Appendix Tab E, V-0289. On August 19, 2002, Patrick completed and faxed to MetLife a form describing her functional limitations. Doc. No. 54 at ¶ 61. She indicated that she would need a recliner if she were to return to work, and that her inability to sit would likely preclude her from performing her duties as a service representative. Id. at ¶ 62. CORE noted in its records that Patrick had been approved for STD benefits through September 3, 2003, and that she did not have a designated return-to-work date. Id. at ¶ 64.

Dr. Donaldson submitted a statement to MetLife on August 29, 2002, which indicated that Patrick could "intermittently" sit, stand or walk for up to one hour during the course of an eight-hour workday. Doc. No. 37-13, pg. 9; Appendix Tab E, V-0294. He reported that Patrick could work for up to four hours per day "to start the process." Id. He also noted that he expected Patrick's condition to improve. Id. Nevertheless, in a portion of the statement asking whether he had advised Patrick to return to work, Dr. Donaldson put a slash mark through the box next to the word "No." Id. As an explanation for his decision not to clear Patrick to return to work, Dr. Donaldson wrote the words "patient to be re-evaluated next visit." Id.

During the first week of September 2002, Patrick's 52 weeks of STD benefits were exhausted. Doc. No. 54 at ¶ 73. In a letter to Patrick dated September 17, 2002, Wendy M. Howell ("Howell"), an absence administrator for Verizon, stated that Patrick's employment with Verizon had been terminated on September 4, 2002, pursuant to a policy requiring the termination of an employee who fails to return to work after the exhaustion of STD benefits. Doc. No. 37-25, pg. 19; Appendix Tab F, PP000115. MetLife apparently sought additional information from Dr. Donaldson on September 27, 2002. Doc. No. 54 at ¶ 75. On October 4, 2002, a MetLife case manager attempted to fax a message to Dr. Donaldson's office inquiring as to whether the earlier request for information had been received. Id. at ¶ 75. The record includes a copy of the inquiry marked with a notation reading "send failed." Doc. No. 37-14, pg. 8; Appendix Tab E, V-0318. It is unclear whether Dr. Donaldson ever received MetLife's request for additional information. That same day, Patrick filed an application for disability insurance benefits under Title II of the Social Security Act [42 U.S.C. §§ 401-433], alleging that she had been disabled since August 28, 2001. Doc. No. 37-52, pg. 17; Appendix Tab K, V-0993.

On October 8, 2002, Verizon forwarded to MetLife a job description for the position of service representative. Doc. No. 54 at ¶ 77. The job description stated that a service representative was required to sit at a stationary work location, and to use a visual display terminal, "for extensive periods of time." Doc. No. 37-14, pg. 10; Appendix E, V-0320. In a letter to Patrick dated October 16, 2002, Paulina Patricia ("Patricia"), a case manager for MetLife, informed Patrick that her claim for LTD benefits had been denied. Doc. No. 54 at ¶ 80. After describing the standards used to determine whether a particular individual was "disabled" under the Plan, Patricia's letter went on to state as follows:

In addition, you must be under the care of a qualified physician who must provide appropriate documentation of your disability. You also must take proper care of yourself and receive proper medical treatment. Otherwise, you will not be eligible for benefits.

Please refer to our letter dated August 9, 2002 requesting that you provide all medical records for review. To date the following information has not been received:

* All office visit notes and test reports from your date of disability through the present including the most recent progress notes and treatment plan.

We have reviewed your entire claim, including the following information that was submitted:

* Attending Physician Statement and Physical Capacity Evaluation form from Dr. Donaldson. He diagnosed you with neuritis/radiculitis.

* Personal Profile Evaluation.

Because no current clinical information has been received to support your disability claim, we must respectfully deny your claim based on a lack of medical evidence.

Doc. No. 37-25, pg. 8; Appendix Tab F, PP00080. Nobody from MetLife had informed Patrick prior to the denial of her claim that she would be afforded at least 45 days to supply the sought-after information. Doc. No. 54 at ¶ 87.

MetLife's file contains a fax sheet from Patricia to Dr. Donaldson dated September 30, 2002, seeking information concerning Patrick's claim for LTD benefits on or before October 14, 2002. Doc. No. 37-14, pg. 16; Appendix Tab E, V-0326. According to MetLife's records, Patrick was told that she could appeal the denial, and that the missing information could be submitted for appellate consideration. Doc. No. 37-28, pg. 7; Appendix Tab G, MM-00000042. Hewitt & Associates ("Hewitt") maintains an office in Lincolnshire, Illinois. Doc. No. 54 at ¶ 92. On October 21, 2002, Patricia sent a letter to Shawn Pettus ("Pettus"), a Hewitt employee, stating that "the medical information provided" had not established that Patrick was "disabled" under the Plan. Id. at ¶ 91.

Patrick appealed the denial of her claim for LTD benefits on November 11, 2002. Id. at ¶ 94. She included Dr. Donaldson's office notes in her record for appeal. Id. Acknowledging that Dr. Donaldson had not responded to MetLife's previous requests for information, Patrick explained in a letter that she should be contacted directly if additional information was necessary in order to resolve her appeal. Doc. No. 37-14, pg. 17; Appendix Tab E, V-0327. In a letter dated November 12, 2002, Patrick stated that sitting for more than fifteen minutes at a time would cause her to endure "severe stabbing pain." Doc. No. 37-14, pg. 18; Appendix Tab E, V-0328.

Dr. Donaldson examined Patrick on December 17, 2002. Doc. No. 54 at ¶ 96. In the "subjective" section of his follow-up report, Dr. Donaldson stated as follows:

She is a year and a half post decompression and fusion. She said she does not have insurance now and is still having back pain. She has been to two pain treatment centers, one in Shadyside and one in Monroeville. She has tried shots. She says she had put on weight. She has quite [sic] smoking and gets low back pain. When I saw her last time, her x-rays showed the fusion to be fairly solid. She continues to have discomfort and is upset today because her disability claim was denies [sic]. I, however, explained to her that with her job at Verizon it is a light duty job and that in my note back in May I did not think she was a good candidate for Social Security Disability since she was still fairly active. She wrote a letter to the Metropolitan Life ...

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