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Adams v. Life Insurance Company of North America

August 3, 2009


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


William Adams brings this action against the Life Insurance Company of North America ("LINA") and the Trustees of Philadelphia Federation of Teachers a/k/a Philadelphia Federation of Teachers ("PFT"), seeking long term disability benefits under a policy of insurance administered by LINA for PFT. Defendants have filed a Motion for Summary Judgment, seeking dismissal of Plaintiff's claim. For the reasons that follow, the Motion is denied.


Plaintiff was an apprentice teacher with the Philadelphia School District beginning on September 24, 2001 at Bartram High School. (Defs. Ex. A at 1.) He worked for approximately 74 days before going on sick leave on March 1, 2002 as a result of a pre-existing back condition.*fn1 (Id.) He remained on sick leave for the remainder of the 2001-02 school year. (Id.) Plaintiff was approved to return to full duty effective September 13, 2003, but remained absent without authorization. (Id.) After a hearing, he was directed to return to work as of January 2, 2003. (Id.) He returned to work at Bartram High School as directed, on January 2, 2003, as a co-teacher of mathematics with another teacher. (Id.) On January 30, 2003, a student bumped into Plaintiff, knocking him off balance and aggravating a previous back injury. (Def. Ex. D at 1; Workers' Comp. Decision at 4.) Plaintiff did not return to work after this incident, but received Workers' Compensation benefits. (Def. Ex. A at 1, Workers' Comp. Decision at 1.) Plaintiff continued to receive Workers' Compensation benefits until February 8, 2006, when a Workers' Compensation Administrative Law Judge ("ALJ") granted the School District of Philadelphia's petition to terminate his benefits. (Workers' Comp. Decision at 8.) The Workers' Compensation ALJ found that Plaintiff had "fully recovered from his January 30, 2003 work injury effective June 11, 2003" and terminated his benefits effective June 11, 2003. (Id.)

On September 6, 2001, before he began working as an apprentice teacher at Bartram High School, Plaintiff applied for Disability Insurance Benefits under the Social Security Act. (8/13/03 Soc. Sec. Admin. Decision at 1.) On August 13, 2003, a Social Security ALJ found that Plaintiff was able to "perform the demands of the full range of sedentary work" and denied Plaintiff's application for Disability Insurance Benefits because he was not disabled. (Id. at 7-9.) Plaintiff appealed this decision, which was vacated and remanded. (3/15/06 Soc. Sec. Admin. Decision at 1.) On remand, the ALJ found that Plaintiff's impairment, "degenerative disc disease of the lumbar spine," was severe and that he had been disabled since May 15, 2000. (Id. at 4-5.) The ALJ further found that Plaintiff was entitled to Disability Insurance Benefits. (Id. at 5.)

Plaintiff filed his claim for long term disability ("LTD") benefits with LINA on February 23, 2006.*fn2 (Pl. Ex. B at 231.) In his claim, Plaintiff stated that the January 30, 2003 incident aggravated a pre-existing injury. (Id.) He described his injury as "herniated lumbar disk, L3, L4 and bulging disks L2-3 and L4-5. Herniation resulted from moving a wooden pallet while working for Eckerd Drugs 9/7/99. Out from school district 3/02 til 12/02, then out from school district 2/03 until present." (Id.)

PFT's LTD policy no. LK-030510 (the "Policy") became effective on June 1, 2001 and covered all active, permanent, full-time employees of PFT. (Policy at 1, 3.) Pursuant to the Policy, LINA will pay disability benefits to employees who become disabled as defined by the Policy while covered by the Policy. (Id. at 8.) In order to be eligible for benefits, an employee must be continuously disabled for 365 days. (Id. at 4, 8.) The Policy defines disability/disabled as follows:

An Employee is Disabled if, because of Injury or Sickness,

1. he or she is unable to perform all the material duties of his or her regular occupation, or solely due to Injury or Sickness, he or she is unable to earn more than 80% of his or her Indexed Covered Earnings; and

2. after Disability benefits have been payable for 24 months, he or she 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 solely due to Injury or Sickness, he or she is unable to earn more than 80% of his or her Indexed Covered Earnings.

(Id. at 4.) The Policy excludes coverage for pre-existing conditions. (Id. at 9.)

LINA denied Plaintiff's application for LTD benefits on May 17, 2006, based on the findings of the Workers' Compensation ALJ who terminated Plaintiff's Workers' Compensation benefits. (Defs. Ex. P.) LINA specifically relied on the following findings of the Workers' Compensation ALJ:

2.b. "Dr. Meller examined Claimant on June 11, 2003. Claimant provided a history of an injury in 1999 while he was lifting items [off] a pallet while working for Eckerd Drugs. For this injury, Claimant treated with a Workers' compensation facility at the Mercy Wellness Center with Dr. Malumed, Dr. Albert, Dr. Bridges, Dr. Friedman and Dr. Salkind. An MRI showed a disc herniation at L3-4, and Claimant underwent epidural injections, one of which provided significant relief. Claimant was out of work until September 2001, when he began working for Employer. After one month, his symptoms worsened. The complaints noted in these records prior to January 30, 2003 are essentially identical to the complaints noted after January 30, 2003. The records of Dr. Salkind noted an April 2, 2000 motor vehicle accident after which claimant underwent a fourth epidural injection and began physical therapy and a medrol dosepack. Claimant failed to mention any motor vehicle accident to Dr. Meller. Surgery was being considered before January 30, 2003."

2.g. "After examining Claimant, taking his history and reviewing the multiple medical records. Dr. Meller concluded that the clinical examination was normal. Claimant has degenerative disc disease that existed prior to January 30, 2003. Claimant was fully recovered from his January 30, 2003 work injury. He may return to his pre-injury employment without restriction. Claimant needs no additional care for his January 30, 2003 work injury. . . . Any symptoms Claimant has are related to the 1999 work injury and 2000 motor vehicle accident. Claimant may perform medium duty work, and any restrictions on his vocational abilities are not related to the January 30, 2003 work injury." (Id. at 1-2.) LINA also relied on the Workers' Compensation ALJ's findings that Plaintiff's testimony about his symptoms was not credible and that Plaintiff had "fully recovered from his January 30, 2003 work injury effective June 11, 2003." (Id. at 2 ¶¶ 6.c., 8, emphasis omitted.) Plaintiff appealed LINA's decision and asked that LINA consider the decision of the Social Security ALJ granting his application for Social Security Disability Benefits on appeal. (Defs. Ex. Q.)

On December 4, 2006, LINA denied Plaintiff's appeal and affirmed the denial of his LTD claim. (Defs. Ex. R.) In its letter explaining its denial of benefits, LINA stated that Plaintiff's position as an apprentice teacher is classified by the Department of Labor as a light duty position. (Id. at 1-2.) The letter characterized the reason Plaintiff stopped working on January 31, 2003 as being due to "degenerative disc disease of his lumbar spine, neck, back and leg pain, tightness in both legs and increased muscle spasms secondary to a work related injury in 1999." (Id. at 2.) The letter also stated that a medical director employed by LINA reviewed Plaintiff's "entire medical chart, concluding that the medical information only documents subjective complaints and provides no objective findings of a functional impairment to support restrictions to preclude Mr. Adams from his regular light demand level occupation." (Id. at 3.) The letter further stated that Plaintiff was ineligible for LTD benefits because his medical records failed "to support a severity of impairment to preclude [him] from performing his regular occupation from January 31, 2003 through January 30, 2004, and to present." (Id.)

LINA later sought an Independent Peer Review of Plaintiff's file, which was completed by Dr. Renat Sukhov, who is Board Certified in Physical Medicine and Rehabilitation. (Defs. Ex. S at 2.) On August 17, 2007, after Dr. Sukhov's review, LINA again denied Plaintiff's claim for LTD. (Defs. Ex. S.) LINA's August 17, 2007 letter denying Plaintiff's claim summarizes Dr. Sukhov's conclusions as follows:

Dr. Sukhov reviewed the medical documentation on file in [its] entirety and advised there is a multitude of medical evidence that supports Mr. Adams [sic] ability to perform at the light functional capacity level for the time period of January 31, 2003 through January 30, 2004 and through the present time. He noted this is consistent with provisions for avoiding excessive lifting [of] more than twenty pounds frequently and pushing and pulling heavy loads above thirty to thirty-five pounds frequently.

In summary, a review of the medical information provided did not reveal a severity of Mr. Adams [sic] condition resulting in restrictions preventing light work activities throughout the Benefit Waiting Period. In addition, the restrictions outlined by Dr. Sukhov do not prevent light physical demand activities. Although Mr. Adams has a history of spinal problems, the documentation does not support a severity of his condition during the Benefit Waiting Period preventing him from performing his occupation as a Teacher. Therefore, we must affirm our previous decision to deny benefits. (Id. at 2.)

Plaintiff subsequently filed the instant lawsuit in the Court of Common Pleas of Philadelphia County, alleging that Defendants improperly denied his claim for LTD benefits. Defendants properly removed the action to this Court on the basis that it is covered by the Employment Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001, et seq.


Summary judgment is appropriate "if the pleadings, discovery and the disclosure materials on file, and any affidavits show that there is no genuine issue as to any material fact and that the moving party is entitled to judgment as a matter of law." Fed. R. Civ. P. 56(c). An issue is "genuine" "if the evidence is such that a reasonable jury could return a verdict for the non-moving party." Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). A factual dispute is "material" if it might affect the outcome of the case under governing law. Id.

"[A] party seeking summary judgment always bears the initial responsibility of informing the district court of the basis for its motion, and identifying those portions of the [record] which it believes demonstrate the absence of a genuine issue of material fact." Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986). Where the non-moving party bears the burden of proof on a particular issue at trial, the movant's initial Celotex burden can be met simply by "pointing out to the district court --that there is an absence of evidence to support the nonmoving party's case." Id. at 325. After the moving party has met its initial burden, the adverse party's response "must -- by affidavits or otherwise as provided in this rule -- set out specific facts showing a genuine issue for trial." Fed. R. Civ. P. 56(e)(2). That is, summary judgment is appropriate if the non-moving party fails to rebut by making a factual showing "sufficient to establish the existence of an element essential to that party's case, and on which that party will bear the burden of proof at trial." Celotex, 477 U.S. at 322. "Speculation, conclusory allegations, and mere denials are insufficient to raise genuine issues of material fact." Boykins v. Lucent Techs., Inc., 78 F. Supp. 2d 402, 408 (E.D. Pa. ...

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