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Magera v. Lincoln National Life Insurance Co.

November 16, 2009

ALISON T. MAGERA PLAINTIFF,
v.
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY, DEFENDANT.



The opinion of the court was delivered by: Judge Caputo

MEMORANDUM

Presently before the Court are the Motion for Summary Judgment of Defendant Lincoln National Life Insurance Company ("Lincoln") and Plaintiff Alison T. Magera's ("Magera") Cross-Motion for Summary Judgment. (Docs. 38, 41.) For the reasons provided below, Defendant's motion will be granted and Plaintiff's motion will be denied. The Court has jurisdiction over this matter pursuant to 28 U.S.C. § 1331.

BACKGROUND

1. FACTUAL BACKGROUND

From June 19, 1999 through December 9, 2003, Plaintiff worked as a pharmaceutical sales representative for Aventis Pastuer, Inc. ("Aventis") (Doc. 46, ¶ 10.) This occupation was primarily sedentary and required some light grasping, finger dexterity, occasional neck twisting, the ability to look down, interpersonal relationship skills, and some exposure to stressful situations. (Admin. Rec. 0465-0466.) Plaintiff's last day of work was December 9, 2003; the following day Plaintiff's disability for fibromyalgia ("FM") and chronic fatigue syndrome ("CFS") began. (Doc. 40, ¶ 12.)

When Plaintiff's disability began, she was covered by a long-term disability ("LTD") plan, sponsored by Aventis, who had delegated discretionary authority to Lincoln to determine eligibility for Aventis plan benefits. (Doc. 40, ¶ 3.) The LTD plan contained the following language that is relevant to this matter:

Totally Disabled and Total Disability mean during the Elimination Period and the next 36 months because of an Injury or Sickness You meet all of the following:

(a) You are unable to do the Material and Substantial Duties of Your Occupation; and

(b) You are receiving Appropriate Evaluation and Treatment from a Physician for that Injury or Sickness; and

(c) Your Work Earnings are less than 20% of Your Indexed pre-Disability Monthly Earnings.

The definition changes 36 months after the end of the Elimination Period. From that point on, Totally Disabled and Total Disability mean because of an Injury or Sickness, all of the following are true:

(a) You are unable to do the Material and Substantial Duties of any occupation for which You are or may become reasonably qualified by education, training, or experience; and

(b) You are receiving Appropriate Evaluation and treatment from a Physician for that Injury or Sickness; and

(c) Your Work Earnings are less than 20% of your Indexed Pre-Disability Monthly Earnings. (Admin. Rec. 0065.) For purposes of this LTD plan, "Own Occupation" was defined as "the duties that You regularly performed for which you were covered under this Policy immediately prior to the date Your Disability began. The occupation may involve similar duties that could be performed with Your Employer or any other employer." (Admin. Rec. 0062.) The "Elimination Period" was the period of time that an employee must be continuously disabled before LTD benefits became available; under the LTD plan, the Elimination Period was one hundred eighty (180) days. (Admin. Rec. 0059.) "Material and Substantial Duties" were defined as duties that:

a) are normally required for the performance of Your own or any occupation; and

b) cannot be reasonably omitted or modified, except that Canada Life*fn1 will consider You able to perform the Material and Substantial duties if You are working or have the capability to work 30 hours per week. (Admin. Rec. 0061.)

Lincoln's literature contains information regarding both FM and CFS, including how they are diagnosed, how they are treated, predicted outcomes for people suffering from these conditions, and the expected length of disability. (Admin. Rec. 0311-0322.) For FM, there is no set criteria for a diagnosis, but a complete physical examination is required for a diagnosis of FM, particularly in light of the lack of diagnostic tests to detect the condition. (Admin. Rec. 0312-0313). FM is a chronic disorder that can only be alleviated, not cured, and therefore the goal is to minimize disability. (Admin Rec. 0314.) Although some individuals are permanently unable to return to their previous occupations, the pain from FM can usually be improved gradually over time. (Admin. Rec. 0315). The first type of specialist listed as appropriate for FM are rheumatologists and the maximum expected length of disability for sedentary work is seven (7) days. (Admin. Rec. 0315-0316.) Much of the information regarding treatment, outcome, and expected disability is the same for CFS. (Admin. Rec. 0321-0322.)

Plaintiff's Elimination Period was set to expire on June 8, 2004. (Doc. 40, ¶ 13.) By letter dated September 21, 2004, Ms. Magera's application for LTD benefits was denied because she was not continuously disabled throughout the Elimination Period, as required by the LTD plan. (Admin. Rec. 0333-0334.) This decision was based primarily on a May 4, 2004 report from Ms. Magera's Rheumatologist, Dr. Charles L. Ludivico of East Penn Rheumatology Associates, that stated that Plaintiff was "completely better after 8 weeks of physiotherapy" and "interested in going back to work to two 4 [hour] shifts." (Admin. Rec. 0694.)

Ms. Magera challenged this decision, and Lincoln ultimately approved her claim for disability benefits and paid all benefits in arrears on August 26, 2005, following a review of Plaintiff's medical condition and medical records. (Doc. 40, ¶ 17-18.) On October 31, 2005, Defendant informed Lincoln that she might be a "good candidate" for Social Security Disability Benefits. (Doc. 42, ¶ 46.) The Social Security Administration denied Ms. Magera's application for benefits, but she appealed this decision with the help of a firm that was hired by Lincoln to represent her. (Doc. 42, ¶¶ 49-50.) On April 17, 2007, Administrative Law Judge James Andres determined that Plaintiff's FM and CFS was "so severe that she is unable to perform any work existing in significant numbers in the national ...


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