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Beverly A. Haisley v. Sedgwick Claims Management Services

March 2, 2011


The opinion of the court was delivered by: Conti, District Judge


I. Introduction

Pending before the court are cross-motions for summary judgment filed by plaintiff Beverly A. Haisley ("Haisley"or "plaintiff") and defendants Sedgwick Claims Management Services, Inc. ("Sedgwick"), PNC Financial Services Group, Inc. ("PNC"), and the PNC Financial Services Group, Inc., Long Term Disability Plan (the "Plan" and together with Sedgwick and PNC "defendants"). (ECF Nos. 56 & 59.) For the reasons that follow, Haisley‟s motion for summary judgment will be granted in part, and defendants‟ motion for summary judgment will be denied. The Plan will be required to pay long term disability ("LTD") benefits to Haisley for the period commencing on October 3, 2007, and ending on October 2, 2009, and the case will be remanded for a determination whether plaintiff is entitled to benefits after October 2, 2009.

II. Background

Haisley was born on April 13, 1951. (ECF No. 1 ¶ 7.) She was employed by PNC between May 3, 1971, and June 22, 2007. (Administrative Record ("AR") AR0034.) As of June 22, 2007, she was working as a Collections/Recovery Team Manager. (ECF No. 104 ¶ 1.) In this capacity, Haisley managed a team of adjustors responsible for collecting on accounts that had been delinquent for thirty days or more. (ECF No. 96 ¶ 2.) Her monthly salary was $4,708.33. (Id. ¶ 1.)

Haisley‟s mother died on June 28, 2007. (AR0027.) Haisley applied for short-term disability ("STD") benefits. (ECF No. 96 ¶ 18.) This request was based, at least in part, on depression and anxiety suffered by Haisley as a result of her mother‟s death. (Id.) At that time, Haisley was also suffering from peripheral neuropathy. (AR0027-29.) PNC approved Haisley‟s request for STD benefits for a full period commencing on July 5, 2007, and concluding on October 2, 2007. (ECF No. 96 ¶¶ 18-19.) She received STD benefits at the rate of 100% of her monthly salary. (Id. ¶ 19.)

The Plan provides full-time, salaried employees who are unable to work for more than ninety days with long-term disability ("LTD") benefits of up to 70% of their base salaries. (ECF No. 104 ¶ 2.) Haisley participated in the Plan because of her employment with PNC. (Id. ¶ 1.) PNC established a "Group Benefits Trust" to fund LTD disability payments made pursuant to the Plan. (AR0296-97.) As the Plan Administrator, PNC has the power "[t]o determine the eligibility and status of any [e]mployee with respect to Plan participation." (AR0233, AR0245.) PNC administers and funds the Plan as follows:

5. The Plan is a fully self-funded employee welfare benefit plan as defined in the Employee Retirement Income Security Act of 1974, as amended ("ERISA").

The Plan provides long term disability benefits for eligible employees of PNC. A third party does not insure the Plan. It is self-funded by means of a separate trust established by PNC solely for the purpose of providing benefits. The Trust is known and referred to as the "Group Benefits Trust" (the "GBT").

6. PNC makes fixed, periodic cash contributions to the GBT based on calculations and projections of its future long term disability liability performed by an independent actuary. PNC holds no residual interest in the assets of the GBT. Rather, any and all monies in the trust are contributed without condition at all times and at all times must be used for the exclusive benefit of Plan participants or beneficiaries.

7. Long term disability benefits determined to be payable under the terms of the Plan are paid from the GBT. (Kerry A. Allen, Aff. Sept. 11, 2009, AR0334.)

The Plan is administered pursuant to a service agreement (the "Service Agreement") executed by PNC and Sedgwick in December 2004. (AR0251-76.) The Service Agreement delegates to Sedgwick the responsibility for administering LTD claims under the Plan. (AR0271.) In accordance with the Service Agreement, Sedgwick receives, investigates and responds to LTD claims filed by employees of PNC. (ECF No. 96 ¶ 11.) Under the Service Agreement, PNC is responsible for providing Sedgwick with sufficient funds to cover LTD claims, and Sedgwick is expressly relieved of the obligation to advance its own funds to cover such claims. (AR0273.) The Plan defines the terms "Total Disability" and "Totally Disabled" as follows:

21. "Total Disability" and "Totally Disabled" mean that because of Injury or Sickness:

a. The Participant cannot perform each of the material duties of his or her regular occupation; and

b. After benefits have been paid for 24 months, the Participant cannot perform each of the material duties of any gainful occupation for which he or she is reasonably fitted by training, education or experience.

(AR0234.) The Plan contains a "Mental Illness Limitation," which provides:

a. Benefits for Total Disability due to mental illness will not exceed 24 months of Monthly Total Disability Benefit payments unless the Participant meets one of the following:

(1) The Participant is in a hospital or institution and is still Totally Disabled as a result of the mental illness at the end of the 24-month period. In this case, the Monthly Total Disability Benefit will be paid during the Participant‟s confinement in the hospital or institution.

(2) If the Participant is still Totally Disabled when he is discharged from a hospital or institution as set forth in III.14.a.(1), the Monthly Total Disability Benefit will be paid for a recovery period of up to 90 days.

(3) If the Participant becomes re-confined in a hospital or institution as a result of such mental illness during the recovery period for at least 14 days in a row, Total Disability Benefits will be paid for the confinement and another recovery period up to 90 more days.

Notwithstanding the foregoing, benefits for Total Disability due to mental illness will not be paid for a period longer than 180 days from the expiration of the 24-month period.

(AR0242.) The term "mental illness," as used in the language of the Plan, means "mental, nervous or emotional diseases or disorders of any type." (AR0243.)

At the conclusion of her STD period, Haisley believed that she was still incapable of performing the duties of her job. (ECF No. 96 ¶¶ 20-21.) She applied for LTD benefits on October 11, 2007. (AR0053-58.) On the application, Haisley indicated that she was disabled due to depression, anxiety and neuropathy. (AR0053.) She reported that she first noticed her symptoms on May 2, 2007, and that her last day of work was June 22, 2007. (Id.)

In support of her claim, Haisley submitted written reports which were supplied by her treating health-care providers. (ECF No. 96 ¶¶ 22-26.) Included with these reports were the results of nerve conduction studies which were conducted on August 15, 2007. (AR0075-76, AR0086-87.) These studies showed Haisley to be suffering from "diffuse peripheral neuropathy" that was deemed to be of "mild to moderate severity." (AR0076.) Charlotte Graham ("Graham"), an LTD case worker employed by Sedgwick, requested additional information from Haisley‟s treating physicians. (AR0084-85.)

In response to an inquiry from Graham dated October 19, 2007, Dr. Dushan Majkic, Haisley‟s primary care physician, reported that Haisley was suffering from both peripheral neuropathy and a relapse of major depression. (AR0084.) Dr. Majkic opined that Haisley was unable to concentrate because of the side effects of her medication, she could not sit or stand for prolonged periods of time, and her prognosis for returning to gainful employment was "undetermined." (Id.)

In a letter to Graham dated November 9, 2007, Dr. Sidney W. White, Haisley‟s clinical psychologist, stated that he began to treat Haisley on July 17, 2007. (AR0088.) According to Dr. White, the "immediate precipitant" of Haisley‟s symptoms was the death of her mother on June 28, 2007. (AR0089.) In the letter, Dr. White explained:

Ms. Haisley currently does not possess the functional capabilities just mentioned that are necessary for the effective performance of her job. Besides the pain from the Peripheral Neuropathy, Ms. Haisley is emotionall [sic] drained and physically exhausted most days. She does not have the motivation, energy, and emotional strength to follow leadership, much less provide it for her employees. Ms. Haisley‟s current cognitive impairments are equally compromising and preclude the effective performance of her job. She is unable to sustain focus and concentration on a consistent basis. While her cognitive abilities are intact, they are nevertheless slowed and deliberate. Ms. Haisley is not currently able to process information efficiently or make decisions quickly. She is also experiencing lapses in her short-term memory.

Ms. Haisley views her current absence from work as a necessity, and this is the recommendation of both Dr. Majkic and myself. Ms. Haisley‟s absence from work is thus a collaborative decision. I am hopeful that Ms. Haisley‟s depressive symptoms will eventually remit, but at the present time and foreseeable future I do not believe she can perform her work.

The symptoms and impairments that I have noted are based both on Ms. Haisley‟s self-report and on my own clinical interview interactions and observations of Ms. Haisley. I have tried to describe specific and concrete tasks inherent in Ms. Haisley‟s work. I have then tried to indicate how Ms. Haisley‟s physical, emotional, and cognitive impairments preclude any effective performance of her work-related tasks.

(AR0090.) Dr. White expressed his willingness to provide further information in connection with Haisley‟s LTD claim. (AR0091.)

On November 30, 2007, Graham sent Haisley a letter stating that Sedgwick approved her application for LTD benefits.*fn1 (ECF No. 63, Ex. K, BAH00125-27.) The applicable LTD period began on October 3, 2007. (AR0027.) A Sedgwick supervisor recommended on December 6, 2007, that the "approval" of Haisley‟s claim be rescinded until additional medical records could be received and evaluated. (AR0025.) In order to receive LTD benefits under the Plan, Haisley was required to apply for disability benefits under the Social Security Act ("SSA"), 42 U.S.C. §§ 401-33, 1381-83f. (AR0283.) For this reason, she applied for social security disability benefits. (ECF No. 96 ¶ 29.) Haisley was ultimately awarded disability insurance benefits under Title II of the SSA. (AR0016; ECF No. 63, Ex. K, BAH000071.)

In a letter dated December 20, 2007, Graham informed Haisley that her claim for LTD benefits had been "formally suspended" as of December 1, 2007, due to "a lack of current treatment information on file supportive of continuing total disability." (AR0100.) In that letter Graham stated that Dr. White‟s report of November 9, 2007, had not been supported by treatment records or documentation concerning Haisley‟s medications. (AR0101.) Haisley was given until January 17, 2008, to provide Sedgwick with more detailed information about her treatment regimen. (Id.)

Haisley was experiencing discomfort in both her lower extremities. (AR0102.) On December 27, 2007, she was examined by Dr. Richard B. Kasdan, a neurologist. (Id.) Suspecting that Haisley‟s problems had a "lumbar source," Dr. Kasdan recommended that she undergo a magnetic resonance imaging ("MRI") scan. (Id.) Although the MRI scan revealed that Haisley had experienced "minor disc changes," it showed "nothing to explain her leg numbness." (AR0103.)

Dr. White responded to the suspension of Haisley‟s LTD benefits in a letter to Graham dated December 31, 2007. (AR0094-95.) He claimed that Graham "misrepresented" the contents of his earlier report. (AR0094.) After providing more specific information about Haisley‟s medication regimen, Dr. White wrote:

As I indicated in my 11/9/07 report, and as may be gleaned from the above-noted medications, Ms. Haisley is struggling with a ...

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