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Michael Marshall v. At&T Umbrella Benefit Plan

April 8, 2011

MICHAEL MARSHALL,
PLAINTIFF,
v.
AT&T UMBRELLA BENEFIT PLAN NO. 1,
DEFENDANT.



The opinion of the court was delivered by: Judge Nora Barry Fischer

MEMORANDUM OPINION

I.INTRODUCTION

Plaintiff Michael Marshall ("Plaintiff") filed the instant action against the Defendant AT&T Umbrella Benefit Plan No. 1 ("Defendant plan") pursuant to the Employee Retirement Income Security Act ("ERISA") of 1974, § 502, 29 U.S.C. § 1132, challenging the Defendant's decision to deny him short-term disability ("STD") benefits under the terms of the Defendant's Disability Income Program. Defendant plan administered the benefit plan for employees of AT&T Mobility Services LLC, the Plaintiff's employer at all relevant times to this action. Presently pending before the Court for consideration is the Defendant plan's motion for summary judgment. For the reasons outlined herein, the Court GRANTS Defendant plan's motion, with prejudice.

II.FACTUAL BACKGROUND

A.General Background

Plaintiff is an individual that resides at 617 Three Degree Road in Butler, Pennsylvania.

(R. at 1). Defendant plan is a benefit plan operated for employees of AT&T Mobility, LLC. (R. at 1-2). Plaintiff is a former store manager for AT&T Mobility, LLC and is an "Eligible Employee" under the AT&T Disability Income Program. (R. at 296). Plaintiff was initially employed by AT&T Mobility, LLC on or about June 1, 2006. (R. at 3).

Plaintiff received a performance appraisal for the year 2008 that indicated a decline in performance from 2007 and that he was not meeting many of the established goals for his position. (see Marshall Dep. Exs. 4, 5, 6). In February 2009 Plaintiff was placed on a performance improvement plan due to his decline in performance. (Document 57-2 at P. 11-13).

B.AT&T Disability Income Program and Short-Term Disability Benefits

The AT&T Disability Income Program ("Program") is an employee welfare benefit plan and a Program under the defendant plan. (R. at 298). Under the Program, Eligible Employees may be eligible for short term disability ("STD") benefits. (R. at 298). STD benefits "are designed to provide some income replacement if an eligible employee cannot work, with or without reasonable accommodations, because of an approved Total Disability and/or Partial Disability that result from either illness or injury." (R. at 298). Under the Program, STD benefits "include benefits for Total Disability and Partial Disability" and "begin on the eighth consecutive day of absence from work due to an approved Total Disability or Partial Disability."

(R. at 298). An eligible employee "must meet the Eligibility Requirements for the Program before the eighth consecutive calendar day of absence from work due to an approved Total Disability or Partial Disability." (R. at 300).

"Total Disability" or "Totally Disabled," for the purposes of STD benefits under the Program, means "because of illness or injury, you are unable to perform all of the essential functions of your job or another available job assigned by your Participating Company with the same full-time or part-time classification for which you are qualified." (R. at 300). "Partial Disability" or "Partially Disabled," means that "because of illness or injury, you are unable to perform all of the essential functions of your job or another available job assigned by your Participating Company with the same full-time or part-time classification for which you are qualified, for the same number of hours that you were regularly scheduled to work before your disability." (R. at 300).

The Claims Administrator is the entity appointed by the Plan Administrator "to grant or deny or review claims under the Program." (R. at 326). The Plan Administrator in this case is AT&T Inc. (R. at 329). The Claims Administrator is AT&T Integrated Disability Service Center ("IDSC") which is administered by Sedgwick Claims Management Services, Inc. ("Sedgwick").

(R. at 333). The Claims Administrator "determines all claims for benefits under the Program" and has sole discretion to determine whether an Eligible Employee has a disability that qualifies him or her for STD benefits under the Program. (R. at 332, 301). Here, the IDSC "has been delegated authority by the Plan Administrator to determine whether a particular eligible employee who has filed a claim for benefits is entitled to benefits under the Program. This includes the authority to determine claims and appeals on these matters." (R. at 332). Any determination made by the Plan Administrator (or a delegated third party, such as the Claims Administrator) will only be overturned if it is "arbitrary and capricious." (R. at 332).

Program costs are paid either by the employer or through a trust that is established for the Program; no Program benefits are provided by insurance. (R. at 331).

C.Claims and Appeals Processes

Eligible employees may file claims for STD benefits under the Program in the manner set forth on pages 31-32 of the Summary Plan Description. (R. at 321-22). If a claim for STD benefits is denied, the eligible employee may appeal the denial by filing a written request for review in the manner set forth on pages 32-33 of the Summary Plan Description. (R. at 322-23).

As part of filing an appeal, the eligible employee is instructed "to include any new or additional evidence or materials in support of [his/her] appeal that [he/she] wish[es] the Claims Administrator to consider." (R. at 323, 366). The IDSC guide specifies that on appeal, an employee will need to submit medical information to support his/her disability benefits claim.

(R. at 361).

The appeal is determined by "[a] qualified individual who was not involved in the

decision to deny [the] initial claim." (R. at 323). The Claims Administrator "may consult with, or seek the participation of, medical experts as part of the appeal resolution process." (R. at 323). The Claims Administrator "has full and exclusive authority and discretion to grant and deny claims and appeals under the Program." (R. at 322). An appeal "may be decided entirely on the basis of evidence submitted in writing . . ." (R. at 323). A review and decision on the appeal must be made within 45 days of receipt unless the eligible employee is notified in writing that more time is needed. (R. at 323).

D.Application for STD Benefits

Plaintiff initiated a claim for STD benefits under the Program on or about February 9, 2009. (R. at 38-46). In his claim for STD benefits, Plaintiff alleged he is disabled due to depression and anxiety and bipolar disorders. (Document 54 at P. 5). The Claims Administrator issued a letter to Plaintiff on February 9, 2009 acknowledging the Plaintiff's claim and providing all the necessary information needed for submitting a claim for STD benefits from the Defendant plan. (R. at 38-46). The letter included a form titled "Instructions to Physician" specifically outlining procedures to be taken if an employee is missing work due to a mental illness. (R. at 44). The letter also requested that the Plaintiff submit medical information by February 24, 2009 to support his STD benefits claim. (R. at 38-39). The letter further advised that if the documentation furnished by the employee's ...


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