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James Matson v. Axa Equitable Life Insurance Company

September 15, 2011


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


This is an Employee Retirement Income Security Act ("ERISA") case. James Matson claims that he is disabled and unable to work. He seeks long-term disability benefits under a policy he had through his employer and administered by the Life Insurance Company of North America ("LINA"). LINA contends that Matson has failed to produce satisfactory evidence that he qualifies as disabled under the policy and therefore refuses to pay him long-term disability benefits. Matson also has a policy with the AXA Equitable Life Insurance Company ("AXA"). AXA is currently paying long-term disability benefits to Matson under this policy but has a disagreement with Matson about the amount of an offset to which AXA is entitled as a result of social security disability benefits Matson is receiving. LINA also claims that any benefits it must pay Matson are subject to a similar offset provision. Before the Court are the cross-motions for summary judgment of all parties. For the reasons that follow, the Court will grant Matson summary judgment against LINA on the issue of payment of long-term disability benefits, deny LINA's motion for summary judgment on that issue, grant summary judgment to AXA and LINA on the issue of the offset, and deny Matson's motion for summary judgment on the offset issue. Finally, the Court will deny Matson's request for attorneys' fees.


A. The Policy

Matson worked as a senior program analyst at Quest Diagnostics, Inc. (LINA's Statement of Undisputed Facts in Supp. of Mot. for Summ. J. [LINA's Undisputed Facts] ¶ 1.) He participated in both Quest's short-term and long-term disability benefits plans. (Id. ¶ 2.) Quest provided benefits under the short-term disability plan, which LINA administered. (Id. ¶ 3.) Matson could receive a maximum benefit of twenty-six weeks under the short-term disability policy. (Id.) Matson's long-term disability benefits were provided through a policy issued by LINA. (Id. ¶ 4.)

According to the long-term disability policy, the employee "must provide the Insurance Company . . . satisfactory proof of Disability before benefits will be paid. . . . The Insurance Company will require continued proof of the Employee's Disability for benefits to continue." (J.A. at 366.) The long-term disability policy provided:

Definition of Disability/Disabled

The Employee is considered Disabled if, solely because of Injury or Sickness, he or she is:

1. unable to perform the material duties of his or her Regular Occupation; and

2. unable to earn 80% or more of his or her Indexed Earnings from working in his or her Regular Occupation.

After Disability Benefits have been payable for 24 months, the Employee is considered Disabled if, solely due to Injury or Sickness, her or she is:

1. unable to perform the material duties of any occupation for which he or she is, or may reasonably become, qualified based on education, training or experience; and

2. unable to earn 60% or more of his or her Indexed Earnings.

The Insurance Company will require proof of earnings and continued Disability. (Id. at 361.) "Regular Occupation" is defined as:

The occupation the Employee routinely performs at the time the Disability begins.

In evaluating the Disability, the Insurance Company will consider the duties of the occupation as it is normally performed in the general labor market in the national economy. It is not work tasks that are performed for a specific employer or at a specific location. (Id. at 377.) Thus, for the first two years of a claimed disability, to receive long-term disability benefits, a participant must provide satisfactory proof that he cannot perform the duties of his own occupation. (LINA's Undisputed Facts ¶ 10.) After two years, the participant must provide satisfactory proof that he cannot perform the duties of any occupation. (Id.)

B. Matson's Medical History

On February 26, 2001, Matson had surgery for a herniated disc. (J.A. at 495.) On February 13, 2006, Matson complained of chronic and worsening leg cramps, numbness, and limited movement. (J.A. at 511.) As a result, he received steroid injections on February 13 and March 2, 2006. (Id. at 509, 513.) Matson had right L4-L5 microdiscectomy surgery on March 28, 2006 to alleviate intractable right leg pain that radiated up the right side of his body. (Id. at 498.) On January 4, 2007, Matson had a C5-6 and C6-7 anterior cervical discectomy and fusion due to radiating neck and right arm pain. (Id. at 501.) Following a liver biopsy, Matson was diagnosed with chronic hepatitis in 2008. (Id. at 520.)

Matson saw Dr. Jeffrey Friedman in April of 2007 to address his pain issues. Dr. Friedman noted that although Matson's right hand was much improved, Matson continued to report numbness in both hands along with ongoing neck and shoulder pain and lower back discomfort. (Id. at 543.)

An MRI in February of 2009 "did not show anything worrisome from the surgical standpoint" although Matson continued to complain about neck tightness and radiating discomfort. (Id. at 528.) Matson's shoulder was examined in June of 2009, and he was diagnosed with tendinosis with full thickness or near full thickness tear in the mid-tendon. (Id. at 531.) On September 3, 2009, Dr. Elliot Leitman performed surgery on Matson to repair a torn right rotator cuff. (Id. at 505.)

Matson also had MRIs in February and March of 2010 to follow up on the chronic pain he was experiencing. The imaging revealed a moderate focal right central disc protrusion and severe right neural foraminal stenosis. (J.A. at 535-41.) On February 25, 2010, a lumbar spine MRI of Matson displayed bulging discs causing minimal compression of the thecal sac and moderate to severe right and moderate to severe left neural foraminal stenosis. (Id. at 482.) A February 26, 2010 cervical spine MRI showed bulging discs, a flattening of the spine, and moderate to severe bilateral neural foraminal stenosis. (Id. at 477.) A thoracic spine MRI performed a month later showed a T2-T3 disc protrusion causing a severe right neural foraminal stenosis. (Id. at 480.) On March 29, 2010, Dr. William Murphy evaluated Matson and noted Matson's chronic, radiating pain as well as his bilateral L5-S1 radiculopathy. (Id. at 485.) On April 15, 2010, Dr. Murphy noted that Matson complained of neck and lower back pain, and shoulder weakness. The EMG study performed showed bilateral C5 and left C6 radiculopathy. (Id. at 473.) Dr. Murphy maintained that Matson was "disabled from all employment pending further response to treatment" and that Matson's prognosis for full recovery and return to gainful employment was poor. (Id. at 471.)

Dr. Edward Murphy, Psy.D., performed a neuropsychological screening evaluation on Matson on June 10, 2010. He noted that Matson reported significant persistent pain, lightheadedness, and depression. (Id. at 408.) Matson also experienced persistent fatigue that worsened when he had to concentrate on tasks. (Id.) The evaluation showed that Matson's automatic memory skills were intact, and he showed no impairment in his verbal fluency. (Id. at 409.) Matson was taking Oxycontin, Oxycodone, and Xanax. (Id.) There was no indication of any cognitive rigidity or inflexibility in his thinking, but "[i]t is evident that pain factors and/or medications tend to diminish his ability to sustain attention on tasks. . . . [His] deficits are likely more noticeable from a functional standpoint. Mr. Matson tends to tire quickly with tasks involving mental activity." (Id. at 409-10.) Murphy did not find a neurological basis for Matson's complaints but deemed it common for people with severe pain to show deficits in terms of functional attention and memory abilities. (Id. at 410.) He concluded that Matson was "disabled from returning to his employment. Cognitively, he would have a difficult time meeting the demands of his work as his symptoms of chronic pain, fatigue, and medications would significantly tend to interfere in his ability to complete his job functions on a day-to-day basis. His symptoms have continued to exacerbate over several years." (Id.)

At some point after receiving a diagnosis of dizziness, memory loss, and unspecified idiopathic neuropathy, Matson was referred to a neurologist, Dr. Philip Adelman. (Id. at 551.) Dr. Adelman, whose office had tracked Matson's progress since February of 2006, also provided his opinion on Matson's ability to work. Based on his review of Matson's file, he opined that Matson was disabled from all employment. (Id. at 467.) He concluded that Matson's chronic pain prevented him from effectively functioning on a daily basis and that Matson would be unable to "reliably work in a sedentary capacity seated at a computer terminal and concentrate as has been required in his previous job capacity. It is my opinion that he would not be able to function reliably and effectively in any work capacity given his overriding pain syndrome." (Id.)

Matson completed a Functional Capacity Evaluation on March 19, 2010. Matson was required to perform a number of tasks as part of the evaluation. He was able to complete the sitting task, though he frequently shifted, grimaced, and reported back pain. (Id. at 554-55.) He was not able to complete the standing task and reported low back and right leg pain. (Id. at 555.) Matson was unable to walk slowly on a treadmill or climb stairs due to fatigue and pain in his lower back and right hip. (Id.) He could not maintain his balance when requested to squat or crouch and was forced to "literally crawl[] out of and back into a chair utilizing it for significant support." (Id. at 556.) He struggled to reach overhead, showing decreased motion; he also reported increasing low back and leg pain when making repetitive foot motions. (Id. at 557.) He failed to meet the twenty-fifth percentile when his static lifting ability was measured, which indicated a performance deficiency. (Id. at 559.) He also performed poorly on tests measuring how quickly and accurately he could work with his hands. (Id. at 560.) Overall, his "performance demonstrated ...

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