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Kimberly A. Balas v. the Pnc Financial Services

February 29, 2012

KIMBERLY A. BALAS, PLAINTIFF,
v.
THE PNC FINANCIAL SERVICES GROUP, INC. AND AFFILIATES, LONG TERM DISABILITY PLAN, DEFENDANT.



The opinion of the court was delivered by: David Stewart Cercone United States District Judge

Electronic Filing

MEMORANDUM OPINION

I. INTRODUCTION

Plaintiff, Kimberly A. Balas ("Balas" or "Plaintiff"), filed a Complaint against Defendant, the PNC Financial Services Group, Inc. and Affiliates Long Term Disability Plan (the "Plan" or "Defendant"), alleging wrongful denial of long term disability ("LTD") benefits under the Plan pursuant to § 502(a)(1)(B) of the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132(a)(1)(B). The parties have filed cross-motions for summary judgment, and the matters are now before the Court.

II. STATEMENT OF THE CASE

Balas was employed by PNC as a Compliance Specialist from June 26, 1990, through March 23, 2007. Plaintiff's Statement of Undisputed Material Facts ("Pl. SUMF") ¶¶ 1 &7; Defendant's Statement of Undisputed Material Facts ("Def. SUMF") ¶ 1. The job responsibilities of a PNC Compliance Specialist included coordination and oversight of the requirements of the compliance program, including monitoring and reporting compliance with regard to the Bank Secrecy Act. Def. SUMF ¶ 1. As an employee of PNC, Balas was a participant in the Plan. Pl. SUMF ¶ 3; Def. SUMF ¶ 2.

The Plan provides full-time, salaried employees who are out of work for longer than ninety (90) days, with LTD benefits. Def. SUMF ¶ 2. The Plan is a self-funded employee welfare benefit plan, whose benefits are paid out of a separate trust established exclusively for the benefit of the participants or beneficiaries. Def. SUMF ¶ 3. PNC is the Plan Administrator. Def. SUMF ¶ 4. PNC and Sedgwick Claims Management Services, Inc. ("Sedgwick") entered into an Administrative Service Agreement ("Services Agreement") under which PNC delegated its discretionary authority to construe the terms of the Plan and determine eligibility for LTD benefits under the Plan. Def. SUMF ¶ 6. Under the Services Agreement, Sedgwick was conferred the discretion to evaluate and decide claims and any appeals of denied claims. Id.

Under the Plan, "Total Disability" and "Totally Disabled" means that "because of Injury or Sickness":

The [employee] cannot perform each of the material duties of his or her regular occupation; and After benefits have been paid for 24 months, the [employee] cannot perform each of the material duties of any gainful occupation for which he or she is reasonably fitted by training, education or experience.

Administrative Record ("AR") 9. PNC will pay a monthly LTD benefit after the "Elimination Period" upon receiving proof that the employee is totally disabled due to sickness or injury and the employee requires the regular attendance of a physician. AR 9-10. The LTD benefit will be paid for the period of "Total Disability" if, upon request by PNC, the employee provides proof of continued "Total Disability" and regular attendance of a physician. AR 10. LTD benefits cease on the earliest of the date that Total Disability ceases, the date the employee fails to provide proof of Total Disability, or the date the employee ceases employment with PNC. AR 10, 14 & 18.

On June 13, 2007, Balas submitted an "Employee Application for Benefits" seeking LTD benefits in which she stated that she was unable to work due to extreme fatigue, mental confusion and forgetfulness. AR 461. Balas listed her last day of work as March 23, 2007. Id. In support of her application, Balas submitted a "Treating Physicians Statement" completed by Monika Kassyk, M.D. ("Dr. Kassyk"). AR467-469. Dr. Kassyk listed Balas' primary diagnosis as chronic fatigue syndrome and memory loss. AR 467. Though Dr. Kassyk indicated that Balas was unable to stay awake, needed frequent rests, and indicated that the date for release to return to work "depended on final diagnosis," Dr. Kassyk said Balas was released to return to work without restriction. AR 469.

After review of Balas' submissions, Sedgwick denied Balas' request for LTD benefits by letter dated August 30, 2007. AR 160-163. Specifically, Sedgwick found:

[I]nsufficient clinical medical evidence to support your inability to perform each of the material duties of your own occupation as Compliance Specialist throughout the elimination period. Therefore, you are not eligible for LTD benefits . . .

AR 161. Balas appealed this initial denial by letter dated September 21, 2007, citing her disability due to chronic fatigue syndrome. AR 159. On October 18, 2007, Sedgwick forwarded Balas' LTD claim file to Network Medical Review ("NMR"), an independent third-party, for reviews of medical experts in the fields of Physical Medicine and Rehabilitation, Internal Medicine, and Pulmonary Diseases. Def. SUMF ¶ 3. NMR then referred the LTD claim file to Insurance Appeals, Ltd. ("Insurance Appeals"), an accredited review organization. Id.

Philip Jordan Marion, M.D., M.S., M.P.H. ("Dr. Marion"), who is board certified in both Physical Medicine and Rehabilitation, and Pain Management, reviewed the disability claim file for Insurance Appeals. AR 180-183. Based on his review, Dr. Marion made the following findings:

From a physical medicine and rehabilitation perspective, [Balas] is not disabled from her unrestricted job as of 03/26/07.

The clinical findings consist primarily of her self-reported fatigue complaints. This is not supported by any specific deficits via physical examination or radiological studies. The patient remains otherwise functionally independent.

The patient's complaints of fatigue are clinically significant; however, they are not supported by any specific underlying objective impairment.

AR 181-182. As his rationale, Dr. Marion offered the following:

The patient had complaints of fatigue not associated with any specific underlying objective findings via physical examinations or radiological studies. She remains otherwise functionally independent, ambulatory and not restricted from driving a motor vehicle. From a physical medicine and rehabilitation perspective, there remains no objective impairment to support any specific inability to perform her regular unrestricted job . . .

AR 182.

Clayton T. Cowl, M.D., M.S. ("Dr. Cowl"), who is board certified in Internal Medicine, Preventive Medicine/Occupational Medicine, and Pulmonary Diseases, reviewed the disability claim file for Insurance Appeals. AR 184-186. Based on his review, Dr. Cowl made the following findings:

Based on the medical information provided, [Balas] is not disabled from her unrestricted job as of 03/26/07.

AR 185. Dr. Cowl offered the following rationale for his opinion:

There are no objective data provided that substantiates inability to perform clerical sedentary work duties from a respiratory perspective. This is supported by the fact that her pulmonary function testing was normal and her primary care provider also supports the fact that [Balas] would not be considered functionally impaired on a respiratory bass. Although, she was treated briefly for brochitic symptoms and wheezing, these might be more functional than infectious or asthmatic in nature. As such, it is the opinion of the reviewer that [Balas] does not require bronchodilation or inhaled corticosteroids based on the data provided.

AR 186.

Michael Gross, M.D. ("Dr. Gross"), who is board certified in Internal Medicine and Nephrology, also reviewed the disability claim file for Insurance Appeals. AR 187-189. Based on his review, Dr. Gross made the following findings:

From an internal medicine standpoint, from the standpoint of chronic fatigue syndrome . . . [Balas] would be disabled from her regular job as of 03/26/07 to present.

The clinical findings in this case are related to chronic fatigue syndrome with inability to stay up for more than 2 or 3 hours before requiring a rest period. With this ...


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