United States District Court, E.D. Pennsylvania
James H. WHITE, Plaintiff,
PRUDENTIAL INSURANCE COMPANY OF AMERICA, Defendant.
[Copyrighted Material Omitted]
John J. Leonard, Hugh J. Hutchison, Leonard Sciolla Hutchison Leonard & Tinari LLP, Philadelphia, PA, for Plaintiff.
Emily S. Costin, Alston & Bird LLP, Washington, DC, Jaclyn DiLascio Malyk, Nada Maalouf Peters, Cuyler Burk, LLC, Parsippany, NJ, for Defendant.
SLOMSKY, District Judge.
| II. || FACTUAL AND PROCEDURAL SUMMARY || 622 |
| III. || ERISA STANDARD OF REVIEW || 625 |
| || A. || Definition of " Disability" and Plaintiff's Depression and Anxiety || 628 |
| || B. || Events of the Automobile Accident || 630 |
| || C. || Plaintiff's Physicians || 632 |
| || || 1. || Dr. DiBella, Dr. Anderson, Dr. Kralick, and Dr. Kaplan || 632 |
| || || 2. || Dr. Mañon-Espaillat || 632 |
| || || 3. || Dr. Maitz and Dr. Divi || 633 |
| || || 4. || Dr. Michel and Dr. Shapiro— Independent Non-Treating Consultants || 633 |
| || || 6. || Dr. Picariello and Barry Belt, M.A. || 634 |
| || D. || Prudential's Reviewing Consultants || 634 |
| || || 1. || Dr. Obianwu and Dr. Yohman || 634 |
| || E. || The Administrative Record Establishes That Plaintiff Suffered a Traumatic Brain Injury on April 21, 2007 in an Automobile Accident || 636 |
| || F. || Errors in the Administrative Record || 637 |
| || G. || Mistakes Undermining Prudential's Fact-Finding || 638 |
Under the Employee Retirement Income Security Act of 1964 (" ERISA" ), a district court has jurisdiction to enforce the rights of a plan participant with a long-term disability. Plaintiff James White brought this action for enforcement of his rights under a provision of ERISA, 29 U.S.C. § 1132(a)(1)(B), after Defendant Prudential Insurance Company of America (" Prudential" ) terminated his long-term disability benefits. Plaintiff alleges he endured a traumatic brain injury in a rollover automobile accident, while Prudential contends that at most, he suffers from a mental illness not caused by trauma. Under the Long Term Disability Policy (" the Plan" ), if a disability is due solely to mental illness, disability benefits are limited to twenty-four months.
The Plan defines a disability as follows:
You are disabled when Prudential determines that:
• you are unable to perform the material and substantial duties of your regular occupation due to your sickness or injury; and
• you have a 20% or more loss in your indexed monthly earnings due to that sickness or injury.
After 60 months of payments, you are disabled when Prudential determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.
(Administrative Record (" R." ) at D1210 (emphasis in original).) The plan defines " sickness" as " any disorder of your body or mind, but not an injury.... Disability must begin while you are covered under the plan." ( Id. ) " Injury" is defined as " a
bodily injury that is the direct result of an accident and not related to any other cause. Injury which occurs before you are covered under the plan will be treated as a sickness. Disability must begin while you are covered under the plan." ( Id. ) The Plan language limiting benefits for disability due to mental illness is as follows:
Disabilities which, as determined by Prudential, are due in whole or part to mental illness have a limited pay period during your lifetime. The limited pay period for mental illness is 24 months during your lifetime.
Mental illness means a psychiatric or psychological condition regardless of cause. Mental illness includes but is not limited to ... depression ... or ... anxiety ....
(R. at D1218-19 (emphasis in original).)
The parties have filed cross-motions, asking the Court to decide this matter on the administrative record. (Doc. Nos. 17, 18). Because Plaintiff's disability is not caused by mental illness, but caused by a physical injury due to a serious automobile accident, the twenty-four month limitation period for mental illness does not apply here, and he should receive benefits for his continuing disability due to sickness or injury. Therefore, the Court will grant Plaintiff's Motion for Judgment on the Administrative Record and deny Prudential's Motion. In reaching this conclusion, the Court has reviewed de novo the Administrative Record and considered the parties' Memoranda of Law in Support of their Motions (Doc. Nos. 17-1, 18-1), Responses in Opposition (Doc. Nos. 21, 23), and Replies in Further Support of the Motions (Doc. Nos. 27, 28).
II. FACTUAL AND PROCEDURAL SUMMARY
Before April 21, 2007, Plaintiff was employed as Chief Operating Officer, Chief Financial Officer, and Director of Risk Management at Holt Oversight & Logistical Technologies (" Holt" ). (Doc. No. 18-1 at 7.) His responsibilities were extensive and required a high degree of professional skill. ( Id. at 7-8.) The work required performing complex tasks under pressure and meeting financial goals and objectives set by the employer. ( Id. at 8.) He earned an annual salary of $255,000. ( Id. at 7.)
On April 21, 2007, Plaintiff was driving an SUV on Interstate 95 with his wife Anita, three of his four children, James Jr., Colin, and Sophia, and his nephew Thomas. ( Id. at 9.) While traveling at highway speed, his SUV was struck by another vehicle at the driver's side rear wheel. ( Id. ) The collision caused his SUV to flip over numerous times before landing on its roof, and then to slide some distance, upside-down, before stopping against a barrier. (R. at D632.) The roof of the SUV caved in along with the windshield. Plaintiff claims he and his wife both lost consciousness during the accident.  (R. at D120-22.)
Plaintiff was transported to Thomas Jefferson University Hospital. (Doc. No. 18-1 at 10.) His medical records from the hospital visit do not detail any head trauma, complaints of headache, or other head pain. (R. at 260-306.) His discharge instructions note only a mild bulging of cervical discs C6-7, and that he was given a prescription of oxycodone and ibuprofen. (R. at D296-97.) Immediately after being discharged from Jefferson Hospital, Plaintiff visited his wife, who was admitted to Hahnemann University Hospital. (Doc. No. 18-1 at 10.) While there, Plaintiff became " dizzy, sweaty, and almost passed out while assisting [his] wife." (R. at D137.) He was then admitted to the emergency room at Hahnemann Hospital for evaluation. (Doc. No. 18-1 at 10.) Plaintiff was discharged without a diagnosis of head trauma.
A week after the accident, for reasons not clear in the Administrative Record, Plaintiff lost his job as chief financial officer at Holt. (Doc. No. 17-1 at 6.) He was offered a position as chief operating officer at one of Holt's subsidiaries, which he declined to accept. ( Id. ) He did not return to work in any position after the accident, and continued to see doctors through the summer of 2007.
On September 12, 2007, after exhausting his sick, personal, and vacation time, Plaintiff applied for Long-Term Disability benefits with Prudential, the insurance company administering and covering such benefits through his employer, Holt. (Doc. No. 18-1 at 15.) On November 27, 2007, Prudential denied Plaintiff's claim for benefits, citing the report of Dr. Kaplan, one of the treating physicians, that Plaintiff was " alert and oriented.... could sit, stand, and walk without physical limitation," and that " Dr. Kaplan opined that [Plaintiff] had no objective evidence of traumatic brain injury." (R. at 1158-60.) Prudential also noted and relied upon the following:
[A] lack of intensity of treatment between your discharge from the hospital and treatment by Dr. Kaplan on September 4, 2007. We would expect that if your pain complaints or memory and concentration difficulties were so debilitating to impair functioning, you would have sought medical treatment. In our telephone conversation on November 1, 2007, you indicated that you help your wife with your three year old child, you help make dinner, you do some yard work and that you are able to drive.... All of these activities indicate that you remain active and are able to function.
(R. at D1159.)
On January 8, 2008, Plaintiff filed a timely appeal from the denial of benefits, submitting updated medical records. (R. at D932-34.) On July 14, 2008, Prudential upheld the denial of benefits, again citing the failure to satisfy the Plan definition of disability. (R. at D1130-38.)
On February 6, 2009, Plaintiff filed a second appeal. He submitted additional evidence to Prudential. On May 7, 2009, Prudential overturned the denial of benefits and determined that Plaintiff was eligible for coverage. (R. at D1112-14.) Prudential asserted: " Based on additional information submitted during the course of Mr. White's second appeal, we ...