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Killebrew v. Prudential Insurance Company of America

United States District Court, M.D. Pennsylvania

April 27, 2017

RENEE KILLEBREW, Plaintiff,
v.
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA, Defendant.

          MEMORANDUM

          A. Richard Caputo United States District Judge

         Presently before the Court are Cross Motions for Summary Judgment filed by Plaintiff Renee Killebrew (“Killebrew”) and Defendant The Prudential Insurance Company of America (“Prudential”). For the reasons that follow, Prudential's Motion (Doc. 23) will be granted and Killebrew's Motion (Doc. 26) will be denied.

         I. Factual Background[1]

         A. The Parties

         Plaintiff Renee Killebrew began working for J.P. Morgan Chase Bank, N.A. (“JP Morgan”) on April 25, 2005, ultimately advancing to the position of vice president and branch manager. (Plaintiff's Statement of Facts (“PSOF”) ¶ 27, Doc. 26-1; Defendant's Statement of Facts (“DSOF”) ¶ 11, Doc. 25.) Killebrew's last day of work at JP Morgan was on January 27, 2012, after being diagnosed with multiple sclerosis (“MS”). (PSOF ¶ 27; DSOF ¶ 12; Defendant's Response to Plaintiff's Statement of Facts (“DR”) ¶ 27, Doc. 31.) As an employee of JP Morgan, Killebrew participated in the JP Morgan Chase Long-Term Disability Plan (the “Plan”), which provided certain disability insurance benefits to eligible employees of JP Morgan if certain requirements were satisfied. (DSOF ¶ 1.) JP Morgan funded the long-term disability component of the Plan through the purchase of a group long-term disability insurance policy issued by Defendant Prudential. (PSOF ¶ 5.) JP Morgan is the sponsor of the Plan, and Prudential is the claims administrator. (DSOF ¶ 2.)

         B. The Plan

         In order to receive long-term disability (“LTD”) benefits under the terms of the Plan, a participant must be found to be “disabled.” (PSOF ¶ 6.) Under the Plan, there are two distinct standards of “disability”: (1) the Regular Occupation standard, and (2) the Any Gainful Occupation standard. (DSOF ¶¶ 3, 32.) A participant is deemed “disabled” under the Regular Occupation standard when she:

(1) Is unable to perform the material and substantial duties of her regular occupation due to her sickness or injury; and
(2) Is under the regular care of a doctor; and
(3) Has a 20% or more loss in her monthly earnings due to that sickness or injury.

         (DSOF ¶ 3.) A participant is deemed “disabled” under the Any Gainful Occupation standard when, after receiving payments under the Regular Occupation standard for twenty-four (24) months, Prudential determines that due to the same sickness or injury the participant is:

(1) Unable to perform the duties of any gainful occupation for which she is reasonably fitted by education, training or experience; and
(2) Under the regular care of a doctor.

(Id.)

         “Material and substantial duties” are defined as duties that “are normally required for the performance of your regular occupation and cannot be reasonably omitted or modified.” (Id.)

         “Regular Occupation” is defined as “the occupation you are routinely performing when your disability begins. Prudential will look at your occupation as it is normally performed instead of how the work tasks are performed for a specific employer or at a specific location.” (Id.)

         “Any Gainful Occupation” is defined as “an occupation, including self-employment, that is or can be expected to provide you with an income within 12 months of your return to work, that exceeds: 80% of your indexed monthly earnings, if you are working; or 60% of your monthly earnings, if you are not working.” (Id.)

         Under the Plan, the claimant bears the burden of providing proof of disability. (Doc. 23-2, at 000144.[2]) The Plan contains the following proof statement with respect to making an initial LTD benefits claim submission:

         Your proof of claim, provided at your expense, must show:

(a) That you are under the regular care of a doctor.
(b) Appropriate documentation of your monthly earnings.
(c) The date your disability began.
(d) Appropriate documentation of the disabling disorder.
(e) The extent of your disability, including restrictions and limitations preventing you from performing your regular occupation or any gainful occupation.
(f) The name and address of any hospital or institution where you received treatment, including all attending doctors.
(g) The name and address of any doctor you have seen.

(Id.) The Plan also states that “[f]or your [LTD] claim, [Prudential] may request that you submit proof of continuing disability, satisfactory to Prudential, indicating that you are under the regular care of a doctor. In some cases, you will be required to give Prudential authorization to obtain additional medical information, and to provide non-medical information . . . as part of your . . . proof of continuing disability.” (Id. at 000144-145.) The Plan further provides that Prudential may require claimants to be “examined by doctors, other medical practitioners or vocational experts of [Prudential's] choice, [and that] Prudential will pay for these examinations.” (Id. at 000128.) Prudential may also require a claimant “to be interviewed by an authorized Prudential Representative, ” and “[r]efusal to be examined or interviewed may result in a denial or termination” of a claim. (Id.)

         Prudential enumerates several documents concerning the Plan, the content of which affects the Court's standard of review in this case.

         First, Prudential relies on a document entitled the Health & Income Protection Program for JP Morgan Chase Bank and Certain Affiliated Companies (the “wrap document”). (DSOF ¶ 4.) Section 4.2 of the wrap document states in pertinent part:

Benefits under the Program or a Plan will be paid only if the Program Administrator or its delegate decides in its discretion that a Participant is entitled to them. The Program Administrator may delegate this authority to . . . one or more Claims Administrators. . . . The Program Administrator and its authorized delegate(s) shall perform their duties, and, in their sole discretion, determine appropriate courses of action in light of the reason and purpose for which this Program is established and maintained.

(Id.) Section 4.3 of the wrap document states in pertinent part: “Whenever benefits under a Plan or Plan Option are provided under an insurance policy, the Insurer shall be the designated Claims Administrator for such benefits, and the Program, Program Administrator and the Committee assumes no liability or responsibility for any coverage or benefits provided under such Plan or Plan Option.” (Id.) Prudential, as the insurer of the LTD component of the Plan, is thus defined and designated under the Plan as a “Claims Administrator” for and over its policy. (PSOF ¶ 21.)

         Prudential also identifies the JP Morgan Chase Summary Plan Description (“SPD”), which states:

The Plan Administrators for the JP Morgan Chase U.S. Benefits Program have complete authority in his or her sole and absolute discretion to construe and interpret the terms of the plans and any underlying policies and/or contracts, including eligibility to participate in the plans.
. . .
. . . the Plan Administrators have delegated their discretion to decide claims and appeals to the claims administrators . . .
. . .
The Plan Administrator has delegated all fiduciary responsibilities and decisions regarding a claim for a denied benefit under these plans to the applicable claims administrator.

(DSOF ¶ 7.)

         Another document, which Prudential identifies as an “additional section at the end of the Certificate of Coverage, ” but instead appears to be part of the SPD (see PSOF ¶ 20; DR ¶ 20), states: “The Prudential Insurance Company of America as Claims Administrator has the sole discretion to interpret the terms of the Group Contract, to make factual findings, and to determine eligibility for benefits. The decision of the Claims Administrator shall not be overturned unless arbitrary and capricious.” (Doc. 23-2, at 000156.)

         C. Killebrew's LTD Benefits Claim

         1. Initial Denial and Appeal Under the Regular Occupation Standard

         On or about May 14, 2012, Killebrew filed her claim for LTD benefits based on her MS diagnosis. (DSOF ¶ 14; PSOF ¶ 27.) In support of her claim, Killebrew submitted records from Neurology Associates, including records from her neurologist, Dr. Katara, and diagnostic studies. (DSOF ¶ 15.) Prudential first requested an internal review by Susan Palermo, R.N. (Id. ¶ 16.) Nurse Palermo noted that the physical exams conducted by Dr. Katara “consistently noted normal gait w/symmetrical arm swing, no drift or gross focal weakness with motor testing and EE's upper/lower extremity strength has been 5/5.” (Doc. 23-2, at 001592.) Nurse Palermo further noted that Killebrew was “consistently noted to be alert, oriented w/no indication of lethargy, slurred speech, balance/coordination abnormalities or an inability of EE to self-administer prescribed medications. . . .” (Id.) Additionally, Nurse Palermo stated that although Killebrew complained of not being able to use her right hand, on physical exams she was consistently found to have 5/5 upper strength with no motor/sensory abnormalities noted. (Id.) Nurse Palermo concluded that despite Killebrew's complaints of low energy, sleeping during the day, and an inability to use her right (dominant) hand, “there is no medical basis to restrict” her after June 1, 2012. (Id.; see DSOF ¶¶ 16-18.)

         Relying on Nurse Palermo's assessment, Prudential denied Killebrew's LTD benefits claim on July 30, 2012. (DSOF ¶ 19.) Prudential determined that Killebrew “would be capable of returning to work full time and [did] not meet the definition of disability. . . .” (Doc. 23-2, at 001507.) On August 12, 2012, Killebrew filed an appeal of Prudential's decision. (PSOF ¶ 30; DR ¶ 30.) Killebrew listed multiple ongoing issues stemming from her diagnosis that impacted her life, including an inability to drive, severe exhaustion, and various painful sensations and burnings. (Doc. 23-2, at 000364-365.) Killebrew also stated that Dr. James Kerrigan, M.D., Killebrew's treating neurologist, was the only doctor with whom she discussed her MS treatments, not Dr. Katara. (Id. at 000365; see PSOF ¶ 51.) Attached to the appeal letter was an office note from Dr. Kerrigan dated August 8, 2012, in which Dr. Kerrigan noted that Killebrew was, inter alia, “having pain symptoms most persistently in the right hand, ” experienced fatigue, and complained of difficulty focusing. (Doc. 23-2, at 000368.)

         In response to Killebrew's appeal, Prudential requested an independent external review of the medical evidence. (DSOF ¶ 21.) Prudential contracted with MCMC to identify a doctor to conduct the review. (Id.) MCMC selected Dr. Michael D. Snyder, M.D., board certified in psychiatry and neurology, who conducted the review on September 12, 2012. (Id.) Dr. Snyder's review included a review of the records from Dr. Katara and Dr. Kerrigan. (Id. ¶ 22.) Based on the documentation provided, Dr. Snyder found that Killebrew had some medically necessary restrictions and limitations due to relapsing-remitting MS from January 28, 2012 forward. (Doc. 23-2, at 000384.) Dr. Snyder stated that this condition resulted in “some mild neurological deficits which support some degree of impairment and warrant restrictions/limitations. . . .” (Id.) However, Dr. Snyder concluded that these limitations did not prevent Killebrew from engaging in full-time work, stating:

The claimant is capable of full-time work. Sitting is unrestricted in an eight hour day. The claimant may stand/walk combined up to two hours in an eight hour day; there is no limit on the amount of standing/walking at one time within those two hours. The claimant may lift, carry, push and pull with the left hand up to 20 pounds occasionally and up to 10 pounds frequently. The claimant may lift, carry, push and pull with the right hand up to 10 pounds occasionally. The claimant may finger, feel and handle with the right hand rarely (up to [3%] of the workday). As the claimant's ability to type/keyboard would be expected to be slower, the claimant should be allowed to work at her own pace and would need five minute breaks after every 30 minutes of typing/keyboarding. Reaching overhead, at the waist and below the waist with the right hand is limited to occasionally. . . .

(Id.) Dr. Snyder also found that Killebrew's complaints regarding her inability to drive long distances, inability to use her right hand without pain, and inability to perform detailed mental tasks were not supported by the documentation. (Id. at 000386.)

         In connection with her appeal, Prudential also conducted a review of Killebrew's occupation. (DSOF ¶ 26.) Vocational rehabilitation specialist Karen Gibson, M.S., C.R.C., performed a review of Killebrew's position and duties on September 17, 2012. (Id.) Ms. Gibson concluded that the material and substantial duties of Killebrew's position as a branch manager were sedentary and required up to 33% of occasional fingering and frequent handling and reaching. (Id.)

         Based on these two reviews, Prudential determined that Killebrew could not perform the material and substantial duties of her regular occupation as a branch manager because she had a 3% limitation on fingering and handling with her right hand and was unable to do bi-manual reaching. (Id. ¶ 27.) As a result, Prudential approved Killebrew's LTD benefits claim under the Regular Occupation standard effective July 28, 2012. (Id.)

         On January 22, 2013, Prudential requested an addendum medical review from Dr. Snyder as part of Prudential's ongoing review of Killebrew's capacity and prognosis. (Id. ΒΆ 28.) Dr. Snyder reviewed additional medical records from Dr. Kerrigan and Dr. Mullen, ...


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