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Hilbert v. The Lincoln National Life Insurance Co.

United States District Court, M.D. Pennsylvania

June 19, 2017



          SYLVIA H. RAMBO, United States District Judge

         In this action arising under the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§ 1001-1461 (“ERISA”), both sides have moved for summary judgment relating to Defendant's denial of Plaintiff's claim for long-term disability benefits. The primary issue before the court is whether the plan administrator abused its discretion in denying Plaintiff's claim. The cross motions have been fully briefed, and, for the reasons discussed below, the court will grant Defendant's motion for summary judgment and deny Plaintiff's motion.

         I. Factual Background

         The following facts come alternatively from the parties' statements of material facts accompanying their summary judgment motions and from the Administrative Record (“AR”), which the parties jointly submitted to the court. While the parties do raise some disputes and denials to their opponent's statement of material facts, all of those disputes and denials pertain to the weight that should be given to certain evidence, the correct interpretation of evidence, or the justifiability of certain decisions made by Lincoln. There does not appear to be any dispute as to the actual facts underlying this case and therefore, the court considers those facts to be undisputed. They can be summarized as follows.

         Plaintiff Yvonne Hilbert (“Plaintiff) began working as a customer service representative for Delta Dental on July 1, 2011. The position required, inter alia, the ability to sit for up to six hours of an eight hour day and to lift up to ten pounds occasionally.

         While employed by Delta Dental, Plaintiff was a participant in an employee welfare benefit plan (the “Plan”), which included both short-term disability (“STD”) and long-term disability (“LTD”) coverage. The Plan was funded, in part, by a Group Insurance Policy providing STD benefits, policy number 000010106767 (the “STD Policy”), and by a Group Insurance Policy providing LTD benefits, policy number 000010106766 (the “LTD Policy”). Defendant The Lincoln National Life Insurance Company (“Lincoln”) issued both policies to Delta Dental. Plaintiff's effective date of coverage under both policies was November 1, 2011.

         Relevantly, the LTD Policy states that Lincoln will pay disability benefits to an insured employee after the completion of the Elimination Period, if he or she: “(1) is Totally Disabled; (2) becomes Disabled while insured for this benefit; (3) is under the Regular Care of a Physician; and (4) at his or her own expense, submits proof of continued Total Disability and Physician's care to the Company upon request.” (AR at 88.) The Elimination Period is defined as “180 calendar days of Total Disability caused by the same or a related Sickness or Injury, which must be accumulated within a 360 calendar day period.” (Id.) Totally Disabled means “[d]uring the Elimination Period and Own Occupation Period, . . . that due to an Injury or Sickness the Insured Employee is unable to perform all of the Main Duties of his or her Own Occupation.” (Id. at 76.) “After the Own Occupation Period, [Totally Disabled] means that due to an Injury or Sickness the Insured Employee is unable to perform all of the Main Duties of any occupation for which his or her training, education, experience of physical or mental capacity will reasonably allow.” (Id.) “Own Occupation” is defined as “the occupation, trade or profession . . . in which the Insured Employee was employed with the Employer prior to the Disability. . . . It means a collective description of related jobs, as defined by the U.S. Department of Labor Dictionary of Occupational Titles.” (Id. at 73.) “Main Duties” are “those job tasks that . . . are normally required to perform the Insured Employee's Own Occupation; and . . . could not reasonably be modified or omitted.” (Id. at 72.)

         Plaintiff stopped working at Delta Dental on September 18, 2012, and on September 25, 2012, she filed a STD claim under the STD Policy stating that a “[c]ombination of back and leg pain and depression [made her] unable to function.” (Id. at 1377.) Lincoln approved Plaintiff's STD claim based on a September 28, 2012 Attending Physician Statement in which Plaintiffs treating psychiatrist, Dr. Jagadeesh Moola, reported that Plaintiff was unable to work due to severe depression, as well as Plaintiff's participation in an intensive Acute Care Partial Hospitalization/Intensive Outpatient Program for depression in October 2012. Lincoln paid Plaintiff the maximum duration of benefits available under the STD Policy through March 19, 2013.

         After the expiration of Plaintiff s STD benefits, Lincoln began evaluating whether she would be eligible for long-term benefits under the LTD Policy. Unlike the STD Policy, the LTD Policy contains a pre-existing condition provision under which coverage will not be provided for any disability resulting from a pre-existing condition, meaning “a Sickness or Injury for which the Insured Employee received medical advice or treatment within 3 months prior to the Insured Employee's Effective Date.” (Id. at 95.) Thus, pursuant to this provision, Plaintiff would not be eligible for LTD benefits if she received treatment for the disabling condition during the three months prior to her effective date of coverage, i.e., between August 1, 2011 and November 1, 2011 (the “Look Back Period”).

         A LTD benefit specialist with Lincoln, Sarah Ricker (“Ms. Ricker”), requested Plaintiffs medical records and determined that Plaintiff had received treatment for depression during the Look Back Period. After this determination was confirmed by two nurses and a board certified psychiatrist, Lincoln concluded that Plaintiffs depression was a pre-existing condition for which Plaintiff would not be eligible for LTD coverage. As such, to be eligible for LTD benefits, Plaintiff had to show that she was independently totally disabled as of September 18, 2012 due to a condition other than depression. Because Plaintiff had indicated in her initial claim for STD coverage that her disability stemmed not only from depression but also from back and leg pain, Ms. Ricker requested updated medical records from PRISM, a clinic focused on physical medicine and rehabilitation, where Plaintiff treated with Physician Assistant Jennifer Tanner and Dr. Michael Lupinacci, in order to assess whether Plaintiff was independently totally disabled due to her back and leg pain. These records may be summarized, in pertinent part, as follows.

         During a March 1, 2012 physical examination, Ms. Tanner observed that Plaintiffs knees were “doing very good, ” that she had full strength in her lower extremities “with good range of motion of her back, and that she “was sitting comfortably in the exam chair in no acute distress.” (Id. at 466.) Ms. Tanner encouraged Plaintiff to exercise and stretch on a daily basis. At a March 22, 2012 pain management appointment, Ms. Tanner similarly noted that Plaintiff was “sitting comfortably in the exam chair with no acute distress, ” and had a “good range of motion of her back” with full strength of lower extremities. (Id. at 465.) At a June 11, 2012 appointment with Ms. Tanner, Plaintiff reported that “her knee and low back pain are being managed well with her current regime, ” but that she “has pain with forward flexion of her back, as well as with extension, which produce radicular symptoms down her legs.” (Id. at 464.) On examination, Ms. Tanner noted that Plaintiff maintained full strength in her extremities. (Id.) Following a physical examination on September 13, 2012-four days before Plaintiff stopped working-Ms. Tanner noted that Plaintiff experienced “tenderness over the lumbrosacral paraspinal muscles . . . and pain with extension to about 10 degrees, ” as well “impressions of “[b]ilateral degenerative joint disease” and “degenerative disc disease.” (Id. at 956.) However, Ms. Tanner also noted that Plaintiff had a non-antalgic gait and full strength in her extremities, and “encouraged [Plaintiff] to continue exercising and stretching.” (Id.) Ms. Tanner did not indicate any need for work restrictions. During a December 13, 2012 physical examination, Ms. Tanner noted that Plaintiff had “5/5 strength throughout lower extremities” and “has shown improvement and overall functional mobility and quality of life with her medications. Depression is what has been a big issue for her now.” (Id. at 1322.) On January 14, 2013, Plaintiff reported to Ms. Tanner that, due to back and leg pain, “[s]he cannot stand for any period of time or walk for any period of time.” (Id. at 1285.) On examination, Plaintiff had a “non-antalgic gait” and “good strength throughout her upper and lower limbs.” (Id.) Ms. Tanner noted that Plaintiff's “mental health has been a major problem” which “is certainly . . . part of her increased pain level and also decreased motivation ” (Id. at 1286.)

         Also included in Plaintiffs medical file were records from office visits with her primary care physician, Dr. Rowehl. These records reflect that Dr. Rowehl consistently performed physical examinations and noted Plaintiffs reports of pain. (See, e.g., Id. at 1155 (9/23/11 - abdominal pain), 1169 (7/27/11 - hip and abdominal pain), 430 (2/16/12 - back and leg pain), 412 (6/5/12 - eye pain).) Notably, Plaintiff saw Dr. Rowehl on September 17, 2012-the day she stopped working-for complaints of foot pain. Following a physical examination, Dr. Rowehl's general impression was tendinitis of the Achilles tendon. There is no indication in the record that Plaintiff reported back or leg pain. Similarly, during visits with Dr. Rowehl on November 1, 2012 and February 15, 2013 for diabetes and depression, Plaintiff did not report back or leg pain.

         Based on these records, it appeared to Ms. Ricker that Plaintiffs physical examinations were normal, that her pain was stable and manageable, and that she was encouraged to remain active. Ms. Ricker determined that Plaintiffs depression was her disabling condition.

         Nonetheless, Ms. Ricker asked Nurse Disability Consultant Judy Jacobsen, R.N. (“Nurse Jacobsen”) to review the medical information and comment on Plaintiff's functionality. Included in this information was a December 12, 2012 Attending Physician's Statement signed by Ms. Tanner stating that Plaintiff was unable to work as of September 17, 2012 because she could not “stand, walk for extended period of time” or lift more than ten pounds. (Id. at 1326.) Ms. Tanner indicated that Plaintiffs condition had “regressed” and it was “unknown” when Plaintiff would be able to return to work. (Id.) However, also included in Plaintiff's file was a November 19, 2012 work capacity form that Ms. Tanner completed for the Department of Welfare, stating that Plaintiff was temporarily disabled due to degenerative joint disease and back pain from November 31, 2012 to October 31, 2013. After reviewing Plaintiff's claim file in its totality, Nurse Jacobsen concluded that there was no medical evidence of impairment due to back, knee or shoulder pain from September 18, 2012 through January 13, 2013. As of January 13, 2013, however, Plaintiff had limitations relating to right shoulder pain lasting through October 2013 when she had surgery to repair a torn tendon. Because Plaintiff had not shown that she was totally disabled as of September 18, 2012 due to a physical condition independent of her depression, Nurse Jacobsen agreed that Plaintiff was not eligible for LTD benefits.

         On November 19, 2013, Plaintiff sent Ms. Ricker a letter she received from the Social Security Administration (“SSA”) stating in part that, beginning March 2013, Plaintiff was receiving $396.00 per month in Social Security Disability benefits (“SSDI”). (AR 933.) The letter did not indicate what condition(s) the SSA found disabling or the date on which the SSA found Plaintiff to be disabled. (See id.)

         By letter dated November 26, 2013, Ms. Ricker notified Plaintiff that she was not entitled to LTD benefits. In the letter, Ms. Ricker stated that “the medical documentation contained in your claim file indicates your depression condition is pre-existing and no benefits are payable for this condition.” (Id. at 930.) Addressing Plaintiffs leg, shoulder and back pain, Ms. Ricker explained that, although her shoulder condition became impairing in January 2013, Plaintiff did not qualify for benefits because coverage under the LTD Policy had terminated on September 18, 2012 when Plaintiff was no longer actively at work and was not totally disabled under the LTD Policy. Ms. Ricker stated that Plaintiff could appeal the determination by submitting a letter with “[m]edical records to support [the] appeal such as office and treatment notes, laboratory results, x-rays and testing results.” (Id. at 930.)

         On April 15, 2014, Plaintiff, represented by Attorney Michael Grabhorn, timely appealed Lincoln's denial of LTD benefits. In the letter, Mr. Grabhorn did not challenge Lincoln's determination that Plaintiff received treatment for depression during the Look Back Period. Instead, he argued that Plaintiff was indeed physically unable to return to work as of September 18, 2012, and pointed to Lincoln's prior approval of Plaintiffs STD benefits based on “Dr. Tanner's objective findings that [Plaintiff]'s degenerative disc disease and facet anthropathy precluded her from performing the duties of her own occupation.” (Id. at 572.) In support of his appeal, Mr. Grabhorn submitted 717 pages of Plaintiff's medical records and portions of her social security file.

         Appeals Specialist Lisa Kurtz, a Lincoln employee with no prior role in Plaintiffs claim, referred Plaintiffs file to Disability Nurse Consultant Virginia Rush (“Nurse Rush”), who, like Nurse Jacobsen, found no evidence of impairment from Sept 18, 2012 until Plaintiffs rotator cuff surgery in October 2013. Nurse Rush based her opinion on Plaintiff's “unremarkable” lumbar spine x-rays and her consistently normal physical examinations, as well as a physical abilities report completed by Dr. Christine Daecher, DO in connection with Plaintiffs application for SSDI, indicating that Plaintiff had a sedentary work capacity. (Id. 533-38). Specifically, Dr. Daecher stated that Plaintiff could lift and carry up to twenty pounds occasionally; sit for up to three hours at a time for a total of eight hours over an eight-hour workday; stand for up to two hours, and walk for up to one hour over an eight-hour workday. (Id.) Dr. Daecher noted that Plaintiff was “most limited by her obesity.” (Id. at 536.) Relying on Nurse Rush's opinion, Ms. Kurtz upheld the initial decision that Plaintiff failed to prove she was totally disabled due to any physical condition from September 18, 2012 forward, commenting as follows:

Based on the information in the file, we find that the medical documentation does not support that there are restrictions and limitations that would render [Plaintiff] unable to perform her own occupation beyond the date last worked based upon any physical condition. She managed her back pain with medications and a TENS unit. X-rays of the lumbar spine were unremarkable. The abilities form indicates sedentary capacity. [Plaintiff] did not have complaints regarding shoulder injury until January 2013, well after the date in which she ceased working. As noted previously[, ] depression was determined to be a pre-existing condition and ...

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