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Noga v. Reliance Standard Life Insurance Co.

United States District Court, E.D. Pennsylvania

August 27, 2019

LEO NOGA, Plaintiff,


          SCHMEHL, J.

         Plaintiff, Leo Noga (“Noga”), brings the instant action to challenge the denial of his claim for disability benefits pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1132(a)(1)(B) against Reliance Standard Life Insurance Company (“Reliance”), the insurance company that funded and administered the disability insurance plan provided by his employer, Fulton Financial. Noga claims that Reliance's denial of his claim for long term disability benefits was arbitrary and capricious.

         The parties have each moved for summary judgment. Noga argues that the record supports a finding of disability and therefore, Reliance's determination that he is not entitled to a long term disability benefits was incorrect. Reliance maintains that its decision to deny benefits to Noga was not arbitrary and capricious but was based on substantial evidence contained in the record that Noga was not entitled to long term disability benefits. After a thorough examination of the administrative record, I find that Reliance acted in an arbitrary and capricious manner when it denied Noga's disability benefits. Therefore, I will grant Noga's motion for summary judgment and deny Reliance's motion for summary judgment.

         I. BACKGROUND

         Reliance issued group long term disability policy number LTD120852 to Fulton Finance Corporation. (Administrative Record 1-33) (“AR.”) While Noga was employed full-time by Fulton, he was insured under this policy. (AR 329-332.) The policy grants Reliance the discretion to determine benefit eligibility and requires Noga to submit satisfactory proof of total disability. (AR 16, 20.) The policy defines total disability to mean “that as a result of an Injury or Sickness, during the Elimination Period and thereafter an Insured cannot perform the material duties of his/her Regular Occupation.” (AR 12.) The policy defines Regular Occupation to mean:

the occupation the Insured is routinely performing when Total Disability begins. We will look at the Insured's occupation as it is normally performed in the national economy, and not the unique duties performed for a specific employer or in a specific locale.

         (AR 12.) Noga's job with Fulton required him to drive to client meetings. (AR 360-61.) Noga's occupation involves “mostly sitting, may involve standing or walking for brief periods of time.” (AR 363.) When asked by Reliance “[w]hat part of your occupation can't you do?” Noga responded “cannot drive to work, can't stand, walking limited.” (AR 200.)

         Reliance admits that Noga worked in a sedentary occupation, and that his job description included the requirement that he “[m]ust be able to drive to outside locations to initiate and continue sales calling effort.” (AR 360-361.) Noga stopped working for Fulton effective February 27, 2015, and subsequently applied for benefits under the policy. (AR 333-341.) Everett Hills, M.D., completed the attending physician section of the disability application and identified neurogenic muscular atrophy as Noga's primary diagnosis and diabetes, hypothyroidism and hypertension as secondary conditions. (AR 342-343.) Noga's symptoms were identified as “leg weakness.” (AR 342.)

         Reliance accepted Noga's claim for long term disability benefits on August 20, 2015. (AR 242-244.) Reliance paid disability benefits in the amount of $4299.61 less Noga's Social Security benefits effective August 25, 2015, until December 27, 2017, when his benefits were terminated. (AR 203, 299-304.)

At the time Reliance decided that Noga was entitled to benefits effective August 25, 2015, it had Noga's medical records reviewed by in-house medical personnel, Nurse Finnegan. (AR 125.) Nurse Finnegan determined: “Based on medical provided claimant with ongoing complaints of lower extremity weakness, EMG positive for right upper ulnar nerve involvement (although no complaints associated with upper extremity). Records do not support any cognitive deficits however claimant has been referred to psych. Based on medicals claimant lacks consistent work function and precluded from stand and walk on greater than an occasional basis. Claimant with hx of depression, Etiology of complaints and symptoms remain unknown, suspect a psychiatric contribution. Recommend obtaining medicals from PCP, Neurologist, Psychiatrist to assess claimants status beyond 10/1/15.”

         (AR 125.) On August 18, 2015, Reliance management reviewed this matter and stated: “Agree with recommendation to approve claim at this time under the policy 24 month M&N limitation [Mental & Nervous] (update plan duration) and continue to follow up for copies of ongoing medical work up results, including psych assessment.” (AR 186.)

         Reliance sent an approval letter to Noga that stated: “The policy refers to this as your maximum benefits period. Based on the group policy, benefits are payable for a period of 24 months if a disability occurs as a result of a mental or nervous disorder.” (AR 243.)

         On January 26, 2016, Reliance approved the claim for waiver of premium on the life insurance Fulton provided for Noga. (WOP 52-53.) The amount of this life insurance was $172, 000. (WOP 52-53.)

         Reliance continued to monitor Noga's condition and on August 15, 2017, his file was referred to a member of Reliance's medical staff. The file was reviewed by Leslie Moore, a registered nurse employed by Reliance. Nurse Moore stated as follows:

Based on the medical records, there was prior mention of chronic pain and right wrist and ulnar neuropathy, and polyneuropathy; however, there is no mention of ongoing wrist neuropathy, pain or swelling. Claimant reports pain is 7/10 but is unclear where. Based on the complaint of chronic pain, claimant lacks work function; however, to better assess pain, would suggest obtaining pharmacy records to determine what medications claimant has filled, and who is prescribing them, and returning for review with medical records from all actively treating providers.

         (AR 130.) Based on Nurse Moore's suggestion, Reliance requested additional records, which were received on August 18, 2017, and September 11, 2017. (AR 195.)

         On September 18, 2017, Reliance's in-house nurse, Nurse Vicho, reviewed Noga's medical records and found:

Based on the review of medical records provided, claimant is precluded from engaging in any sustained work function on a frequent and consistent basis ongoing due to persistent diabetic neuropathy on lower legs along with continued painful left shoulder following rotator cuff repair. Co-morbid with chronic fatigue, poor endurance and obesity. Consider updating records in about 5-6 months including serial narratives from Orthopedic, Surgery, Endocrinology and PCP along with diagnostic studies and laboratory studies for further file direction.

         (AR 131.)

         On October 10, 2017, Nurse Moore requested an independent medical examination through MES. (AR 1168-1171.) MES hired Dr. John Kline to conduct the examination, and Dr. Kline examined Noga on November 28, 2017. (AR 1185.) Dr. Kline confirmed the diagnoses of diabetic peripheral neuropathy, hypothyroidism, gastroesophageal reflux disorder, erectile dysfunction with penile implantation, prior history of right lower extremity trauma for which Noga underwent multiple surgical interventions. (AR 1191.) Noga informed Dr. Kline that he stopped working due to diabetic peripheral neuropathy and reported significant lower limb pain and weakness. (AR 1185-1186.) Noga told Dr. Kline that he sleeps 2-3 hours during the day and would fall asleep while driving. (AR 1186.) Noga stated that he wore braces on his legs for about a year but that at the time of the examination, only required them intermittently. (AR 1186.) Noga “keeps a cane in his car in case he was to need it, ” but did not require an assistive device during the examination. (AR 1187, 1189.)

         Dr. Kline inquired as to Noga's subjective tolerance levels and reported that Noga “does not demonstrate any difficulty sitting. He states the length of time he is able to stand and ambulate varies, depending on how he feels that day.” (AR 1186.) Noga told Dr. Kline that he “smokes only medicinal marijuana as well as chews THC gummies. He does admit to alcohol utilization, which he states he drinks perhaps two Manhattans in a day and switches to wine in the evening hours.” (AR 1187.)

         During the examination, Noga exhibited “full, complete, and normoactive range of motion of the cervical spine, both shoulders, elbows, wrists metacarpal phalangeal, and interphalangeal joints.” (AR 1189.) He also had “full, complete, and normoactive range of motion of the lumbosacral spine, both knees, and ankles. He did demonstrate some mild range of motion of both hips, exhibiting some mildly limited internal and external rotation bilaterally.” (AR 1189.) Dr. Kline tested Noga's muscle strength and noted “normal 5/5 strength” in his upper and lower extremities. (AR 1190.) Dr. Kline found that Noga's “prognosis for recovery in sensory impairment is poor. The sensory impairment that Mr. Noga currently has is permanent in nature and over time will either remain static or progress.” (AR 1192.) Based on Noga's diagnoses, Dr. Kline expected self-reported complaints such as numbness, tingling and neuropathic pain; however, Dr. Kline also concluded that Noga “demonstrate[d] a high degree of symptom exaggeration or inappropriate pain behavior.” (AR 1191-92.) Dr. Kline concluded that Noga:

. . . would be capable of gainful employment. He would be capable of performing work within a light modified capacity, lifting or carrying up to maximum of 20 pounds. He would warrant no restriction on sitting. His walking would be limited to 10-15 minute intervals, with his standing limited to 20-30 minutes, without the utilization of any assistive devices. This may improve to some extent with his braces as well as utilization of a single point cane, which he did not bring to today's evaluation.
Mr. Noga does not demonstrate any cognitive deficits. Mr. Noga's production rate in performing activities that require standing and walking on a regular basis clearly would be impaired, though his rate of productivity at a seated position would not be altered. Mr. Noga would not warrant any restriction on utilizing either of his upper extremities for fine manipulation, reaching, grasping, or repetitive upper extremity activities. He would not be restricted from reaching at a desk level, above mid chest or below, fingering or feeling with tactile sensation in either upper extremity, and he voices no complaint within his hands and has no significant deficit on clinical evaluation. A physical capabilities form has been provided to me, which I have completed in its entirety.
Mr. Noga indicated that he is currently driving. If his proprioception once again should become substantially worse, Mr. Noga may benefit from hand controls to assist with his driving, as he does not demonstrate any upper extremity deficits.

         (AR 1192-1193.)

         After Dr. Kline's IME, and pursuant to a letter dated December 21, 2017, Reliance notified Noga of its decision to terminate benefits effective December 27, 2017. (AR 299-304.) On December 22, 2017, Reliance terminated the wavier of premium on Noga's life insurance (WOP 58-60.) Noga appealed from the termination decision on January 2, 2018, and ...

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