Coleman v. American International Group, Inc. Group Benefit Plan

87 F. Supp. 3d 1250, 2015 U.S. Dist. LEXIS 46734, 2015 WL 1738421
CourtDistrict Court, N.D. California
DecidedApril 9, 2015
DocketCase No. 14-cv-01584-VC
StatusPublished

This text of 87 F. Supp. 3d 1250 (Coleman v. American International Group, Inc. Group Benefit Plan) is published on Counsel Stack Legal Research, covering District Court, N.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Coleman v. American International Group, Inc. Group Benefit Plan, 87 F. Supp. 3d 1250, 2015 U.S. Dist. LEXIS 46734, 2015 WL 1738421 (N.D. Cal. 2015).

Opinion

[1252]*1252ORDER DENYING PLAINTIFF’S MOTION FOR JUDGMENT; GRANTING DEFENDANTS’ MOTION FORJUDGMENT

Re: Dkt. Nos. 36, 39

VINCE CHHABRIA, United States District Judge

Introduction

Plaintiff Kathee Colman brought this suit under the Employee Retirement Income Security Act of 1974 (“ERISA”), alleging that Defendants American International Group, Inc. Group Benefit Plan (the “Plan”), and Hartford Life and Accident Insurance Company (“Hartford”) failed to extend long-term disability benefits in violation 28 U.S.C. § 1132. The parties filed cross-motions for judgment. Because the plaintiff has failed to establish that Hartford abused its discretion in denying further long-term disability benefits beyond August 2013 based on its determinations that, (i) the plaintiff had exhausted her benefits for a disability arising from a mental illness, and (ii) she had not shown she was disabled as the result of her physical ailments, the plaintiffs motion is denied. The defendants’ motion is granted in full.

I. Findings of Fact1

A. Plan Terms

The Plan provides long-term disability benefits for a claimant who is' disabled because of: (1) “accidental bodily injury”; (2) “sickness”; (3) “Mental Illness”; (4) “Substance Abuse”; or (5) “pregnancy.” AR 1511. For the first 24 months from the date of initial eligibility for benefits, a claimant is disabled within the meaning of the Plan if the claimant is unable to perform one or more of the essential duties of his or her occupation. Thereafter, to continue to receive benefits, a claimant must show that he or she is prevented from performing one or more of the essential duties of any occupation. Id.

For a disability caused by mental illness, the Plan provides a maximum of 24 months of benefits payments in a lifetime.2 “Mental Illness” is defined as “any psychological, behavioral or emotional disorder or ailment of the mind, including physical manifestations of psychological, behavioral or emotional disorders, but excluding demonstrable structural brain damage.” AR 1512.

B. Colman’s Disability Claim

In February 2008, Colman left her position as a claims adjuster for American International Group and filed for short-term disability benefits. Colman had previously been diagnosed with a number of illnesses, including fibromyalgia. At the end of the Plan’s short-term disability period, she filed a claim for long-term disability benefits. At Hartford’s request, she also filed a claim for Social Security disability benefits.

In October 2008, Hartford, the insurer and claims administrator for long-term disability benefits under the Plan, approved Colman’s claim. AR 229-232. Hartford determined that Colman’s disability had begun on February 1, 2008, and that she was eligible for benefits as of August 1, 2008. (Under the terms of the Plan a claimant is only eligible for long-term dis[1253]*1253ability benefits payments after a 182-day “elimination period.”)

In April 2010, Hartford sent Colman a letter notifying her that she was reaching the end of her benefits period for a condition that prevented her from performing the essential duties of her occupation and that, as of August 2010, she would need to show that she was totally disabled — unable to perform the essential duties of any job — to continue receiving long-term disability benefits. AR 195.

In July 2010, after receiving records from Colman’s psychologist, Hartford sent Colman a letter stating that information Hartford had received showed that Col-man had been disabled “due to a Mental Nervous Condition” since June 2009. Hartford stated that Colman would therefore exhaust her benefits for disability caused by a mental illness in June 2011. The letter also informed Colman that it was “awaiting the medical information requested from your physicians ... to continue to evaluate your physical function. This information is needed in order to determine if you meet the policy definition of Disability and continue to qualify for benefits on and after 08/01/2010, due to a physical condition.” AR 184.

In April 2011, Colman was examined by Dr. Ekaterina Malinovsky. Dr. Malinov-sky reported to Hartford that, due to a combination of Colman’s chronic pain, depression, and the side effects from her pain medication, Colman would continue to be completely disabled through April 2012.

In August 2011, Hartford requested that Colman undergo an independent medical examination. Dr. Aubrey Swartz conducted the examination. In his report, Dr. Swartz opined that Colman’s physical ailments were not so severe as to render her totally disabled. Based on the activity restrictions in Dr. Swartz report, Hartford determined that Colman would be able to perform the essential duties of a number of occupations, including her own former occupation as a claims adjuster.

In October 2011, Hartford notified Col-man that she no longer fell within the Plan’s 'definition of disabled, and would therefore receive no further benefits beyond October 31, 2011. The letter informed Colman that she had exhausted her benefits for disability arising from mental illness, and that Dr. Swartz’s examination showed that her physical disabilities were not so severe as to preclude her from working in any occupation. AR 162-64.

Colman appealed this determination, providing hundreds of pages of additional documents. In her appeal, Colman also questioned Hartford’s claim procedures and Swartz’s impartiality. As part of its review of Colman’s appeal, Hartford sent Colman’s file to University Disability Consortium for independent review. Two doctors, an orthopedist and a pain management specialist, reviewed Colman’s file. The orthopedic specialist opined that Col-man did not have any orthopedic problems that would cause her to be completely disabled. The pain management specialist, opined that neither Colman’s pain nor any side effects from her pain medication would prevent her from performing sedentary work, so long as she was able to take regular rest periods.

In November 2012, Hartford sent Col-man a letter notifying her that, after reviewing her appeal, it was reversing its earlier determination that Colman was no longer disabled. Hartford acknowledged that its decision to invoke the mental illness limitation as of June 2009 had been “premature,” because “it was not clearly established that [Colman’s]'physical complaints were not impairing at that time.” AR 151. Hartford informed Colman that [1254]*1254it was retroactively reinstating Colman’s benefits payments, effective August 2011. It stood by its prior determination that, as of August 1, 2011, Colman’s physical ailments did not prevent her from working in any job, but acknowledged that Colman’s “behavioral health complaints continue[d] to prevent her from returning to gainful employment.” Hartford stated that it would restart the 24-month mental illness benefits period as of that date, and would therefore pay benefits based on Colman’s disabling mental illness until August 2013. Finally, the letter informed Colman that nothing about this determination would preclude her from submitting additional evidence that her physical ailments were disabling, and that if Hartford received such information, it would remove the 24-month limitation on her benefits. Id.

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87 F. Supp. 3d 1250, 2015 U.S. Dist. LEXIS 46734, 2015 WL 1738421, Counsel Stack Legal Research, https://law.counselstack.com/opinion/coleman-v-american-international-group-inc-group-benefit-plan-cand-2015.