Dorsey v. Provident Life & Accident Insurance

167 F. Supp. 2d 846, 2001 U.S. Dist. LEXIS 16354, 2001 WL 1198632
CourtDistrict Court, E.D. Pennsylvania
DecidedOctober 5, 2001
DocketCIV. A. 01-1072
StatusPublished
Cited by18 cases

This text of 167 F. Supp. 2d 846 (Dorsey v. Provident Life & Accident Insurance) is published on Counsel Stack Legal Research, covering District Court, E.D. Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Dorsey v. Provident Life & Accident Insurance, 167 F. Supp. 2d 846, 2001 U.S. Dist. LEXIS 16354, 2001 WL 1198632 (E.D. Pa. 2001).

Opinion

MEMORANDUM AND ORDER

KATZ, Senior District Judge.

Now before the court are cross-motions for summary judgment in the above-eap-tioned action filed under the Employee Retirement Income Security Act of 1974, 29 U.S.C.A. § 1001 et seq. Because the court finds that the insurance company’s decision to deny benefits was arbitrary and capricious, the plaintiffs motion for summary judgment is granted and the defendant’s motion for summary judgment is denied.

I. Background

Plaintiff Cheryl Dorsey brings this action against the defendant, Provident Life and Accident Insurance (Provident), following Provident’s denial of her claim for long-term disability (LTD) benefits. The plaintiff applied for benefits on the grounds that she suffered from fibromyal-gia, a disorder characterized by diffuse musculoskeletal pain, stiffness, paresthe-sia, nonrestorative sleep and easy fatigability. Harrison’s Principles of Internal Medicine 1706-07 (Kurt J. Isselbacher, et al., eds., 13th ed.1994). Fibromyalgia is a rheumatological disorder that manifests itself through a variety of symptoms including,

generalized aching and stiffness of the trunk, hip and shoulder girdles. Other patients complain of generalized aching and muscle weakness. Patients perceive that their joints are swollen; however, joint examination is normal.... Patients complain of exhaustion and wake up tired. They also awake frequently at night and have trouble falling back asleep. Symptoms are made worse by stress or anxiety, cold, damp weather, and overexertion.... Disorders commonly associated with fibromyalgia include irritable bowel syndrome, irritable bladder, headaches (including migraine headaches), and dysmeorrhea.

Id. at 1706. Fibromyalgia is diagnosed by its clinical manifestations, and, in particular, manifestation of tender sites which “are exquisitely more tender than adjacent areas.” Id. Joint and muscle examination is normal and there are no laboratory abnormalities associated with the disorder. Id. While some patients respond well to treatment, “others continue to have chronic disease which may be only partially relieved, if at all.” Id.

The history of plaintiffs claim for benefits is as follows. 1 Dorsey worked as Director of Sales and Marketing at Zurich Payroll Solutions until she became ill in February, 1999. App. to Def.’s Summ. J. Mot. at PLACL00004. 2 In August, 1999, she submitted an application for long term disability benefits to defendant Provident Life and Accident Insurance. App. at PLACL00001-55. Dorsey’s application stated that she suffered from severe migraines and cervical strain, and her primary care physician indicated that she suffered from “severe fibromyalgia, severe migraines, [and] cervical strain.” App. at PLACL00006. On August 24, 1999, case manager Karen Mathis, a registered nurse (RN), spoke with the plaintiff and the plaintiffs employer, as well as reviewed her medical records. App. at PLACL00060-61. In an internal memo, *849 Mathis noted that an independent doctor had examined the plaintiff, that she was receiving short-term disability payments, and that her employer described her job as requiring some travel. Id. Mathis recommended gathering more medical information from Dorsey’s primary care physician, rheumatologist, and physical therapist. Id.

On September 29, 1999, RN Julie Ken-nelly conducted a second review of Dorsey’s claim. App. at PLACL00071-72. In her report, titled “DCM review,” Nurse Kennelly discussed the medical records submitted by the plaintiff and noted that many doctors had diagnosed Dorsey with fibromyalgia. Id. Even though the doctors were unanimous in their diagnosis, the Kennelly concluded that there was not enough data to support their conclusions stating:

[although several physicians give the insured the diagnosis of fibromyalgia none of them list all the trigger points or other findings of the syndrome. Depression is usually associated with this diagnosis, however, the insure [sic] denies any depression and no diagnosis of such is given. Due to lack of medical support the diagnosis does not appear conclusive.... Duration of disability cannot be made at this time, as there is not enough information to support insured’s inability to perform her job without accommodations.”

App. at PLACL00071-72. Kennelly then recommended that Provident obtain all the available medical records and review the claim again.

On October 8, 1999, Dr. David Chesner, Dorsey’s rheumatologist, submitted a detailed letter to Provident on behalf of Dorsey. Dr. Chesner gave a thorough description of the plaintiffs medical condition and indicated that she was seeing a psychologist for the depression caused by her illness stating:

[A m]usculoskeletal examination revealed severe fibromyalgia trigger points present diffusely throughout the axial and appendicular skeleton.... Cheryl Dorsey is completely and totally disabled from seeking gainful employment at this time. This is secondary to severe fibromyalgia syndrome with chronic fatigue and cognitive impairment. There is no cure for fibromyal-gia, and therefore the therapies are somewhat limited. Her pain level has persisted despite numerous attempts with narcotic analgesics and antidepressants. Her prognosis for recovery is extremely poor.

App. at PLACL00465-67.

A physical therapist then examined the plaintiff at Provident’s request and conducted a functional capacity evaluation (FCE) on. November 18, 1999. App. at PLACL00215. According to the therapist, the plaintiffs performance during this evaluation placed her in the light category of work. However, the therapist noted that it was “questionable” whether the plaintiff gave her full effort throughout the entire test. App. at PLACL00210-15. Provident conducted video surveillance of the plaintiff for three full days beginning November 17th culminating in a fifteen minute videotape showing the plaintiff driving her children to school as well as walking slowly to and from her car for very brief periods of time. 3

On January 10, 2000, Dr. Nancy Beecher, conducted Provident’s only physician review of the plaintiffs disability claim. However, it is unclear whether Dr. Beecher reviewed all of the medical records or simply the FCE and surveillance tape, 4 *850 and her report only referenced those two sources. App. at PLACL00216-17. Dr. Beecher’s report concluded that the plaintiff was capable of performing light physical demand work, App. at PLACL00216 - 17, and noted that Dorsey was “said to have given less than [a] full effort [on] the evaluation based on grip testing.” App. at PLACL00217.

In addition, Pam Perdue, Provident’s Rehabilitation Consultant, performed an analysis of the FCE and the plaintiffs job requirements on January 18, 2000. Per-due employed a generic description of Dorsey’s job at Zurich and determined that it fell in the medium work category. App. at PLACL00222-30.

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167 F. Supp. 2d 846, 2001 U.S. Dist. LEXIS 16354, 2001 WL 1198632, Counsel Stack Legal Research, https://law.counselstack.com/opinion/dorsey-v-provident-life-accident-insurance-paed-2001.