Foster v. Sedgwick Claims Management Services, Inc.

125 F. Supp. 3d 200, 2015 U.S. Dist. LEXIS 114408, 2015 WL 5118360
CourtDistrict Court, District of Columbia
DecidedAugust 28, 2015
DocketCivil Action No. 14-1241 (JEB)
StatusPublished
Cited by7 cases

This text of 125 F. Supp. 3d 200 (Foster v. Sedgwick Claims Management Services, Inc.) is published on Counsel Stack Legal Research, covering District Court, District of Columbia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Foster v. Sedgwick Claims Management Services, Inc., 125 F. Supp. 3d 200, 2015 U.S. Dist. LEXIS 114408, 2015 WL 5118360 (D.D.C. 2015).

Opinion

MEMORANDUM OPINION

JAMES E. BOASBERG, United States District Judge

Plaintiff Kelly Foster, a former employee of Sun Trust Bank, brought this action under the Employee Retirement Income Security Act of 1974, claiming that Defendants Sedgwick Claims Management Services, Inc. and the Bank’s Short-Term and Long-Term Disability Plans improperly denied her disability benefits. She asserts that she submitted sufficient medical evidence of conditions — including fibromyalgia, fatigue, and anxiety disorder — that render her “totally disabled” within the meaning of the Plans, and she further maintains that she has satisfied all of the Plans’ other preconditions for receiving benefits.

Disagreeing with Foster’s contentions, Defendants have filed a Motion for Summary Judgment. They first point out that the Short-Term Disability Plan is not even governéd by ERISA. They also argue that the deniál of long-term benefits was appropriate in light of the aggregate medical evidence and the eligibility requirements of the Plans.

Concluding that Defendants are entitled to judgment, the Court will grant them Motion.

I. Background

Sun Trust Bank automatically enrolls all of its employees in the company’s ShorfiTerm Disability (STD) and Long-Term Disability (STD) Benefits Plans after six months of employment. See Mot., Exh. 2 (STD Benefits Handbook) at ' 1. Plaintiff, formerly a Mortgage Loan Closer at Sun Trust, was enrolled in both Plans'. See Mot., Exh. 5 (STD Claim File) at 1. Sun Trust retains Sedgwick as the claims administrator for both of its Disability Benefits Plans. See Mot., Exh. 4 (Affidavit of [203]*203Anna M. Grant) at 1. . The claims administrator “make[s] a determination regarding whether your medically-documented claim entitles you to a Long-Term Disability [or Short-Term Disability] benefit.” Mot., Exh. 3 (LTD Plan) at 11.

Enrolled employees are eligible for STD benefits if the claims administrator determines that for more than five consecutive business days, the employee is “not able, solely because of disease or injury, to perform the material duties of their own occupation and are under the regular care of a physician.” STD Benefits Handbook at 2. This determination is to be based on “[objective medical documentation supporting the employee’s claim.’ ” Id. at 1.

An employee is eligible for LTD benefits, conversely, if, after 180 consecutive calendar days of total disability, he or she remains disabled. See LTD Plan at 4. During the entirety of this 180-day “waiting period,” the employee must be entitled to STD benefits or Workers Compensation, see id., the latter of which is not at issue here. , The waiting period commences on the first day the employee is absent from work as a result of his or her disability, and it is broken (and must be restarted) .if the employee returns to work for more than 30 days. Id. These requirements are laid out in the Plan documents and are discussed in more detail in the Analysis. See infra Section III.B.1.

According to Foster, she suffers from a series of disabling conditions, including fibromyalgia and fatigue. See STD Claim File at 1, 23. She filed her first claim for disability benefits under Sun Trust’s STD Plan in January 2012. See Mot., Exh. 7 (Claim Log I) at 36. Sedgwick conditionally approved Plaintiffs claim but later discontinued her benefits the following month, after she failed to provide medical support for a continuing disability. See Mot., Exh. 8 (Letter Discontinuing Temporary-. Benefits) at 1.

Foster then filed another STD benefits claim — the claim at issue in this action — on August 20, 2012. See STD Claim File at 1. On two occasions after the filing of this claim, Sedgwick notified -Plaintiff that she had to file medical documentation in support of her claim before September 7, 2012. See id. at 4,15. After Foster failed to do so, Sedgwick denied her claim-on September 10, 2012.. See id. at 18. Five days after the deadline,- Dr. Robert May-field 'submitted an. Attending Physician Statement in support of Plaintiffs claim, in which he reported that she suffered from fibromyalgia, dry eyes, and anxiety. See id. at 20-22 (Statement of Dr. Mayfield). His diagnosis cited an MRI performed in 2011, and he noted that further objective findings would require additional testing. See id. at 23. Finding that this Statement did not constitute “satisfactory” objective medical documentation of Plaintiffs disability, , Sedgwick again. denied her STD claim on September 13, 2012. See Mot., .Exh. 13 (Claim Log II) at 46-47; STD Claim File at 26-27.

On September 25, 2012, Sun Trust terminated Foster’s employment as a result of-her absence from work. See Grant Aff. ¶4. On that same day, a second physician, Dr. James Sutherland, submitted an Attending Physician -Statement on her behalf. See Mot., Exh. 14 (Statement of Dr. Sutherland). Although this Statement confirmed many of Dr. Mayfield’s diagnoses, it also indicated that Plaintiffs physical condition did not functionally limit her activities of daily living and did not merit driving restrictions. See id. at 2.

Plaintiff, through counsel, formally appealed the denial of her claim for STD benefits, which she was permitted to do even .after her termination. See STD Claim File at 28. After additional review, [204]*204including consultation with independent physicians, Sedgwick upheld this denial on March 29, 2013. See Mot., Exh. 16 (STD Appeal Denial).

Plaintiff next filed a claim for benefits under Sun Trust’s LTD Plan on October 31, 2013. See Claim Log II at 4. Sedgwick denied this claim on November 8, on the basis that Foster had not established that she was entitled to STD benefits or Workers’ Compensation for the duration of the 180-day waiting period. Mot., Exh. 17 (LTD Denial Letter). Plaintiff appealed the denial of her claim for LTD benefits on January 10, 2014, but Sedgwick upheld it on January 27. See Claim Log II at 2.

Foster then filed this action on July 21, 2014, seeking to clarify and enforce her rights under the benefits plans, as permitted by ERISA. See 29 U.S.C. § 1132(a).

II. Legal Standard

“There is a divide among the circuit courts of appeal ... as to whether Fed. R.Civ.P. 56 is necessarily the appropriate mechanism to resolve a § 1132(a)(1)(B) ERISA claim for denial of benefits.” Horton v. Life Ins. Co. of N. Am., No. 14-3, 2015 WL 1469196, at *12 (D.Md. Mar. 30, 2015). Because the D.C. Circuit has not ruled on the question and because both parties endorse the use of Rule 56, the Court will proceed under that framework. It notes that its decision would be the same under Rule 56 (no material dispute of fact regarding whether Sedgwick abused its discretion) as under Rule 52 (no abuse of discretion).

Summary judgment is appropriate when “the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law.” Fed.R.Civ.P. 56(a); see also Anderson v. Liberty Lobby, Inc.,

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125 F. Supp. 3d 200, 2015 U.S. Dist. LEXIS 114408, 2015 WL 5118360, Counsel Stack Legal Research, https://law.counselstack.com/opinion/foster-v-sedgwick-claims-management-services-inc-dcd-2015.