Jones v. Life Insurance Co. of North America

829 F. Supp. 2d 165, 51 Employee Benefits Cas. (BNA) 2432, 2011 U.S. Dist. LEXIS 54876, 2011 WL 1979936
CourtDistrict Court, W.D. New York
DecidedMay 20, 2011
DocketNo. 08-CV-6586
StatusPublished
Cited by2 cases

This text of 829 F. Supp. 2d 165 (Jones v. Life Insurance Co. of North America) is published on Counsel Stack Legal Research, covering District Court, W.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Jones v. Life Insurance Co. of North America, 829 F. Supp. 2d 165, 51 Employee Benefits Cas. (BNA) 2432, 2011 U.S. Dist. LEXIS 54876, 2011 WL 1979936 (W.D.N.Y. 2011).

Opinion

DECISION and ORDER

MICHAEL A. TELESCA, District Judge.

INTRODUCTION

Plaintiff, Charles R. Jones (“Plaintiff’), brings this action pursuant to the Employee Retirement Security Act of 1974, 29 U.S.C. §§ 1001 et seq. (“ERISA”), seeking long term disability benefits under an employee benefit plan (the “Plan”) offered by his former employer, Electronic Data Systems Corporation, and issued by Life Insurance Company of North America (“LINA”). Plaintiff alleges that he is disabled according to the Plan and therefore, he is entitled to long term disability benefits. He further alleges that LINA breached a fiduciary duty owed to the him by denying his claim for benefits. Defen[167]*167dants deny Plaintiffs allegations and counterclaim for restitution based on Plaintiffs receipt of Social Security Disability benefits, for which it alleges that it is entitled to offset under the Plan.

Defendant LINA asserts that defendants Electronic Data Systems Corporation (“EDS”) and Cigna Group Insurance (“Cigna”) were improperly named as defendants this case. LINA attests that Cigna is not a legal entity and is merely a service mark used by LINA. See Def. Resp. to PI. Rule 56.1 Statement(Doeket #46), note 1. Further, the Complaint does not contain any factual allegations against EDS, as LINA made all decisions regarding Plaintiffs claim for benefits, which are ultimately paid by LINA. (Docket # 1.) Plaintiff has neither responded to LINA’s arguments nor sought to amend his Complaint to include additional factual allegations against EDS or to contest LINA’s assertion that Cigna is merely a service mark. Accordingly, EDS and Cigna are hereby dismissed as defendants in this case, and the Clerk of the Court is hereby directed to remove Electronic Data Systems Corporation and Cigna Group Insurance from the caption.

Both Plaintiff and LINA move for summary judgement pursuant to Rule 56 of the Federal Rules of Civil Procedure (“Rule 56”). Plaintiff argues that he was wrongfully denied benefits under the plan and that LINA breached a fiduciary duty owed to him pursuant to ERISA. See PL Mem’s of Law (Docket #36). LINA argues that its decision to deny Plaintiff benefits is supported by the administrative record (“AR LINA”) and that, as the insurer, it does not owe the Plaintiff a fiduciary duty. See Def Mem’s of Law (Docket # 40, 45). LINA further contends that according to the Plan and a reimbursement agreement signed by the Plaintiff, Plaintiff is required to reimburse LINA for any overpayment of benefits resulting from the receipt of other disability benefits, including Social Security Disability benefits. Id.

For the reasons set forth below, this Court grants in part and denies in part both Plaintiff and Defendant LINA’s Motions for Summary Judgement. LINA is hereby Ordered to calculate and pay Plaintiff the benefits due under the contract, retroactive to October 26, 2006 with interest. Such benefits, however, shall be offset by $35, 877.40, the amount owed to LINA resulting from Plaintiffs receipt of Social Security Disability benefits, pursuant to the Plan and reimbursement agreement.

BACKGROUND

The following facts are taken from the parties’ submissions pursuant to Local Rule 56.1 and the administrative record submitted in connection with the instant motion. See AR LINA and Docket #’s 36, 39, 46. Plaintiff began working for Electronic Data Systems Corporation (“EDS”) on March 1, 2004 as a computer systems administrator. While employed by EDS, Plaintiff was a participant in an employee benefit plan, which included long term disability insurance, issued by LINA to EDS.

Plaintiff began experiencing neck and back pain and his treating physician, Dr. Nicolas Venci, took him out of work on April 20, 2004. After submitting medical records from Dr. Venci and Dr. James Maxwell, Plaintiffs treating neurosurgeon, indicating that Plaintiff was suffering from degenerative disc disease, which required surgery, and carpal tunnel syndrome, LINA approved Plaintiffs claim for short term disability benefits through October 25, 2004. Thereafter, based on additional documentation regarding his condition, Plaintiff was approved for an initial period [168]*168of long term disability insurance coverage beginning on October 26, 2004. During the initial period under the Plan, which lasts 24 months, “The Employee is considered Disabled if, solely because of Injury or Sickness, he or she is: (1) unable to perform the material duties of his or her Regular Occupation; and (2) unable to earn 80% or more of his or her Indexed Earnings from working in his or her Regular Occupation.” (AR LINA at 210, emphasis added).

Plaintiff underwent an anterior cervical fusion on December 2, 2004. Following the surgery and the estimated recovery period, in June 2005, LINA medical di7 rector, Dr. Scott Taylor reviewed Plaintiffs claim and determined that the initial period of long term disability should continue, as the medical records from Plaintiffs treating physicians and x-rays indicated that Plaintiff had not completely healed from the surgery. Accordingly, Plaintiff continued to receive long term disability benefits. See AR LINA at 71-2.

Plaintiffs claim was reviewed again in December 2005 by Ann Conaway, RN. Ms. Conaway found that Plaintiffs condition had improved, based on an updated x-ray which showed healing of the surgical fusion, and a note from a nurse practitioner in Dr. Maxwell’s office, who reported that Plaintiffs fusion was progressing slowly and that Plaintiff had reported some post-surgical improvements in his condition. Accordingly, Conaway concluded that the “available medical evidence did not support permanent functional impairment.” See Def. Local Rule 56.1 Statement at ¶ 27.

Conaway made this determination, however, after reviewing evidence from Dr. Maxwell, opining that Plaintiff was permanently disabled due to neck and back pain that worsened with physical activity. See AR LINA 282. Dr. Maxwell also stated that Plaintiff was unable to devote more than an hour to any activity and that his pain was so severe that he could not work. Dr. Maxwell attributed the pain to post-surgical nerve scarring, but further surgery was not an option. Dr. Maxwell also noted the worsening of Plaintiffs carpal tunnel syndrome. At that time, Conaway noted that Plaintiffs pain medications included flexeril and sulindac. He was also taking medication for allergies, hypertension and depression. Physical therapy was discontinued because it aggravated Plaintiffs pain. See AR LINA at 49.

Thereafter, LINA arranged for Plaintiff to complete a Functional Capacity Assessment (“FCE”) in January 2006. Daniela Morone, a physical therapist from Greater Rochester Physical Therapy, completed the FCE over a two day period. See AR LINA 445-454. She stated that Plaintiff was cooperative during the FCE and “was willing to work to his maximum abilities.” Id. at 452.

Morone found that Plaintiff was capable of performing sedentary level work, which requires the ability to “exert up to 10 pounds of force occasionally and/or a negligible amount of force frequently ...

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829 F. Supp. 2d 165, 51 Employee Benefits Cas. (BNA) 2432, 2011 U.S. Dist. LEXIS 54876, 2011 WL 1979936, Counsel Stack Legal Research, https://law.counselstack.com/opinion/jones-v-life-insurance-co-of-north-america-nywd-2011.