Michaels v. Equitable Life Assurance Society

305 F. App'x 896
CourtCourt of Appeals for the Third Circuit
DecidedJanuary 5, 2009
Docket07-4256
StatusUnpublished
Cited by12 cases

This text of 305 F. App'x 896 (Michaels v. Equitable Life Assurance Society) is published on Counsel Stack Legal Research, covering Court of Appeals for the Third Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Michaels v. Equitable Life Assurance Society, 305 F. App'x 896 (3d Cir. 2009).

Opinion

OPINION OF THE COURT

VAN ANTWERPEN, Circuit Judge.

Appellant-Plaintiff Lawrence Michaels appeals from the District Court’s decision affirming the denial of long-term disability benefits by the Equitable Life Assurance Society of the United States Employees, Managers, and Agents Long-Term Disability Plan and AXA Financial, Inc., the Appellees-Defendants. For the following reasons, this Court will vacate the District Court’s decision and remand for further *898 proceedings in accordance with this opinion.

I. Facts and Procedural History-

Appellant Lawrence Michaels sustained a midshaft fracture of his left femur during a horseback riding accident on July 12, 1997. As a result of this injury, a rod was implanted into his femur. App. at 669, 943. Following this surgery, Michaels began treatment with Dr. Eric Katz, an orthopedic surgeon, and he has continued this treatment throughout all periods relevant to this litigation.

At the time of his injury, Michaels was employed at a law firm as a tax attorney, but the law firm terminated his employment effective December 31, 1998 because he was unable to perform the duties required of him due to his “physical[] impair[ment] and severe[] restriction] with respect to travel for the purpose of business development and servicing of clients.” App. at 677, 679. In January 1999, following this termination, Michaels accepted a position with the Equitable Life Assurance Society of the United States (“Equitable”), 1 an organization that provided short- and long-term disability insurance to its employees via the Equitable Life Assurance Society of the United States Employees, Managers, and Agents Long-Term Disability Plan (“Plan”); 2 Michaels enrolled in the Plan and received a copy of the Summary Plan Description 3 (“SPD”).

Aetna U.S. Healthcare (“Aetna”) administered Equitable’s Plan until December 31, 2003, and MetLife became the Plan administrator on January 1, 2004. 4 The SPD provides that “[a] period of total disability will end after 24 months of receiving disability benefits if it is determined that the disability arises from or on account of ... a mental condition described in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders.” App. at 152. Further, the Plan set forth two different definitions for “total *899 disability” based on the duration of the claimant’s disability period:

• during the first two years of your period of disability, you’re unable to report to work and perform all of the material or essential duties of your own occupation due to illness or injury; and
• after the first two years of your period of disability, you’re unable to engage in any gainful occupation for which you are, or may reasonably become, qualified by education, training, or experience, other than work under an approved rehabilitation program.

Id. (emphasis added).

On May 25, 1999, Michaels stopped working and filed a claim for total disability benefits; he has not engaged in any gainful employment since that date. Aetna certified Michaels for a period of short-term disability beginning in May 1999. While this initial certification did not state the basis for the grant of benefits, an entry in Aetna’s internal claims system from May 26, 1999 makes reference to Michaels’s implanted femoral rod as well as his major depression. To facilitate its disability assessments, Aetna requested Michaels’s existing medical records as well as ongoing “Managed Disability Statements” from Dr. Katz and Dr. Aaron Tessler, Michaels’s psychiatrist. Following the receipt of a Managed Disability Statement from Dr. Katz on June 2,1999, in which he characterized Michaels’s return to work as “unknown,” Aetna extended his certification for short-term benefits through July 6, 1999. Id. at 247-48, 697. Katz described Michaels’s “persistent and increasing” pain in his left hip resulting from the implanted femoral rod and recommended that he limit his “ambulatory and sitting activities.” Id. at 248, 702. Aetna recertified Michaels’s claim for benefits for another thirty-one days beginning on July 22, 1999 based on the clinical information submitted by Dr. Katz.

An entry in Aetna’s claims processing system details a July 23, 1999 voicemail from Dr. Tessler, which stated that Michaels suffered from depression, had difficulty concentrating, and exhibited diminished organizational skills. In a Managed Disability Statement received on July 28, 1999, Dr. Tessler added that Michaels’s ability to return to work was “unclear.” Id. at 265, 717. Aetna periodically recertified Michaels and, in November 1999, approved Michaels for long-term disability benefits. Thereafter, Aetna periodically recertified him for continued long-term benefits under the Plan. The letter notifying Michaels of his approval for long-term benefits did not specify the basis for his benefits, but it did provide that he would be ineligible for long-term disability payments after twenty-four months if his disability was “the result of a mental condition.” Id. at 577-79. Further, it provided that if Michaels was still eligible for long-term disability benefits after May 25, 2001, he would be required to meet the “more stringent ‘any occupation’ definition of disability.” App. at 579. This provision of the SPD, quoted supra, provides that the claimant’s inability to perform the duties of his own occupation is sufficient to qualify as “totally disabled” in the first twenty-four months of disability, but, after twenty-four months of disability, the claimant must be unable “to engage in any gainful occupation.”

Following Aetna’s approval of long-term disability benefits for Michaels, Dr. Katz and Dr. Tessler continued to treat him. Dr. Katz reported Michaels’s ongoing “pain and stiffness in the left hip region” that was “aggravated by even short periods of sitting and standing” as well as Michaels’s “difficulty in ambulation.” In the course of treatment, Dr. Katz and *900 Michaels repeatedly discussed the possible removal of the femoral rod; this procedure was never completed, apparently because the doctors could not assure Michaels that the surgery would relieve his symptoms. Dr. Tessler reported continued mood instability for Michaels and diagnosed him with Bipolar Disorder in March 2000.

In June 2000, Aetna arranged appointments for Michaels to undergo a psychological examination and an Independent Medical Examination (“IME”) with psychologist Dr. Donald Hiebel and psychiatrist Dr. Jerome Schnitt, respectively. Dr.

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Bluebook (online)
305 F. App'x 896, Counsel Stack Legal Research, https://law.counselstack.com/opinion/michaels-v-equitable-life-assurance-society-ca3-2009.