Miles v. Principal Life Insurance

831 F. Supp. 2d 767, 2011 WL 6291203, 2011 U.S. Dist. LEXIS 145442
CourtDistrict Court, S.D. New York
DecidedDecember 14, 2011
DocketNo. 10 Civ. 0702 (VM)
StatusPublished
Cited by1 cases

This text of 831 F. Supp. 2d 767 (Miles v. Principal Life Insurance) is published on Counsel Stack Legal Research, covering District Court, S.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Miles v. Principal Life Insurance, 831 F. Supp. 2d 767, 2011 WL 6291203, 2011 U.S. Dist. LEXIS 145442 (S.D.N.Y. 2011).

Opinion

DECISION AND ORDER

VICTOR MARRERO, District Judge.

Plaintiff Ralph Miles (“Miles”) brings this action against defendants Principal Life Insurance Company (“Principal”) and Venable, LLP Long Term Disability Plan (the “Plan,” and together with Principal, “Defendants”) under the Employment Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. 1132 et seq., challenging Principal’s denial of Miles’s claim for long term disability (“LTD”) benefits. Miles asserts claims for withheld benefits and declaratory relief pursuant to 29 U.S.C. § 1132(a)(1)(B) and for attorney’s fees under 29 U.S.C. § 1132(g)(1). The parties have agreed to forego summary judgment motions in favor of a bench trial on the administrative record pursuant to Rule 52 of the Federal Rules of Civil Procedure, and Muller v. First Unum Life Ins. Co., 341 F.3d 119, 124 (2d Cir.2003) (describing summary judgment in ERISA actions “as essentially a bench trial ‘on the papers’ with the District Court acting as the finder of fact”).

The Court now sets forth its findings of fact and conclusions of law pursuant to Rule 52(a) of the Federal Rules of Civil Procedure. As explained below, the Court concludes that Principal’s denial of Miles’s claim for LTD benefits (the “Initial Determination”) and affirmation of that denial on review (the “Final Determination”) were neither arbitrary nor capricious. Accordingly, the Court authorizes entry of judgment in favor of Defendants.

I. FINDINGS OF FACT1

A. MILES’S INITIAL CLAIM FOR LTD BENEFITS

1. The Policy

When Miles submitted his claim for LTD benefits to Principal in May 2009, he [771]*771was a 53-year-old commercial real estate attorney who had been employed as a partner at the law firm Venable, LLP (“Venable”). Principal is the issuer and administrator of Venable’s group LTD insurance policy (the “Policy”), which covered Miles while he was a partner at the firm.

Under the Policy, a claimant is considered “disabled” if, because of sickness or injury, he is “unable to perform the majority of the Substantial and Material Duties of his ... Own Occupation.” (Admin. Rec. at 733.) The Policy defines “Substantial and Material Duties” as “[t]he essential tasks generally required by employers from those engaged in a particular occupation that cannot be modified or omitted.” (Id. at 726.) To qualify for LTD benefits, a claimant must prove both that he is disabled and that the disability has persisted throughout a 180-day “elimination period.” (Id. at 685.)

The Policy also provides that “Principal may require a Member to be examined by a Physician ... during the course of a claim;” failure to comply with this requirement may “be cause for suspension or denial of the Member’s benefits.” (Id. at 681.) Finally, the Policy vests Principal with “complete discretion to construe or interpret the provisions” of the policy and “to determine eligibility for benefits.” (Id. at 722.)

2. Miles’s Claim

Miles filed a claim for LTD benefits on May 5, 2009. In his application, Miles stated that after a ten-month period of hearing loss in his left ear, he was forced to stop working on April 17, 2009 due to the sudden onset of high-frequency noises in both ears (bilateral tinnitus), intractable ear and head pain, and a feeling of disorientation. (Id. at 1758.) Miles submitted with his application a statement from his attending ear, nose and throat (“ENT”) specialist, Kenneth Etra (“Etra”), which noted these symptoms but reported that their etiology could not be determined. (Id. at 1757.) Etra opined “it seems that [Miles] will at the present time be unable to carry on his job.” (Id.)

Miles described in his application the essential tasks of his occupation:

communicating with others (including lengthy negotiation sessions) in person, by phone, and via computer or Blackberry; reading and understanding complex documents (both paper and electronic); drafting and revising dense and often lengthy documents; memorizing detailed facts; thinking about difficult problems and devising solutions; and supervising the work of associates.

(Id. at 1758.) These tasks “had to be done both quickly and carefully, often under significant time pressure, and sometimes late into the night.” (Id.) Principal does not dispute that these are the essential tasks of Miles’s occupation as an attorney and partner in a large-firm commercial real estate practice.

3. Principal’s Evaluation Process

After an August 10, 2009 phone interview with Miles, Principal’s claim examiner Diana Norman (“Norman”) advised Miles in an August 11, 2 009 letter of the information Principal had received to date. [772]*772Norman informed Miles that in order to continue its evaluation, Principal needed contact information for Miles’s other physicians, medical documentation to support the severity of his symptoms, and confirmation from his physicians “regarding the specific restrictions and limitations they have imposed, which prevent [Miles] from performing [his] own occupation.” (Id. at 4410.)

In addition to a statement from Venable confirming his salary and status as a partner, Principal obtained medical records from the following physicians treating Miles’s illness: (1) Etra, (2) internist Steven Kobren, (3) neurologist Itzhak C. Haimovic (“Haimovic”), and (4) neurologist Richard H. Blanck. These records included the results of various diagnostic tests as well as correspondences between the doctors. On September 1, 2009, Principal contacted each of Miles’s physicians and requested that they answer specific questions about his illness and complete a form known as a “Work Status Sheet.” (Id. at 582-84.)

On October 26, 2009, Janet Hromatko (“Hromatko”), a nurse employed by Principal, conducted a review of all the documentation related to Miles’s claim as of that date. (Id. at 2413.) Following the review, Hromatko and Norman agreed that Principal should obtain an independent medical evaluation (“IME”) by a neurologist and ENT specialist to review the records and consult with attending physicians Etra and Haimovic. (Id.)

In an October 27, 2009 letter, Principal advised Miles of its decision to seek an IME and noted deficiencies in the medical proof submitted on his behalf.

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Related

Miles v. Principal Life Insurance
720 F.3d 472 (Second Circuit, 2013)

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Bluebook (online)
831 F. Supp. 2d 767, 2011 WL 6291203, 2011 U.S. Dist. LEXIS 145442, Counsel Stack Legal Research, https://law.counselstack.com/opinion/miles-v-principal-life-insurance-nysd-2011.