Oslowski v. Life Insurance Co. of North America

139 F. Supp. 2d 668, 2001 U.S. Dist. LEXIS 8426, 2001 WL 401575
CourtDistrict Court, W.D. Pennsylvania
DecidedApril 12, 2001
DocketCIV. A. 99-356
StatusPublished
Cited by3 cases

This text of 139 F. Supp. 2d 668 (Oslowski v. Life Insurance Co. of North America) is published on Counsel Stack Legal Research, covering District Court, W.D. Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Oslowski v. Life Insurance Co. of North America, 139 F. Supp. 2d 668, 2001 U.S. Dist. LEXIS 8426, 2001 WL 401575 (W.D. Pa. 2001).

Opinion

Memorandum Opinion

COHILL, Senior District Judge.

Tanya M. Oslowski filed this action in the Court of Common Pleas of Allegheny County against the Life Insurance Company of North America (“LINA”), the insurer that carried her employer’s group disability insurance policy, seeking the long tern disability benefits which the defendant had denied. LINA removed the case to this court, since Oslowski was seeking benefits due under a plan covered by the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. §§ 1001 et seq., 1132(a)(1)(B). Presently before us is plaintiffs motion for summary judgment (Doc. 22) and accompanying brief. Defendant has filed a brief in opposition (Doc. 33), which requests that we deny plaintiffs motion and grant summary judgment in its favor. For the reasons set forth below, we will grant summary judgment in this matter in favor of the defendant and against the plaintiff.

Background

Plaintiff Tanya M. Oslowski was employed as a claims specialist by State Farm Mutual Automobile Insurance Company (“State Farm”). In October of 1995, she began treatment for depression. At first, she received short term disability paid by her employer. After six months, an Application for Long Term Disability Insurance was sent to defendant LINA, which carried State Farm’s long term disability insurance policy. Pl.’s Ex. C (plaintiffs claims file) at 357. This insurance was an employee benefit, and Oslowski paid for it through payroll deduction.

The summary plan description (“SPD”) of the applicable policy, Long Term Disability Income Policy LK-6900 (“Disability Income Plan” or “the Plan”), shows that State Farm appointed the Life Insurance Company of North America to administer *671 the long term disability plan. Pl.’s Ex. B. Plan documents granted LINA the power “to make all reasonable rules and regulations required in the administration of the Plan and for the conduct of its affairs, to make all determinations that the Plan requires for its administration, and to construe and interpret the Plan.” Pl.’s Ex. B at 5280. Furthermore, LINA processed all claims, notified claimants if any additional information, such as a medical examination was required, and either paid or denied the claim. PL’s Ex. B at 5310.

The Disability Income Plan provided for a disabled employee to receive an amount equal to 65% of her wages, less any other applicable benefits. PL’s Ex. C at 333. In order for the Plan Administrator to find a covered employee “not disabled,” and thereby to deny benefits, it had to deter-miné that she was capable of being employed at a job which would pay her 80% of the wages she was earning at the time of her disability.

When Oslowski filed her claim for benefits, LINA requested information from her treating physicians, Donald J. Wilfong, M.D., who had apparently treated the plaintiff for sinus problems, James Garver, M.D., her gynecologist, and John Delaney, M.D. who treated her for depression. PL’s Ex. C at 273-82. .

Dr. Delaney stated that he had begun treating the plaintiff for depression on October 24, 1995. Her appointments were scheduled weekly until January of 1996, when they were reduced to every two weeks. Dr. Delaney prescribed Paxil, an anti-depressant medication. Dr. Delaney went on to describe Oslowski’s condition:-

I have not seen the need to provide psychological testing to this patient because the diagnosis was relatively clear. I feel she is really unable to do any type of job at this point. She suffers from a rather fragile ego and is barely able ‘to maintain the activities of her home with her children and this requires the help of her husband as well. Prior to this depression she was able to function quite well without any real difficulty maintaining herself both at home arid at the job. At this time I really feel that she is totally disabled. I feel that she is unable to do anything except those things which she can do as far as taking care of the children. I feel, at this point, her prognosis is- guarded in view of her depression being so long lasting.

-PL’s Ex. C at 273-74.

After reviewing the records in plaintiffs claims file, LINA approved her claim for Long Term Disability Benefits on June 12, 1996. PL’s Ex. C at 333-34. The approval letter informed her that to qualify for benefits during the first 24 months, she must be unable to perform the essential duties of her occupation. However, to continue to qualify for benefits after the first two years, she must be unable to engage in the essential duties of any occupation. LINA stated that it would be requesting periodic updates on the status of her disability, and that it could have an examination performed by a physician of the insurer’s choice. Id. at 334.

Oslowski’s request for Social Security Disability Benefits was denied on July 16, 1996. PL’s Ex. C at 283-85.

At the defendant’s request, Oslowski was examined by Lawrence Lobl, M.D. Dr. Lobl filed a psychiatric evaluation and report on October 31, 1996, and a separate report on November 19, 1996. PL’s Ex. C at 238-248; 228-229. Dr. Lobl agreed with Dr. Delaney’s diagnosis that Oslowski had suffered a major depression in 1995, and stated that the depression was in partial remission. He disagreed with Dr. Delaney’s conclusion that the plaintiff was totally disabled. Dr. Lobl reported that:

It does seem clear that Ms. Oslowski did suffer a Major Depression in the spring *672 and fall of 1995. Although there may-have been biochemical aspects to this, family history seems largely negative and patient was, indeed, under multiple stresses. She found family life was stressful, her marriage unhappy and work increasingly stressful. She was having fantasies of fleeing. She reacted at first with symptoms of anxiety and then major depression following an angry confrontation at work.
In my view, it is the combination of stressors that precipitated the depression. Her work situation, although apparently difficult, does not, as she describes it, seem beyond the usual stresses of a difficult workplace. Treatment has been with psychoactive medications and psychotherapy on an intermittent basis with some, but not total improvement. In her current situation, Ms. Oslowski seems more angry, withdrawn and apathetic than depressed. Her functional capacities appear to be good although she is fragile and, I feel, would have difficulty returning to work in her old position, although her current functional capacities are good. I do not feel, however, that she is totally disabled from a psychiatric point of view and I feel that planning for return to some kind of work should be started.

Pl.’s Ex. C at 243-44.

Dr. Lobl added: “I do not feel that the patient, at this time, is totally disabled, and I do feel that it may be in her best interest to begin planning to return her to work, as long as there is some intervention to ease the social situation which impedes her return.” Pl.’s Ex. C at 245.

In response to a subsequent query from the insurer, as to whether Oslowski could return to the same job with another employer, Dr. Lobl stated:

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Bluebook (online)
139 F. Supp. 2d 668, 2001 U.S. Dist. LEXIS 8426, 2001 WL 401575, Counsel Stack Legal Research, https://law.counselstack.com/opinion/oslowski-v-life-insurance-co-of-north-america-pawd-2001.