Patterson v. Prudential Insurance Co. of America

693 F. Supp. 2d 642, 2010 U.S. Dist. LEXIS 142898
CourtDistrict Court, S.D. Texas
DecidedMarch 10, 2010
DocketCivil Action H-08-2127
StatusPublished
Cited by2 cases

This text of 693 F. Supp. 2d 642 (Patterson v. Prudential Insurance Co. of America) is published on Counsel Stack Legal Research, covering District Court, S.D. Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Patterson v. Prudential Insurance Co. of America, 693 F. Supp. 2d 642, 2010 U.S. Dist. LEXIS 142898 (S.D. Tex. 2010).

Opinion

MEMORANDUM AND ORDER

EWING WERLEIN, JR., District Judge.

Pending are defendants The Prudential Insurance Company of America’s (“Prudential”) and AON Employee Benefit Committee’s Motion for Summary Judgment (Document No. 44). After having considered the motion, response, 1 the applicable law, and the administrative record, Defendants’ motion will be granted.

*644 I. Background

Plaintiff Andrew Patterson claims, pursuant to ERISA § 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B), that Prudential wrongly-denied his continuing long-term disability (“LTD”) benefits under AON’s Group Disability Insurance plan (the “Plan”) when it determined he was not totally disabled. Prior to claiming disability, Plaintiff worked for AON as a Senior Insurance Specialist for eight months. 2 Plaintiffs job was classified as “sedentary,” 3 as it involved recording and documenting client losses, ensuring prompt reporting to carriers, and responding to general client inquiries. 4 Plaintiff was college-educated, -with a bachelor’s degree in teaching. 5 A rather lengthy summary is required of events arising over four years’ time and medical evaluations and opinions rendered by at least eight physicians.

July 2002: Plaintiffs Injury

Plaintiff fell down a flight of stairs at work on July 22, 2002. 6 He incurred injuries to both of his knees, both wrists, his lower back, one testicle, and his neck; he also complained of depression. 7 He underwent arthroscopic knee surgery on both knees in September and October 2002, 8 and suffered from decreased range of motion and pain due to his back. Plaintiff saw Dr. Angel Perez for pain management; his medications included Celebrex, Trazadone, Vicodin, and Paxil. 9 In September 2003, Plaintiff also received epidural blocks in his back from Dr. David Tomaszek in an attempt to relieve his pain. 10

As a result of the injuries and corresponding surgeries, Plaintiff received Short Term Disability benefits through their maximum duration, January 20, 2003. 11

*645 Relevant Plan Language and Approval of Claim for LTD Benefits

To receive LTD benefits after the end of his Short Term Disability period, Plaintiff was required to be “totally disabled” under the following definition in the Plan:

“Total Disability” exists when Prudential determines that all of these conditions are met:
(1) Due to Sickness or accidental Injury, both of these are true:
(a) You are not able to perform, for wage or profit, the material and substantial duties of your occupation.
(b) After the Initial Duration of a period of Total Disability, you are not able to perform for wage or profit the material and substantial duties of any job for which you are reasonably fitted by your education, training or experience. The Initial Duration is shown in the Schedule of Benefits.
(2) You are not working at any job for wage or profit.
(3) You are under the regular care of a Doctor. 12

In June 2003, Prudential approved Plaintiffs claim for LTD benefits, retroactive to January 21, 2003. 13 Benefits were offset by Plaintiffs successful workers compensation and Social Security Disability benefits claims. 14

April 2001: Prudential’s First LTD Denial and Subsequent Reinstatement

Albert Kowalski, M.D., conducted an internal file review to evaluate Plaintiffs functionality in April 2004. He concluded that Plaintiffs depression, knee problems, lumbar radiculopathy, and cervical spine stenosis and herniated disc were not so debilitating as to prevent him from performing his “usual sedentary occupation.” 15 Prudential terminated Plaintiffs LTD as of May 1, 2004, because Plaintiff “no longer [met] the definition of being Disabled from performing the duties of [his] own occupation.” 16 Plaintiff requested reconsideration, informing Prudential that he was in the midst of continuing efforts to get his insurer to approve payment for back surgery recommended by his orthopedic surgeon, Dr. Stephen Esses, to address the pain caused by his radiculopathy. 17 Prudential reinstated Plaintiffs LTD on May 18, 2004. 18

2004-2005: Continued LTD Approval Past Initial Duration

Dr. Esses performed back surgery on Plaintiff on February 2, 2005. 19 In the meantime, the Initial Duration of the Plan ended January 21, 2005. On that date, the standard for “Total Disability” changed from Plaintiffs incapability to perform the material and substantive duties of his former occupation to incapability to perform any occupation for which he was reasonably fitted by education, training, or experience. 20 Prudential approved continued *646 LTD payments on January 20, 2005, pending Plaintiffs February 2005 back surgery. 21 Post-surgery, Plaintiff reported to Dr. Son Nguyen of the Texas Pain Institute that his neck felt better, but still rated his pain at three to four on a one through ten scale (ten being the highest); in March 2005, Plaintiff reported a level of pain of 5/10, and numbness in his right hand. 22 However, Dr. Esses noted in Plaintiffs February follow-up that Plaintiff had done “extremely well,” and showed full motor strength in his upper extremities. 23 In his March 31, 2005 visit to Dr. Esses, Plaintiff indicated he had joined a health club and was going to start an exercise program. 24 Plaintiff still experienced some muscular pain, but, according to Dr. Esses, it was much improved since before the surgery. 25

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693 F. Supp. 2d 642, 2010 U.S. Dist. LEXIS 142898, Counsel Stack Legal Research, https://law.counselstack.com/opinion/patterson-v-prudential-insurance-co-of-america-txsd-2010.