Schultz v. PNC Financial Services Group, Inc. & Affiliates Long-Term Disability Plan

58 F. Supp. 3d 782, 2014 U.S. Dist. LEXIS 157911, 2014 WL 5796721
CourtDistrict Court, E.D. Kentucky
DecidedNovember 6, 2014
DocketCivil Action No. 13-156-DLB-CJS
StatusPublished

This text of 58 F. Supp. 3d 782 (Schultz v. PNC Financial Services Group, Inc. & Affiliates Long-Term Disability Plan) is published on Counsel Stack Legal Research, covering District Court, E.D. Kentucky primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Schultz v. PNC Financial Services Group, Inc. & Affiliates Long-Term Disability Plan, 58 F. Supp. 3d 782, 2014 U.S. Dist. LEXIS 157911, 2014 WL 5796721 (E.D. Ky. 2014).

Opinion

MEMORANDUM OPINION AND ORDER

DAVID L. BUNNING, District Judge.

I. Introduction

Plaintiff Daniel Schultz (hereinafter “Schultz”) filed this action against Defendant PNC Financial Services Group, Inc. and Affiliates Long-Term Disability Plan (hereinafter “LTD Plan”) pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”). See 29 U.S.C. §§ 1001-1461. Schultz seeks review of the plan administrator’s decision to deny his claim for long term disability benefits stemming from a back injury sustained in March 2012. The parties have filed cross-motions for judgment on the administrative record (Docs. # 22 and 23), which are now fully briefed and ripe for the Court’s review (Docs. # 24 and 25). For reasons set forth herein, Plaintiff Schultz’s Motion for Judgment on the Administrative Record (Doc. # 23) is granted and Defendant LTD Plan’s Motion for Judgment on the Administrative Record (Doc. #22) is denied.

II. Factual and Procedural Background

Schultz has worked for PNC Financial Services Group (hereinafter “PNC”) as a Special Assets Manager (hereinafter “SA”) II since December 8, 2003. (AR 8). This position not only “requir[es] broad real estate experience to implement effective workout strategies for PNC sponsored loans and investments in [mjultifamily real estate,” it “contemplate[s] training and directing asset management and underwriting staff to effectively implement the resolution strategies proposed by the special assets department.” (AR 10). While the SA position is “generally a desk job,” travel is “an important and critical aspect.” (AR 128). An SA manages a portfolio of 10 to 12 properties throughout the country, which they must visit on a quarterly basis. (Id.). Accordingly, an SA “is expected to travel several times per month, which requires carrying bags, walking, driving and air travel.” (Id.).

As a PNC employee, Schultz participated in the LTD Plan, which “provides 60% coverage [or 70% if you elect additional LTD coverage]1 of your pre-disability eligible compensation if an approved total disability, due to injury or illness occurring on or off the job, keeps [an employee] out of work beyond 91 consecutive calendar days.” (AR 183). Under the terms of the Plan, an employee is considered disabled if [785]*785a “disability makes [him or her] unable to perform the material or essential duties of [his or her] occupation as it is normally performed in the national economy.” (AR 184). The claims administrator is responsible for determining whether an employee’s disability meets this definition. (Id.).

The Plan provides that “LTD benefits' may be less than expected, not paid at all, or stopped” if the employee no longer meets the definition of disabled. (AR 192). Failure’ to satisfy certain Plan requirements, submit proof of disability upon request and cooperate in the administration of the claim may also result in reduction or denial of benefits. (Id.). Additionally, the Plan may penalize an employee for “re-fus[ing] any appropriate, available treatment or fail[ing] to comply with [his or her] treatment plan.” (Id.). The term “treatment” includes “consulting, receiving care or services provided by or under the direction of a physician including diagnostic measures.” (Id.).

The LTD Plan is completely self-funded by means of a Group Benefits Trust (hereinafter “GBT”) “established by PNC solely for the purpose of providing benefits.” (AR 261). PNC then makes fixed, periodic cash contributions to the GBT “based on calculations and projections of its future long term disability liability performed by an independent actuary.” (Id.). While the GBT’s trustee, Pittsburgh National Bank, has “no duty to determine or collect any contributions by [PNC] as to the Plan,” it is “solely accountable for monies or properties actually received by it.” (AR 227). GBT funds are used to pay long-term disability benefits owed under the terms of the Plan. (AR 261).

Neither PNC nor Pittsburgh National Bank furnishes administrative services in connection with the LTD Plan. (AR 202-223, 228). Pursuant to an Administrative Services Only Agreement (hereinafter “Agreement”), Liberty Life Assurance Company of Boston (hereinafter “Liberty”) assumed responsibility for the operation and administration of the LTD Plan. (AR 214). As the plan administrator, Liberty has the “exclusive discretionary authority to determine eligibility for benefits under the Plan, to construe the terms of the Plan and.to determine any question which may arise in connection with its operation or administration, except to the extent that the Plan Administrator has authorized the claims administrator to make such determinations.” (AR 196). The plan administrator’s decisions are “conclusive and binding” upon employer, participating employee and survivors or assignees thereof. (Id.). However, employees retain the right to file a written appeal in accordance with the LTD Plan’s procedures. (Id.).

In March 2012, Schultz injured his back while moving a television set in the driveway of his home in Fort Thomas, Kentucky. (AR 34). His pain worsened over the next few days, prompting him to visit his chiropractor.2 (AR 38, 76). When these treatments provided only temporary pain relief, Schultz made an appointment with his family physician, Dr. John Redden (hereinafter “Dr. Redden”). (AR 76). On April 17, 2012, Dr. Redden diagnosed him with thoracic/lumbar pain and referred him to St. Elizabeth Healthcare (hereinafter “St. Elizabeth”) for physical therapy. (Id.). During his physical therapy evaluation, Schultz explained that his pain increased “[s]everely when sitting over half hour; begins to increase slightly when standing over half hour,” thus preventing [786]*786him from traveling for work or sitting at his desk. (Id.). The physical therapist gave Schultz a Home Exercise Plan (hereinafter “HEP”) and scheduled sessions twice a week for six weeks. (Id.).

On April 20, 2012, Schultz stopped going to work. (AR 15). He began receiving short-term disability benefits (hereinafter “STD benefits”) three days later. (AR 21). Under the LTD Plan, STD benefits are payable for a maximum period of 91 consecutive calendar days. (AR 183). If an employee’s disability extends beyond this 91 day period, referred to as the LTD Elimination Period, he or she may be eligible to receive LTD benefits. (Id.). However, payment of STD benefits does not guarantee that an employee will also be entitled to LTD benefits because each type of benefit has different requirements. (Id.).

At his first physical therapy session, Schultz did not have “specific point tenderness along [his] spine,” but experienced “increased pain with palpation of thoracic musculature around spine” and was “unable to tolerate repeated flexion/extension.” (AR 80). The physical therapist noted that Schultz “would benefit from further imaging (likely MRI) to allow for more specified diagnosis/treatment plan prior to continuation of physical therapy at this time.” (Id.). The next day, Schultz returned to Dr. Redden’s office for a follow-up. (AR 84). Dr. Redden referred Schultz to St. Elizabeth for x-rays of his lumbar and thoracic spine. (AR 72-74). The lumbar x-ray revealed “[m]ild degenerative change with spurring,” as well as “[m]ild to moderate narrowing of L5-S1 interspace.” (AR 73).

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58 F. Supp. 3d 782, 2014 U.S. Dist. LEXIS 157911, 2014 WL 5796721, Counsel Stack Legal Research, https://law.counselstack.com/opinion/schultz-v-pnc-financial-services-group-inc-affiliates-long-term-kyed-2014.