Tortora v. SBC Communications, Inc.

739 F. Supp. 2d 427, 2010 U.S. Dist. LEXIS 77769, 2010 WL 3154566
District Court, S.D. New York·Decided July 30, 2010·No. 09 Civ. 7895(SAS)·Published·Cited by 6 cases

Opinion

OPINION AND ORDER

SHIRA A. SCHEINDLIN, District Judge:

I. INTRODUCTION

Susan Tortora (“Plaintiff’) brings this action against AT & T Inc. (“AT & T”) (fik/a SBC Communications Inc. (“SBC”)), AT & T Umbrella Plan No. 1 (of which the AT & T Disability Income Plan (the “Plan”), f/k/a SBC Disability Income Plan, is a component program), AT & T Integrated Disability Service Center, and Sedgwick Claims Management Services, Inc. (“Sedgwick”) (collectively, “Defendants”) for failure to pay employee disability benefits. She alleges that the Plan administrator abused its discretion by not affording her claim a full and fair review, as required by the Employment Retirement Income Security Act of 1974 (“ERISA”). She also claims the decision to deny her benefits was arbitrary and capricious because it was not supported by substantial evidence. The parties cross-move for summary judgment pursuant to Federal Rule of Civil Procedure 56(b). For the following reasons, Plaintiffs cross-motion for summary judgment is denied and Defendants’ motion for summary judgment is granted.

II. BACKGROUND 1

A. The Parties

Tortora began working for AT & T— then known as SBC Communications — in *431 1988. 2 She held a number of positions at various AT & T subsidiaries over the years. Beginning on September 13, 2002, Tortora worked as a Senior Business Manager in the Richardson, Texas office of AT & T Services Inc. (“AT & T Services”). 3 During her employment, Tortora was the beneficiary of the AT & T Disability Income Plan (the “Plan”) — an ERISA-governed employee benefit plan. 4 AT & T serves as Plan Administrator, 5 and has appointed Sedgwick — an independent claims management company — as Claims Administrator. 6

B. The Plan

The Plan grants complete discretion to any duly-appointed Claims Administrator to construe the terms of the Plan and determine claimants’ eligibility for benefits. 7 Specifically, the Plan provides that the

Claims Administrator ... shall have full and exclusive authority and discretion to grant and deny claims under the Plan, including the power to interpret the Plan and determine the eligibility of any individual to participate in and receive benefits under the Plan. The decision of the ... Claims Administrator ... shall be final and conclusive and shall not be subject to further review. 8

Under the Plan, eligible beneficiaries can receive both Short-Term Disability Benefits (“STD Benefits”) and Long-Term Disability Benefits (“LTD Benefits”). 9 To qualify for STD Benefits, an employee must have a “Total or Partial Disability,” 10 meaning “that because of Illness or Injury, an Employee is unable to perform all of the essential functions of [her] job or another available job assigned by [AT & T] with the same full-or part-time classification for which the Employee is qualified.” 11 Beneficiaries may receive STD Benefits for a maximum of fifty-two weeks, after which they may become eligible for LTD Benefits. 12 With regard to LTD Benefits, “Total Disability” or “Totally Disabled” means “that because of Illness or Injury, an Employee is prevented from engaging in any employment for which the Employee is qualified or may reasonably become qualified based on education, train *432 ing, or experience.” 13 The Plan further states that “[a]n Employee is considered Totally Disabled if he is incapable of performing the requirements of a job other than the one for which the rate of pay is less than 50% of his Basic Wage Rate before his [LTD] started.” 14

C. Claims Administration

Sedgwick is given sole responsibility for administering claims for both STD and LTD Benefits under the Plan. 15 Pursuant to its agreement with AT & T, Sedgwick must meet certain performance benchmarks — including claimant satisfaction — or it may be subject to a monetary penalty. 16 Sedgwick’s compensation is not affected by the approval or denial of claims it administers. 17 The Sedgwick employees charged with making benefit determinations, moreover, do not receive bonuses or incentive pay based on claim outcomes. 18

Sedgwick refers cases where medical documentation is received but deemed insufficient to support the claim to Network Medical Review Co. Ltd. (“NMR”) — a network of independent physician advisors— for consideration. Sedgwick pays NMR for its services, but its compensation is not based on the outcome of claims. 19 Neither AT & T nor Sedgwick has any control over which physicians are assigned to review submitted claims. 20 NMR’s independent physician advisors conduct “paper reviews” of the files submitted to them, but do not actually examine the patients to determine their eligibility for benefits. 21

D. Tortora’s Benefits Claims

Tortora went on disability leave from her job on August 22, 2005 due to a respiratory infection. 22 Following the seven-day waiting period, Sedgwick approved Tortora for STD Benefits, which she received from August 29, 2005 to September 22, 2005. 23 Tortora returned to work on September 26, 2005, but left early the next day and never returned. 24

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Tortora v. SBC Communications, Inc., 739 F. Supp. 2d 427, 2010 U.S. Dist. LEXIS 77769, 2010 WL 3154566 (S.D.N.Y. 2010).

739 F. Supp. 2d 427 (Tortora v. SBC Communications, Inc.) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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