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SALIAMONAS v. CNA

January 10, 2001

JACK SALIAMONAS, PLAINTIFF,
v.
CNA, INC., DEFENDANT.



The opinion of the court was delivered by: Bucklo, District Judge.

MEMORANDUM OPINION AND ORDER

Jack Saliamonas has coronary artery disease and severe aortic insufficiency, and he has had two coronary bypass surgeries to correct a history of angina. He worked for Elmhurst Memorial Hospital in a very stressful job. His disability insurer, CNA, Inc. ("CNA"), however, denied him disability benefits because it said Mr. Saliamonas can perform sedentary work and is therefore not disabled. Mr. Saliamonas sued for wrongful denial of benefits under ERISA, 29 U.S.C. § 1132 (a)(1)(B), claiming that he is disabled from his occupation. I grant Mr. Saliamonas' motion and deny CNA's motion.

I.

Mr. Saliamonas worked for Elmhurst Memorial Hospital as a Programmer Analyst II. The job summary describes his position as a computer systems manager. He worked on the Medipac team of the Information Services Department, which handles patient accounting, medical records and registration. He was on call twenty-four hours a day, seven days a week on a rotating schedule. Mr. Saliamonas has a history of heart disease and angina, and sometimes experienced chest pains while at work. After two coronary bypass surgeries, Elmhurst Memorial Hospital took Mr. Saliamonas off of the rotating on-call schedule, but the stress of the job caused his condition to deteriorate. On August 7, 1998, Mr. Saliamonas took medical leave from the hospital. Mr. Saliamonas submitted a claim for disability benefits to the defendant, CNA, which provides a group long-term disability policy ("the Policy") to the employees of Elmhurst Memorial Hospital. He claimed that he was unable to return to work as a result of heart and artery disease.

Dr. Lawrence Barr submitted an Attending Physician's Statement as part of Mr. Saliamonas' claim. Dr. Barr circled the option on the form that said "Dates totally disabled" but he failed to fill out the spaces for the dates. Dr. Barr noted that Mr. Saliamonas' condition had improved but he checked the box on the form that said he did not expect a fundamental or marked change in the future. Dr. Barr listed Mr. Saliamonas' physical impairment as Class Four on a scale of five: "moderate limitation of functional capacity; capable of clerical/administrative (sedentary) activity," and 60-70% impairment. Dr. Barr left a number of areas of the form blank, including the dates of disability and mental/nervous impairment. The only restriction he placed on Mr. Saliamonas' activities was heavy lifting. In the Sick Leave Verification Report, Dr. Barr diagnosed Mr. Saliamonas with coronary artery disease and severe aortic insufficiency, and said that Mr. Saliamonas could not return to work because his disability was permanent. In a letter to CNA on February 22, 1999, Dr. Barr expressed his concern about the effect of work-related stress on Mr. Saliamonas' permanent heart condition. Dr. Barr also reiterated that Mr. Saliamonas was suffering from severe aortic insufficiency.

The Policy provides total disability benefits for a 24-month period if the insured employee, because of sickness or injury, is:

(1) continuously unable to perform the substantial and material duties of his regular occupation;
(2) under the regular care of a licensed physician other than himself; and
(3) not gainfully employed in any occupation for which he is or becomes qualified by education, training or experience.

Mr. Saliamonas challenges his denial of benefits pursuant to ERISA, and both parties move for summary judgment.

II.

Summary judgment is appropriate where there are no genuine issues of material fact and the moving party is entitled to judgment as a matter of law. Fed. R.Civ.P. 56(c); Lexington Ins. Co. v. Rugg & Knopp, 165 F.3d 1087, 1090 (7th Cir. 1999). When considering a motion for summary judgment, I review the entire record, drawing all reasonable inferences in the light most favorable to the nonmoving party. Cornfield by Lewis v. Consolidated High School Dist. No. 230, 991 F.2d 1316, 1320 (7th Cir. 1993). I will consider the cross motions for summary judgment together.

A denial of benefits challenged under ERISA is reviewed de novo unless the benefit plan gives the administrator discretionary authority to determine eligibility for benefits or to construe the terms of the plan. Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989); Herzberger v. Standard Ins. Co., 205 F.3d 327, 330 (7th Cir. 2000). There is a presumption against discretion and in favor of de novo review that can only be overcome by an express grant of discretion to the plan administrator: See Herzberger, 205 F.3d, at 330-31. The level of specificity the Seventh Circuit requires to overcome this presumption is indicated by the "safe harbor" language recommended by the Herzberger court: "`Benefits under this plan will be paid only if the plan administrator decides in his discretion that the applicant is entitled to them.'" Id. at 331. This language is not required, but the Seventh Circuit will not find that a plan administrator has discretion without language of comparable explicitness.

The Policy in this case provides that it "will pay the Monthly Benefit for each month of Total Disability which continues after the Elimination Period," and that "[b]enefits will be paid monthly immediately after [w]e receive due written proof of loss." CNA argues that this language and language from the Summary Plan Description ("SPD") confers discretion sufficient to ...


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