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DEAL v. PRUDENTIAL INSURANCE COMPANY OF AMERICA

May 22, 2003

CATHI DEAL, PLAINTIFF,
v.
PRUDENTIAL INSURANCE COMPANY OF AMERICA, DEFENDANT.



The opinion of the court was delivered by: Elaine E. Bucklo, United States District Judge.

MEMORANDUM OPINION AND ORDER

Plaintiff Cathi Deal sued defendant Prudential Insurance Company of America ("Prudential") under section 1132(a)(1)(B) of ERISA, 29 U.S.C. § 1001 et seq., to recover benefits under an employee benefit plan ("Plan") underwritten and insured by Prudential. Following a paper trial in which both sides submitted trial briefs and presented oral arguments, I find that Ms. Deal is entitled to benefits under the Plan.

I. Background

Ms. Deal was employed as a human resources director, administrative assistant, and office manager by Telephone & Data Systems, Inc. until June 1998 when she suffered an injury to her left knee in an elevator accident. Ms. Deal returned to work briefly until the end of November 1998. In February 2000, Ms. Deal filed a claim for long term disability payments based on her knee injury. Her claim was approved by Prudential, and in May 2000 she began receiving benefits, including retroactive payments from December 1998 onward.

Ms. Deal saw a host of medical professionals for both physical and psychological conditions arising out of her knee injury and associated pain. She was diagnosed with Moderate Major Depressive Disorder. In October 2000, Prudential notified Ms. Deal that her initial period of benefits would expire in December, and that it would conduct an evaluation to determine Ms. Deal's eligibility for continued benefits,

In April 2001, Prudential determined that Ms. Deal was no longer eligible for benefits under the Plan. Ms. Deal appealed this decision, submitting additional medical reports with her appeal. Her appeal was denied in September 2001. She submitted an appeal to this decision in October 2001, which again was denied by Prudential. In November 2001, Ms. Deal initiated this lawsuit.

II. Eligibility for Benefits

As discussed in my decision denying summary judgment, Prudential's denial of benefits is not entitled to deferential review, but rather I examine the benefits determination de novo and may consider evidence not before the plan administrator. Deal v. Prudential Ins. Co., 222 F. Supp.2d 1067, 1068-70 (N.D. Ill. 2002). Claims for benefits brought under 29 U.S.C. § 1132(a)(1)(B) are essentially assertions of contractual rights under an employee benefit plan. Tolle v. Carroll Touch, Inc., 977 F.2d 1129, 1133 (7th Cir. 1992). As such, "the employee must establish that she has satisfied the conditions necessary for benefits under the plan." Robyns v. Reliance Standard Life Ins. Co., 130 F.3d 1231, 1235 (7th Cir. 1997) (internal quotation omitted).

A. Total Disability

Under the Plan, employees are entitled to benefits while they are totally disabled. (R. at 00164.) The Plan defines total disability as follows:

"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.
2. You are not working at any job for wage or profit.

3. You are under the regular care of a Doctor.

(R. at 00164.) Prudential initially agreed that Ms. Deal was totally disabled under this definition when it approved her claim for benefits on May 1., 2000. (R. at 00467-68.) Prudential subsequently determined that she was no longer entitled to continued benefits on April 18, 2001. (R. at 00204-07.) The issue before me now is whether Ms. Deal satisfied, and continues to satisfy, the conditions necessary for benefits under the Plan.

Prudential does not contest that Ms. Deal is not currently working and is under the regular care of a doctor. The only contested issue with respect to total disability is whether Ms. Deal is able to perform any job for which she is reasonably fitted. Dr. Anthony Brown, a physician chosen by Prudential to conduct an independent medical examination of Ms. Deal, concluded that "[t]here would appear to be no reasonable way to allow this patient to work, even in a sedentary capacity." (R. at 00416.) Prudential., however, points to an April 17, 2001 fax received from Dr. Henry Finn, one of Ms. Deal's physicians, confirming that "Ms. Deal is capable ...


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