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ADAMS v. CIGNA GROUP INSURANCE LIFE ACCIDENT DISABILITY CO.

January 20, 2004.

DELORES ADAMS, Plaintiff,
v.
CIGNA GROUP INSURANCE LIFE ACCIDENT DISABILITY CO., Defendant



The opinion of the court was delivered by: BLANCHE MANNING, District Judge

MEMORANDUM AND ORDER

Plaintiff Delores Adams brought this action against CIGNA Group Insurance Life Accident Disability Co. ("CIGNA"), alleging that CIGNA wrongfully terminated her long term disability benefits ("LTDB"). This matter comes before this Court on CIGNA's motion for summary judgment, pursuant to Federal Rule of Civil Procedure 56. For the following reasons, the motion is DENIED.

BACKGROUND*fn1

  This action stems from a long-term disability insurance plan ("the Plan") established and funded by Adams' former employer, the AT & T. Corporation ("AT & T"), and administered by CIGNA. Page 2

  A. Relevant Policy Provisions

  At issue in this case is whether Adams was "disabled" as set forth in the Plan, and therefore entitled to LTDB. To receive benefits under the Plan, Adams was required to show that she was "unable to do any job for any employer for which [she] is qualified; or may become reasonably qualified by training, education, or experience, other than a job that pays less than 50% of [her] Eligible Base Pay at the time [she] became disabled."

  B. Claim for Long-Term Disability Benefits

  AT&T employed Adams as a customer service representative from February 2, 1987 to December 5, 1994. On November 30, 1993, almost a year before she was terminated, Adams went on short-term disability leave, for which she received benefits from AT & T. After her short-term benefits expired, Adams completed an application for LTDB under the Plan on December 1, 1994.

  Adams claimed that she qualified for LTDB because she suffered "systematic dystrophy in her right leg which led her to suffer from constant pain in her right leg and thigh." As a result of this pain, Adams contended that she was prevented from sitting, standing, or walking for long periods of time. The medication which Adams took to relieve the pain allegedly caused her drowsiness which prevented its use during work hours. Consequently, Adams asserted that she qualified for LTDB because she could not engage "in any gainful employment" at that time.

  At CIGNA's request, Adams submitted medical records from her doctors. On March 23, 1995, after reviewing her medical records, CIGNA denied Adams' claim. This denial was based in large part on the fact that one of Adams' doctors, Dr. Zelkowita, stated that she could "perform work which requires no physical activity." Therefore, because her position at AT & T was "sedentary in nature," CIGNA found that Adams was not disabled as defined in the Plan. Page 3

  C. Appeal and Approval of Temporary LTDB

  Adams subsequently appealed this denial and submitted records from another treating physician, Dr. Flimlin, medical director of the Ingalls Center for Outpatient Rehabilitation, Dr. Flimlin opined that Adams should be considered disabled until she completed a "functional restoration program." After reviewing her claim, a CIGNA claims representative found that: (1) Adams had been "diagnosed with chronic pain syndrome"; (2) "various treatments . . . have been tried [over] three years, but with no real improvement in [Adams'] symptoms"; and (3) the doctors, "who have attempted to diagnose and treat" Adams, "feel [her] pain is real." Based on this information, the claims representative stated that CIGNA "should approve this claim." CIGNA subsequently approved her claim and granted Adams LTDB on a preliminary basis.

  D. Termination of LTDB

  To make a final determination of her claim, CIGNA scheduled Adams to take a functional capacities evaluation ("FCE"), so that an occupational specialist could make a more definite determination as to whether she qualified for LTDB under the Plan. Adams subsequently underwent two separate FCEs, one by her own doctor, Dr. Flimlin, and one by an independent occupational therapist. A FCE measures a person's physical capacity to perform various types of jobs. Based on the result of the FCE, Dr. Flimlin opined that Adams would be able to return to "light or medium work." Likewise, the occupational therapist concluded that Adams could perform light to medium work. CIGNA also had Adams perform a "transferable skills study," which identified occupations ...


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