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