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LOCKHART v. JEFFERSON PILOT FINANCIAL INSURANCE COMPANY

April 27, 2004.

LEONORA LOCKHART, Plaintiff,
v.
JEFFERSON PILOT FINANCIAL INSURANCE COMPANY, Defendant



The opinion of the court was delivered by: IAN LEVIN, Magistrate Judge

MEMORANDUM OPINION AND ORDER

Pursuant to Section 502(a)(1)(B) of the Employee Retirement Income Security Act (hereinafter "ERISA") of 1974, Plaintiff Leonora Lockhart (hereinafter "Plaintiff") seeks judicial review of the final decision of Defendant Jefferson Pilot Financial Insurance Company (hereinafter "Defendant") denying her long-term disability insurance benefits under a group policy issued to her employer, the Illinois Hospital Association (hereinafter "MA"). This matter comes before the Court on cross-motions for summary judgment. For the reasons hereinafter set forth, the motions for summary judgment of both parties are denied.

BACKGROUND FACTS

 I. Introduction

  Plaintiff, an attorney, was employed in a non-legal position at the IHA as a Risk Management Consultant from April 24, 1997 through January 31, 2002. (Def.'s LR 56.1(a)(3)St. ¶ 1.) Plaintiffs principal function as a Risk Management Consultant was to provide risk management services to insured physicians and hospitals and to assist them in developing and maintaining an effective internal risk management program. (Id. ¶ 10.) Plaintiffs responsibilities included inter alia performing underwriting site visits at applicant hospitals and publishing a quarterly newsletter for insured physicians. (JPF*fn1 0275.)

 II. Group Policy

  As a benefit of Plaintiff's employment, she participated in the IHA's Long Term Disability Plan (hereinafter "Plan"), which is an employee welfare benefit plan established and maintained by the IHA in accordance with ERISA.*fn2 (Def.'s LR 56.1(a)(3) St. ¶ 3.) The Plan's long-term disability coverage is provided pursuant to a group policy issued to the IHA by Defendant. (Id. ¶ 4.) The group policy defines "Total Disability" and "Totally Disabled" as follows:
1. During the Elimination Period [180 days] and Own Occupation Period [48 months], it means that due to an Injury or Sickness that the Insured Employee is unable to perform each of the main duties of his or her regular occupation.
2. After the Own Occupation Period, it means that due to an Injury or Sickness the Insured Employee is unable to perform each of the main duties of any gainful occupation which his or her training, education or experience will reasonably allow. (JPF 0016, 0030, 0054, 0071.)
The group policy provides that an insured's claim must provide the following:
Proof of claim must be provided at the Insured Employee's own expense. It must show the date the Disability started, its cause and degree. It must show any restrictions on performing the duties of the Insured Employee's regular occupation. (JPF 0024, 0063.)
  The IHA paid one hundred percent of the cost for Plaintiff's disability insurance coverage. (Def. `s LR 56. l(a)(3) St. ¶ 8.) An insured's coverage under the group policy ends when the insured is no longer employed by the IHA. (Id. ¶ 9.) The group policy provides insureds, upon termination of their employment, the opportunity to convert their group disability coverage into individual disability coverage. (Id.) However, insureds, who exercise their conversion rights, are responsible for paying the cost of their converted coverage. (Id.)

 III. Plaintiffs Unsatisfactory Performance

  On April 23, 2001, the IHA conducted an annual performance review of Plaintiff covering the period from May 2000 through April 2001. (Def.'s LR 56.1(a)(3)St. ¶ 14.) Ms. Cheryl Church, Plaintiffs supervisor, stated the following in Plaintiff's April 23, 2001 annual performance review:
Last year [during the 1999-2000 annual performance review] five goals were established for you. Again, only one issue of the quarterly newsletter for physicians was completed. The newsletter is important, for one reason, it makes the risk management services visible.
* * *
I still have concerns about your productivity. Your final work products are generally very well done. However, you spend more time on some tasks than it seems you should. You should continue to keep focused on a particular assignment that you are working on, and learn to appreciate what additional factors and information have no relevance to the assignment. (JPF 0248.)
In addition, in a written memo dated October 19, 2001, Ms. Church stated the following regarding Plaintiff's job performance:
I met with Penny [Lockhart] this morning to discuss my concerns with her productivity. [Some of the] [e]xamples discussed included the Dr. John Warner Bariatric Surgery survey report, which took almost two weeks to write. I told her that the report was well done but took way too long. We also discus s[ed] that she cannot seem to handle more than one project at a time. [An] example given was the HPIP survey done in May that has not been summarized yet.
* * *
I also told her she might want to think about other options for work that she might be better suited to. (JPF 0246.)
Subsequently, on January 31, 2002, the IHA terminated Plaintiff's employment due to poor performance. (Def.'s LR 56. l(a)(3) St. ¶¶ 2, 20.) Ms. Church's January 31, 2002 termination memo to Plaintiff stated:
This is to summarize the discussion we had today whereby I advised you that your employment is being terminated, effective immediately.
This action is being taken because of ongoing concerns about your limited ability to recognize and understand clinical risk management issues and your poor productivity. (JPF 0245.)
  Following her termination, Plaintiff retained an attorney who worked with counsel for the IHA in developing two letters for Plaintiff: a letter of recommendation and a letter regarding her alleged disability.*fn3 (Def. `s LR 56.1(a)(3) St. ¶ 22.) In a letter dated April 9, 2002, the IHA attorney agreed to the following language with respect to Plaintiff's letter of recommendation:
 
[Plaintiff] was very enthusiastic about her work and was always willing to accept new assignments and challenges. She exhibited sound judgment and completed her assignments in a very thorough and professional manner.*fn4 She has excellent writing and communication skills. I would recommend her for any position requiring these skills. (JPF 0165.)
Moreover, in a letter dated the same date, the IHA attorney agreed to the following language in a letter regarding her alleged disability:
At the end of her employment, it appeared that [Plaintiff's] performance was adversely affected by her medical condition. (JPF 0165.)
  After Plaintiff was terminated on January 31, 2002, she was no longer a covered insured under the group policy. (Def.'s LR 56, l(a)(3) St. ¶ 25.) On February 28, 2002, Defendant extended the time period (by thirty-one days) for former employees, including Plaintiff, to exercise their conversion privilege under the group policy. (Id. ¶ 26.) After Plaintiff's termination, she inquired about converting her group disability insurance coverage into individual disability insurance coverage, but decided not to convert (and continue) her coverage. (Id. ¶ 28.)

 IV. Disability Claim

  On July 24, 2002, Plaintiff filed a claim for long-term disability benefits alleging she was disabled due to psoriatic arthritis*fn5 since January 24, 2002, the last day Plaintiff alleges she worked.*fn6 (Pl's LR 56.1(a)(3) St. ¶ 13; JPF 0281.) In her claim for benefits, Plaintiff alleged that she had had pain and stiffness in her hands during the past several years (i.e., 2000 and 2001) and, more recently, she had experienced pain in her feet and neck. (JPF 0283.) Plaintiff indicated that her pain and stiffness were worse in the mornings and she had to lie in bed for thirty minutes to an hour before she felt well enough to get out of bed. (Id.) Plaintiff further stated that her condition made it difficult for her to get dressed and attend to her personal hygiene which included bathing as well as brushing her teeth and hair. (Id.)

  In her claim for disability benefits, Plaintiff indicated that because her joint pain was worse during cold or wet weather, she frequently went to wanner locales in the years 2000 and 2001. (JPF 0283.) Plaintiff also stated that "fatigue is a tremendous problem" and she did not sleep well due to joint pain and muscle aches. (Id.) She indicated that her medications cause side effects which include bronchitis, sinusitis, conjunctivitis, nosebleeds and psoriatic flare-ups.*fn7 (JPF 0283-84.) Moreover, Plaintiff stated that she has a history of depression and that her physical limitations prevented her from walking which was one way she managed her depression and stress. (JPF 284.) She further indicated that before she stopped working, she avoided out-of-town travel as much as possible, had difficulty in getting files out of cabinets, was very tired after sitting at a desk for extended periods of time, came in as late as possible due to early morning pain and stiffness, and could not stuff packets for mailings. (Id.)

 V. Medical Evidence

  A. Dr. Shelly L. Betman

  Plaintiff supported her claim for long-term disability benefits with numerous medical records and reports from her treating physicians. For instance, Plaintiff submitted an April 26, 2002 Attending Physician Statement from her internist, Dr. Shelly L. Betman, M. D. (JPF 296-97.) In the Attending Physician Statement, Dr. Betman noted that Plaintiff has severe deformity, swelling and tenderness in her DIP joints (joints in the fingertips) as well as pain and swelling in her PIP joints (joints at the middle of the finger) in both of her hands. (JPF 0296.) Dr. Betman indicated that Plaintiff was unable to use her fingers for word processing, opening file cabinets and pulling out files, and traveling with and setting up ...


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