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Tomassi v. Prudential Insurance Co. of America

June 19, 2007

SCOTT C. TOMASSI, PLAINTIFF,
v.
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA, DEFENDANT.



The opinion of the court was delivered by: Judge Joan Humphrey Lefkow

MEMORANDUM OPINION AND ORDER

Magistrate Judge Morton Denlow Plaintiff, Scott C. Tomassi ("Tomassi"), filed this action to recover long term disability benefits under an employee welfare benefits plan governed by the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001 et seq. This case is brought pursuant to ERISA Section 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B), to recover past benefits and to enforce and clarify Tomassi's rights to future benefits. Subject matter jurisdiction is based on ERISA Section 502(e)(1), 29 U.S.C. § 1132(e)(1). Currently before the court is the motion of defendant The Prudential Insurance Company of America ("Prudential") to stay the proceedings or, alternatively, for an administrative remand [#9]. For the following reasons, the motion is denied.

1. Background

Tomassi, a partner at the Chicago law firm Schiff Hardin LLP, claims that he has been unable to practice law since May 16, 2005 due to the fact that he suffers from an idiopathic form of Polyarteritis Nodosa ("PAN"), a rare, potentially life-threatening condition that involves systemic vasculitis or inflammation of the blood vessels.*fn1 PAN has caused Tomassi organ injury, pain, extreme fatigue, weakness, gastrointestinal upset, and weight loss. In addition, the medications that he takes to control PAN have side effects of difficulty sleeping, agitation, and difficulty concentrating.

Tomassi is a participant in the Schiff Hardin LLP Long Term Disability Plan ("the Plan"), an employee welfare benefit plan governed by ERISA. Prudential is the insurer of benefits as well as the claim administrator of the Plan. Tomassi applied for long-term disability benefits under the Plan on November 7, 2005. Prudential denied his claim by letter of February 10, 2006, determining, among other things, that Tomassi's records did not contain a comprehensive psychiatric assessment or other evidence or documentation to support his claims of cognitive impairment. Prudential conluded that Tomassi was able to perform the sedentary and light duty work that his job as an attorney required and that he was therefore not disabled.

Tomassi submitted a request for reconsideration*fn2 of the denial on August 9, 2006, along with 201 pages of medical records, which Prudential received on August 12, 2006. Prudential received an additional 525 pages of Tomassi's medical records on August 14, 2006, for a total of 726 pages. Prudential confirmed receipt of Tomassi's appeal on August 22 in a letter that said, "If you have any additional information to submit, please forward it to our office promptly ...." Prudential provided a decision/update date of September 28, 2006*fn3 and said, "If we are unable to make a determination on Mr. Tomassi's claim by September 28, 2006, we will contact you not later than that date to advise you of our need for an extension of time to make a decision."*fn4

The Plan's Summary Plan description provides as follows regarding the appeal of a denied claim:

If your claim for benefits is denied ... you or your representative may appeal your denied claim in writing to Prudential within 180 days of the receipt of the written notice of denial .... You may submit with your appeal any written comments, documents, records and any other information relating to your claim....

The Prudential Appeals Review Unit shall make a determination on your claim appeal within 45 days of the receipt of your appeal request. This period may be extended by up to 90 days if Prudential deems that special circumstances require an extension of time. A written notice of the extension, the reason for the extension and the date that the Prudential Appeals Review Unit expects to render a decision shall be furnished to you within the initial 45-day period. However, if the period of time is extended due to your failure to submit information necessary to decide the appeal, the period for making the benefit determination will be tolled from the date on which the notification of the extension is sent to you until the date on which you respond to the request for additional information.*fn5 [The provisions in this paragraph are required by the Department of Labor regulations for ERISA plans. See 29 C.F.R. § 2560.503-1(i)(1), (3).]

If the claim on appeal is denied in whole or in part, you will receive a written notification from Prudential of the denial.... If a decision on appeal is not furnished to you within the time frames mentioned above, the claim shall be deemed denied on appeal. [This provision is also required by Department of Labor regulations. See 29 C.F.R. § 2560.503-1(l).]

The Department of Labor regulations also provide,

[T]he period of time within which a benefit determination on review is required to be made shall begin at the time an appeal is filed in accordance with the reasonable procedures of a plan, without regard to whether all the information necessary to make a benefit determination on review accompanies the filing. In the event that a period of time is extended as permitted pursuant to paragraph ...

(i)(3) of this section due to a claimant's failure to submit information necessary to decide a claim, the period for making the benefit determination on review shall be tolled from the date on which the notification of the extension is sent to the claimant until the date on ...


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