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Juszynski v. Life Insurance Company of North America

March 27, 2008

DOUGLAS JUSZYNSKI, PLAINTIFF,
v.
LIFE INSURANCE COMPANY OF NORTH AMERICA, DEFENDANT.



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

MEMORANDUM OPINION AND ORDER

After plaintiff Douglas Juszynski ceased work in July 2001 due to peripheral neuropathy and back, neck, and leg pain, he applied for long-term disability ("LTD") benefits, which defendant Life Insurance Company of North America ("LINA") approved and began paying on January 1, 2002. On September 30, 2005, LINA terminated Juszynski's benefits. After LINA denied his appeals, Juszynski brought suit against LINA pursuant to ERISA § 502(a)(1)(B) (29 U.S.C. § 1132(a)(1)(B)), seeking reinstatement of LTD benefits. Both parties have stipulated that the court may (1) consider the claim record without any further authentication or foundation and (2) conduct a trial on the papers submitted by the parties and issue judgment pursuant to Fed. R. Civ. P. 52. Juszynski has moved for summary judgment pursuant to Fed. R. Civ. P. 56 or, in the alternative, entry of judgment in his favor pursuant to Fed. R. Civ. P. 52. The defendant has filed a cross-motion for summary judgment pursuant to Fed. R. Civ. P. 56 or, in the alternative, entry of judgment in its favor pursuant to Fed. R. Civ. P. 52.

For the following reasons, Juszynski's motion [#37] will be granted, LINA's motion [#41] will be denied, and the court will enter judgment pursuant to Rule 52 in favor of Juszynski.

FACTUAL BACKGROUND

Juszynski worked for Marconi Medical Services, Inc. as a Senior Service Engineer from February 24, 1969 until July 5, 2001. Pl.'s Statement of Fact ("SF") ¶ 6. As a benefit of his employment, Juszynski received LTD coverage under a group insurance plan. Pl.'s SF ¶ 7. On July 5, 2001, Juszynski ceased working due to peripheral neuropathy and back, neck, and leg pain. Pl.'s SF ¶ 6. These symptoms stemmed from a number of conditions, including cervical and lumbar spondylosis, gait ataxia, and degenerative joint disease.*fn1 Pl.'s SF¶ 10.

In December 2001, Juszynski applied to LINA for LTD benefits. Under the policy, disability is defined as (1) the inability of the employee "to perform all the material and substantial duties of his or her regular occupation, or . . . to earn more than 80% of his or her Indexed Covered Earnings" or (2) after benefits have been payable for 24 months, the inability of the employee "to perform all the material and substantial duties of any occupation for which he or she may reasonably become qualified based on education, training or experience, or . . . to earn more than 80% of his or her Indexed Covered Earnings." Def.'s SF ¶ 9 (emphasis added). In December 2001, Juszynski's primary care physician, Dr. Peter MacEntee, identified the illnesses and symptoms that caused him to stop working as (1) peripheral neuropathy, (2) cerebellar degeneration, (3) chronic alcoholism, (4) gout, (5) recurrent falls, and (6) multiple fractures. Def.'s Resp. to Pl.'s SF ¶ 25; Def.'s Ex. A, at LINA 462--63. Dr. MacEntee also opined that due to Juszynski's severe physical limitations and the likelihood of continued deterioration, he was permanently disabled. Def.'s Ex. A, at LINA 462--63. LINA approved LTD benefits commencing on January 1, 2002, at a rate of $2,772 per month. Pl.'s SF ¶ 12.

Juszynski also applied for Social Security Disability Insurance Benefits. Pl.'s SF ¶ 20. On March 31, 2001, the Social Security Administration determined that he was disabled as of July 3, 2001 and entitled to benefits. Pl.'s SF ¶ 20. Beginning in January 2002, Juszynski received $1,598 per month in social security benefits, which LINA offset against its LTD benefits payments so that Juszynski's net monthly benefit from LINA was $1,174. Pl.'s SF ¶ 20.

On June 19, 2002, Dr. MacEntee sent a follow-up evaluation form to the insurance company opining that due to severe peripheral neuropathy, "patient is permanently disabled." Pl.'s SF ¶ 26; Def.'s Ex. A, at LINA 393. On October 18, 2002, Dr. MacEntee again opined that Juszynski was permanently disabled and also classified Juszynski's physicial impairment as "Class 5," which is defined as "severe limitations of functional capacity; incapable of minimal sedentary activity." Def.'s Resp. to Pl.'s SF ¶ 27.

On August 1, 2003, LINA contacted Juszynski to inform him that the end of the initial 24-month period of his disability benefits was approaching and that it had begun investigating whether he was eligible for continued benefits under the "any occupation" definition of disability in the policy. Def.'s SF ¶ 27.

In October and November 2003, Juszynski underwent femoral popliteal bypass surgeries in both extremities in an effort to treat his peripheral arterial disease*fn2 and occlusion. Both of these surgeries were performed by vascular surgeon Dr. Anwar S. Choudry. Def.'s SF ¶ 28. On December 17, 2003, Dr. Choudry reported on a follow-up medical request form that Juszynski was unable to work at that time and that it was unknown whether he would be able to perform essential job functions. Def.'s Resp. to Pl.'s SF ¶ 31; Def.'s Ex. A, at LINA 302.

On January 22, 2004, after reviewing his updated medical information, LINA informed Juszynski that it had approved continued LTD benefits based on its determination that he was totally disabled from performing any occupation. Def.'s SF ¶¶ 30--31. In its letter to Juszynski, LINA noted that it would "periodically request from you and your attending physician, proof of your continuing total disability from any occupation. The payment of future benefits will depend on this certification . . . ." Def.'s SF ¶ 31.

In March 2005, MRI findings showed degeneration in both the cervical spine and the lumbar spine.

On July 28, 2005, LINA learned that Juszynski had last been seen by Dr. Choudry on August 31, 2004 and had missed his scheduled follow-up visit with Dr. Choudry in February 2005. Def.'s SF ¶ 34. On August 22, 2005, LINA wrote to Juszynski, requesting updated medical information and completion of a medical disclosure authorization, as well as a disability questionnaire, by September 6, 2005. When LINA did not receive a response to its first request, it again wrote to Juszynski, and advised him that if LINA did not receive the requested information, it would assume that he was no longer claiming disability benefits. Def.'s SF ¶ 36.

On October 6, 2005, LINA conducted a "second eye review" of Juszynski's claim and decided to terminate his benefits. Def.'s SF ¶¶ 37--38. On October 7, 2005, LINA sent a letter to Juszynski stating that it terminated benefits because it had not received any medical evidence to substantiate Juszynski's continued total disability from any occupation. Def.'s SF ¶ 38.

Juszynski contends that he had responded to LINA's request and provided updated information in a timely fashion, citing notes in LINA's records confirming receipt of a letter dated September 12, 2005. Pl.'s Resp. to Def.'s SF ¶ 38. LINA's notes indicate that the correspondence from Juszynski was "received in incoming mail on 10/10/05. However mail was dated 09/12/05. Unsure if it was misplaced in other persons claim file or not." Def.'s Ex. A, at LINA 574.

On October 17, 2005, Juszynski submitted his first appeal to LINA, requesting reconsideration of its decision to terminate his LTD benefits. Def.'s SF ¶ 41. In his appeal, Juszynski identified his attending physicians as primary care physician Dr. MacEntee, neurologist Dr. Nestor Ivkov, and cardiologist Dr. Gutom Patel. Def.'s SF ¶ 43. LINA contacted each of the three physicians and requested updated medical information. Def.'s SF ¶ 43.

Dr. Patel returned a blank physical ability assessment form, referring LINA to Juszynski's primary care physician, Dr. MacEntee. Def.'s SF ¶44. Dr. Ivkov returned the forms, but only provided the date of the last and next office visit and referred LINA to Juszynski's medical records, which Dr. Ivkov had attached. Def.'s SF ¶ 46. Dr. Macentee provided a completed physical ability assessment form which restricted Juszynski's ability to walk and stand to "occasionally," or less than 2.5 hours in an 8 hour work day, and concluded that Juszynski was totally disabled due to a number of conditions, including diabetes, gout, and peripheral neuropathy. Pl.'s Resp. to Def.'s SF ¶ 48; Def.'s Ex. A, at LINA 193--94. LINA notes that Dr. MacEntee "plac[ed] no restriction on Plaintiff's ability to sit," Def.'s SF ¶ 48, but it is not clear from the form that Dr. MacEntee's omission of any information about Juszynski's ability to sit (by leaving that section of the form blank) was meant to indicate that Juszynski had no physical limitations in that area; rather, it appears equally likely that Dr. MacEntee simply failed to complete that section of the form.*fn3 Dr. Choudry also returned a medical request form in which he did not identify any restrictions or limitations on Juszynski, but referred LINA to Juszynski's primary care physician, Dr. MacEntee. Pl.'s Resp. to Def.'s SF ¶ 51; Def.'s Ex. A, at LINA 136--38.

Two individuals at LINA, Nurse Case Manager Alan Pieper and Assistant Medical Director Dr. John Mendéz, reviewed the medical records in Juszynski's file. On January 24, 2006, Pieper opined that Dr. MacEntee's restrictions and limitations were not supported by any diagnostic testing or exam findings. Def.'s SF ¶ 52. On or around January 31, 2006, Dr. Mendéz opined that the most recent notes in Juszynski's file, dated November 14 to December 19, 2005, did not list any significant physical limitations and did not support the limitations and restrictions provided by Dr. MacEntee, who on November 17, 2005 had opined that Juszynski was totally disabled. Def.'s SF ¶¶ 53--54.

On February 7, 2006, LINA contacted Juszynski via telephone and communicated its decision to uphold its denial of LTD benefits. Def.'s SF ¶ 55. During the telephone call, LINA explained that its basis for denial was that neither Juszynski's neurologist nor his cardiologist had provided any restrictions that would preclude his return to work. Def.'s SF ¶ 56. LINA also sent Juszynski a letter dated February 7, 2006, outlining the reasons for its denial and concluding that "there is no documentation of significant physical limitations, such as significant loss of range of motion and/or strength deficits that would preclude you from returning to work" and "the restrictions provided by Dr. MacEntee on November 17, 2005 do not correlate with the available medical documentation." Def.'s SF ¶ 57.

On February 15, 2006, LINA received a completed physical ability assessment form from neurologist Dr. Ivkov, which opined that Juszynski could sit between 2.5 and 5.5 hours and stand or walk not more than 2.5 hours per day during an 8-hour work day. Def.'s SF ¶¶ 60--61. Dr. Ivkov also noted that when Juszynski came for his appointment, he was limping and using a cane and that he had an antalgic gait. Pl.'s SF ¶ 41.

On or around June 9, 2006, plaintiff made a second appeal to LINA, requesting again that they reconsider their decision to terminate LTD benefits. Def.'s SF ¶ 62. On July 6, 2006, LINA referred the file for medical review and a transferable skills analysis. Def.'s SF ¶¶ 63--64. On July 10, 2006, Vocational Rehabilitation Counselor Adrian P. Jenkins conducted a transferable skills analysis in which he concluded that Juszynski was capable of performing either of two occupations: Customer Support Specialist or Test Fixture Designer. Def.'s SF ¶¶ 65--66. On July 12, 2006, Lead Medical Director Marie F. Hatam conducted a review of the medical information in Juszynski's file and concluded that "[t]he medical records reviewed support the [physical assessment form] filled out by Dr. Ivkov on February 15, 2006, which support [the restrictions and limitations] and the positions found by [the transferable skills analysis] at sed[entary] level of capacity." Def.'s SF ¶ 67.

On July 25, 2006, LINA again upheld its termination of LTD benefits. As support for its decision to deny Juszynski's second appeal, LINA (1) cited the physical ability assessment form completed by Dr. Ivkov, (2) stated that "the medical documentation does not support Mr. Juszynski's inability to function in a sedentary capacity," and (3) cited the transferable skills analysis in which Jenkins concluded that Juszynski was capable of ...


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