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Harper v. Reliance Standard Life Insurance Co.

May 8, 2008

FRANKIE HARPER PLAINTIFF,
v.
RELIANCE STANDARD LIFE INSURANCE COMPANY DEFENDANT.



The opinion of the court was delivered by: Magistrate Judge Geraldine Soat Brown

MEMORANDUM OPINION AND ORDER

Plaintiff Frankie Harper ("Harper") filed a complaint alleging that Reliance Standard Life Insurance Company ("Reliance") violated the Employee Retirement Income Security Act of 1974 ("ERISA"), specifically 29 U.S.C. §§1132(e)(1) and 1132(f), in the course of administering an employee welfare benefit plan on behalf of Harper's employer, Michael Reese Hospital. Harper and Reliance have each filed a motion for summary judgment pursuant to Fed. R. Civ. P. 56. For the reasons set out herein, Harper's motion is granted, and Reliance's motion is denied.

PROCEDURAL BACKGROUND

Harper's Complaint alleges that Reliance wrongfully denied her claim for long-term disability benefits, thus denying her plan benefits. [Dkt 1.] The parties consented to the jurisdiction of a United States Magistrate Judge pursuant to 28 U.S.C. §636(c)(1) and Local Rule 73.1. [Dkt 16, 17, 18.]

FACTUAL BACKGROUND

Frankie Harper was employed as a Medical Surgical Registered Nurse at Michael Reese Hospital when she was involved in a car accident outside of work that injured her back and shoulder. (Pl. Facts ¶ 7.)*fn1 Harper was covered by a group long-term disability insurance plan sponsored by Michael Reese Hospital. (Pl. Facts ¶ 8.) The plan purchased a disability insurance policy, underwritten and administered by Reliance, Policy No. LTD 108647 ("the Policy"). (Pl. Facts ¶ 8.) The Policy was part of an "employee welfare benefit plan" as defined in 29 U.S.C. § 1002(1), and Harper was a "participant," as defined in 29 U.S.C. § 1002(7). (Pl. Facts ¶ 9.)

The Policy Provisions

The Policy includes the following relevant provisions:

INSURING CLAUSE: We will pay a Monthly Benefit if an Insured:

(1) is Totally Disabled as the result of a Sickness or Injury covered by this Policy;

(2) is under the regular care of a Physician;

(3) has completed the Elimination Period; and

(4)submits satisfactory proof of Total Disability to us. (AR 107.)*fn2

"Totally Disabled" and "Total Disability" mean, that as a result of an Injury or Sickness:

(1) during the Elimination Period and for the first 24 months for which a Monthly Benefit is payable, an Insured cannot perform the material duties of his/her regular occupation . . . . (AR 99, emphasis added.)

The "Elimination Period" is "a period of consecutive days of Total Disability, as shown on the Schedule of Benefits page, for which no benefit is payable. It begins on the first day of Total Disability." (AR 98.) In other words, in order for Harper to receive benefits, she must be unable to perform the material duties of her regular occupation for the duration of the Elimination Period. For 24 months thereafter, she is eligible to receive benefits if she continues to be unable to perform the material duties of her regular occupation.*fn3

The Policy also provides the following under "PAYMENT OF CLAIMS": When we receive written proof of Total Disability covered by this Policy, we will pay any benefits due. . . .

Reliance Standard Life Insurance Company shall serve as the claims review fiduciary with respect to the insurance policy and the Plan. The claims review fiduciary has the discretionary authority to interpret the Plan and the insurance policy and to determine eligibility for benefits. Decisions by the claims review fiduciary shall be complete, final and binding on all parties. (AR 103.)

Claim Background

Even prior to the accident in February 2005, Harper had a history of medical problems extending back to 1990. (Pl. Facts ¶¶ 13-44.) Her records reveal that Harper received treatment for degenerative changes in her knees, shoulders and back, as well as for hip pain. (Pl. Resp. Facts ¶ 6.) Harper's records also describe a variety of other diagnoses, such as lupus, coronary artery disease, chronic or congenital heart failure, diabetes, chronic obstructive pulmonary disease, and hypertension, all of which she had lived with prior to her car accident. (Pl. Resp. Facts ¶ 13.)

Harper stopped working on February 11, 2005, the day of the accident, and three days later applied for Social Security benefits. (Pl. Facts ¶¶ 45-46.) On July 1, 2005, Harper applied for long-term disability benefits from Reliance, claiming "severe low back pain and bilateral shoulder pain." (AR 132-135.)*fn4 Elsa Perez, Benefits Administrator at Michael Reese Hospital, filled in the employer section of Harper's application, including writing "see job description" for the description of Harper's occupation as a Medical Surgical Registered Nurse. (Def. Resp. Facts ¶ 48.) The "job description" is a Michael Reese Hospital document summarizing the requirements and qualifications for a Medical Surgical Registered Nurse. (AR 189-195.) It included a "Physical Effort" category, stating: "This position requires the ability to lift up to 50 lbs. Maximum with frequent lifting and/or carrying of objects weighing up to 25 lbs. is required. [sic] Stooping, kneeling, reaching and manual dexterity required. . . . The job requires 10% sitting and 90% standing or walking. . . . [S]tands or walks a good portion of the work time . . . . Must be able to move patients using proper body mechanics. Fine motor skills required." (AR 192.)

Harper's job duties required physical capabilities that she did not have after the accident, according to her treating physician Dr. Farmer. (See AR 421-22.) Harper submitted Dr. Farmer's evaluation along with other records and documents to Reliance as part of her claim.*fn5 Dr. Farmer, the only doctor who evaluated her for those purposes, set forth Harper's physical restrictions after the accident in an Attending Physician's Statement, dated July 1, 2005. (Id.) He stated, in part, that in an eight hour day with two breaks and lunch, Harper could carry a maximum of ten pounds and occasionally carry small objects, and that she could not bend or squat at the waist. (Id.) Harper was capable of sitting or driving for one to three hours, could not stand or walk, and could not use her upper extremities for simple grasping, for pushing or pulling, or for fine manipulation. Harper also could not climb or reach above her shoulder, could not kneel, crawl or use her feet to operate foot controls. (Def. Resp. ¶ 51; AR 422.) Dr. Farmer wrote that Harper would indefinitely be restricted. (Id.)

Reliance's review of Harper's application is set out in a form titled Medical/Vocational Review. (AR 408). The top portion provides that it is "[t]o be completed by the Examiner," and the second portion of the page is "[t]o be completed by the Medical Department." (Id.) The Medical Department ...


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