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Reed v. Prudential Insurance Company of America

September 10, 2008

KENNETH REED, PLAINTIFF,
v.
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA, DEFENDANT.



The opinion of the court was delivered by: Joan B. Gottschall United States District Judge

Judge Joan B. Gottschall

Magistrate Judge Martin C. Ashman

MEMORANDUM OPINION AND ORDER

Plaintiff Kenneth Reed ("Reed") and defendant The Prudential Insurance Company of America ("Prudential") have filed cross-motions for summary judgment with respect to Reed's suit filed pursuant to Section 502(a)(1)(B) ("§ 502") of the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132(a)(1)(B). Both parties' motions seek summary judgment pursuant to Federal Rule of Civil Procedure 56(c) or, alternatively, pursuant to Federal Rule of Civil Procedure 52(a). For the reasons set forth below, both parties' cross-motions for summary judgment are denied.

I. BACKGROUND

Kenneth Reed, a 49 year old white male, was employed by Dynergy, Inc. ("Dynergy") as a shift technician until September 9, 2005 (or September 16, the parties disagree on the precise date), when he ceased working, complaining of fibromyalgia, osteoarthritis, chronic fatigue, and depression. At the time he ceased working, Dynergy maintained short-term and long-term disability income protection under a benefits plan (the "Plan") that was fully insured by Prudential. The parties do not dispute that Reed qualified as a "participant" under the terms of the Plan.

The portion of the Plan relevant to total disability benefits states in part: You are disabled when Prudential determines that:

* you are unable to perform the material and substantial duties of your regular occupation due to your sickness or injury; and

* you have a 20% or more loss in your indexed monthly earnings due to that sickness or injury.

After 24 months of payments, you are disabled when Prudential determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience. .

We may require you to be examined by doctors, other medical practitioners or vocational experts of our choice. Prudential will pay for these examinations. We can require examinations as often as it is reasonable to do so. We may also require you to be interviewed by an authorized Prudential Representative. (emphases in original). The parties dispute whether Reed received short-term disability payments after he left Dynergy until March 1, 2006: Reed maintains that he did, whereas Prudential maintains that he instead received salary continuance from Dynergy through that interval. Neither party disputes that Reed also applied to Dynergy for long-term disability ("LTD") benefits, claiming "severe fibromyalgia with chronic pain in joints and depression." Reed's application was duly forwarded to Prudential, which reviewed his application and medical records. Reed was also interviewed via telephone by Prudential agent Will Truesdale.

Prudential ultimately denied Reed's claim for LTD benefits. Reed appealed Prudential's denial, submitting further medical records, and Prudential referred the file for a three-day surreptitious surveillance and activity check; the surveillance was conducted on May 1-3, 2006. On June 21, 2006, Prudential also referred Reed's entire application for external review by both a rheumatologist and a psychiatrist (neither of whom conducted a personal examination of Reed). After receiving their evaluation of Reed's medical records, Prudential denied Reed's appeal on July 17, 2006.

On January 12, 2007, Reed filed a second appeal for reconsideration of Prudential's denial of LTD benefits, including additional medical data. Prudential forwarded Reed's file to the same reviewing rheumatologist and psychiatrist who had conducted the prior review of Reed's first appeal. Both physicians filed addenda to their previous reports, and following Reed's submission of additional records on February 15, 2007, the reviewing physicians filed additional comments on Reed's application. Prudential forwarded the reviewing physician's reports to Reed, who submitted a response without filing any additional medical records. This response was forwarded to the reviewing physicians for comment and, upon receiving their ...


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