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Suson v. PNC Financial Services Group, Inc.

United States District Court, N.D. Illinois, Eastern Division

July 31, 2017

JODI SUSON, Plaintiff,
v.
THE PNC FINANCIAL SERVICES GROUP, INC. AND AFFILIATES LONG TERM DISABILITY PLAN and THE PNC FINANCIAL SERVICES GROUP, INC., Defendants.

          MEMORANDUM OPINION AND ORDER

          AMY J. ST. EVE, District Court Judge:

         Before the Court are the parties' cross-motions for summary judgment pursuant to Federal Rule of Civil Procedure 56(a). (R. 62, R. 66.) Plaintiff Jodi Suson seeks a declaratory judgment that Defendant THE PNC FINANCIAL SERVICES GROUP, INC. (“PNC”) arbitrarily and capriciously denied her request for long-term disability benefits under THE PNC FINANCIAL SERVICES GROUP, INC. AND AFFILIATES LONG TERM DISABILITY PLAN (hereinafter “the Plan”) in violation of the Employee Retirement Insurance Security Act (“ERISA”), 29 U.S.C. § 1001 et seq. (R. 62.) Suson also seeks statutory penalties against PNC for its alleged failure to provide her with the trust agreement for the Plan. (R. 62.) PNC, however, also seeks a declaratory judgment that it properly denied Suson's request for long-term disability benefits after a full and fair review, and in accordance with ERISA. (R. 66.) PNC also seeks a denial of Suson's request for statutory penalties. (R. 66.) For the following reasons, the Court grants Suson's motion for summary judgment (R. 62.) in part and denies it in part. The Court denies Defendants' motion for summary judgment (R. 66) in part and grants it in part.

         BACKGROUND

         Suson is a former employee of PNC and participated in the Plan. (R. 64, PNC 56.1(a)(3) Stmt. Facts, at ¶ 1.) PNC is the Plan Sponsor and Plan Administrator of the Plan, which is an employee welfare benefit plan governed by ERISA. (Id. at ¶ 3.) The Plan provides long-term disability (“LTD) benefits at 60% or 70% of participants' pre-disability eligible compensation if a participant becomes disabled and is unable to work for longer than 91 consecutive days. (R. 72, AR 836.) Liberty Life Assurance Company of Boston (“Liberty”) is the Plan's claim administrator. (R. 69, Suson 56.1(a)(3) Stmt. Facts, at ¶ 3.)

         I. The Plan

         The Plan provides the following discretionary authority:

         Plan Administrator

The Plan Administrator shall have the authority to control and manage the operation and administration of the Plan. The Plan Administrator shall have the exclusive discretionary authority to determine eligibility for benefits under the Plan, to construe the terms of the Plan and to determine any question which may arise in connection with its operation or administration, except to the extent that the Plan Administrator has authorized the claims administrator to make such determinations. Its decisions or actions in respect thereof shall be conclusive and binding upon the employer and upon and all participants and survivors, their beneficiaries, and their respective heirs, distributes executors, administrators and assignees; subject, however, to the right of the participant or survivor to file a written claim or appeal under the procedures described above. The Plan Administrator may delegate any of its duties hereunder to person or persons it may designate from time to time.

(R. 72, AR 848.)

         The Plan defines the following relevant terms, in pertinent part, as follows:

         Definition of LTD

         For disabilities that extend beyond 91 consecutive calendar days and are considered long term, the definition of disability is as follows:

- For the first 24 months (from the date LTD benefits begin): you are disabled if your disability makes you unable to perform the material or essential duties of your own occupation as it is normally performed in the national economy.
- After you have been disabled for 24 months: you are disabled if your disability makes you unable to perform the material duties of any occupation for which you are or can become qualified to perform by education, training or experience.

(R. 72, AR 837.)

         Claims

Claims for benefits under the Plan must be submitted in writing to the claims administrator. If your claim is wholly or partially denied, written or electronic notice of the decision shall be furnished within a reasonable period of time, but not later than 45 days after receipt of the claim by the Plan.

(Id, AR 847.)

         Proof of Claim

As a condition of receiving benefits under the Plan, any person may be required to submit whatever proof the Plan Administrator may require (either directly to the Plan Administrator or to any person delegated by it.)

(Id., AR 851.)

         Appeals

         If your claim for benefits under the Plan is denied, you (or your representative) may appeal the adverse benefit determination by submitting a request for review in writing to the claims administrator within 180 days after your receipt of the written or electronic notice of denial. The Plan shall provide a review that does not afford deference to the initial adverse benefit determination that is conducted by an appropriate named fiduciary of the Plan who is neither the individual who made the adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual.

         If the adverse determination was based in whole or in part on a medical judgment, the appropriate named fiduciary shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. The Plan shall identify any medical or vocation experts whose advice was obtained on behalf of the Plan in connection with the claimant's adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination. Any health care professional engaged by the Plan for purposes of consultation shall be an individual who is neither an individual who was consulted in connection with the adverse benefit determination that is the subject of the appeal, nor the subordinate of any such individual. In connection with your appeal, you are entitled to review pertinent documents and submit issues and comments in writing to the Plan. A hearing may be held in the discretion of the Plan Administrator for the purpose of making factual findings. (Id., AR 847-48.)

         II. Factual Background

         Starting on July 30, 2012, Suson worked for PNC as a Financial Specialist I. (R. 69, Suson 56.1(a)(3) Stmt. Facts, at ¶ 7.) According to the job profile that PNC sent to Liberty, the position of Financial Specialist I required Suson to:

1.) Serve as the Branch Focal Point for PNC Investments in the branch ecosystem to cultivate and develop investment relationships by profiling customers and providing guidance regarding choices and performing transactions or service requests as needed, 2.) Recommend a limited PNCJ [sic] Investment Product set resulting from analysis of customer needs in order to determine product suggestions that meet the customer's long-term objectives (recommendations/sales of Investment Product sets based on appropriate FINRA licensing status). 3.) Assist Branch Manager with Investment Goals by coaching and training staff and organizing and leading focused activities, and 4.) Perform Branch Banking duties as needed.

(Id. at ¶ 8.)

         A. Suson's Medical History

         Suson was diagnosed with bipolar disorder in 1996 and has received regular psychiatric treatment. (Id. at ¶ 10.) Since the late 1990s, Dr. Blaise Wolfrum has treated Suson for her bipolar disorder. (Id.) In addition, Suson has also been diagnosed with fibromyalgia and several other degenerative joint diseases for which she has received regular treatment. (Id.) In September 2009, Suson began receiving chiropractic treatment from Dr. Warren E. Wolschlager. (Id. at ¶ 11.) Suson was treated at least 22 separate times from September 3, 2009 through May 19, 2010, and reported severe pain in her mid-back, low-back, and neck. (Id.)

         On June 26, 2012, Suson saw her primary care physician, Dr. Stephanie Bartels. (Id. at ¶ 12.) Suson reported that she fell ten days earlier and had left hip pain, as well as right side, neck and shoulder pain. (Id.) Suson saw Dr. Bartels again on July 3, 2013, complaining of persistent neck pain since her fall. (Id. at ¶ 13.) Dr. Bartls ordered an MRI of Suson's cervical spinal cord which showed spondylosis and arthritis at multiple levels of her cervical spine. (Id.) Suson again saw Dr. Bartels on November 18, 2013 and reported that, the previous week, she was flushed, very hot, and had a spell where she could not breathe. (Id. at ¶ 14.) Dr. Bartles observed that Suson had a “flighty” affect, was not answering questions directly, and had rapid speech. (Id.) Dr. Bartels noted that Suson's symptoms could be panic attacks and that she was somewhat manic. (Id.) Dr. Bartels instructed Suson to follow up with her psychiatrist. (Id.)

         Suson again saw Dr. Bartles on December 11, 2013 due to pain and swelling in her left index finger, which Suson said was difficult to bend. (Id. at ¶ 15.) Dr. Sharon Spak-Schreiner treated Suson and ordered an X-ray of the hand. (Id.) The X-ray showed narrowing of the first carpometacarpal joint spaces and mild associated sclerosis in the left index finger and mild narrowing of the DIP joint of the second finger. (Id.)

         On December 16, 2013, Suson saw Dr. Wolfrum and reported that she could not stay focused and was yelling at her peers. (Id., at ¶ 16.) Suson began a leave of absence from PNC on December 17, 2013 due to erratic behavior cause by bipolar disorder. (Id. at ¶ 17.) Suson applied for and began receiving short-term disability (“STD”) benefits from PNC's STD plan. (Id.) The following week, Dr. Wolfrum completed a Behavioral Health Provider's Statement of Work Capacity and Impairment which documented depression, erratic behavior, and anxiety. (Id. at ¶ 18.) On December 27, 2013, Suson told Dr. Wolfrum that she continued to suffer from sleep problems and bipolar symptoms. (Id. at ¶ 19.)

         At Dr. Wolfrum's recommendation, Suson was hospitalized at Alexian Brothers Behavioral Health Hospital on January 8, 2014 and enrolled in their partial hospitalization program. (Id. at ¶ 20.) Hospital notes show an initial diagnostic impression of bipolar disorder and anxiety. (Id.) Suson stated that she was having mixed moods of depression and mania. (Id.) Alexian Brothers medical notes state that Suson's speech was pressured, her mood was anxious, and her thought process was digressive. (Id.) The notes also reflect that she had an elevated mood and was laughing often. (Id.) On January 8, 2014, Suson reported that her health plan “forced her to change her behavioral health medications” and that she had experienced several deaths in her family as well as a toxic work environment in the months before her hospitalization. (Id. at ¶ 20.) A counselor evaluated Suson on January 10, 2014, diagnosed her with bipolar disorder not otherwise specified, and noted a Global Assessment of Functioning (“GAF”) score of 36.[1] (Id.) Dr. Raymond Gouttama treated Suson while at Alexian Brothers. (Id. at ¶ 22.) Dr. Gouttama's psychiatric evaluation states: “The patient stated that she has problems with sleep. She isolates herself, feeling hopeless and helpless, and no motivation. She has mood swings. There are times when she is depressed and crying and other times euphoric and somewhat hyper. The patient denies abusing alcohol or drugs.” (R. 72, AR 568.) Suson was discharged to outpatient psychotherapy on January 30, 2014. (R. 69, Suson 56.1(a)(3) Stmt. Facts, at ¶ 22.)

         Suson continued to receive treatment from Dr. Wolfrum. (Id. at ¶ 23.) On January 31, 2014, Dr. Wolfrum opined that Suson could return to work as early as February 3, 2014, and released her to work on that date with certain restrictions and accommodations. (Id.) In early May 2014, Dr. Wolfrum completed an updated Statement of Work Capacity and noted that Suson was unable to work due to her fibromyalgia, bipolar disorder, related anxiety, crying spells, pain when stressed, racing thoughts, and her ability to be easily distracted. (Id.)

         Suson left her active employment with PNC on May 2, 2014 and resumed STD leave. (Id. at ¶ 24.) Liberty sent a letter dated June 29, 2014, advising Suson that her STD benefits would terminate and that her LTD elimination period would be satisfied as of July 31, 2014. (Id. at ¶ 25.) The letter also stated that Liberty would review her claim for LTD benefits and requested a disability claim form, activities questionnaire, claimant information form, claimant supplementary statement, authorization for release of information, and an attending physician statement. (Id.)

         B. Suson's Long-Term Disability Benefits claim

         Suson's last day of work for PNC occurred on June 24, 2014. (R. 64, PNC 56.1(a)(3) Stmt. Facts, at ¶ 15.) Suson made a claim for LTD benefits on July 24, 2014, due to bipolar disorder, fibromyalgia, and depression. (Id.) Suson and her medical providers supplied Liberty with her medical treatment records. (R. 69, Suson 56.1(a)(3) Stmt. Facts, at ¶ 27.) On July 25, 2014, Suson completed a Claimant Supplementary Statement and an Activities Questionnaire. (Id. at ¶ 28.) Suson indicated that she could sit for 30 minutes, stand for 15-20 minutes, and walk for no more than 60 minutes at a time. (Id.) Suson stated that problems focusing, memory loss, daily panic attacks, excessive crying ...


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