Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Pettaway v. Teachers Insurance and Annuity Association of America

March 30, 2010

SONYA PETTAWAY, PLAINTIFF,
v.
TEACHERS INSURANCE AND ANNUITY ASSOCIATION OF AMERICA, ET AL., DEFENDANTS,



The opinion of the court was delivered by: Reggie B. Walton United States District Judge

MEMORANDUM OPINION

The plaintiff, Sonya Pettaway, brings this action under the Employee Retirement Income Security Act of 1974 (the "ERISA"), 29 U.S.C. §§ 1132(a)(1)(B), (a)(3), and 1133 (2006), against the Teachers Insurance and Annuity Association of America (the "Teachers' Association"), Standard Benefit Administrators (the "SB Administrators"), and the National Academy of Sciences Group Total Disability Insurance Plan (the "Academy Plan" or "Plan") (collectively the "defendants") alleging that the defendants violated the ERISA by wrongfully terminating her benefit coverage and by not following proper procedures in the course of administering her claim. See Complaint ("Compl.") ¶¶ 1, 13, 16-17. The defendants deny the allegations. See Answer of the National Academy of Sciences Group Total Disability Insurance Plan ("Def. Acad.'s Answer") ¶¶ 1, 16-20; Answer of the Teachers' Association and the SB Administrators ("Defs. Teachers'/Adm'or's Answer") ¶¶ 16-19. The Court previously ruled that the plaintiff's claims were not time-barred under the doctrine of equitable tolling, Pettaway v. Teachers Ins. & Annuity Ass'n of America, 547 F. Supp. 2d 1, 7-8 (D.D.C. 2008) (Walton, J.), and currently before the Court are the parties' cross-motions for summary judgment.*fn1 Upon consideration of the parties written submissions and the administrative record in this case, for the reasons set forth below the Court must deny the plaintiff's motion and grant summary judgment to the defendants.

I. BACKGROUND

A. The Academy Plan

During the time period relevant to this litigation, the plaintiff was employed by the National Academy of Sciences (the "Academy") and enrolled in the disability plan it sponsored as a benefit for its employees. Compl. ¶ 6; Def. Acad.'s Answer ¶ 6. See generally Def. Acad.'s Mem., Attach. A to Declaration ("Decl.") of Shelia Wright (National Academy of Sciences Total Disability Insurance Plan). The Academy Plan is accompanied by a Summary Plan Description. See generally Def. Acad.'s Mem., Attach. B to Decl. of Shelia Wright (Total Disability Insurance Plan Summary Plan Description) (the "Plan Description").*fn2 The Academy Plan was created pursuant to the ERISA as an employee benefit plan, it is underwritten by the Teachers' Association,*fn3 Compl. ¶¶ 4, 7; Defs. Teachers'/Adm'or's Answer ¶ 7, and the SB Administrators serve as the administrator of the Academy Plan,*fn4 Compl. ¶ 5; Pl.'s Stmt. ¶ 6; Defs. Teachers'/Adm'or's Answer ¶ 5.

The Academy Plan states that participants "shall be entitled to benefits under the Plan as set forth in the Policy," Acad. Plan at 4.1, which is identified as "the Group Policy [number] D1129 issued by the [Teachers' Association]," id. at 1.6. See generally Def. Acad.'s Mem., Attach. C to Decl. of Shelia Wright, (D-1129 Group Total Disability Insurance Certificate) (the "Policy") at A.R. 26-169.*fn5 If a participant qualifies, she receives benefits in the form of monthly payments equal to sixty percent of her basic monthly salary, up to a certain amount, as well as annuity premium benefits to compensate for lost retirement contributions. Id., at A.R. 164-65.

According to the Policy, benefits are awarded to participants who are "totally disabled" or have a "total disability." Id., at A.R. 165. The terms are used interchangeably and are defined as follows:

(1) for the Elimination Period shown in Part I, and for the next 24 months, being completely unable due to sickness, bodily injury, or pregnancy to perform the material and substantial duties of your Normal Occupation; and

(2) after those 24 months, being unable due to sickness, bodily injury, or pregnancy to perform the material and substantial duties of any occupation for which you are reasonably qualified by education, training, or experience.

You must be under the Regular Care of a Physician, other than yourself or a member of your family.

Id., at A.R. 143.*fn6 The Elimination Period applicable to the plaintiff's claim is six months, meaning that after receiving benefits for twenty four months, the definition of total disability shifts from the first definition to the second. See id., at A.R. 165 (providing the two definitions of the Elimination Period). In other words, and relevant to the dispute in this case, in order to receive benefits after the first twenty four months of payments, participants must be under the "Regular Care of a Physician" and demonstrate they are "unable due to sickness, bodily injury, or pregnancy to perform the material and substantial duties of any occupation for which [they] are reasonably qualified by education, training, or experience." Id., at A.R. 143.

In order to demonstrate their entitlement to benefits, participants must provide "proof of [their] Total Disability" to the Teachers' Association. Id., at A.R. 146. According to the Policy, examples of the kinds of proof required are "statements of treating physicians; copies of test reports or examinations; x-rays; hospital records; medical examinations by impartial specialists at [the Teachers' Association's] expense; investigations conducted by [the Teachers' Association] or outside agencies." Id., at A.R. 146. The Plan Description adds that the "insurance carrier may require a medical exam." Def. Acad.'s Mem., Attach. B to Decl. of Shelia Wright (Plan Description) at 8. The Policy also states that "[w]ritten proof of continued Total Disability is required at reasonable intervals to be determined by [the Teachers' Association]," and further indicates that "[a]ll proof must be satisfactory to [the Teachers' Association]." Def. Acad.'s Mem., Attach. C to Decl. of Shelia Wright at A.R. 146.

With respect to the Teachers' Association's role in administering claims, it is given that authority from two sources. Def. Acad.'s Mem., Attach. B to Decl. of Shelia Wright (Plan Description) at 3, 8. The first source for this authority is found in the Plan Description under the section entitled "Total Disability," which provides that "the determination of your total disability is made solely by the insurance carrier[,]" id., Plan Description at 3, and the Teachers' Association is listed as the insurer for the Academy Plan in a later section of the Plan Description titled "Summary of ERISA Information," id., Plan Description at 12. The second source for the authority, also found in the Plan Description under the heading "Claims Procedures," states that the "[Teachers' Association] has full power and discretionary authority under the group policy to control and manage the operation and administration of the group policy, subject only to the participant's rights of review and appeal under the group policy." Id., Plan Description at 8. The same section declares that the

[Teachers' Association] has all the powers necessary to accomplish these purposes in accordance with the terms of the group policy including, but not limited to, the following: (1) determining the benefits and amounts payable therefor[e] to any participant or beneficiary; (2) establishing and administering a claims review and appeal process; and (3) interpreting, applying, and administering the provisions of the group policy.

Id., Plan Description at 8.

If the Teachers' Association denies an application for benefits, the Policy states that the Teachers' Association must send a written denial to the claimant "specify[ing] the reason(s) for the denial, the provisions of the contract on which the denial is based, and how to ask for a review." Def. Acad.'s Mem., Attach. C to Decl. of Sheila Wright at A.R. 147. Participants therefore have the right to appeal a denial of an application for benefits. Id.

B. The Plaintiff's Medical Condition

The plaintiff, who is college educated, was employed as a technical trainer at the Academy and was enrolled in the Academy Plan when she injured her back in an automobile accident on January 10, 2000. Pl.'s Stmt. ¶¶ 1, 3; Def. Acad.'s Stmt. ¶¶ 1, 13. She did not report to work the next day and remained on leave until she eventually underwent back surgery in September 2000. Pl.'s Stmt. ¶¶ 3-4; Def. Acad.'s Stmt. ¶ 13. On October 5, 2000, the plaintiff was approved for long term disability benefits. Def. Acad.'s Stmt. ¶ 13.

About a year later, in November 2001, the Teachers/Administrator started contacting the plaintiff requesting updates regarding her condition. Id. ¶ 17. In January 2002, the plaintiff provided to the Teachers/Administrator records from her treating physician, Dr. Bernard Stopak, a neurosurgeon. Pl.'s Stmt. ¶¶ 10, 13; Def. Acad.'s Stmt. ¶ 19. Dr. Stopak's records reflected that he had not seen the plaintiff in about a year, and he later advised the Teachers/Administrator that he did not have proper authorization to conduct further diagnostic studies of her condition. Def. Acad.'s Stmt. ¶ 19. In light of this information, the Teachers/Administrator asked the plaintiff to undergo an Independent Medical Examination ("IM Examination") to assess her current condition. Id. ¶ 20.

After some scheduling difficulties,*fn7 the plaintiff underwent the IM Examination on August 28, 2002. Pl.'s Stmt. ¶ 11. Dr. Arthur Korbine, the examining physician, reported that the plaintiff was a "healthy appearing female who gets up easily from the chair[,] . . . walks in a normal fashion[,]" and walks "equally well on heels and toes." Defs. Teachers'/Adm'or's Mem., Ex. A to Decl. of Andrew M. Altschul at A.R. 321. Examination of her lower extremities showed "normal strength, tone, reflex and sensory exam" and that "[s]traight leg raising causes back pain but no leg pain." Id. Dr. Kobrine's impression was that the plaintiff "continues to complain of symptoms of radiculopathy but has had no diagnostic study since surgery,"*fn8 and recommended that the plaintiff undergo a Magnetic Resonance Imaging scan ("MRI"). Id. On November 13, 2002, after a further review of plaintiff's "file by an independent physician consultant and a transferable skills assessment," the Teachers/Administrator informed the plaintiff that it would stop paying her benefits after December 2002 because her condition did not qualify as a total disability as defined by the Policy. Pl.'s Stmt. ¶ 11; Def. Acad.'s Stmt. ¶ 30.

On November 20, 2002, the plaintiff appealed the decision to terminate her benefits.

Pl.'s Stmt. ¶ 12. In support of her appeal, the plaintiff provided a personal letter she had written explaining her condition, a copy of the recent August 2002 IM Examination report, and a report from Dr. Stopak dated November 28, 2000. Defs. Teachers'/Adm'or's Mem. at 7. Other than her letter, id., Ex. A to Decl. of Andrew M. Altschul at A.R. 836, the Teachers/Administrator already had copies of the other documents, and it therefore affirmed the denial of her claim because the plaintiff had not submitted any new evidence. Def. Acad.'s Stmt. ¶ 31. The January 14, 2003 denial letter from the Teachers/Administrator informed the plaintiff that her appeal request "must be accompanied by medical documentation including, but not limited to, physicians' office notes, test report results, hospital records, therapy notes, consultation and/or narrative reports that support your disability." Defs. Teachers'/Adm'or's Mem., Ex. A to Decl. of Andrew M. Altschul at A.R. 839.

Thereafter, the plaintiff saw several physicians in the first few months of 2003, and records from these visits were provided to the Teachers/Administrator. Pl.'s Stmt. ¶ 12; Def. Acad.'s Stmt. ¶ 33. Included among the documents provided was "a Lumbosacral Myelogram with a Post Myelogram" Computerized Axillary Tomography scan ("CT scan"), both performed on February 21, 2003. Pl.'s Stmt. ¶ 12. According to the radiologists' reports accompanying these procedures, the myelogram exhibited a "mild ventral extradural defect at L3-4" and a "[s]table first degree retrolisthesis at L4-5[,]" Defs. Teachers'/Adm'or's Mem., Ex. A to Decl. of Andrew M. Altschul at A.R. 1327, and the CT scan showed a "[m]ild circumferential disk bulge at L3-L4" and a "[m]inimal circumferential disk bulge at L4-L5." Id., at A.R. 1328. Also included in the submission were more recent reports from Dr. Stopak, showing that he had scheduled a second back surgery for April 23, 2003, in part because the plaintiff's condition had become "more aggravated" following a slip and fall in Atlantic City in January 2003. Id., at A.R. 351, 361. The surgery was postponed, however, because the plaintiff had to attend a medical hearing around that same time and therefore the surgery had to be rescheduled. Def. Acad.'s Stmt. ¶ 34.

On April 22, 2003, the plaintiff was involved in a second automobile accident. Id. She was examined two days later by Dr. Stopak who recommended, "with no question in [his] mind," that the plaintiff undergo a second back surgery for a "total decompressive lumbar laminectomy [of] L3-4 and L4-5." Defs. Teachers'/Adm'or's Mem., Ex. A to Decl. of Andrew M. Altschul at A.R. 361. In a follow-up note, dated July 8, 2003, Dr. Stopak predicted that the plaintiff's post-surgery recovery time would be at least three to six months, and estimated that after recovering the plaintiff would "be able to return to work with restrictions of avoiding excessive bending and lifting over [twenty] pounds." Id., at A.R. 379.

On August 12, 2003, the Teachers/Administrator sent a letter to the plaintiff confirming the reinstatement of her disability benefits. Def. Acad.'s Stmt. ¶ 36. Dr. Arnold Kraminer, the reviewing physician for the Teachers/Administrator, based the decision on the pending surgery, and suggested that the Teachers/Administrator contact the plaintiff three to six months after the surgery to inquire about her condition. Id. ¶ 35. Dr. Kraminer indicated, however, that if "for any reason the planned surgery [was] not performed[,] updated medical information should ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.