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Foster v. Sedgwick Claims Mgmt. Servs., Inc.

United States District Court, D. Columbia.

August 28, 2015

KELLY FOSTER, Plaintiff,
v.
SEDGWICK CLAIMS MANAGEMENT SERVICES, INC., et al., Defendants

Page 201

          For KELLY FOSTER, Plaintiff: Denise Marie Clark, LEAD ATTORNEY, CLARK LAW GROUP, PLLC, Washington, DC.

         For SEDGWICK CLAIMS MANAGEMENT SERVICES, INC., Commissioner for the District of Columbia, SUN TRUST BANK SHORT AND LONG TERM DISABILITY PLANS, Sun Trust Bank In-House Counsel, Defendants: James Taylor Heidelbach, LEAD ATTORNEY, GEBHARDT & SMITH LLP, Baltimore, MD; Gregory L. Arbogast, PRO HAC VICE, GEBHARDT & SMITH LLP, Baltimore, MD.

Page 202

         MEMORANDUM OPINION

         JAMES E. BOASBERG, United States District Judge.

         Plaintiff Kelly Foster, a former employee of Sun Trust Bank, brought this action under the Employee Retirement Income Security Act of 1974, claiming that Defendants Sedgwick Claims Management Services, Inc. and the Bank's Short-Term and Long-Term Disability Plans improperly denied her disability benefits. She asserts that she submitted sufficient medical evidence of conditions -- including fibromyalgia, fatigue, and anxiety disorder -- that render her " totally disabled" within the meaning of the Plans, and she further maintains that she has satisfied all of the Plans' other preconditions for receiving benefits.

         Disagreeing with Foster's contentions, Defendants have filed a Motion for Summary Judgment. They first point out that the Short-Term Disability Plan is not even governed by ERISA. They also argue that the denial of long-term benefits was appropriate in light of the aggregate medical evidence and the eligibility requirements of the Plans.

         Concluding that Defendants are entitled to judgment, the Court will grant their Motion.

         I. Background

         Sun Trust Bank automatically enrolls all of its employees in the company's Short-Term Disability (STD) and Long-Term Disability (STD) Benefits Plans after six months of employment. See Mot., Exh. 2 (STD Benefits Handbook) at 1. Plaintiff, formerly a Mortgage Loan Closer at Sun Trust, was enrolled in both Plans. See Mot., Exh. 5 (STD Claim File) at 1. Sun Trust retains Sedgwick as the claims administrator for both of its Disability Benefits Plans. See Mot., Exh. 4 (Affidavit of

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Anna M. Grant) at 1. The claims administrator " make[s] a determination regarding whether your medically-documented claim entitles you to a Long-Term Disability [or Short-Term Disability] benefit." Mot., Exh. 3 (LTD Plan) at 11.

         Enrolled employees are eligible for STD benefits if the claims administrator determines that for more than five consecutive business days, the employee is " not able, solely because of disease or injury, to perform the material duties of their own occupation and are under the regular care of a physician." STD Benefits Handbook at 2. This determination is to be based on " [o]bjective medical documentation supporting the employee's claim.'" Id. at 1.

         An employee is eligible for LTD benefits, conversely, if, after 180 consecutive calendar days of total disability, he or she remains disabled. See LTD Plan at 4. During the entirety of this 180-day " waiting period," the employee must be entitled to STD benefits or Workers Compensation, see id., the latter of which is not at issue here. The waiting period commences on the first day the employee is absent from work as a result of his or her disability, and it is broken (and must be restarted) if the employee returns to work for more than 30 days. Id. These requirements are laid out in the Plan documents and are discussed in more detail in the Analysis. See infra Section III.B.1.

         According to Foster, she suffers from a series of disabling conditions, including fibromyalgia and fatigue. See STD Claim File at 1, 23. She filed her first claim for disability benefits under Sun Trust's STD Plan in January 2012. See Mot., Exh. 7 (Claim Log I) at 36. Sedgwick conditionally approved Plaintiff's claim but later discontinued her benefits the following month, after she failed to provide medical support for a continuing disability. See Mot., Exh. 8 (Letter Discontinuing Temporary Benefits) at 1.

         Foster then filed another STD benefits claim -- the claim at issue in this action -- on August 20, 2012. See STD Claim File at 1. On two occasions after the filing of this claim, Sedgwick notified Plaintiff that she had to file medical documentation in support of her claim before September 7, 2012. See id. at 4, 15. After Foster failed to do so, Sedgwick denied her claim on September 10, 2012. See id. at 18. Five days after the deadline, Dr. Robert Mayfield submitted an Attending Physician Statement in support of Plaintiff's claim, in which he reported that she suffered from fibromyalgia, dry eyes, and anxiety. See id. at 20-22 (Statement of Dr. Mayfield). His diagnosis cited an MRI performed in 2011, and he noted that further objective findings would require additional testing. See id. at 23. Finding that this Statement did not constitute " satisfactory" objective medical documentation of Plaintiff's disability, Sedgwick again denied her STD claim on September 13, 2012. See Mot., Exh. 13 (Claim Log II) at 46-47; STD Claim File at 26-27.

         On September 25, 2012, Sun Trust terminated Foster's employment as a result of her absence from work. See Grant Aff. ¶ 4. On that same day, a second physician, Dr. James Sutherland, submitted an Attending Physician Statement on her behalf. See Mot., Exh. 14 (Statement of Dr. Sutherland). Although this Statement confirmed many of Dr. Mayfield's diagnoses, it also indicated that Plaintiff's physical condition did not functionally limit her activities of daily living and did not merit driving restrictions. See id. at 2.

         Plaintiff, through counsel, formally appealed the denial of her claim for STD benefits, which she was permitted to do even after her termination. See STD Claim File at 28. After additional review,

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including consultation with independent physicians, Sedgwick upheld this denial on March 29, 2013. See Mot., Exh. 16 (STD Appeal Denial).

         Plaintiff next filed a claim for benefits under Sun Trust's LTD Plan on October 31, 2013. See Claim Log II at 4. Sedgwick denied this claim on November 8, on the basis that Foster had not established that she was entitled to STD benefits or Workers' Compensation for the duration of the 180-day waiting period. Mot., Exh. 17 (LTD Denial Letter). Plaintiff appealed the denial of her claim for LTD benefits on January 10, 2014, but Sedgwick upheld it on January 27. See Claim Log II at 2.

         Foster then filed this action on July 21, 2014, seeking to clarify and enforce her rights under the benefits plans, as permitted by ERISA. See 29 U.S.C. § 1132(a).

         II. ...


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