United States District Court, D. Massachusetts
MEMORANDUM AND ORDER RE: DEFENDANTS' MOTION FOR SUMMARY JUDGMENT AND PLAINTIFF'S CROSS-MOTION FOR SUMMARY JUDGMENT (Dkt. Nos. 39 & 42)
MICHAEL A. PONSOR, District Judge.
Plaintiff Elsa Salvador brings this ERISA claim, 29 U.S.C. § 1132, to recover long-term disability benefits against Defendants Liberty Life Assurance Company of Boston and Massachusetts Mutual Life Insurance Company Long Term Disability Income Plan. On February 28, 2014, the parties filed cross-motions for summary judgment. For the reasons that follow, the court will deny Plaintiff's motion and allow Defendants' motion.
II. FACTUAL BACKGROUND
A. The Plan
The Plan grants both short-term disability (STD) and long-term disability (LTD) benefits to covered individuals who qualify as disabled. Pursuant to the Plan, Defendants have "the authority, in [their] sole discretion, to construe the terms of this policy and to determine benefit eligibility." (A.R. -27.) The Plan definition of disability comprises two phases. Within the first 24-month period, an employee is considered disabled if she "is unable to perform all of the material and substantial duties of [her] occupation" due to her injury or illness. (A.R. -6.) After that initial 24-month period, the individual qualifies as disabled if she cannot perform, "with reasonable continuity, " the major duties of either her previous occupation or "any other occupation for which [she] is or becomes reasonably fitted." (Id.)
The policy provides LTD benefits for both physical and mental illness and defines the latter as "mental, nervous or emotional diseases or disorders of any type." (A.R. -17.) However, the Plan contains a coverage limit for mental illnesses. The provision provides that the LTD benefit for disability due to "Mental Illness and Alcohol or Drug Abuse will not exceed 24 months" unless the covered individual is in a hospital or institution at the end of the 24-month period. (A.R. -17.) The LTD benefit continues for the duration of any in-patient treatment due to mental illness and ceases thereafter. (Id.)
B. Plaintiff's Initial Claim for LTD Benefits
On July 14, 1980, Plaintiff began working for Massachusetts Mutual Life Insurance Company ("MassMutual"). As an employee, Plaintiff was eligible for LTD coverage which she obtained from Defendant Liberty, effective as of January 1, 2000. On June 10, 2009, Plaintiff suffered a severe nervous breakdown at work in front of her colleagues and supervisor. The next day, she put in a claim for STD benefits, stating that she was unable to work due to depression, anxiety, post-traumatic stress disorder (PTSD), and obsessive compulsive disorder (OCD) involving work-related stress, as well as chronic back pain. Plaintiff received STD benefits from June 18 through December 9, 2009.
Thereafter, Plaintiff applied, and was approved, for LTD benefits, effective December 10, 2009. The letter awarding Plaintiff her LTD benefits did not reference the Plan's mental health limitation. (A.R. -998-99.) Around this time, Plaintiff also successfully negotiated a return to work part-time with MassMutual, which she notified Defendants of in November 2009. Accordingly, from January 11 to April 10, 2010, Plaintiff simultaneously worked on a part-time basis and received her LTD benefit payments, less an offset for the compensation she received for her part-time work.
After awarding Plaintiff LTD benefits, Defendants also put her in touch with a law firm to assist her in applying for Social Security disability benefits. On May 26, 2010, Plaintiff was awarded Social Security disability benefits.
The parties dispute whether Plaintiff's initial claim for LTD benefits was solely based on her mental health conditions, as Defendants assert, or whether Plaintiff also included her back problems as a basis for disability, which Plaintiff asserts. Regardless, the claims history indicates that, while Defendants initially focused their inquiry into Plaintiff's claim on her depression, PTSD, and anxiety, they later looked into her back problems. (A.R. -771-73.)
By letter dated October 12, 2011, Defendants notified Plaintiff of the 24-month limitation on LTD benefits awarded for mental illness. (A.R. -726.) Between August and November 2011, Defendants investigated Plaintiff's claim for LTD benefits. They requested and received updates from Plaintiff's chiropractor and orthopedic physician, and referred her claim to a consulting physician. After reviewing Plaintiff's claim, Defendants determined that, though Plaintiff was completely disabled due to her mental illness, her physical ailments did not meet the definition of disability under the policy. Accordingly, the 24-month mental illness limitation applied, and Plaintiff's LTD payments would end.
Defendants notified Plaintiff of this decision by letter dated November 14, 2011. (A.R. -713.) Erroneously, the letter stated that her condition met the definition of "non-verifiable, " a separate provision of the policy. (Id.) Moreover, Defendants incorrectly calculated the appeal deadline date they gave her in the letter; they used the date of the letter notifying Plaintiff of the termination of benefits instead of the date the benefits were actually terminated. (A.R. -714.) After Plaintiff brought this to Defendants' attention, they corrected the error by letter on February 8, 2012, and told Plaintiff she had until June 7, 2012, to submit her materials for appeal. (A.R. -634-35.) The letter also informed Plaintiff of her right to request a review of the decision by an Appeals Review Unit and that she should submit all the documentation relevant to her disability for the review.
On December 9, 2011, when Plaintiff reached the 24-month mental illness limitation, Defendants ceased their LTD payments to her. (A.R. -71.) On January 29, 2012, Plaintiff notified Defendants of her intent to appeal the loss of benefits.
C. Plaintiff's Medical Background
1. Mental Disability
On June 10, 2009, Plaintiff had a nervous breakdown and went on STD leave. On January 20, 2010, Plaintiff's social worker, Michele Critelli, LICSW, sent a letter to Defendants recommending that Plaintiff begin a structured dialectical behavior therapy program. (A.R. -972.) On January 29, 2010, Plaintiff's psychotherapist, Piyush Johari, MD, also recommended dialectical behavior therapy to treat Plaintiff's diagnoses of depression, PTSD, and severe anxiety. (A.R. -973.) In response to his letter, Defendants sent Dr. Johari a questionnaire, in which he confirmed Plaintiff's diagnoses of major depression, generalized anxiety, PTSD, irritable bowel syndrome, hyperthyroidism, and work stress. (A.R. -960-65.)
Defendants also asked Plaintiff to participate in an independent psychiatric examination through MLS Group of Companies, Inc., to which she agreed. On March 23, 2010, Dr. Marvin Zelman conducted a three-hour examination. Additionally, around this time, Defendants hired New England Risk Management to provide surveillance on Plaintiff. Dr. Zelman prepared a report of Plaintiff's mental condition, for which he reviewed the surveillance account, the medical records provided by Plaintiff, and his own examination notes. (A.R. -948-54.) Dr. Zelman concluded that the medical evidence supported Plaintiff's primary diagnosis of major depression, that she was unable to return to work as a supervisor or function in a normal work setting with co-workers, and that her prognosis was "quite unfavorable." (A.R. -953-54.)
2. Physical Disability
Plaintiff also experienced physical impairments during this time period. Plaintiff's records from an August 2, 2011, visit with her chiropractor, Dr. George Langlitz, show that she complained of moderate buttock pain, mild low back pain, and minimal neck and back pain, with worsening symptoms. (A.R. -781.) On August 10, 2011, Plaintiff reported in a questionnaire that she had to adjust her sitting when her coccyx bone began to hurt, that she required a break from sitting every hour or so, and that standing or walking for long periods hurt her mid and lower back. (A.R. -772.) Further, Plaintiff expressed her belief that both her mental and physical problems prevented her from working. (A.R. -773.)
Based on these reports, in October 2011, Defendants referred Plaintiff's claim to a consulting physician, Dr. Gary Ierna, a board-certified chiropractor. Dr. Ierna reviewed Plaintiff's file and concluded that her physical condition did not prevent her from working an eight-hour day because he could find no support for any "functional impairment from a musculoskeletal perspective." (A.R. -738.) He noted that, for the most part, the evidentiary support for her physical symptoms was her own subjective report of symptoms with little else. (A.R. -739.) Accordingly, Dr. Ierna found Plaintiff capable of returning to work. (A.R. -738.) Nonetheless, in light of her reports of pain, he also concluded that certain restrictions and limitations on work were appropriate: "From 6/6/11 through 9/30/11: Limit prolonged sitting, standing and walking to one hour ...