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Ampe v. The Prudential Insurance Company of America

United States District Court, D. Massachusetts

October 17, 2018

JAMES AMPE
v.
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA, et al.

          MEMORANDUM AND ORDER ON JAMES AMPE'S MOTION FOR SUMMARY JUDGMENT AND DEFENDANTS' CROSS-MOTION FOR JUDGMENT ON THE RECORD

          RICHARD G. STEARNS UNITED STATES DISTRICT JUDGE.

         Plaintiff James Ampe moves for summary judgment following a rejection of his application for long-term disability (LTD) benefits. This court has jurisdiction under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1132. Defendants Prudential Insurance Company of America (Prudential), Massachusetts Institute of Technology (MIT), and the MIT LTD Plan (collectively defendants), cross-move for a brevis disposition. Because I find that defendants abused their discretion by failing to adequately consider or address Ampe's evidence of mental disability, the cross-motions will be denied and the case remanded to defendants for further proceedings consistent with this opinion.

         FACTUAL BACKGROUND

         Ampe is a 53-year-old electrical engineer who worked as a Senior Development and Test Engineer for MIT Lincoln Laboratories from 2008 to January 26, 2015.[1] The duties of Ampe's position included frequent interactions with clients as well the duties ordinarily attendant to those of an electrical engineer.

         In August of 2011, Ampe fell and struck his head in the bathroom of his home. Following the accident, Ampe complained of cognitive fatigue, difficulty concentrating, and an inability to focus in a noisy environment. In September and October of 2012, Ampe presented to Dr. Sheba Khumbani, a neurologist, for testing. Dr. Khumbani found that, while Ampe was “functioning in the average range for verbal abilities and in the very superior range for visual-spatial skills, ” R. at 896, he had “experienced a significant decline since the possible concussion and his residual symptoms, including physical, cognitive, and emotional/behavioral changes, are consistent with what is often seen in post-concussive syndrome.” R. at 897.[2]

         Despite the diagnosis, Ampe continued to work, taking intermittent FMLA leave. His annual performance reviews, however, deteriorated markedly over time. Following the 2014 review, which was the worst that Ampe had ever received, MIT informed him that it would provide no further accommodations and recommended that he apply for LTD benefits. Ampe did so on February 14, 2015.

         MIT's LTD Plan, under which Ampe was covered, provided:

You will be considered totally disabled if you are prevented by bodily injury, sickness, disease, or mental disorder from engaging in your own occupation. After the first 24 months, you will be considered totally disabled only if you are prevented by bodily injury, sickness, disease, or mental disorder from engaging in any occupation for which you are reasonably fitted by education, training, or experience.

R. at 715 (emphasis in original).[3]

         In assembling his LTD claim, Ampe relied on the diagnosis of his treating physician, Dr. Seth Herman. According to Dr. Herman, Ampe had suffered a traumatic brain injury in 2011 and “continues to be limited by post brain injury symptoms especially dizziness, fatigue, headache, nausea, confusion, [sic] irritability. He is not able to tolerate work and 32 hours or more of work is not medically feasible.” R. at 737. Turning to Ampe's prognosis, Dr. Herman opined:

         Mr. Ampe's post-concussion syndrome symptoms and condition are causally related to his fall on 8/29/2011 . . . . Some patients never return to [sic] prior level of functioning. What we do know is that up to 5 to 15% continue to suffer persistent post concussions symptoms.

Id.

         On April 27, 2015, Dr. Rajesh Wadhwa, Prudential's Vice President and Medical Director, rejected Ampe's claim after reviewing Dr. Herman's report, the vestibular therapy records of Janet Callahan (a Massachusetts General Hospital physical therapist), Dr. Khumbani's 2012 evaluation, and quality-of-life correspondence between Ampe and his wife. Dr. Wadhwa faulted Dr. Khumbani's diagnosis principally because of her failure to perform “validity testing.”[4] R. at 1359. He also dismissed Dr. Herman's report and the physical therapy records as “not relevant and current.” Id. He recommended, however, that Prudential “please consider [a] fresh neuropsychiatric IME.” R. at 1359. When MIT refused to pay for the IME, Ampe volunteered to subsidize the cost. The offer was refused.

         On May 11, 2015, Prudential rejected Ampe's claim. In a letter explaining the denial to Ampe, Prudential noted that, while it had considered Dr. Herman's report, “corresponding medical records have not been provided for our review to assess how you present upon clinical examination.” R. at 1274. The denial letter repeated Dr. Wadhwa's conclusions, stating that Dr. Khumbani's testing results and the physical therapy notes “[did] not support a current cognitive impairment.” In an apparent reference to Dr. Khumbani's report, Prudential stated that she did “not provide validity testing and [did] not provide ...


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