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DIONIDA v. RELIANCE STANDARD LIFE INS. CO.

April 12, 1999

MERCEDES C. DIONIDA, PLAINTIFF,
v.
RELIANCE STANDARD LIFE INSURANCE COMPANY, ST. LUKE'S HOSPITAL GROUP LONG TERM DISABILITY INSURANCE PROGRAM, DEFENDANTS.



The opinion of the court was delivered by: Trumbull, United States Magistrate Judge.

OPINION AND ORDER ON CROSS-MOTIONS FOR SUMMARY JUDGMENT

I. INTRODUCTION

Dionida submitted a claim for disability benefits arising from back and shoulder problems. Reliance initially approved Plaintiff's claim, but shortly thereafter reviewed her claim and denied it based on a Transferable Skills Analysis that identified eight "suitable occupations" for Dionida. On Dionida's appeal of the denial, Reliance affirmed its decision to deny her claim.

For the reasons discussed below, the court reviews de novo, rather than for abuse of discretion, Reliance's decision to deny benefits. "The court finds that under either standard of review, Reliance's decision was erroneous because it applied an "any occupation" standard rather than the "regular occupation" standard required by the LTD Plan. Based on the fully developed record, the only possible conclusion is that Dionida is unable to perform the duties of her regular occupation, and is thus entitled to benefits.

II. FACTS

On July 17, 1995, Dionida submitted to Reliance a statement of claim for long term disability benefits under an insurance policy issued to her employer, St. Lukes Hospital. In her statement of claim, she identified her disability as "severe low back pain radiating to right leg, and right shoulder." The LTD Plan's description of "Total Disability" requires that during the first 66 months*fn1 of disability the claimant be unable to perform the material duties of his or her "regular occupation." She described her occupation as "Staff Registered Nurse."

The administrative file for Dionida's claim contains several supporting records from her doctors. Prior to Reliance's initial approval of Dionida's claim, the primary support for her claim came from her treating physician, Cesar Ortiz, M.D. Dr. Ortiz completed a Physician's Statement of Disability form supplied by Reliance. In it he identified the diagnoses as: 1) Chronic Degenerative Change in Acromioclavicular Joint with Encroachment on Rotation Cuff; 2) Degenerative Arthritis of Lumbar Spine with Slipped of L4 on L5; and 3) Bilateral Radiculopathy. He indicated that Dionida was totally disabled from her regular occupation and from any occupation.

There are also several other Disability Certificates and Doctor's Certificates in the administrative file that Dr. Ortiz apparently filled out for submission to St. Lukes and California's Employment Development Department ("EDD") in connection with Dionida's disability leave and disability claims. The file also contains copies of Dr. Ortiz's records and a Physical Capacities form he filled out at Reliance's request. On the Physical Capacities form, he indicates that Dionida is capable of lifting/carrying a maximum of ten pounds, which is characterized on the form as "sedentary work." He also indicates restrictions on bending, squatting, climbing, reaching above the shoulder, kneeling, crawling and using foot controls. The administrative record also contains a few records from other doctors that do not add materially to the information "provided by Dr. Ortiz.

In addition to the medical records, Reliance asked Dionida and St. Lukes Hospital to submit information regarding Dionida's job. A job description from St. Lukes states that Dionida's job requires a "full range of body motion including handling and lifting patients . . ." and an ability to lift and carry items weighing up to 40 pounds. A Job Analysis Description submitted by St. Lukes states that Dionida's job requires her to carry items weighing 26 to 49 pounds ten percent of the time, items weighing 50 to 100 pounds ten percent of the time, and items weighing over 100 pounds ten percent of the time.

Reliance approved Dionida's claim on February 1, 1998. Six weeks after approving Dionida's claim, Defendants decided to require Plaintiff to submit to an independent medical examination ("IME").). The M.D. was performed by Robert Branick, He stated in his report that:

  "1) The results of the physical examination are
  inconclusive in determining significant disability.
  The objective studies that are available do document
  disability related to impingement of the, right
  shoulder as well as fairly mild degenerative changes
  in the lumbar spine which will cause some restrictions
  as mentioned above, that is, repetitive bending,
  stooping, lifting, and carrying of weights in excess
  of 25 pounds.
  "5) This has been answered above. Barring appropriate
  medical or surgical treatment, the patient will have
  permanent limitations.
  "6) The patient's limitations will interfere with the
  ability to work as a registered nurse. Any other work
  that could be carried out aside from that requiring
  bending, lifting, and carrying would be permissible.
  Sedentary work, keyboard work, work requiring
  mobility, etc., would all be permissible."

Dr. Branick also completed a Physical Capacities form, on which he indicates that Dionida was capable of lifting/carrying a maximum of 20 pounds (in his narrative report he says 25 pounds), which is characterized on the form as "light work." He also indicates restrictions on bending, climbing, and reaching above the shoulder.

Based on Dr. Branick's IME report and Physical Capacities form, Reliance asked its Vocational Rehabilitation Consultant, Rabia Rosen, to do a Transferable Skills Analysis ("TSA"). Rosen reported the results of the TSA in a memorandum dated June 19, 1996. Rosen stated that "[b]ased on her work history and her current capabilities and utilizing the OASYS system,*fn2 a TSA was performed and eight suitable occupations were identified for this claimant." Accompanying the memorandum is a computer printout that contains: 1) a DOT occupation description for "Nurse, General Duty"; 2) a ...


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