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Seitles v. Unum Provident

September 29, 2009


The opinion of the court was delivered by: Frank C. Damrell, Jr. United States District Judge


This matter is before the court on the parties' cross-motions for judgment on the administrative record, pursuant to Federal Rule of Civil Procedure 52,*fn1 arising out of defendants UnumProvident Corporation and Unum Life Insurance Company of America's (collectively, "defendants" or "UNUM") denial of plaintiff Ginger Seitles' ("plaintiff") claim for long-term disability ("LTD") benefits.*fn2

For the reasons set forth below, the court finds that the proper standard of review of this matter is abuse of discretion, as opposed to de novo, and thereunder, the court finds that UNUM did not act arbitrarily or capriciously in denying plaintiff's LTD benefits claim. As such, the court DENIES plaintiff's motion for judgment in her favor and HEREBY GRANTS judgment in favor of UNUM.


A. The Policy

The California Independent System Operator ("CAL ISO"), plaintiff's former employer, purchased the UNUM Group Long Term Disability Policy Number 519640 (the "Plan") to provide long-term disability coverage for its active, eligible employees. Relevant to this action, the Plan provides, in pertinent part, as follows:


You are disabled when UNUM determines that:

-- you are and substantial duties limited from performing the material due to sickness or injury of your regular occupation; and

-- you have a 20% or more loss in your earnings indexed monthly due to the same sickness or injury.

After 24 months of payments, you are disabled when UNUM determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience. (Administrative Record ["AR"], filed July 29, 2009 [Docket #30], UACL00021.)


The policy is delivered in and is governed by the laws of the governing jurisdiction and to the extent applicable by the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments. When making a benefit determination under the policy, UNUM has discretionary authority to determine your eligibility for benefits and to interpret the terms and provisions of the policy. (AR: UACL00015.)


Your coverage under the policy or plan ends on the earliest of: . . . -the date you are no longer in an eligible group . . . -the last day you are in active employment except as provided under the covered layoff or leave of absence provision. (AR: UACL00018.)

ELIGIBLE GROUP(S): All employees in active employment. (AR: UACL00009.)

MINIMUM HOURS REQUIREMENT: Employees must be working at least 30 hours per week. (AR: UACL00009.)

ACTIVE EMPLOYMENT means that you are working for your Employer for earnings that are paid regularly and that you are performing the material and substantial duties of your regular occupation. You must be working at least the minimum number of hours as described under Eligible Group(s) in each plan. (AR: UACL00043.) (Emphasis in original.)

B. Plaintiff's Employment History

Plaintiff worked for CAL ISO as a Senior Market Integration Engineer. CAL ISO is a not-for-profit public-benefit corporation charged with operating the majority of California's high-voltage wholesale power grid. Plaintiff was hired by CAL ISO on July 7, 1997, and her last date of employment was November 16, 2001.*fn3 Although plaintiff now asserts that she left her employment because of a disability (AR: UACL00348-00349), records from plaintiff's personnel file indicate that she was terminated because of job performance issues. Her personnel file includes an October 11, 2001 memorandum entitled "Performance Improvement Plan for Ginger Seitles." (AR: UACL00846-00849). Said memorandum indicates that plaintiff's managers, supervisors and co-workers had complained about certain inappropriate behavior by plaintiff, including that she "barged" into issues in which she had no involvement, "jumped to conclusions" unnecessarily and made "racially insensitive slurs." (Id.) CAL ISO scheduled a further review of plaintiff's performance for November 15, 2001. However, on November 11, 2001, plaintiff entered into a settlement agreement with CAL ISO wherein she agreed to the termination of her employment in exchange for a payment of $27,742.68, representing four months pay; plaintiff also released CAL ISO from any claims arising from the termination of her employment. (AR: UACL00881-883.) Notably, there are no records in plaintiff's personnel file which indicate that, during the entirety of her employment with CAL ISO, she had any issues relating to her physical ability to perform her job due to multiple sclerosis ("MS") (which plaintiff now maintains rendered her disabled from performing her job for the company). (AR: UACL00846-849.)

Following the termination of her employment with CAL ISO, plaintiff began looking for new employment. (AR: UACL00954-00959, UACL001249, UACL001253, UACL001256, UACL001257.)*fn4 Ultimately, she did not accept other employment. She explained in a later personal injury action that she declined certain positions due to injuries she sustained in an automobile accident in July 2002. (See Section E below.)

C. UNUM's Review of Plaintiff's Initial Benefits Claim

On May 7, 2003, sixteen months after her employment with CAL ISO had ended, plaintiff filed a Disability Claim Form with UNUM in which she asserted she was unable to work as of November 16, 2001 due to MS that had been diagnosed in April 1998. She claimed her MS symptoms had worsened over time. (AR: UACL00348.) In support of her claim, plaintiff submitted an Attending Physician's Statement from Philip B. Baldi, D.O., who concluded that plaintiff had been disabled since November 16, 2001 due to neck pain, MS, cervical disease and shoulder pain. Dr. Baldi listed plaintiff's restrictions as "anything that will exacerbate back [and] shoulder [pain], like bending, lifting, reaching, [and] computer work." (AR: UACL00352.)

In reviewing plaintiff's claim, UNUM considered various medical records predating plaintiff's claimed date of disability of November 16, 2001 as well as records post-November 16, 2001. The pre-November 16 records included the following: (1) a June 19, 2001 report from Dr. Baldi indicating that plaintiff complained of a rash, gastroenteritis and nausea (AR: UACL00442); and (2) a November 13, 2001 report from Dr. James C. Stoody, a neurologist, indicating that plaintiff complained of a "stabbing discomfort in her feet and numbness in her extremities" but "denied any motor impairment;" Dr. Stoody performed an examination of plaintiff and concluded that there were "no significant abnormalities on motor, sensory, reflex testing, cranial nerve exam or gait and station assessment;" Dr. Stoody described that plaintiff's symptoms were "entirely subjective at this point in time" but that her ...

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