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Whalen v. Standard Insurance Co.

November 5, 2009


The opinion of the court was delivered by: David O. Carter United States District Judge


The Court conducted a one day bench trial on August 18, 2009. Defendants and Plaintiff filed trial briefs and supporting exhibits and both parties filed supplemental briefing, including Revised Proposed Findings of Fact and Conclusions of Law, on August 25, 2009. At the Court's request, the parties also filed supplemental briefing regarding the standard of review on August 25, 2009, and the Court also entertained additional supplemental briefing regarding the standard of review, which Defendants filed on September 17, 2009, and Plaintiff responded to on September 22, 2009. Having considered the submissions by the parties and all admissible evidence, the Court hereby enters its Findings of Fact and Conclusions of Law in conformity with Federal Rule of Civil Procedure 52.



1. The policy at issue in this case is Standard Insurance Company Group Long Term Disability Policy No. 642193-B ("LTD Plan"), which Defendant Standard Insurance Company ("Standard") issued to Pacific Life Insurance Company ("Pacific Life"), effective January 1, 2006, as amended from time to time. [Administrative Record ("AR") 09.]

2. William Whalen ("Plaintiff") was employed by Pacific Life for over twenty-eight years, since 1979, and was an LTD Plan Participant. [AR 585.]

3. The LTD Plan is an employee health and welfare long-term disability benefit plan.

4. Standard also evaluated Plaintiff's eligibility for benefits pursuant to his Short Term Disability Policy.

5. Standard was the administrator of the Short Term Disability Policy.

6. Standard acted as the adminsitrator and, pursuant to the Plan's Insuring Clause, payor of the LTD Plan. [AR 16.]

7. Plaintiff's claims for short-term and long-term disability benefits were decided by Standard concurrently. [AR 107.]

8. Standard acted as both a claims decider and a claims payor for Plaintiff's disability claims.

9. The "Allocation of Authority" section of the LTD Plan provides Standard the authority to administer claims: "[W]e have full and exclusive authority to control and manage the Group Policy, to administer claims, and to interpret the Group Policy and resolve all questions arising in the administration, interpretation, and application of the Group Policy." [AR 32.] According to the Policy, Standard's authority includes, but is not limited to, the right to resolve all matters when a review has been requested; the right to establish and enforce rules and procedures for the administration of the Group Policy and any claim under it; and the right to determine eligibility for insurance, entitlement to benefits, the amount of benefits payable; and the sufficiency and the amount of information it may reasonably require to make these determinations. [AR 32-33.] The Allocation of Authority provision concludes that "[s]ubject to the review procedures of the Group Policy, any decision we make in the exercise of our authority is conclusive and binding." [AR 33.]

10. The LTD Plan states that a claimant must submit satisfactory proof of disability to Standard. [AR 30.] To be considered "disabled" the LTD Plan states that a claimant must be unable, "as a result of Physical Disease, Injury, Pregnancy, or Mental Disorder . . . to perform with reasonable continuity the material duties of [his] Own Occupation." [AR 20.]

11. "Own Occupation" is defined as "any employment, business, trade, profession, calling or vocation that involves Material Duties of the same general character as the occupation [a claimant is] regularly performing for [the claimant's] Employer when Disability begins." [Id.]

12. Material Duties are defined by the LTD Plan as those "essential tasks, functions and operations, and the skills, abilities, knowledge, training and experience, generally required by employers from those engaged in a particular occupation." [AR 21.]

Condition for which Disability Claimed

13. On July 7, 2006, Plaintiff was involved in a serious traffic accident. [AR 442.] He was waiting at a traffic light, but when the light changed to green the car in front of him failed to move. A driver approaching at high speed from the rear did not notice that the cars at the light hadn't moved. He slammed into Plaintiff's car from behind at 45 miles per hour. [AR 443.]

14. Following the accident, Plaintiff went to a hospital where he was given x-rays and treated for pain in his neck, back and ribs. [AR 298, 337.]

15. Following the accident, Plaintiff returned to work and remained at work through May 2007.

16. Plaintiff initially consulted a chiropractor, Dr. Douglas Di Siena, on July 19, 2006. [AR 786.] Dr. DiSiena conducted muscle tests showing "a relative loss of strength in the right deltoid [i.e. shoulder muscle] and right pectoralis [i.e. chest muscle]." [AR 314.] Dr. DiSiena also noted that Plaintiff had loss of movement in his cervical spine. [Id.]

17. Dr. Di Siena treated Plaintiff for several months after the accident. Dr. DiSiena's Final Report noted that Plaintiff's prognosis "remains poor at this time." [AR 316.] He also observed that Plaintiff "truly benefited from the chiropractic and additional ancillary care we provided to him." [AR 317.]

18. Plaintiff also consulted Dr. John Dorsey, an orthopedic surgeon, at Dr. DiSiena's referral. Dr. Dorsey examined Plaintiff on August 2, 2006. [AR 870.] During this examination, Dr. Dorsey documented that Plaintiff made no complaints of pain on palpation of the cervical spine or paracervical musculature. [AR 872.] Dr. Dorsey also commented that "[r]ange of motion of the cervical spine is within normal limits without complaints of pain." [Id.] Upon examination he had a normal range of motion with complaints of pain at the limits of motion. [Id.]

19. Plaintiff consulted with another orthopedist, Dr. Daniel Capen, on August 18, 2006. Plaintiff reported aching-to-sharp pain in his cervical spine with pain radiating through his shoulders, extending to his upper arms, as well as numbness in the left arm extending into his left index finger and left thumb and pain in his neck radiating to the back of his head. [AR 299]. Dr. Capen observed Plaintiff to have a normal gait with no deformity of the spine, although he noted limited range of motion in the cervical and lumbar spine and that Plaintiff's paraspinal muscles were tender. [AR 300.] X-rays of the cervical spine showed some narrowing at C6-7, and x-rays of the lumbar spine revealed a very slight scoliosis. [AR 302.] Dr. Capen ordered MRIs of Plaintiff's spine and prescribed pain medications, anti-inflammatories, and muscle relaxants. [AR 302-03.]

20. Plaintiff had MRIs of his cervical and lumbar spine taken on August 24, 2006. [AR 304-12.] The MRIs showed disc desiccation through the cervical spine, osteophytes at C4 through C7, C5-6 and C6-7. [AR 304.] The MRIs also showed disk protrusions in the lumbar spine in L2-3, L3-4, and L4-5. [AR 308.]

21. In December 2006, Plaintiff saw a neurologist, Dr. Kirkorowicz, who recommended patient avoid all physical and emotional stress. [AR 354-59.]

22. Plaintiff also saw a pain specialist, Dr. Clifford Bernstein, in January of 2007. Dr. Bernstein utilized epidurals and nerve blocks in an attempt to alleviate the pain, but Plaintiff's pain was not relieved through this treatment. [AR 336.]

23. In March of 2007 Plaintiff consulted with a second neurologist, Dr. Michael Mahdad. At that point, Plaintiff was suffering from constant neck pain which "becomes very sharp and very painful and [] will start to radiate down into the left arm--associated with numbness & paresthesia." [AR 346.] Dr. Mahdad diagnosed Plaintiff with "[c]ervical sprain/strain associated with left ...

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