Haber v. Reliance Standard Life Insurance Co.

FINDINGS OF FACT AND CONCLUSIONS OF LAW

          MICHAEL W. FITZGERALD United States District judge.

         Plaintiff Orly Haber brings this action against Defendant Reliance Standard Life Insurance Company for recovery of long-term disability benefits under the Employee Retirement Income Security Act of 1974 (“ERISA”). This matter came on for trial before the Court sitting without a jury on April 5, 2016. The parties did not present any additional evidence at trial but argued from the Administrative Record and supplemental evidence filed with the Court. The Court admitted the Administrative Record and Exhibit 1 to the Declaration of Robert F. Keehn in Support of Plaintiff’s Initial Trial Brief (Docket No. 21). Following the parties’ arguments, the Court took the matter under submission.

         Having carefully reviewed the record and the arguments of counsel, as presented at the trial and in their written submissions, the Court now makes the following findings of fact and reaches the following conclusions of law under Rule 52 of the Federal Rules of Civil Procedure. Any finding of fact that constitutes a conclusion of law is also hereby adopted as a conclusion of law, and any conclusion of law that constitutes a finding of fact is also hereby adopted as a finding of fact.

         I. FINDINGS OF FACT

         1. Plaintiff Orly Haber is an individual and citizen of the State of California.

         2. Defendant Reliance Standard is a corporation duly organized and existing pursuant to the laws of the State of Illinois with its principal place of business located in Philadelphia, Pennsylvania.

         A. Haber’s Employment

         3. Between 2000 and 2011, Haber worked as a salesperson for Neiman Marcus (“NM”). Haber’s work required a certain level of physical exertion, including being able to continuously stand and walk for approximately 67-100% of the time.

         4. As an NM employee, Haber was insured as a member of a group short-term disability (“STD”) policy as well as group long-term disability policy (“LTD Policy”).

         B. The LTD Policy

         5. Under the LTD Policy, Reliance Standard pays a monthly benefit to “an [insured employee who] (1) is Totally Disabled as the result of a Sickness or Injury covered by this Policy; (2) is under the regular care of a Physician; (3) has completed the Elimination Period; and (4) submitted satisfactory proof of Total Disability.”

         6. For Class 2 employees like Haber, the Policy considers an insured employee “Totally Disabled” if s/he “cannot perform the material duties of his/her Regular Occupation” “during the Elimination Period and for the first 24 months for which a Monthly Benefit is payable.” The Policy has a 180-day Elimination Period. An employee’s “Regular Occupation” is “the occupation the [employee] is routinely performing when Total Disability begins.” The first 24 months for which a Monthly Benefit is payable is known as the “Regular Occupation” period of the LTD Policy.

         7. After the Regular Occupation period, the Policy considers an insured employee “Totally Disabled” if the employee “cannot perform the material duties of Any Occupation.” “Any Occupation” is defined as “an occupation normally performed in the national economy for which [the employee] is reasonably suited based upon his/her education, training or experience.” The period following the Regular Occupation period is known as the “Any Occupation” period of the LTD Policy.

         C. Haber’s History of Illness, Medical Treatment, and Disability Claims

         8. In January 2011, Haber stopped working at NM. She submitted a claim for STD benefits based on reported symptoms of neck, shoulder, and back pain.

         9. That same month, Haber complained of back pain to her primary physician, Dr. Amanuel Sima. Dr. Sima referred Haber to physical therapy and ordered an MRI of Haber’s lumbar spine. The MRI came back normal. Dr. Sima extended Haber’s time off from work, ordered her to continue with physical therapy, and referred her to Dr. Neel Anand, a spine surgeon who recommended surgery to the cervical spine.

         10. Between February and April 2011, Haber continued seeing Dr. Sima and reported continued pain in her neck, back, and arm, as well as associated numbness in her arms. Dr. Sima’s records consistently reported that a physical examination of Haber revealed “upper extremity numbness with neck [range of motion].”

         11. In June 2011, Haber underwent cervical spine surgery.

         12. Following the surgery, Haber’s STD claim was approved and paid through the maximum 180-day STD period, from January 2011 through July 2011.

         13. In the months immediately following the surgery, Haber continued to see Dr. Sima and complain of pain in her neck, back, and arm, as well as associated numbness in her arms. Dr. Sima’s records beginning June 2011 and through April 2013, however, no longer reported any upper extremity numbness revealed by a physical examination. Dr. Sima’s August 2011 records also indicated that he expected Haber to make a “full recovery” in less than 12 months.

         14. In August 2011, Haber submitted a claim for LTD benefits based on the reported pain in her back, shoulder, neck, arms, and hands.

         15. Between August 2011 and May 2012, Dr. Sima’s records indicated that Haber’s “Chief Complaint” was limited to persistent neck and upper back pain. Between September 2011 and March 2012, Dr. Sima’s records indicated that Haber herself denied “any upper extremity weakness.”

         16. In March 2012, Reliance Standard notified Haber that her LTD claim had been approved and that she would receive LTD benefits beginning (retroactively) July 2011. Haber’s LTD benefits were thus paid under the policy’s “Regular Occupation” 24-month period of disability, from July 2011 to July 2013. Reliance Standard explained that Haber would reach the end of the 24-month Regular Occupation period in July 2013, before which Defendant would begin to ...