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Grisham v. Life Insurance Co. of North America

October 25, 2007


The opinion of the court was delivered by: Chief Judge Curtis L. Collier


This is a lawsuit brought by Angela Grisham ("Plaintiff") against Life Insurance Company of North America and CIGNA Companies Long Term Disability Plan ("Defendants") for disability benefits pursuant to the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§ 1001 et seq. Before the Court are three motions: Plaintiff's motion for judgment on the administrative record or, in the alternative, to remand to Defendant for another claims determination (Court File No. 17); Defendant's motion for judgment on the administrative record, and to oppose Plaintiff's motion for judgment on the administrative record (Court File No. 20); and, Plaintiff's motion for judicial notice or, in the alternative, to expand the record (Court File No. 22). This Court also considers the other motions filed in opposition to the motions above (Court Files Nos. 24, 25, 26).

For the foregoing reasons, this Court DENIES Plaintiff's motion for judicial notice and to expand the record; GRANTS Defendant's motion for judgment on the administrative record; DENIES Plaintiff's motion for judgment on the administrative record as it pertains to short-term disability benefits; and, DENIES as moot Plaintiff's motion as it pertains to long-term disability benefits.


A. Plaintiff's Employment and Illness History

Plaintiff was employed as an administrative assistant or "executive secretary" to the Service Center Leader at CIGNA's Chattanooga location (Court File No. 2, Am. Compl., ¶ 5; Admin. R. ("A.R.") at 86). Plaintiff began her employment in March 2002 (Court File No. 18, Mem. in Supp. of Pl.'s Mot. for Summ. J. on A.R., p. 1).

In March 2003, Plaintiff appears to have taken a brief period of short-term disability leave (A.R. at 73-78). On June 12, 2003, Plaintiff left work due to "devastating" pain (Court File No. 17, p. 2), and did not return. Plaintiff suffers from nephrolithiasis or kidney stones (Court File No. 2, ¶ 8). This condition causes pain, decreased renal functioning, and sometimes depression and/or disordered sleep (id. ¶¶ 9-11). Plaintiff's treatment has included narcotic painkillers (id. at ¶ 9), lithitripsies,*fn1 nephrostomy drainage tubes,*fn2 and ureteral stents (Court File No. 18, p. 3-4) (citing multiple records in A.R.).*fn3

Plaintiff developed a 3.5 cm kidney stone, which could not be passed and required multiple lithotripsies to break up the fragments (A.R. at 197). Plaintiff's doctor sent a letter to CIGNA's claims manager summarizing Plaintiff's treatment. According to Dr. David A. Sahaj ("Dr. Sahaj"), treatment began on June 23, 2003 with ureteral stenting followed by ESWL (id.). Although Plaintiff had "excellent fragmentation" of the large stone, she "developed a right ureteral steinstrasse . . . complicated by an episode of stent obstruction and right sided pyelonephritis" (id.).*fn4 Plaintiff was hospitalized because of this infection from July 31, 2003 to August 6, 2003, and her stent was replaced by a nephrostomy tube (id.).

Plaintiff underwent additional ESWL procedures on August 19,*fn5 August 29, September 19, and October 10, 2003 (A.R. at 197, 248). Plaintiff had an office visit on September 15, 2003 (A.R. at 247), and was briefly hospitalized to replace her nephrostomy tube on September 19, 2003 (A.R. at 197). In early October, Plaintiff underwent ureteroscopic extraction of stone fragments, had the nephrostomy tube removed, and the stent replaced (id.). At the time of Dr. Sahaj's letter, Plaintiff still had a stent in place to finish clearing stone fragments from her ureter. Dr. Sahaj "anticipate[d] her either passing her residual stones or having them removed endoscopically in the near future" and also "anticipate[d] several more weeks in total with a [sic] ureteral stent" (id.). This letter is the most recent record in Plaintiff's claim file.

B. The Disability Benefits Plan

As a benefit, CIGNA provided its employees with short- ("STD") and long-term ("LTD") disability coverage under a plan funded by CIGNA and administered by the Life Insurance Company of North America, a CIGNA subsidiary. This "Plan" pays STD benefits to an employee with a "covered disability that begins at a time when [the employee] ha[s] STD Plan coverage." (A.R. at 6). The parties do not dispute Plaintiff had STD Plan coverage under the Plan, but dispute whether Plaintiff had a "covered disability." The Plan defines this as:

[I]f, because of a medical condition related to an accident, illness or pregnancy: ! You are unable to perform the essential functions of your current or a similar role for at least six consecutive scheduled work days; ! The essential duties that you cannot perform cannot be reassigned to another person in order to accommodate your return to work; ! You cannot, based on your lack of work experience or on work restrictions related to your medical condition, be reassigned to another position within 15% of the market value of your current role; and ! Your physician provides objective medical evidence to support his or her assessment of your medical condition. (Id.).

The Plan provides for the termination of benefits at the earliest of:

! You refuse or discontinue medical treatment that is necessary for your recovery

. . . ; ! Your physician releases you to return to work; ! Your disability is no longer a covered disability; . . . ! You are unable to provide satisfactory medical evidence of a covered disability;

. . . or ! You refuse or fail to comply with Disability Management Solutions in the administration of the claim, including but not limited to, failing to provide information or documents needed to determine whether benefits are payable or the actual benefit amount due, or providing false information. (Id. at 9).

C. Procedural History of Plaintiff's Claim

Plaintiff filed a claim for STD benefits on June 23, 2003, using "kidney stones" as her disabling condition (Court File No. 17, p. 2; A.R. at 177). Her application was initially approved (A.R. at 90). However, by letter dated September 24, 2003, Defendant terminated Plaintiff's benefits, effective September 1, 2003 (A.R. at 124). This letter cites the following reasons for the termination:

[T]here must be medical evidence that supports your inability to perform your essential job duties. Based on documentation regarding your position as an Executive Secretary, your duties are sedentary in nature. We consider medical evidence that supports a disability to be a measurable abnormality, which is evidenced by one or more standard medical diagnostic evaluations . . . that support and substantiate the presence of a physical condition that would result in a functional limitation significant enough to preclude an individual from performing the essential duties of their [sic] job or reasonable temporary accommodations . . . . You were advised on September 10, 2003 that additional medical [evidence] [sic] was needed by September 14, 2003 to consider benefits beyond August 24, 2003. We received and reviewed a packet of records from Dr. Sahaj on September 12, 2003 with his most recent note the lithotripsy completed on August 29, 2003. No additional office notes, test results or specialist visits were received beyond August 29, 2003. In summary, we have received no objective medical information to support that you are totally disabled from your sedentary position as an Executive Assistant. We have further approved your claim to August 31, 2003 and benefits are denied as of September 1, 2003.

At this point in time, you do not satisfy the definition of disability as defined by the plan and we must deny your claim. (A.R. at 124-25). The letter included instructions on how to appeal.

Plaintiff appealed in a letter dated October 27, 2003 and supported by records dated through October 13, 2003; Plaintiff also stated she had two surgeries that had not yet been dictated but which would be faxed to Defendant as soon as Plaintiff had a follow-up appointment (A.R. at 131). Despite these new records, Plaintiff's appeal was finally denied on November 25, 2003 (A.R. at 134) ("Final Denial"). The Final Denial letter cites the following reasons for affirming the termination of benefits: there were no clinical findings to support Plaintiff's inability to perform the essential functions of her sedentary position; Plaintiff's doctor opted to "leave the issue [determining Plaintiff's disability] between [Plaintiff] and CIGNA"; and an independent medical ...

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