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Young v. Prudential Insurance Co. of America

March 31, 2008

KAREN YOUNG, PLAINTIFF,
v.
PRUDENTIAL INSURANCE COMPANY OF AMERICA, D/B/A PRUDENTIAL FINANCIAL, INC., DEFENDANT.



The opinion of the court was delivered by: Thomas W. Phillips United States District Judge

(Phillips/Shirley)

MEMORANDUM OPINION

This action under the Employee Retirement Insurance Security Act ("ERISA"), 29 U.S.C. § 1001 et seq., is presently before the court on plaintiff's motion for summary judgment [Doc. 8] and supporting memorandum [Doc. 9] and defendant's response in opposition to plaintiff's motion for summary judgment/defendant's cross-motion [Doc. 10]. For the reasons that follow, plaintiff's motion for summary judgment is denied and defendant's cross-motion for judgment is granted.

I. BACKGROUND

Plaintiff Karen Young was employed as a retirement plans specialist by Sea Ray Boats, Inc., a subsidiary of Brunswick Corporation. Through this employment, plaintiff was covered by the long term disability ("LTD") benefits plan underwritten by defendant, Prudential Insurance Company of America, Inc. ("Prudential"). Brunswick Corporation served as the plan sponsor and administrator, while Prudential, in addition to underwriting the claim, served as the claims administrator.

Plaintiff was diagnosed with fibromyalgia in 1996 by her rheumatologist, Marvin Beard, M.D. Plaintiff's primary care physician, Stephen Pershing, M.D., treated plaintiff for this condition, which steadily improved until October 2002, when plaintiff began presenting symptoms again, exacerbated by point stress and personal issues. In January 2003, plaintiff was diagnosed with a breast carcinoma, at which time she stopped working. Her symptoms at this time included pain, fatigue, migraines, weakness, numbness, blurred vision, soreness, diarrhea, lack of mobility, poor memory and concentration, and sleep disorders. Plaintiff underwent a lumpectomy in February 2003 and received radiation treatment through May 2003.

Plaintiff began receiving short-term disability ("STD") benefits on February 10, 2003. In June 2003, having determined that plaintiff had sufficiently recovered from her breast cancer, Prudential terminated her STD benefits and denied plaintiff's claim for long-term disability ("LTD") benefits. This latter determination was subsequently overturned on administrative appeal, and plaintiff began receiving LTD benefits in February 2004, retroactive to July 2003. Prudential determined that she was eligible for these LTD benefits due to her psychiatric condition(s).

Under the policy provisions, Prudential reviews every claim for benefits after twenty-four months of payments. Under the policy, after this initial twenty-four-month pay period, the requirements for disability become more stringent. To be disabled, the beneficiary must now be precluded from performing any gainful occupation for which he is qualified, in contrast to the initial determination of disability, under which a beneficiary need only be precluded from performing his current occupation. Disability due in whole or in part to mental illness, including depression, is also restricted to a twenty-four-month pay period. On July 26, 2005, Prudential determined that plaintiff continued to meet the requirements of disability and continued her LTD benefits, "provided that [she] remain totally impaired" under the terms of the policy. Upon reevaluation in June 2006, Prudential again reviewed plaintiff's complaints of breast carcinoma, fibromyalgia, migraines, carpal tunnel syndrome, and severe depression. Prudential found that while plaintiff had "multiple somatic complaints," she nevertheless was able to "maintain a level of activity and use of [her] hands that demonstrates that [she has] the capability of performing sedentary work" with some restrictions, and therefore denied plaintiff further LTD benefits. Prudential also suggested occupations which it found matched plaintiff's ability to work.

Plaintiff appealed the decision through Prudential's appeals process. In each of the two appeals, Prudential additionally relied on a surveillance video taken of plaintiff in her garden, as well as an independent file review by a board-certified internist with a subspeciality in rheumatology. Prudential again determined that plaintiff was not disabled as defined by the policy; plaintiff was further denied benefits due to her depression, a condition for which disability benefits under the policy are limited to twenty-four months of payment. Having exhausted all administrative appeals, on March 21, 2007, plaintiff commenced the instant action.

II. STANDARD OF REVIEW

Under Rule 56(c) of the Federal Rules of Civil Procedure, a court may grant summary judgment only when there is no genuine issue of material fact and the moving party is entitled to judgment as a matter of law. Fed. R. Civ. Pro. 56(c). "A fact is material only if it might affect the outcome of the case under the governing law." Williams v. Int'l Paper Co., 227 F.3d 706, 710 (6th Cir. 2000). Accordingly, this court must review the record under the rubric of applicable ERISA law to determine whether either party is entitled to judgment as a matter of law.

"As a general principle of ERISA law, federal courts review a plan administrator's denial of benefits de novo, 'unless the benefit plan gives the plan administrator discretionary authority to determine eligibility for benefits or to construe the terms of the plan.' " McDonald v. Western-Southern Life Ins. Co., 347 F.3d 161, 168 (6th Cir. 2003) (quoting Wilkins v. Baptist Healthcare Sys., Inc., 150 F.3d 609, 613 (6th Cir. 1998)). If the plan administrator has such discretionary authority, then a decision to deny benefits is reviewed "under 'the highly deferential arbitrary and capricious standard of review.' " Id. at 168-69 (quoting Yeager v. Reliance Std. Life Ins. Co., 88 F.3d 376, 380 (6th Cir. 1996)). Such discretionary authority does not hinge on "magic words"; rather, courts are directed "to focus on the breadth of the administrators' power-their 'authority to determine eligibility for benefits or to construe the terms of the plan.' " Perez v. Aetna Life Ins. Co., 150 F.3d 550, 555 (6th Cir. 1998) (quoting Block v. Pitney Bowes, Inc., 952 F.2d 1450, 1453 (D.C. Cir. 1992) (other quotations omitted)). The Sixth Circuit has therefore "consistently required that a plan contain 'a clear grant of discretion [to the administrator] to determine benefits or interpret the plan.' " Id. (quoting Wulf v. Quantum Chem. Corp., 26 F.3d 1368, 1373 (6th Cir. 1994)).

Plaintiff has conceded that the arbitrary and capricious standard applies here, [Doc. 9 at 8], as the plan sub judice places the onus on Prudential to determine whether the beneficiary is disabled. This standard is applied as follows:

The arbitrary and capricious standard is the least demanding form of judicial review of administrative action. When applying the arbitrary and capricious standard, the [c]court must decide whether the plan administrator's decision was rational in light of the plan's provisions. Stated differently, when it is possible to offer a reasoned explanation, based on the evidence, for a particular outcome, that outcome is not arbitrary or capricious.

McDonald, 347 F.3d at 169 (quoting Williams v. Int'l Paper Co., 227 F.3d 706, 712 (6th Cir. 2000)); accord, e.g., Spangler v. Lockheed Martin Energy Sys., Inc., 313 F.3d 356, 361 (6th Cir. 2002); ...


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