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Smith v. The PNC Financial Services Group

United States District Court, D. Maryland

July 21, 2017



          Marvin J. Garbis United States District Judge

         The Court has before it Defendants' Motion for Summary Judgment [ECF No. 31], Plaintiff's Cross-Motion for Summary Judgment [ECF No. 34], and the materials submitted relating thereto.[1] The Court has reviewed the exhibits and considered the materials submitted by the parties. The Court finds a hearing unnecessary.

         I. BACKGROUND

         Plaintiff Wiley Joseph Smith (“Smith”) worked for Defendant The PNC Financial Services Group, Inc. (“PNC”) from 1990 until September 5, 2013, at which time he was a Regional Manager II in PNC's Realty Services. Smith was a participant in PNC's short and long-term disability plan, a self-funded plan under the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1132 et seq. Smith was diagnosed with depression and anxiety in 2008 and was receiving treatment, but his condition worsened in August 2013, when he became unable to continue performing his job duties as a result of disabling major depression and panic disorder. Smith was granted short-term disability benefits beginning on September 5, 2013. He has never returned to work, and the record contains no evidence indicating that a return to work is reasonably feasible.

         During the period of short-term disability, Smith applied for long-term disability (“LTD”) benefits to commence on December 4, 2013, after the 91-day elimination period covered by the short-term disability benefits. Defendant Liberty Life Assurance Company of Boston (“Liberty Life”), the claims administrator of the policy under which benefits are payable, denied Smith's claim for benefits.

         Smith has brought the instant lawsuit against Defendants PNC, Liberty Life, and The PNC Financial Services Group, Inc. and Affiliates Long-Term Disability Plan (“the Plan”) (collectively “Defendants”) under ERISA, 29 U.S.C. § 1001, et seq., and more specifically, ERISA § 502, 29 U.S.C. § 1132. Smith seeks a declaration of rights under the long-term disability plan at issue, payment of all disability insurance benefits due and owing plus interest, and an award of attorney's fees and costs.

         A. The Benefits Plan

         The Plan is an employee welfare benefits plan as defined by ERISA, 29 U.S.C § 1002(1). The Plan provides full-time, salaried employees who are totally disabled due to injury or illness for longer than ninety-one days (the “Elimination Period”) with LTD benefits of up to 60% of their base salary.[2]

         To qualify for LTD benefits, an employee covered by the Plan must meet the definition of LTD.

For disabilities that extend beyond 91 consecutive calendar days and are considered long term, the definition of disability is as follows:
For the first 24 months (from the date LTD benefits begin): you are disabled if your disability makes you unable to perform the material or essential duties of your own occupation as it is normally performed in the national economy.
. . . .
The claims administrator determines whether your disability meets these definitions.

AR 164, ECF No. 16. The Plan also provides that LTD benefits paid due to a mental illness will stop after 24 months, unless certain circumstances exist, such as confinement in a hospital or institution. AR 170.

         B. Smith's “Occupation”

         Smith was employed as a Regional Manager II in PNC's Realty Services line of business. The job is a “[s]enior level operations position with direct responsibility for all day-today facility management activities for a portfolio of assigned buildings.” AR 13. This includes “interaction with outside property management companies, end-users, tenants, vendors/contractors, problem resolution, and ongoing construction/maintenance projects.” AR 14. The job's essential functions are described as requiring “significant organizational and time management skills” and are considered “critical to the well being of the company.” AR 14. Also, close monitoring of expenses is considered critical with direct responsibility for a budget of $20-50 million dollars per year and shared responsibility for capital/expense projects in excess of $10 million dollars. AR 15, 18. “The requirements of a Regional Manager II are particularly complicated, requiring the management of numerous sites spread out over a large geographic footprint.” AR 17.

         Specific skills and competencies required to perform the job are stated to include:

Must have demonstrated strong oral and written communications skills, leadership, and decision making abilities. Must be able to assess strategic problems and make accurate decisions with significant financial and risk implications. Must be team oriented and have an ability to provide exceptional service to customers and service partners. Must also have the ability to balance increased workload due to the sheer number of properties being managed. The ability to identify opportunities, research, analyze, question information and problem solve is essential. Obtains information from staff, service partners, consultants, vendors and determines appropriate course of action. Must be able to react to emergencies in a decisive manner. Interacts with all levels of management, including Corporate CEOs and LOB heads. Also interfaces with third parry property management firms, all of levels of end users, and various outside consultants, vendors, contractors, code officials, and suppliers.

AR 18.

         C. Illness and Short-term Disability

         Since 2008, when Smith was 55, [3] he has experienced recurrent major depression and has been receiving treatment for depression and anxiety. AR 66. In August 2013, he experienced a recurrence of symptoms including “sense of dread, chest pain, difficulty thinking and getting thoughts out, and panic attacks.” AR 66. He was unable to function at work and was advised by his treating doctor, Stephen W. Saunders, M.D. (“Dr. Saunders”), to remain off work and avoid all stressors. AR 66. He was treated with two antidepressants, an anti-anxiety medication, and a stimulant. AR 66.

         Dr. Saunders met with Smith again in October and on November 21, 2013, at which times Dr. Saunders noted that Smith was in “partial remission only.” AR 66. In Dr. Saunders' letter of December 4, 2013, he summarized that Smith “appears disabled from working in his previous employment, and also any employment at this time.” AR 66.

         Smith stopped working on September 4, 2013 and was granted short-term disability benefits beginning on September 5, 2013 (“Date of Disability”). AR 1, 8. Based on Smith's Date of Disability, the 91-day Elimination Period ended on December 5, 2013, which is also the LTD effective date. AR 1, 164.

         D. LTD Investigation

         1. Initial Review

         Liberty Life reviewed the records that Smith provided in support of his short-term disability claim, which included Dr. Saunders' Office Visit notes. AR 19-22. Liberty Life wrote to Smith on November 12, 2013 requesting further information and documentation that it needed for making an LTD claim determination. AR 23-24. Smith provided the requested documents, including Smith's completed Activities Questionnaire, AR 54-56, and records from Dr. Saunders, AR 58-61 and 65-71, and he spoke with Liberty Life by telephone on November 15, 2013, AR 6-9.

         Smith's own statement explained what prevented him from working:

My depression and anxiety make it very difficult for me to interact with people in work situations or to handle multiple tasks at one time. When anxiety and panic set in I become forgetful and cannot function normally.

AR 56.

         Liberty Life referred Smith's LTD claim for a psychiatric medical review to determine if the record supported any impairments that translated to restriction and limitations. AR 72. The review was performed by Dr. Roland Segal (“Dr. Segal”), who opined in his December 17, 2013 report that the medical records supported a diagnosis of major depressive disorder and generalized anxiety disorder. AR 75-78. Dr. Segal reported there was evidence of impairment through October 1, 2013, but not thereafter. AR 75-78. Dr. Segal added that there was no evidence that the prescribed medications caused any impairment. AR 75-78. Dr. Segal misinterpreted some of Dr. Saunders' notes, reading the notes as indicating that Smith “was stressed by multiple tasks of buying a house and wanting to attend a nursing school and change working to part time.” AR 76, see also AR 83 (“The claimant is apparently buying a house and is either thinking of attending nursing school or is already attending nursing school.”) In actuality, Dr. Saunders' notes indicated that Smith's son (not Smith) was buying a house, and Smith's daughter (not Smith) was entering a nursing program. AR 70, 107.

         Dr. Saunders completed an Attending Physician's Statement on November 21, 2013. AR 60-61. On the form, Dr. Saunders indicated that Smith had a Class 4 Mental/Nervous Impairment, “Patient is unable to engage in stressful situations or engage in interpersonal relations (marked limitations).” AR 61.

         Dr. Saunders also provided a medical summary letter dated December 4, 2013, which stated:

He went off work and was advised to remain off work and avoid all stressors [u]ntil completely being recovered. He was seen by me July 2013, September 2013, Oct 2013, and lastly 11-21-13. At that time he was being treated with 2 antidepressants, an anti-anxiety medication, and a stimulant, and was in partial remission only.
In summary, he appears disabled from working in his previous employment, and also any employment at this time.

AR 66.

         Although Dr. Segal was asked to make at least three separate attempts to contact Dr. Saunders by telephone, he was unable to make the contacts. See AR 75-76, 82-83.[4] Dr. Segal sent a letter to Dr. Saunders on December 17, 2013, stating Dr. Segal's opinion that there was no impairment after October 1, 2013, and asked Dr. Saunders to verify his understanding and provide additional information if any disagreement. AR 79-80. Dr. Saunders responded with a brief hand-written sentence on the bottom of the letter stating: “Note- his symptoms improved when the stress was relieved! (not at work)”. AR 81 (emphasis in original).

         Dr. Saunders called Dr. Segal on December 26, 2013. AR 84. Dr. Segal updated the file with a memorandum stating that Dr. Saunders communicated that Smith “was better at a certain point ‘because he was not working and did not have a stress of that particular job, and that is the reason for his improvement.' This information does not change my opinion as it is outlined in the original memorandum on December 17, 2013.” AR 84. By letter of December 30, 2013, Smith was advised that his LTD claim was denied because he did not meet the Plan's definition of disability, and impairment was not supported beyond October 1, 2013. AR 86-87.

         2. Smith's Appeal

         On January 9, 2014, Smith sent a letter to Liberty Life to appeal the denial of his claim. AR 90.[5] He wrote a follow-up letter on January 15, 2014, providing information that he indicated was either missed, ignored, or misinterpreted by Dr. Segal. AR 94-95. Smith specifically clarified the misleading statements in Dr. Segal's report regarding Smith's buying a house and going to nursing school. AR 95. He also identified restrictions from Dr. Saunders that appeared to have not been taken into consideration. AR 94.

         On January 20, 2014, Dr. Segal provided an addendum to his report, noting that his December 26, 2013 addendum had not made it into the file, nor had Dr. Saunders' brief written response to Dr. Segal's letter: “His symptoms improved when the stress was relieved! (not at work).” AR 119. Dr. Segal noted that his opinion had not changed: “In conclusion, the medical evidence and communications with Dr. Sanders [sic] confirms the opinion as outlined in the original memorandum that there is no medical evidence of psychiatric impairment since October l, 2Ol3.” AR 119.

         Smith's LTD claim file was referred to Liberty Life's appeals unit, and a letter was sent to Smith on January 22, 2014, stating that a decision is generally provided in 45 days, but no longer than 90 days. AR 120. On February 26, 2014, Liberty Life referred Smith's LTD claim file to Behavioral Management, Inc. (“BMI”), an independent vendor, requesting a review to be conducted by an independent physician that was board-certified in psychiatry. AR 133-136. Liberty Life also sent a letter to Smith on February 26, 2014, advising him that his medical records had been referred for further medical review, and a decision would be rendered within the 90-day deadline. AR 137.

         The independent review was assigned to Dr. Sandra Kalnins (“Dr. Kalnins”). AR 139-153. Dr. Kalnins spoke with Dr. Saunders on March 5, 2014, and summarized the conversation by letter dated March 6, 2014. AR 139-140. Dr. Saunders indicated that he disagreed with Dr. Segal, that his records had been misinterpreted, and that he did not consider Smith capable of returning to work. AR 139-140. Dr. Saunders suggested that it may be helpful for Dr. Kalnins to interview Smith.[6] AR 140. Dr. Kalnins also appeared to be under the false impression that Smith had considered going to nursing school himself. AR 139. Dr. Kalnins reviewed Dr. Saunders' records, Dr. Segal's review and correspondence, Smith's job description, and other documents from Smith's LTD claim file. AR 145-147.

         Dr. Kalnins provided a written report to Liberty Life on March 13, 2014. AR 145-149. Dr. Kalnins' review stated:

The available records and teleconference information support diagnoses of recurrent major depression and anxiety disorder. The records support impairing levels of symptoms from 9/5/13 until the next psychiatric visit on l0/l/13, when the claimant's mood was improved and no treatment changes made. The records and the teleconference information from Dr. Saunders do not provide objective evidence of severe and persistent mood, cognitive, or behavioral symptoms preventing the claimant from functioning. Treatment was not consistent with impairing levels of symptoms, where the following would be expected: frequent psychiatric visits with aggressive medication adjustments, documentation of severe and persistent psychiatric symptoms, ongoing intensive therapy, and referrals to higher levels of treatment such as IOP, PHP, or hospitalization if symptoms were persisting.
In teleconference, Dr. Saunders indicated that the claimant was improved when he was placed out of work. The psychiatrist describes the placement out of work as the treatment intervention without explaining how that could be considered active psychiatric treatment.
The records support impairing levels of depression and anxiety from 9/5/13 to l0/l/l3. These symptoms would interfere in the claimant's ability to maintain stable emotions, make complex decisions, concentrate adequately on complex tasks, and maintain stable interpersonal interactions. In an office visit on l0/l/l3, the claimant's mood was described as better and no treatment changes were made. The records do not support severe and persistent mood, cognitive, or behavioral symptoms beyond l0/l/13 and do not indicate levels of psychiatric treatment expected with impairing symptoms. The psychiatrist indicated that there was no return to work plan.

AR 147-148.

         Liberty Life sent Smith a letter on April 10, 2014, upholding its previous determination to deny Smith's LTD claim. AR 154-157.

         3. Request for ...

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