United States District Court, D. New Hampshire
[Copyrighted Material Omitted]
William D. Woodbury, Normandin Cheney & O'Neil PLLC, Laconia, NH, for Susan Fifield.
David F. Schmidt, Chittenden Murday & Novotny LLC, Chicago, IL, Andrew W. Serell, Rath Young & Pignatelli PA, Concord, NH, for HM Life Insurance Co.
JOSEPH N. LAPLANTE, District Judge.
This case arises out of an employee's claim for disability benefits due to abdominal pain, depression, and anxiety. Plaintiff Susan Fifield brought suit under the Employee Retirement Income Security Act (" ERISA" ), 29 U.S.C. §§ 1001 et seq., against her disability insurer, HM Life Insurance Co. (" HM Life" ), its former claims administrator, Broadspire Services Inc. (" Broadspire" ), and its current claims administrator, Aetna Life Insurance Co. (" Aetna" ), each of which terminated or upheld the decision to terminate her long term disability benefits. She asks this court to overturn the decision and award her benefits under her employer's long term disability plan. See id. § 1132(a)(1)(B). The defendants argue that the record fails to establish that Fifield was disabled from performing her job, as required to qualify for long term disability benefits. This court has subject-matter jurisdiction under 28 U.S.C. § 1331 (federal question) and 29 U.S.C. § 1132(e)(1) (ERISA).
Both sides have moved for judgment on the administrative record, see L.R. 9.4(c), and have summarized it in a joint statement of material facts, see L.R. 9.4(b). After oral argument and a careful review of the record, judgment is granted for Fifield because the record shows that the defendants' decision to terminate her long term disability benefits was arbitrary and capricious. Specifically, the administrative record does not support the decision to terminate Fifield's benefits as of October 26, 2005, because the defendants simultaneously authorized benefits for a period prior to that date based on the same medical records. Accordingly, as explained in detail infra, the defendants' decision bears no reasonable relation to the medical evidence in the administrative record, and was not reasoned or supported by substantial evidence.
I. Applicable Legal Standard
The standard of review in an ERISA case differs from that in an ordinary civil case, where summary judgment is designed to screen out cases that raise no trialworthy issues. See, e.g., Orndorf v. Paul Revere Life Ins. Co., 404 F.3d 510, 517 (1st Cir.2005). " In the ERISA context, summary judgment is merely a vehicle for deciding the case," in lieu of a trial. Bard v. Boston Shipping Ass'n, 471 F.3d 229, 235 (1st Cir.2006). Rather than consider affidavits and other evidence submitted by the parties, the court reviews the denial of ERISA benefits based " solely on the administrative record," and neither party is entitled to factual inferences in its favor. Id. Thus, " in a very real sense, the district court sits more as an appellate tribunal than as a trial court" in deciding whether to uphold the administrative decision.
Leahy v. Raytheon Co., 315 F.3d 11, 18 (1st Cir.2002).
For more than eleven years, Fifield worked at Comcast Cable Corporation, Inc. (" Comcast" ) and its predecessor companies as a customer service representative, a sedentary job that involves frequent interaction with customers. As a Comcast employee, Fifield was eligible for and participated in the company's long term disability insurance plan (the " Plan" ), offered through defendant HM Life, which provides up to two years of benefits for a disability resulting from or caused by mental illness or a " self-reported condition."
To receive benefits under the Plan, an employee must be certified as disabled by the Plan's claims administrator (originally Broadspire and, later, Aetna). The Plan defines disability as a " change in your functional capacity to work as a result of your Medical Condition." To receive benefits for the first twelve months of disability, an employee must have a disability that " prevents [her] from performing the Essential Functions of [her] Regular Occupation."
Fifield also participated in Comcast's Short Term Disability Insurance Plan, also offered through HM Life and, for the relevant time period, administered by Broadspire. In early 2005, Fifield applied for short term disability benefits (" STD benefits" ) because of abdominal pain, depression, and anxiety, all of which she had suffered from and sought medical treatment for over the previous several years. Fifield stopped going to work on March 17, 2005. Broadspire authorized STD benefits for Fifield effective March 24, 2005.
Shortly after Broadspire authorized STD benefits, Fifield underwent an endoscopy to determine the cause of her abdominal pain. Dr. Noboru Murakami, who performed the procedure, noted in his report that it revealed " acute and chronic gastritis" and " Barrett's esophagus." Over the next few months, while out of work and receiving STD benefits, Fifield saw Dr. Ethel Hull, a psychologist, numerous times. Dr. Hull opined in June 2005 that Fifield was then suffering from a " [s]ignificant decline of health in response to high stress." Dr. Hull further concluded that Fifield was unable to return to work because of her reaction to work-related stress.
By letter dated September 13, 2005, Broadspire notified Fifield that it had denied her request for continued STD benefits effective September 2, 2005. In the letter, Broadspire wrote that the medical information it had received was " insufficient to support ongoing [STD benefits] as it did not provide any updated abnormal examination findings or diagnostic test results to support continued disability." The letter further stated that to continue benefits, Fifield " must submit information that would support a functional impairment. This information may include observable findings that demonstrate a functional deficit in behavioral, emotional and/or cognitive functioning, the results of a formal mental status examination, and/or the results of psychological based testing with standardized scores."
Subsequently, in October 2005, Fifield saw Dr. Michael Vanaskie, a psychologist, who " agreed to conduct [an] evaluation to meet [the] requirements" set forth in Broadspire's letter. Dr. ...