Gammell v. Prudential Ins. Co. of America, Civil Action No. 06-40226-FDS.

Page 227

600 F.Supp.2d 227

Thomas GAMMELL, Plaintiff, v. PRUDENTIAL INSURANCE COMPANY OF AMERICA, Defendant.

Civil Action No. 06-40226-FDS.

United States District Court, D. Massachusetts.

September 25, 2008.

Jennifer A. O'Brien, Ronald M. Davids, Davids & Associates, P.C., Wellesley, MA, for Plaintiff.

Edward P. O'Leary, Fitzhugh & Mariani LLP, Boston, MA, for Defendant.

MEMORANDUM AND ORDER ON CROSS-MOTIONS FOR SUMMARY JUDGMENT

SAYLOR, District Judge.

This is a dispute concerning the denial of long-term disability benefits. The matter arises under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq. The central legal issue presented is whether the Court should review that denial de novo, or give deference to the plan administrator's decision.

Plaintiff Thomas Gammell was covered by a long-term disability plan as a benefit of his employment with Digital Equipment Corporation, to which Hewlett-Packard Company is the successor-in-interest. Defendant Prudential Insurance Company of America is the claims fiduciary and insurer for the plan. Gammell made a claim for benefits based on a disability resulting from a closed-head injury sustained in a bicycle accident in 1987. Prudential initially approved Gammell's claim for longterm disability benefits in February 1990. Gammell continued to receive benefits for more than 10 years, with periodic reviews by Prudential approximately every two years to verify his ongoing total disability.

In December 2000, a claimant questionnaire completed by Gammell prompted a new round of medical evaluations and renewed scrutiny of Gammell's medical records, ultimately leading Prudential to terminate his long-term disability benefits effective November 2002. After an unsuccessful appeal to Prudential, Gammell filed this action.

Pending before the Court are the parties' cross-motions for summary judgment. For the reasons set forth below, both motions will be denied.

I. Statement of Facts

The following facts are undisputed unless otherwise noted.

A. Gammell's Employment

Plaintiff Thomas Gammell is a resident of Fitchburg, Massachusetts. He began working for Digital Equipment Corporation in 1968.

As an employee benefit, Digital established a long-term disability plan in which qualified employees were allowed to participate. The group long-term disability policy was issued to Digital by defendant Prudential Insurance Company of America, which both insured and administered the plan.¹

B. Initiation of Disability Benefits

After suffering a head injury in a bicycle accident on June 30, 1987, Gammell was diagnosed with post-concussive syndrome of organic origin and a possible seizure disorder. (Administrative Record ("AR") at 75). He states that from the date of the accident to the present, he has suffered from daily headaches, dizziness, fatigue, reduced concentration, and diminished problem-solving and decision-making abilities. Although he attempted to return to work after the accident, Gammell contends that his medical condition prevented him from performing his job duties. His last day of full-time employment at Digital was May 24, 1989.² Following the accident Gammell applied for and was granted short-term disability benefits. His disabling conditions were identified at the time as memory loss, headaches, depression, post-concussive disorder, and a seizure disorder.

On November 13, 1989, Gammell applied for benefits pursuant to Digital's long-term disability plan. Prudential approved the application on February 23, 1990, with benefits retroactive to November 23, 1989. Gammell received benefits under the policy's "Total Disability" provision, which provides as follows:

"Total Disability" exists when Prudential determines that all of these conditions are met

(1) Due to Sickness or accidental injury, both of these are true

(a) You are not able to perform, for wage or profit, the material and substantial duties of your occupation

(b) After the Initial Duration of a period of Total Disability, you are not able to perform for wage or profit the material and substantial duties of any job for which you are reasonably fitted by your education, training or experience. The Initial Duration is shown in the Schedule of Benefits

(2) You are not working at any job for wage or profit

(3) You are under the regular care of a Doctor

(AR at 12) (lack of punctuation in original). Because Prudential paid Gammell disability benefits throughout the "Initial Duration," in order to continue to receive benefits he must demonstrate that he is not able to perform the material and substantial duties of "any job" for which he is reasonably fitted. (Id.).

C. Social Security Disability Benefits

In May 1990, Prudential instructed Gammell that, under the terms of his plan, he was required to apply for Social Security Disability Income ("SSDI") benefits. (AR at 73). His application was initially denied in July. (AR at 77). However, with the help of a Social Security assistance agency paid for by Prudential, that denial was reversed by an Administrative Law Judge in November 1991 after an administrative hearing. In his decision, the ALJ noted that Gammell had undergone neuropsychological testing in 1989 and 1990. In comparing the tests, the ALJ concluded that his "intelligence range had improved significantly in both verbal and performance areas, as he apparently recovered premorbid function levels. On the other hand, his measured memory functions decreased significantly; this loss was thought to be secondary to either organic brain damage or depression ...." (AR at 117). He found that the medical evidence established that Gammell had "severe post-concussion syndrome" and "severe affective disorder with major depression, as well as a possible bipolar disorder." (AR at 118). The ALJ concluded that Gammell "clearly cannot return to that very demanding and stressful work now nor can he do any other work." (AR at 117). Accordingly, he found that Gammell had a "severe impairment" and was "disabled" within the meaning of the Social Security Act, and was therefore entitled to social security disability benefits. (AR at 116-18).

Pursuant to the plan, Prudential reduced Gammell's long-term disability payments in the amount of the SSDI benefits that he received.

D. Review of Gammell's Disability Status

After Gammell began receiving longterm disability benefits, Prudential reviewed his disability approximately every two years to determine whether his condition had improved. (AR at 146, 147). It continued to pay Gammell benefits for more than ten years.

On December 4, 2000, Prudential notified Gammell that the handling of his disability claim had been transferred to Carol Ann Matikiewicz in its Plymouth Meeting, Pennsylvania, office. (AR at 152). Matikiewicz requested that Gammell provide her with a completed claim questionnaire and an authorization for the release of medical records in order to assist her in the claim transfer. Gammell completed the questionnaire and authorization on December 7, 2000. On the questionnaire, he stated that he suffered from "headaches, poor memory, dizzyness [sic ], depression, problems with vision, high blood pressure, [and] concentration." (AR at 157). He also reported that he couldn't remember anything, had "problems keeping appointments," and gets headaches when reading. (AR at 158, 160).

However, Gammell's responses to the questionnaire also suggested at least some functionality in the activities of daily living. He checked boxes on the form indicating that he (1) prepares his own meals (breakfast and lunch); (2) maintains a valid driver's license and drives five times per week at distances of up to 30 miles; (3) performs housework, including laundry, vacuuming, dishwashing, lawn care, and removal of trash and recycling for two hours daily; and (4) shops for food unassisted on a monthly basis. (AR at 159-60). In addition, Gammell stated that he liked to hunt with a bow and arrow, was "trying to learn wood carving and bee keeping," and was active in the Worcester County Beekeepers, Mid-State Antique Auto Club, and the Church of the Good Shepherd. He stated that at his church, he unloaded Christmas trees, took the elderly food shopping, and assisted them with banking and paying bills as a volunteer on an as-needed basis. (AR at 160-61). He also reported that he had "joined a wood carving club, we meet Tuesday nights from 7 to 9." (AR at 162).

When asked on the form whether he could return to work, Gammell responded: "No—I gen. don't feel good, when I have to do simple tasks or even hobbies that require any concentration I always get a headache. Knowing this I feel stressed before I even start." (Id.).

After reviewing the questionnaire, Matikiewicz wrote a claim summary, dated April 13, 2001. In that summary, she reviewed the claim history and stated that "[t]here is very little objective evidence to support the claimant's complaints of a seizure disorder and his emotional and cognitive difficulties. He is very active. It is unclear why he cannot work. Will obtain office notes from his treatment providers and after they are reviewed will determine next activity." (AR at 165).

On April 16, Prudential requested updated medical records from Gammell's treating physicians, Dr. Piamarie Ballarin-Feldman and Dr. Francis D'Ambrosio. Dr. Ballarin-Feldman is a family care physician who formerly shared her practice with Dr. Robert J. Roy, the primary care physician who had initially treated Gammell after the injury; Dr. D'Ambrosio is Gammell's ophthalmologist. In response, Prudential received records from Dr. Ballarin-Feldman and an office note from Dr. D'Ambrosio. On April 21, Dr. Ballarin-Feldman completed a Physical Capacities Evaluation and a Mental Residual Functional Capacity Assessment ("MRFC") in which she stated that Gammell suffered from "permanent cognitive deficits following closed head trauma from 1987" and that he had...