Gentile v. John Hancock Mut. Life Ins. Co., Civil Action No. 95-10222-NMG.

951 F.Supp. 284

Anna M. GENTILE, Plaintiff, v. JOHN HANCOCK MUTUAL LIFE INSURANCE COMPANY, Defendant.

Civil Action No. 95-10222-NMG.

United States District Court, D. Massachusetts.

January 8, 1997.

Richard A. Mulhearn, Worcester, MA, for plaintiff.

Robert V. Deiana, Worcester, MA, for defendant.

MEMORANDUM AND ORDER

GORTON, District Judge.

Plaintiff, Anna Gentile ("Gentile"), brought this suit against her employer, John Hancock Mutual Life Insurance Company ("Hancock"), for Long Term Disability benefits she claims are due to her under the company's employee benefits plan ("the Plan"). The suit is brought under 29 U.S.C. § 1132(a)(1)(B) which permits an employee to challenge benefit eligibility determinations. Hancock denies that Gentile is totally disabled as that term of art is defined by the Plan and denies her entitlement to such benefits. The Plan is an employee welfare benefit plan within the meaning of and subject to the Employment Retirement Income Security Act ("ERISA") 29 U.S.C. § 1001 et seq.

Pending before the Court is defendant's motion for summary judgment on the grounds that plaintiff has submitted no objective medical evidence that she is disabled. Defendant requests in the alternative, if summary judgment is denied, that the arbitrary and capricious standard of review be applied at trial on the grounds that the Plan contract gives the company the requisite discretion to avoid application of de novo review. Also pending before the Court is defendant's motion to strike plaintiff's claim for a jury trial.

I. BACKGROUND

The following facts are recited in the light most favorable to the nonmoving party, plaintiff Gentile. Winnacunnet Cooperative School District v. National Union Fire Ins. Co. of Pittsburgh, PA, 84 F.3d 32, 35 (1st Cir.1996). Gentile is a 60-year-old woman who had worked for Hancock since 1954. From 1983 until the time of her injury, Gentile had been an Office Supervisor in Hancock's Woonsocket, Rhode Island office. On January 4, 1988, plaintiff was injured during the course of her employment by a fall on ice. She suffered injuries to her neck, back, left shoulder and left leg and came under active medical care resulting in diagnoses of sciatica and cervical sprain as well as other multiple sprains, strains and contusions. Subsequently, Gentile developed psychological problems stemming from her injuries and became prone to falling.

Plaintiff twice attempted to return to work for Hancock after the 1988 injury, once in February, 1988 when she returned for approximately two months and again in June, 1988 when she worked for approximately six weeks before leaving finally on July 11, 1988. Plaintiff has not worked since. She was entitled to, and received, salary continuation benefits, for the disability resulting from her fall, until January 4, 1991, as well as worker's compensation benefits which she received until April 17, 1992.

Gentile submitted a claim to Hancock for Long Term Disability ("LTD") benefits in November, 1993. A month later, Hancock arranged and paid for an "Independent Medical Examination" ("IME") of Gentile which resulted in a determination that Gentile was able to perform her previous job with her physical limitations. During its review of Gentile's claims, Hancock received and considered records from an examination of Gentile performed with respect to her Worker's Compensation claim which also concluded that she was able to return to her job.

Several months before filing her claim for LTD benefits with Hancock, a Social Security Administration ("SSA") Administrative Law Judge determined that Gentile was "disabled from any substantial gainful activity." In connection with those proceedings, Gentile was examined by both a physician and a psychiatrist who confirmed the findings of disability made by Gentile's treating physicians.

On July 1, 1994, Hancock approved Gentile's LTD benefits claim effective January 5, 1991. Thirteen days later, Hancock notified Gentile that her LTD benefits would not be paid for time accruing after April 17, 1992 because there was no objective medical documentation to substantiate total disability beyond that date. In that letter from Hancock there was no mention of the findings of Gentile's doctors or those of the SSA. Gentile appealed that denial, submitting further medical reports from her treating physicians, but, on November 16, 1994, Hancock denied the appeal.

The Master Plan under which Gentile claims benefits states that:

Totally disabled means:

1) In order to determine when you start a continuous period of total disability, and for the first 36 months (60 months for Marketing Representatives and Ford Group Office Clerical employees) of such period, only such incapacity, as determined by the Company, and which is due to a physical or mental impairment which keeps you from doing all the essential duties of your occupation; and

(2) after the first 36 months (60 months for Marketing Representatives and Ford Group Office Clerical employees) period and for the rest of such continuous period of total disability, such incapacity which is due to a physical or mental impairment, which keeps you from doing the essential duties of any occupation or employment for which you are qualified by education, training or experience.

Defendant's Exhibit A, p. 3. The Summary Plan Description reads as follows:

The Own/Any Occupation Rule

During the first 36 months after your disability begins (including your Salary Continuance benefit period), you are considered totally disabled under this coverage if you are unable to perform all the essential duties of your regular job with the company.

After that time, you are considered totally disabled if you are unable to perform any gainful job that you're qualified for — by reason of your education, training or experience.

Defendant's Exhibit B, p. 6 (emphasis in the original).

Hancock is the employer, plan administrator and plan insurer. It is also the insurer with regard to pension benefits for Gentile. Years of service counted toward calculation of pension benefits include time spent receiving LTD benefits.

Defendant has moved for summary judgment or, in the alternative, for this Court to review its denial of benefits under an arbitrary and capricious standard.

II. DEFENDANT'S MOTION FOR SUMMARY JUDGMENT

A. Standard of Review

The role of summary judgment is "to pierce the pleadings and to assess the proof in order to see whether there is a genuine need for trial." Mesnick v. General Elec. Co., 950 F.2d 816, 822 (1st Cir.1991), cert. denied, 504 U.S. 985, 112 S.Ct. 2965, 119 L.Ed.2d 586 (1992) (quoting Garside v. Osco Drug, Inc., 895 F.2d 46, 50 (1st Cir.1990)). The burden is upon the moving party to show, based upon the pleadings, discovery, and affidavits, "that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law." Fed.R.Civ.P. 56(c). The Court must view the entire record in the light most hospitable to the non-moving parties and indulge all reasonable inferences in their favor. O'Connor v. Steeves, 994 F.2d 905, 907 (1st Cir.1993).

If the moving party demonstrates that there is "an absence of evidence to support the non-moving party's case," the burden shifts to the non-moving party to establish the existence of a genuine issue of material fact. FDIC v. Municipality of Ponce, 904 F.2d 740, 742 (1st Cir.1990) (quoting Celotex Corp. v. Catrett, 477 U.S. 317, 325, 106 S.Ct. 2548, 2553-54, 91 L.Ed.2d 265 (1986)). The nonmovant may not, however, rest upon mere allegation or denial of the pleadings. Fed.R.Civ.P. 56(e).

B. Absence of Entire Administrative Record

Hancock has moved for summary judgment on the grounds that Gentile has failed to submit objective medical evidence to support her claim that she was totally disabled. Gentile asserts that the motion must be denied because the record before the Court, as submitted by Hancock, does not contain the entire administrative record regarding its review and denial of the claim or Gentile's appeal thereof.

While Gentile cites no case law expressly holding that the fall administrative record is required for review by the Court, those cases which discuss judicial review of a denied benefit under ERISA uniformly assume that the full administrative record forms the basis of such a review, regardless of the standard of review applied. See e.g. Jorstad v. Connecticut General Life Ins. Co., 844 F.Supp. 46, 55 (D.Mass.1994). Contrary to the case at hand, this issue typically manifests itself when a claimant seeks to submit to the Court information which was not available to the fiduciary when it denied the benefit. While the First Circuit has not yet spoken on the issue of whether to permit the Court to review additional information, in the circuits in which the issue has been addressed, the only options contemplated are judicial consideration of 1) a subsequently supplemented record or 2) the record as it existed before the administrator or fiduciary. Miller v. Metropolitan Life Ins. Co., 925 F.2d 979, 986 (6th Cir.1991); accord Sandoval v. Aetna Life & Casualty Ins. Co., 967 F.2d 377, 380-81 (10th Cir.1992); Luby v. Teamsters Health, Welfare & Pension Trust Funds, 944 F.2d 1176, 1184-85 (3rd Cir.1991); Perry v. Simplicity Engineering, 900 F.2d 963, 966 (6th Cir.1990).

According to Gentile, Hancock has not submitted to the Court the medical reports and records from her treating physicians, reports of diagnostic tests, records from the SSA's finding of disability or numerous other documents which comprised the fall administrative record available to the fiduciary when it denied her claim. In the absence of the fall record which is a prerequisite for this Court's review of the determination, summary judgment for Hancock will be denied.

C. Genuine Issues of Material Fact

Even if the full administrative record were in this Court's possession and regardless of the standard...