Joyner v. Cont'l Cas. Co.

RAMONA JOYNER Plaintiff,

v.CONTINENTAL CASUALTY COMPANY Defendant.

Case No. 4:12-cv-00004

UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF VIRGINIA DANVILLE DIVISION

Entered: March 7, 2012

MEMORANDUM OPINION

By: Jackson L. Kiser,

Senior United States District Judge

Before me is Defendant's Motion for Summary Judgment [ECF No. 51], which was filed on November 30, 2012. Plaintiff filed a Response in Opposition to Defendant's Motion [ECF No. 60] on January 31, 2013, and Defendant followed by filing their Response in Support of Summary Judgment [ECF No. 65] on February 14, 2013. On February 25, 2013, I heard oral argument from both sides outlining their respective positions on the law, the facts, and the nature and extent of the record. Having thoroughly reviewed the briefs, the record, and the arguments of counsel, the matter is now ripe for decision. For the reasons stated below, I hereby GRANT Defendant's Motion for Summary Judgment.

I. STATEMENT OF FACTS

This case arises from the allegedly wrongful cancellation of Plaintiff Ramona Joyner's ("Plaintiff") long-term disability ("LTD") benefits by Defendant Hartford, incorrectly sued herein as Continental Casualty Company ("Defendant").¹ On August 26, 2011, Plaintiff filed aComplaint under the Employee Retirement Income Security Act ("ERISA") seeking reinstatement of Plaintiff's LTD benefits under her employee welfare benefit plan ("plan"), which is sponsored by her former employer, Computer Sciences Corporation ("CSC"). Defendant provided Plaintiff with LTD benefits under the plan from August 19, 2005 to January 30, 2010. On January 30, 2010, however, Defendant concluded that Plaintiff was no longer "disabled" under the terms of the plan and stopped providing benefits. Plaintiff's medical history and Defendant's internal decision-making process are detailed below.

A. Plaintiff's Work History and Initial Application for LTD Benefits

In 2000, Plaintiff medically retired from the U.S. Army at the age of thirty-five due to depression and fibromyalgia. (See Def.'s Mot. for Sum. J., Ex. B., pg. 53.) On October 7, 2002, Plaintiff started working at CSC and subsequently enrolled in an employer-sponsored LTD plan. (See Ex. B. at 1080.) On July 22, 2005, however, Plaintiff stopped working at CSC due to her mental and physical condition. (See id.) Shortly thereafter, Plaintiff applied for LTD benefits under the plan. (See id.)

In her initial application for LTD benefits, Plaintiff submitted an Attending Physician Statement from Dr. Richard B. Rosse, her treating psychiatrist, in which Dr. Rosse noted Plaintiff's history of major depression and chronic fatigue syndrome and opined that Plaintiff was unable to return to work due to her "lack of energy, overwhelming depression and easy fatigability." (Id.) Plaintiff also participated in a claimant interview with Defendant, in whichPlaintiff complained of daytime sleepiness, non-restorative sleep, pain, shortness of breath, no energy, and inability to concentrate. (See id. at 53.) Given Plaintiff's symptoms, Defendant conducted a Physical Demands Analysis ("PDA"), which revealed that Plaintiff's job required her to work eight hours per day, five days a week, with flexible break and lunch periods. (See id. at 1055.) According to the PDA, Plaintiff's job required her to: use a computer and telephone; walk for thirty minutes, stand for thirty minutes, and sit one hour at a time for a total of seven hours per day; periodically lift 5-10 pounds; constantly use her fingers; frequently twist her head; and occasionally reach, twist her back, and bend her wrist. (See id.)

After reviewing Plaintiff's application for benefits, Defendant concluded that Plaintiff qualified for LTD benefits under the "Mental/Nervous" provision of the plan, effective August 19, 2005. (See id. at 245-46). Importantly, however, the "Mental/Nervous" provision of the plan limited benefits to a maximum of twenty-four months. (See id. at 11.) Defendant subsequently provided Plaintiff with benefits for the full twenty-four months allowed under the plan, based primarily on Dr. Rosse's updated office visit notes. (See id. at 81-82.)

B. Defendant Extends Benefits Due To Plaintiff's Physical Condition

In March 2007, Defendant began reviewing Plaintiff's medical records to determine if she qualified for LTD benefits beyond the twenty-four month limitation period. (See id. at 094.) Specifically, the plan provided for continued benefits if Plaintiff suffered from a physical condition that caused her to be "continuously unable to engage in any occupation for which [she is] or [can] become qualified by education, training, or experience" (hereinafter "any occupation" provision). (Id. at 8.) Ultimately, Defendant concluded that Plaintiff suffered from a physical disability under the plan, and Defendant continued to award benefits.

Plaintiff's medical records primarily indicated that she was suffering from fibromyalgia and cervical degenerative disc disease. (See id. at 107, 783.) At all times relevant hereto, Plaintiff was under the care of Dr. Owusu-Yaw, a neurologist, and Dr. Cohen, a spine surgeon. (See id. at 800.) In a letter dated July 12, 2007, Dr. Cohen opined that Plaintiff was unable to function at a primarily sedentary level due to symptoms related to her cervical degenerative disc disease. (See id. at 107, 783). Dr. Cohen noted that a cervical laminectomy with fusion procedure was planned, and that Plaintiff would be able to function at a sedentary level twelve weeks after surgery. (See id. at 783). Based on this information, Defendant approved Plaintiff's claim for continued LTD benefits under the "any occupation" provision on July 31, 2007, due to Plaintiff's physical condition. (See id. at 108). The next day, Dr. Owusu-Yaw also submitted his assessment, in which Dr. Owusu-Yaw concluded that Plaintiff was physically impaired from performing sedentary work due to her fibromyalgia and chronic fatigue syndrome. (See id. at 109-10, 753-66).

From December 2007 to September 2008, Defendant continued to follow up with both Plaintiff and her treating physicians, periodically conducting "Milestone Calls" with Plaintiff and requesting physician assessments. During this time, Plaintiff underwent the cervical fusion surgery and reported experiencing some post-operative pain in her spine and shoulder. (See id. at 111.) Plaintiff noted, however, that her overall pain level improved following the surgery. (See id. at 117-19, 728). On September 4, 2008, Defendant conducted a "Milestone Call" with Plaintiff in which she reported that her condition had not changed. (See id. at 120-21.) At this point, however, Defendant began to question the veracity of Plaintiff's statements. While Defendant approved continued benefits, Defendant referred Plaintiff's file to the Special Investigation Unit ("SIU"). (See id. at 699). According to Defendant's records, Defendantbelieved that Plaintiff's symptoms were excessive in light of her medical history. (See id.) It is not clear from the record, however, why Defendant became suspicious of Plaintiff's reported symptoms at that time. Regardless, the SIU accepted the referral and conducted video surveillance of Plaintiff in September and November 2008. (See id. 121, 523). Ultimately, the SIU concluded that Plaintiff's activity levels were consistent with the information she provided, and the SIU closed its investigation on November 19, 2008. (See id. at 124, 523).

C. Defendant Conducts Independent Medical Review and Denies Benefits

In March 2009, Defendant began receiving updated physician assessments, which Defendant (presumably) interpreted as showing signs of improvement. While Dr. Owusu-Yaw continued to state that Plaintiff suffered from fibromyalgia, depression, arthritis, and multi-level disc disease, he noted that Plaintiff could sit for one hour at a time for up to eight hours a day, and concluded that Plaintiff could stand/walk for fifteen minutes at a time for up to an hour a day. (See id. at 594-95.) Defendant also received updated information from Dr. Cohen, who noted that Plaintiff still suffered from cervical degenerative disc disease but opined that Plaintiff had no restrictions on driving, reaching, fingering/handling, and could alternate between sitting and standing every 30 minutes. (See id. at 593). Following receipt of these reports, Defendant conducted a "Milestone Call" with Plaintiff on June 16, 2009, in which she reported that she was "starting to feel better." (Id. at 130-32). In fact, Plaintiff stated that she had been exercising three to four times a week and walking about one mile every day. (See id.)

After receiving this information, Defendant referred Plaintiff's file to Nurse Rowena N. Buckley, a nurse medical care manager, to review whether the medical records continued to support a physical functional impairment. (See id. at 137.) After reviewing the file, Nurse Buckley suggested that Defendant refer the case for an independent medical assessment. (Seeid.) In September 2009, Defendant referred Plaintiff's case to Reliable Review Services, which, in turn, retained Dr. Dayton Dennis Payne, a Board-certified physician in internal medicine and rheumatology, to review the file. (See id. at 140, 641-48.)

As part of his review, Dr. Payne analyzed Plaintiff's medical reports and conducted a peer-to-peer discussion with Dr. Owusu-Yaw, Plaintiff's neurologist. (See id. at 643.) Of note, however, Dr. Payne never spoke with Plaintiff regarding her medical history or then-present symptoms. (See id. at 2283.) In his report, Dr. Payne agreed that Plaintiff suffered from fibromyalgia, osteoarthritis, and degenerative disc disease of the spine. (See id. 643.) Dr. Payne opined, however, that Plaintiff's self-report complaints were "somewhat excessive" in light of her physical condition. (See id.) Ultimately, Dr. Payne concluded that Plaintiff was physically able to perform full-time work with no restrictions on her ability to...