130 F. Supp. 3d 443
D. Mass.2015Background
- Plaintiff Julie Cowern worked as a programmer/analyst and stopped working in April 2009 due to chronic gastrointestinal symptoms; she applied for and received LTD benefits under a Staples plan insured and administered by Prudential.
- The LTD plan grants Prudential discretionary authority and contains a 24-month lifetime benefit limit for disabilities "primarily based on self-reported symptoms" (SRS limitation); SRS are manifestations not verifiable by standard medical tests.
- Prudential initially approved LTD benefits but later concluded the claim was primarily based on self-reported symptoms, applied the 24-month SRS limit, and terminated benefits effective October 29, 2011; two internal appeals were denied.
- The administrative record contains extensive, conflicting medical evidence: treating physicians documented objective findings and functional limitations; Prudential-retained reviewers emphasized lack of a unifying diagnosis and possible narcotic bowel syndrome; some reviewers (including one retained by Prudential) both doubted full-time return-to-work and said there were no GI-generated physical restrictions.
- Prudential commissioned covert surveillance (nine days, <7 minutes video) and used multidisciplinary medical reviews and a vocational consultant; claimant submitted FCE, vocational reports, and an SSA disability award. Prudential relied on select reviews, surveillance, and a vocational report that may have been prepared from an incomplete file.
- The district court applied the arbitrary-and-capricious standard (plan confers discretion), found Prudential’s interpretation/application of the SRS limitation reasonable, but concluded Prudential engaged in selective use of evidence (surveillance, cherry‑picking expert statements, reliance on an incomplete vocational review, and failure to address the SSA award) and remanded for further proceedings. Both summary judgment motions were denied.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether Prudential misinterpreted or improperly applied the SRS limitation | Cowern: Prudential inconsistently and improperly applied SRS, unduly relying on lack of definitive diagnosis | Prudential: consistently denied benefits because condition was primarily self‑reported and lacked objective support | Court: Prudential's SRS interpretation was not an abuse of discretion but must be applied consistently on remand |
| Whether Prudential improperly relied on covert surveillance to deny benefits | Cowern: surveillance did not contradict her reported exacerbations nor show ability to sustain work; reliance was unreasonable | Prudential: entitled to consider surveillance as part of claim review (Cusson) | Court: surveillance here was minimal and did not address the core issues; Prudential’s reliance was arbitrary and capricious |
| Whether Prudential cherry‑picked medical opinions and improperly discounted claimant evidence (FCE, vocational reports, treating doctors) | Cowern: Prudential ignored or failed to address significant contrary evidence (e.g., portions of Dr. Liebermann that supported disability) and gave inadequate reasons for rejecting claimant experts | Prudential: weighed competing evidence and had reason to discount certain reports as unsupported or invalid | Court: Prudential selectively quoted/relied on expert opinions (notably Dr. Liebermann), failed to adequately explain discounting of claimant vocational expert (Parker), and that was arbitrary and capricious |
| Whether Prudential improperly ignored claimant’s SSA disability award and relied on an incomplete vocational review | Cowern: SSA award is relevant evidence and Prudential improperly ignored it; Prudential’s vocational consultant (Grunden) may have reviewed an incomplete file | Prudential: formal SSA award letter not in administrative record, and its vocational reviewer relied on Prudential’s medical reviews | Court: Prudential should have considered SSA award (or asked claimant to supply missing documents); providing an incomplete record to its vocational reviewer and relying on that review was arbitrary and capricious |
Key Cases Cited
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (ERISA denial-of-benefits review standard; de novo unless plan grants discretion)
- Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105 (consideration of administrator conflict and multi-factor review approach)
- Leahy v. Raytheon Co., 315 F.3d 11 (First Circuit on arbitrary-and-capricious review in ERISA cases)
- Colby v. Union Sec. Ins. Co., 705 F.3d 58 (deference to plan administrator where plan grants discretion)
- Cusson v. Liberty Life Assurance Co. of Boston, 592 F.3d 215 (surveillance may be considered when it contradicts claimed limitations)
- Petrone v. Long Term Disability Income Plan, 935 F.Supp.2d 278 (district-court ERISA review and remand for procedural deficiencies)
- Buffonge v. Prudential Ins. Co. of Am., 426 F.3d 20 (remand where administrator’s decision process was flawed)
- Maher v. Mass. Gen. Hosp. Long Term Disability Plan, 665 F.3d 289 (surveillance that confirms limited, housebound lifestyle may not disprove disability)