790 F. Supp. 2d 177
D. Del.2011Background
- Morningred, a Delta Airlines employee with extensive lifting duties, injured May 29, 2008 and sought short-term disability benefits under the Plan.
- Sedgwick CMS, as plan administrator with discretionary authority, denied Morningred's recertification; initial STD benefits were approved only through June 30, 2008.
- Morningred submitted additional medical records diagnosing CRPS; Sedgwick CMS referred records to an independent reviewer, Insurance Appeal Limited.
- Dr. Marks issued a March 4, 2009 report concluding claimant could return July 1, 2008 through November 28, 2008; Sedgwick CMS denied benefits for that period on April 8, 2009.
- Morningred filed suit under ERISA § 502(a)(1)(B) on April 6, 2010; motions for summary judgment were filed by both sides in December 2010 and January/February 2011.
- The court granted in part and denied in part, remanding the July 1–July 23, 2008 disability date for further determination.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| waiver of procedural defects | Morningred exhausted remedies; defects were not cured. | Procedural defects were waived due to failure to pursue administratively. | Procedural waiver found; remand addressed procedural issues on reargument. |
| adequacy of initial denial notice | Notice failed to reference plan provisions and was vague. | Notice provided specific reasons and steps to perfect claim; substantial compliance. | Initial denial letter substantially complied; remedy rested on substantial conformity, not strict literal reference. |
| crediting treating physicians vs. conflicting opinions | CMS improperly disregarded treating physician Dr. Grossinger's opinion. | CMS properly weighed conflicting medical evidence and credited other credible opinions. | CMS acted within discretion weighing conflicting evidence; no arbitrary disregard of treating physicians. |
| workers' compensation evidence | WC agreement showing total disability should inform disability determination. | Plan not bound by WC standards or the agreement absent incorporation. | No binding incorporation of WC standards; WC agreement not dispositive. |
| scope and outcome of remand | Remand should restore benefits pending proper determination for July 1–July 23, 2008. | Remand limited to the July 1–July 23 period; other periods remain judged previously. | Remand limited to determining disability for July 1–July 23, 2008; otherwise affirmed denial. |
Key Cases Cited
- Black & Decker Disability Plan v. Nord, 538 U.S. 822 (U.S. 2003) (reliability and weight of evidence; treating physician considerations)
- Glenn v. Metropolitan Life Insurance Co., 554 U.S. 105 (U.S. 2008) (abuse of discretion review in ERISA rejection of benefits)
- Kosiba v. Merck & Co., 384 F.3d 58 (3d Cir. 2004) (factors assessing arbitrary or capricious plan administration)
- Nord v. Black & Decker Disability Plan, 538 U.S. 822 (U.S. 2003) (limits on crediting evidence inconsistent with treating physicians)
- Harrow v. Prudential Insurance Co. of America, 279 F.3d 244 (3d Cir. 2002) (deference to plan administrator discretion in benefit determinations)