Court: District Court, M.D. Florida; February 18, 2016; Federal District Court
Plaintiff Andrew Ramdeen has challenged the termination of his short-term disability (STD) benefits by The Bank of New York Mellon Corporation (BNYMC) and the denial of long-term disability (LTD) benefits by Prudential Insurance Company under the Employment Retirement Income Security Act of 1974 (ERISA). The court considered motions for summary judgment from both parties, ultimately denying Mr. Ramdeen’s motion and granting the defendants' motion.
BNYMC offers STD benefits through a self-funded program for up to twenty-six weeks, with LTD benefits provided via an insurance group contract with Prudential. Mr. Ramdeen suffered a stroke in October 2008 while employed as a vice president, resulting in significant health issues. He received STD benefits while recovering and underwent rehabilitation, eventually returning to work full time in April 2009, albeit with altered duties due to ongoing deficits.
After working for four years, Mr. Ramdeen stopped working in July 2013 and filed another claim for STD benefits, which was partially approved. His treating physician, Dr. Rajan Kapoor, submitted reports supporting Mr. Ramdeen's inability to work, citing various health conditions. However, BNYMC terminated his STD benefits on October 30, 2013, concluding that Dr. Kapoor's records did not substantiate a continuing disability. Mr. Ramdeen appealed this decision the same day.
Mr. Ramdeen's appeal for Short-Term Disability (STD) benefits included progress notes from Dr. Kapoor dated October 31, 2013, which indicated Mr. Ramdeen was unable to make decisions and work full-time. In December 2013, a BNYMC STD administrator sought clarification on Mr. Ramdeen's condition, noting that Dr. Kapoor’s notes lacked detail. Mr. Ramdeen reported significant memory issues, an inability to recall his job title, and difficulties with typing and writing due to cognitive problems, despite having been retained by BNYMC without poor performance reviews.
BNYMC commissioned Dr. Stephen M. Selkirk to review Mr. Ramdeen’s medical records. Dr. Selkirk confirmed that while Mr. Ramdeen exhibited right-sided weakness, which would limit physical activity, there was no evidence of cognitive dysfunction affecting his ability to perform sedentary work. Consequently, BNYMC upheld its denial of STD benefits on January 7, 2014. Following this, Mr. Ramdeen filed a claim for Long-Term Disability (LTD) benefits.
Prudential's investigation into Mr. Ramdeen's LTD claim revealed he was not using assistive devices or undergoing therapy. Prudential sought further reports from Dr. Kapoor but received no response. Dr. Barbara Parke conducted a review and found that Mr. Ramdeen had functional difficulties post-stroke and likely did not return to a role requiring complex skills. She determined that there was no evidence of a new medical event or a significant change in his condition since 2008 and 2009. Based on Dr. Parke's findings, Prudential denied LTD benefits in January 2014.
BNYMC denied Mr. Ramdeen’s second appeal for STD benefits citing Prudential's denial of his LTD benefits. Mr. Ramdeen subsequently appealed Prudential’s denial of LTD benefits. During its reassessment, Prudential sought an independent peer review from Dr. A. Wayne Meikle, who concluded that while Mr. Ramdeen has mild right-sided weakness from a previous stroke, he is not totally impaired and is capable of work-related activities. Dr. Meikle noted that conditions such as aphasia and memory issues were not supported by medical records, which indicated that Mr. Ramdeen could perform his duties with some restrictions but no total limitations.
Additionally, Prudential consulted Frances Grunden, a vocational rehabilitation consultant, who found that Mr. Ramdeen’s occupation as Vice President at a financial institution aligns with his physical capabilities, requiring only sedentary demands and occasional lifting. Based on the opinions of Dr. Meikle and Ms. Grunden, Prudential upheld its denial of LTD benefits, providing Mr. Ramdeen with a summary of his appeal rights.
Mr. Ramdeen appealed the LTD denial again but did not submit additional evidence. On May 14, 2014, Prudential reiterated its denial, stating no new documentation was provided. Following the exhaustion of his appeals, Mr. Ramdeen seeks recovery of LTD benefits from Prudential and STD benefits from BNYMC, or alternatively, a remand of his LTD claim to Prudential. The document also notes that in ERISA benefit denial cases, the district court functions more as an appellate body, reviewing the administrative determination based on the existing record rather than taking new evidence.
In reviewing the decision to grant or deny benefits under ERISA for abuse of discretion, a motion for summary judgment serves primarily as a method to present the legal issue to the court, thereby bypassing traditional summary judgment tests, such as the existence of a genuine dispute of material fact. ERISA lacks a specific standard for court reviews of benefits decisions made by Plan administrators. However, the Eleventh Circuit has established a six-step framework for such reviews, which requires courts to first determine if the administrator’s decision is "wrong" under a de novo standard. If deemed wrong, the court then assesses whether the administrator had discretion in claims review; if not, the decision is reversed. If discretion existed, the court evaluates whether the decision was supported by reasonable grounds, reviewing it under an arbitrary and capricious standard if grounds are found. The presence of a conflict of interest is considered only as a factor in the decision-making process.
Applying this framework, the court must first evaluate whether Prudential’s denial of Mr. Ramdeen’s long-term disability (LTD) claim was "wrong" under the de novo standard. The evaluation is limited to the information available to Prudential at the time of its decision. The court found that Prudential's decision was not de novo wrong; Mr. Ramdeen failed to demonstrate his disability, as he did not meet the criteria set forth in Prudential's LTD plan, which requires continuous disability for twenty-six weeks and specific conditions relating to the inability to perform job duties, regular medical care, and a significant loss in earnings.
Mr. Ramdeen was under regular medical care and experienced a loss of over 20% in monthly earnings due to his illness. The critical issue is whether he was unable to perform the essential duties of his occupation as a Broker/Dealer Services Unit Manager due to his stroke in 2008 and subsequent cognitive impairment. Prudential defines "regular occupation" as the work performed at the onset of disability and considers the duties in a general sense rather than specific to one employer or location. The policy states that "material or substantial duties" are those necessary for the regular occupation that cannot be omitted or modified.
Although Mr. Ramdeen experienced cognitive difficulties after his stroke, he returned to work full-time for four years without incident, indicating he was capable of performing his duties. The assessment of his condition must focus on 2013, when he stopped working again. Prudential's independent medical reviews found no evidence of a new decline in his functionality, and Dr. Parke noted that Mr. Ramdeen's duties had changed but that there was no justification for his inability to work after four years of successful performance.
The LTD policy's definition of disability requires an inability to perform normally required duties without reasonable modification, and Mr. Ramdeen's ability to work different duties without a reduction in compensation suggests that his prior duties could be modified. Prudential preferred the assessments of independent medical consultants over Mr. Ramdeen’s statements and his treating physician, Dr. Kapoor, asserting that plan administrators need not give special deference to treating physicians' opinions. Dr. Meikle supported this view, stating that cognitive issues were not evidenced in the records post-2013, which primarily noted hypertension as Mr. Ramdeen's diagnosis.
Dr. Kapoor first mentioned Mr. Ramdeen's cognitive impairment only after the termination of his STD benefits, stating that Mr. Ramdeen was "not able to make decision[s]" and "not able to work full time" without further elaboration. Requests for additional information from Prudential went unanswered, and Dr. Kapoor did not communicate with independent physicians seeking clarification on Mr. Ramdeen's condition. The only other evidence of cognitive impairment came from Mr. Ramdeen’s own vague statement about forgetting his job title, which was unsupported by medical records, leading Prudential to assign it little weight. Mr. Ramdeen argued for leniency in filing supportive documentation due to being unrepresented, but this was rejected since the LTD Plan had clear guidelines, and Prudential had provided detailed reasons for denials and the opportunity to submit further evidence, which Mr. Ramdeen did not take. There was no indication that Mr. Ramdeen's alleged cognitive issues hindered his ability to present his claim effectively. Consequently, the denial of LTD benefits was affirmed after a de novo review, and Prudential's motion for summary judgment was granted while Mr. Ramdeen’s motion was denied. Additionally, his request for remand was rejected for lack of demonstrated procedural error or unconsidered evidence. Regarding STD benefits, the parties agreed that these claims fell under the "payroll practice" exception to ERISA, thus governed by ordinary contract law principles.
Ordinary summary judgment standards apply to the claim in question, as opposed to the Blankenship six-step framework. Summary judgment is granted if the moving party demonstrates that there is no genuine dispute regarding any material fact and is entitled to judgment as a matter of law, with the burden resting on the moving party to show an absence of evidence supporting the nonmoving party’s case. The court must view facts and reasonable inferences in favor of the nonmoving party without weighing evidence or assessing credibility. Summary judgment may be granted against a party that fails to adequately establish an essential element of its case.
In this case, the parties agree that there is no genuine dispute regarding the short-term disability (STD) claim against BNYMC. The primary issue is whether BNYMC breached the STD Plan by terminating Mr. Ramdeen’s benefits in October 2013. The STD Plan provides benefits for employees unable to perform their job due to physical or mental illness for at least seven consecutive days but not exceeding twenty-six weeks. Mr. Ramdeen’s claim is based on cognitive impairments from a 2008 stroke; however, evidence indicates he could perform his job with reasonable accommodations for four years prior to 2013, with no medical evidence at the time supporting a finding of disability.
BNYMC did not breach the STD Plan by favoring the independent medical consultant's opinion over Dr. Kapoor's conflicting statements. The Plan specifies that when there is disagreement between the employee’s physician and the company’s physician, the latter's opinion prevails. Dr. Selkirk, the independent consultant, found insufficient evidence to support Mr. Ramdeen’s claimed inability to perform his sedentary job, contrary to Dr. Kapoor’s assessment. Mr. Ramdeen's argument that Dr. Selkirk’s review was unfair is rejected. Dr. Selkirk's opinion was based on comprehensive medical records, not solely on a brief telephone call with a nurse.
BNYMC did not violate the Short-Term Disability (STD) policy by waiting for Prudential's decision on Long-Term Disability (LTD) benefits before denying Mr. Ramdeen’s second appeal for STD benefits. A thorough review of Mr. Ramdeen’s records was conducted prior to the initial denial of his first STD benefits appeal, and no additional information was provided for his second appeal. BNYMC was not required to order an independent neuropsychological evaluation, as the STD policy grants discretion to verify disabilities and places the burden of proof on the claimant. Employees must have their treating physicians complete an Attending Physician’s Statement (APS) to identify disability and treatment, and they are responsible for timely requests and accurate documentation. Mr. Ramdeen's claim of receiving retroactive Social Security disability benefits for January to March 2014 was dismissed because it occurred after BNYMC's review and lacked relevance to the case. As a result, Mr. Ramdeen’s Motion for Summary Judgment regarding the STD claim is denied, and the Defendants’ Motion for Summary Judgment is granted. The court concludes that Mr. Ramdeen has not demonstrated he is disabled under either the LTD or STD Plan, and a judgment is ordered that he takes nothing from the Defendants, with the case to be closed following this judgment.
Citations to the administrative record are made through 'AR' followed by the last three digits of the page number, with documents filed electronically (Docs. 22-33). The case does not involve STD benefits for 2008-2009. BNYMC denied Mr. Ramdeen's request for STD benefits prior to July 24, 2013, based on medical documentation indicating a disability onset of that date, without evidence of disability beforehand (AR 629). Dr. Kapoor's progress notes from the relevant period are largely illegible (AR 506, 519). Dr. Selkirk was unable to communicate with Dr. Kapoor directly despite multiple attempts, only speaking with his nurse, who reported that Mr. Ramdeen could work and did not need a cane, though he exhibited some right-sided weakness (AR 583). Dr. Parke also attempted to reach Dr. Kapoor without success (AR 426, 428). Consequently, the argument that Prudential erred by not ordering an independent neuropsychological evaluation is rejected, referencing Bloom v. Hartford Life, which placed the burden on the claimant to prove disability. However, based on the assessments of Drs. Parke and Meikle, vocational rehabilitation consultant Ms. Grunden concluded that Mr. Ramdeen was capable of performing his job as typically required (AR 407-12).
