Sangha v. Cigna Life Ins. Co. of N.Y.

Citation: 314 F. Supp. 3d 1027Docket: Case No. 17–cv–05158–HSG

Court: District Court, N.D. California; June 18, 2018; Federal District Court

SummaryOriginalCytator Case TreatmentBackward CitatorAnalysis

EnglishEspañolSimplified EnglishEspañol Fácil

Plaintiff Sarabjit Sangha filed a lawsuit against Cigna Life Insurance Company of New York on September 6, 2017, seeking relief under ERISA due to the denial of her long-term disability (LTD) benefits related to chronic pain from cervical degenerative disc disease and spinal fusion surgery. The case involves motions for judgment from both parties and was argued during a bench trial on June 7, 2018. The Court has overturned the denial of LTD benefits effective July 31, 2016, based on the findings of fact and conclusions of law.

Sangha worked as a Buyer/Subcontractor Administrator for Loral Space Communications Inc. since August 2010, under a Group Insurance Policy issued by Cigna, which provides LTD benefits. The Policy stipulates that an employee is considered disabled if they cannot perform their regular occupation due to an injury or sickness, and after 24 months, if they cannot perform any occupation based on their qualifications. To receive benefits, the employee must meet a waiting period, be under physician care, and provide satisfactory proof of disability.

Sangha's condition began after a rear-end collision with a truck on October 26, 2011, leading to severe neck pain and spinal surgery on May 29, 2012. Post-surgery, she continued treatment with her neurosurgeon, Dr. Desmond Erasmus, who repeatedly extended her time off work due to ongoing pain and fatigue, ultimately concluding she was not ready to return to full-time employment.

On April 22, 2013, Plaintiff filed a claim for long-term disability (LTD) benefits with Defendant. The claim was denied on May 31, 2013, with Defendant stating that Plaintiff was eligible for benefits only from November 19, 2011, to October 29, 2012, due to not meeting the Policy's 365-day Benefit Waiting Period. The denial was based on evaluations by Nurse Case Manager Nancy Lescher and Associate Medical Director Dr. Penny Chong, who concluded that Plaintiff's limitations were unsupported. Plaintiff appealed the denial on July 8, 2013, submitting letters from treating physicians, including a progress note from Dr. Erasmus, who linked Plaintiff’s functional difficulties to chronic pain and extended her disability to August 1, 2013. Dr. Schuchard, another supporting physician, indicated Plaintiff was unable to work due to chronic pain and recommended an extension of disability until October 1, 2013, noting associated degenerative changes and secondary depression. In reviewing the appeal, Defendant engaged a third-party vendor, MES Solutions, which involved Dr. Mark D. Watson. He assessed Plaintiff's treatment history and determined she could perform less than sedentary work until February 25, 2013, but could then tolerate more activity, such as standing and walking for up to three hours daily. However, an occupational analysis by Rehabilitation Specialist Melissa Mendez found the restrictions inconsistent with Plaintiff’s job demands. Consequently, Defendant reversed its previous denial of benefits and notified Plaintiff on October 14, 2013.

After a successful appeal, the Defendant provided the Plaintiff with disability benefits for approximately five months while she continued treatment and the Defendant reassessed her claim. In November 2013, Plaintiff underwent extensive testing with Dr. Tulsidas Gwalani, who diagnosed her with several conditions, including failed neck surgery syndrome and chronic pain syndromes. A psychological evaluation by Dr. Robert Avenson in December 2013 indicated that Plaintiff was initially cooperative but displayed significant distress during the assessment, reporting extreme pain levels. Dr. Avenson noted that Plaintiff had realistic goals for pain management and was a suitable candidate for treatment, including opioids. 

Nurse Case Manager JoAnn Orozco and Dr. Chong reviewed Plaintiff's medical records, both concluding that there was insufficient evidence of functional loss to support continued benefits. CIGNA informed Plaintiff on March 14, 2014, that benefits would cease after March 17, 2017. Following this, Plaintiff filed another appeal in April 2014, submitting updated medical records from Dr. Suresh Mahawar, who diagnosed her with cervical disc displacement and recommended specific activity restrictions due to her chronic pain.

Dr. Mahawar conducted a Physical Ability Assessment (PAA) on July 8, 2014, indicating that the Plaintiff could only perform activities such as standing, walking, reaching, and lifting up to 10 pounds occasionally (0 to 2.5 hours per day). He recommended that the Plaintiff could return to work only in a sedentary capacity with specific restrictions, including minimal twisting. CIGNA reviewed the Plaintiff's medical records with Dr. Brock, who noted persistent pain and range of motion limitations due to a multilevel cervical fusion. Dr. Brock concluded that the Plaintiff should avoid lifting over 10 pounds occasionally and could occasionally bend, stoop, or crouch, but otherwise had no significant neurological disturbances.

Based on Dr. Brock's findings, CIGNA reversed its denial of the Plaintiff's long-term disability (LTD) benefits. Following reinstatement, the Plaintiff continued pain management treatments for chronic neck, lower back, and shoulder pain. On January 24, 2016, Defendant reassessed the Plaintiff's LTD eligibility, leading to a Functional Capacity Evaluation (FCE) by Jonathan Blue on May 12, 2016. Mr. Blue found the Plaintiff had limitations in maintaining static positions, could sit for 20 minutes and stand for 15 minutes before experiencing pain, and exhibited an abnormal gait. He concluded that the Plaintiff could tolerate sitting, standing, and walking only on an occasional basis, with specific time limits for each activity, and recommended infrequent bending and squatting.

"Occasional" is defined as 0 to 33% of an 8-hour workday (up to about 2.5 hours), while "infrequent" is less than 1% of such a day. Randy Norris, MS, CRC, CCM, conducted a Transferable Skills Assessment (TSA) on May 17, 2016, based on the Blue Functional Capacity Evaluation (FCE), identifying two suitable occupations in Fremont, California: Financial-Aid Counselor and Procurement Engineer. Following these assessments, the Defendant denied the Plaintiff's long-term disability (LTD) benefits on June 1, 2016, but continued to pay "any occupation" benefits until July 31, 2016, to mitigate financial hardship. The Plaintiff appealed and submitted updated medical records, prompting the Defendant to require an Independent Medical Examination (IME) by Dr. Donald Lee on November 1, 2016. Dr. Lee confirmed the Blue FCE findings and detailed the Plaintiff's abilities, indicating she could sit, stand, walk, and perform various tasks frequently, but had occasional limitations in lifting and carrying.

Subsequently, Cindy A. Herzog, MS, CRC, performed another TSA on November 18, 2016, finding two additional occupations that met the wage requirement: Purchase-Price Analyst and Repair-Order Clerk. The Defendant denied the Plaintiff's appeal on December 19, 2016. The Plaintiff submitted a secondary appeal on June 14, 2017, including various supporting documents such as video statements, declarations, medical records, and results from a Job Simulation Assessment. Despite this evidence, the Defendant upheld the termination of benefits on August 9, 2017, citing independent medical reviews conducted in July 2017 by Dr. Louise Banks and Dr. Laila Laitman. Based on Dr. Banks's findings, Tony Miller, MS, CRC, identified two additional occupations: Expediter and Administrative Assistant. The Plaintiff subsequently filed a lawsuit a month after the Defendant's decision.

ERISA grants claimants a federal cause of action to recover benefits owed under an ERISA plan, specifically under 29 U.S.C. § 1132(a)(1)(B). The court will evaluate the denial of long-term disability (LTD) benefits using a de novo standard, meaning it will independently assess whether the claimant has sufficiently demonstrated disability under the plan's terms, without deferring to the claim administrator's decision. Although previous benefit awards may be relevant to the current assessment of disability, they do not shift the burden of proof from the claimant.

To establish entitlement to LTD benefits from July 31, 2016, the plaintiff must demonstrate, by a preponderance of the evidence, that she meets the policy's definition of disability. According to the policy, disability requires the claimant to be unable to perform material duties of any occupation for which they are qualified and to earn less than 60% of their indexed covered earnings due to injury or sickness. As of July 31, 2016, this threshold was $47,000 annually, or $3,909 monthly.

The plaintiff supports her claim with various evidence, including medical records, findings from an independent review by CIGNA, an award of Social Security Disability benefits, and personal and witness reports describing her chronic pain. Her medical records indicate ongoing debilitating pain from cervical and lumbar degenerative disc disease since 2012, requiring narcotics with disabling side effects. Dr. Mahawar, who has treated the plaintiff consistently since June 2014, has documented significant work restrictions due to her condition, including limitations on sitting, lifting, and using her hands, and has characterized her prognosis as "guarded." He asserts that she is unable to perform even low-stress jobs and has detailed specific limitations on her ability to sit, stand, lift, and carry, as well as her anticipated absenteeism from work.

Dr. Erasmus's findings from 2016 confirm the ongoing and worsening nature of Plaintiff's condition, noting increasingly severe cervical pain and a mature fusion from C4-C7 observed through x-rays. He recommended continued trigger point and epidural injections, which Plaintiff regularly pursued. In a November 2016 report, Dr. Erasmus identified degeneration of the C3-4 disc and described Plaintiff's chronic pain management, ongoing fatigue, and low back pain with bilateral radiation. MRI studies indicated early disc degeneration and small white matter lesions in the brain, contributing to Plaintiff's forgetfulness.

Defendant argues that restrictions from Drs. Mahawar and Erasmus align with a sedentary capacity; however, this claim is weakened by selective quotation of Plaintiff's records that omit critical observations about her pain. For instance, while Defendant cites a normal gait noted by Dr. Mahawar, they ignore his contemporaneous remarks on Plaintiff's sitting and standing limitations due to chronic pain and her difficulties with shoulder and cervical spine movement. Defendant also highlights that Dr. Mahawar indicated Plaintiff could "occasionally" grasp, stand, walk, or reach, but does not clarify that "occasionally" refers to a limited duration of 0 to 2.5 hours within an 8-hour workday. Although Dr. Mahawar noted that Plaintiff could "frequently" sit for 2.5-5.5 hours, the Court finds her actual sitting capacity is likely in the lower half of this range based on prior assessments that she could not sit for more than 1 hour without a break and could only sit or stand for less than 2 hours in an 8-hour workday.

Plaintiff's claim for disability is supported by her severely limited use of hands, inability to perform repetitive movements, and consistent reports of chronic pain, corroborated by Dr. Erasmus's evaluation and MRI reviews. The defendant's argument that Dr. Erasmus's findings are based solely on subjective complaints is countered by legal precedents emphasizing that a claimant's credible self-reported symptoms, even if not fully backed by objective evidence, must be considered. The defendant's references to unrelated medical visits from 2016 and 2017 do not undermine Plaintiff's chronic pain claims and instead reveal long-standing issues like chronic low back pain and spinal stenosis. Furthermore, an April 2017 functional capacity evaluation (FCE) indicates that Plaintiff does not meet the physical demands for sedentary work, noting her limitations in sitting, standing, and lifting. This assessment reinforces the conclusion that her condition significantly impairs her ability to maintain a consistent work schedule and perform tasks effectively.

Ms. Peterson's assessment of the Plaintiff's job suitability was based on a Job Site Analysis (JSA) that included a vocational interview, typing tests, and other office task assessments. The Plaintiff's test scores indicated low percentiles in various areas: 17th for spatial reasoning, verbal reasoning, word knowledge, and manual speed/dexterity; 32nd for perceptual speed/accuracy and numerical aptitude; and 50th for mechanical reasoning and language usage. Ms. Peterson noted the Plaintiff's unscheduled breaks during testing, resting during lunch, and ongoing reports of pain and concentration difficulties. She concluded that the Plaintiff lacked the physical capacities and stamina required for her previous role as a Buyer/Subcontractor Administrator or any related full-time occupation. The Defendant challenged the reliability of the Plaintiff's Functional Capacity Evaluation (FCE) and JSA, arguing they relied on self-reports and were contradicted by concurrent records. However, this argument was deemed unpersuasive due to the objective measurements contained in the FCE and the lack of credibility in the Defendant's presentation of the Plaintiff's medical records. Overall, the consistency and severity of the medical reports, along with the April 2017 FCE/JSA, support a finding of disability under the Policy.

CIGNA's independent review, alongside Plaintiff's medical records, is central to the discussion of Plaintiff's claim for long-term disability (LTD) benefits. Both parties reference the Blue Functional Capacity Evaluation (FCE), Dr. Lee's Independent Medical Examination (IME), and CIGNA’s Transferable Skills Analysis (TSA) as pivotal in CIGNA's denial of benefits after July 31, 2016. However, CIGNA's findings do not support the denial. Mr. Blue's assessment indicates that Plaintiff's ability to work is severely restricted: she can only sit, stand, or walk occasionally, with specific limits on continuous durations (sitting less than 20 minutes, standing less than 15 minutes, and walking less than 10 minutes). According to definitions provided, "occasional" translates to 0 to 2.5 hours in an 8-hour workday, which is insufficient for sedentary work, as established in case law. Plaintiff’s medical records and additional evaluations reinforce her limited capacity to perform even sedentary tasks, further diminishing the weight of CIGNA's May 2016 TSA based on the Blue FCE. The findings from Plaintiff's April 2017 Job Site Assessment (JSA) and FCE provide a more comprehensive assessment of her abilities, accounting for pain behaviors and other limitations that were not considered in the earlier Blue FCE. CIGNA has not contested this comparative evidence.

Dr. Lee's November 1, 2016 Independent Medical Examination (IME) exhibits significant methodological flaws and inconsistencies. He concluded that the Plaintiff could sit, stand, and walk for 2.5 to 5.5 hours daily, a finding not supported by the Plaintiff's treating physicians, who did not endorse such capabilities. Additionally, Dr. Lee's conclusions contradict a Blue Functional Capacity Evaluation (FCE), which indicated the Plaintiff could only perform those activities for 0 to 2.5 hours. Dr. Lee's report also contains internal errors, undermining its reliability. Consequently, Ms. Herzog's November 2016 Transferable Skills Analysis (TSA), which relies on Dr. Lee's IME, is similarly questionable.

Dr. Banks' July 27, 2017 report, also cited by the Defendant, found that the Plaintiff could sit without restrictions, frequently stand and walk, and lift 10 pounds occasionally. However, Dr. Banks failed to adequately explain the basis for these restrictions and his qualitative observations support the Plaintiff’s disability claim. He confirmed that the Plaintiff is physically limited due to cervical and lumbar degenerative disease, particularly highlighting her history of cervical degenerative disease and a prior fusion surgery. Dr. Banks explicitly contradicted Dr. Lee, stating that the IME did not accurately reflect the Plaintiff's difficulties with repetitive tasks.

The Defendant's motion referenced surveillance footage of the Plaintiff engaging in various activities, asserting that this does not negate her claimed limitations under the policy. Previous case law indicates that limited activities, such as bending to place a walker in a car or running errands, do not equate to the ability to sustain an eight-hour workday, particularly in a sedentary role.

The evidence indicates that the plaintiff's medical condition, particularly in her arms, limits her ability to perform sedentary jobs. The majority of medical evidence supports the plaintiff's claim for long-term disability (LTD) benefits. Although the court does not consider the plaintiff's Social Security Disability benefits as binding, it acknowledges their persuasive value. The Administrative Law Judge (ALJ) determined that the plaintiff was disabled from May 14, 2014, until the decision date of November 17, 2016. The Social Security Administration defines disability as an inability to engage in substantial gainful activity due to a medically determinable impairment expected to last at least 12 months.

The ALJ found that the plaintiff's allegations were consistent with the medical evidence, which included reports of disabling neck and back pain and reduced dexterity in her right hand. Although the ALJ concluded that the plaintiff could perform sedentary work with limitations, some of these limitations contradicted her physicians' findings. The ALJ gave significant weight to Dr. Omar Bayne’s opinions, who noted that the plaintiff had "less than sedentary residual functional capacity," including difficulties with ambulation and reduced strength. The ALJ also considered a "less than sedentary" statement from Dr. Mahawar, consistent with previous observations of the plaintiff.

Dr. Gerald Belchick, the SSA's vocational expert, concluded that the plaintiff was incapable of performing any work, stating there were no jobs available in the national economy that matched her age, education, experience, and functional capacity. The ALJ accepted this opinion, noting that the plaintiff had no transferable skills.

Additionally, statements from the plaintiff and third-party witnesses, including family and co-workers, corroborate her claims of debilitating chronic pain, medication side effects, and significant changes in her personality and quality of life due to her condition.

Plaintiff and her partner submitted video statements from February 2017 detailing Plaintiff's severe pain and its associated side effects. Defendant contests the credibility of these self-reports, claiming they are self-serving and lack corroboration. However, the Court finds Plaintiff's descriptions credible and aligned with her treating physicians' findings and medical records, concluding that she meets her burden of proof for disability under the Policy as of July 31, 2016.

Regarding attorney's fees and costs, Plaintiff has requested these in her motion. Under ERISA, courts can award reasonable attorney's fees and costs at their discretion. The Ninth Circuit typically grants fees to a prevailing ERISA plaintiff unless special circumstances arise. Defendant did not address attorney's fees in their filings, so the Court will defer its ruling on this matter until it is fully briefed. Plaintiff is permitted to file a motion for fees under Civil Local Rule 54-5 within 14 days of the judgment.

The Court overturns Defendant's denial of benefits, ruling in favor of Plaintiff for Long-Term Disability (LTD) benefits post-July 31, 2016. The parties are ordered to meet within 30 days to resolve the amount of benefits and prejudgment interest owed to Plaintiff and to propose a consistent judgment. Additionally, the Administrative Law Judge (ALJ) determined Plaintiff's limitations allow her to lift and carry up to 10 pounds, stand or walk for two hours, and sit for six hours in an eight-hour workday, among other physical capabilities.