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Pfifer v. Sedgwick Claims Management Services Inc.

United States District Court, S.D. Texas, Houston Division

September 30, 2019

ALLISON PFIFER, Plaintiff,
v.
SEDGWICK CLAIMS MANAGEMENT SERVICES INC., Defendant.

          MEMORANDUM OPINION AND ORDER

          KENNETH M. HOYT UNITED STATES DISTRICT JUDGE

         I. INTRODUCTION

         The plaintiff, Allison Pfifer (“Pfifer” or “the plaintiff”), commenced the instant action against the defendant, Sedgwick Claims Management Services, Inc. (“Sedgwick”), pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1132 (a)(1)(B), [1] alleging that Sedgwick, the Claims Administrator, wrongfully denied her claims for short-term disability (“STD”) benefits pursuant to the 3M Short Term Disability Plan and long-term disability (“LTD”) benefits pursuant to the 3M Long Term Disability Plan. Both plans are sponsored by 3M Company (“3M”) and governed by ERISA. The plaintiff seeks compensation for denied benefits, interest and attorneys’ fees and costs.

         Pending before the Court are Sedgwick’s motion for summary judgment and memorandum of law in support thereof (Dkt. No. 21), the plaintiff’s response in opposition to Sedgwick’s motion for summary judgment (Dkt. No. 24), Sedgwick’s reply (Dkt. No. 25), the plaintiff’s cross-motion for summary judgment (Dkt. No. 22) and Sedgwick’s response in opposition to the plaintiffs cross-motion for summary judgment (Dkt. No. 23). After having carefully considered the motions, responses, reply, the record and the applicable law, the Court determines that Sedgwick’s motion for summary judgment should be GRANTED; and the plaintiffs cross-motion for summary judgment should be DENIED.

         II. FACTUAL BACKGROUND

         The plaintiff, Pfifer, is a 64-year old female who worked as a “Lead Proposal Writer[2]” for 3M. During the relevant time, the plaintiff participated in a 3M-sponsored Short Term Disability Plan (“STD Plan”) and Long Term Disability Plan (“LTD Plan”) for eligible employees, effective January 1, 2016. Pursuant to the specific terms of the STD Plan and the LTD Plan, 3M’s Director, Total Rewards Program Management, is designated as the Plan Administrator with the authority to delegate “its full and final discretionary power and authority with respect to benefit determinations to the Claims Administrator.” (Dkt. No. 21, App. 3 at 3M00001479; App. 4 at 3M00001446.). Sedgwick is identified as the Claims Administrator with the discretionary authority to interpret the Plans’ terms and decide questions of eligibility for coverage. (Id. at 3M00001482, 3M00001449).

         An employee participant’s eligibility for benefits under the STD Plan is determined as follows:

Eligibility for Benefits
You are eligible to receive [STD] benefits under the Plan only if the Claims Administrator determines that:
• You are eligible and covered under the Plan;
• You meet the Plan’s definition of Disabled (including providing Objective Medical Evidence of your disability, when requested by the Claims Administrator);
• Your disability is not one excluded from coverage under the Plan; and
• You satisfy all other eligibility requirements under the Plan.
To be eligible for STD benefits, you must provide sufficient Objective Medical Evidence of your disability. The Claims Administrator determines whether you have provided sufficient Objective Medical Evidence of your disability and may require more than one examination. You may be required to provide the Claims Administrator with continuing proof of your disability and prove that you are under the regular care of a physician. You must provide this proof at your own expense and within the timeframe required by the Claims Administrator. Failure to comply with the Claims Administrator’s requests may impact your eligibility for and payment of benefits.

(Id. at 3M00001461.). The term “disabled” is defined under the STD Plan as follows:

Disabled Defined
You are considered Disabled for purposes of the Plan only if the Claims Administrator determines that due to an illness, injury, pregnancy or other medical condition you are unable to perform the material duties of:
• Your regular and customary occupation at 3M; or
• Any other appropriate job offered by 3M.
In addition, you must be under the regular and continuous care of a licensed Health Care Provider, unless such treatment is not medically necessary given the nature of your disability.
The Claims Administrator determines whether or not you are Disabled on the basis of Objective Medical Evidence and any other relevant evidence.
Please Note : Social Security’s decision is not considered when determining your eligibility for STD benefits. Therefore, if the Social Security Administration approves you for disability benefits, it doesn’t mean you are eligible for 3M STD benefits.

(Id.).

         An employee participant’s eligibility for benefits under the LTD Plan is determined as follows:

         Eligibility for Benefits

         You are eligible to receive [LTD] benefits under the Plan only if the Claims Administrator determines that:

• You are eligible and covered under the Plan;
• You meet the Plan’s definition of Disabled (including providing Objective Medical Evidence of your disability, when ...

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