Opinion ID: 2829974
Heading Depth: 2
Heading Rank: 1

Heading: Factual Background and Administrative

Text: Proceedings Sovereign Bank employed Stevens as a Retail Investment Financial Consultant II from October 2, 2006, through October 5, 2010. During his employment, Stevens received treatment for ankylosing spondylitis, a chronic inflammatory disease. As we have indicated, Santander sponsored and funded an STD benefits plan for its employees and engaged Liberty Mutual as the plan’s administrator. But even though Liberty Mutual was the plan administrator, Santander retained final decision-making authority in the review of STD claims and Santander paid any benefits awarded. Under the STD plan, a covered employee, such as Stevens, is considered “disabled” if objective medical evidence demonstrates that he is unable to perform the “material and substantial” duties of his own occupation, in Stevens’s case as a Retail Investment Financial Consultant II. “Material and substantial” duties are those normally required to be performed that cannot be eliminated or modified. Santander also purchased an LTD benefit plan from Liberty Mutual. The administration and funding of the LTD plan 4 differed from that of the STD plan because Liberty Mutual both administered and had final decision-making authority under the LTD plan and paid benefits awarded under the plan. To qualify for LTD benefits, an employee needs to show that he is “unable to perform the Material and Substantial duties of his Own Occupation” for an “elimination period” of 180 days, and thereafter cannot perform these duties for the next 24 months. During the “elimination period,” an employee does not receive benefits under the LTD plan, but he can receive LTD benefits during the 24-month “Own Occupation” period that follows. However, during the elimination period the employee may be eligible for STD benefits, and thus the two plans complement each other as LTD benefits can start when STD benefits stop.1 After the expiration of the 24-month “Own Occupation” period, an employee will be eligible for LTD benefits only if he demonstrates that he is “unable to perform, with reasonable continuity, the Material and Substantial Duties of Any Occupation.” (J.A. 67.) On or about October 5, 2010, Stevens began a leave of absence from Sovereign Bank due to worsening symptoms related to his medical condition. Consequently, Stevens filed a claim with Liberty Mutual for STD payments as he asserted that he was subject to qualifying physical restrictions and cognitive impairments. Liberty Mutual reviewed records of Stevens’s treating rheumatologist and approved his request for STD 1 In his brief Stevens indicates that “[t]he short-term disability (‘STD’) coverage provide[s] for up to 25 weeks of benefits (177 [sic] days of disability) following a 5 day elimination period.” (Appellee’s br. 5.) 5 benefits through December 21, 2010.2 In December, Liberty Mutual reviewed updated medical information and approved payment of STD benefits through February 5, 2011. Liberty Mutual again reviewed Stevens’s updated records in February 2011, this time determining that his medical reports did not substantiate Stevens’s subjective complaints of pain. Accordingly, it forwarded the case for review to an independent physician, Dr. Sara Kramer, a board certified physician in internal medicine and rheumatology. After Dr. Kramer reviewed Stevens’s records and spoke with Stevens’s treating rheumatologist, she concluded that Stevens could return to work provided that he was allowed certain accommodations, including being permitted to stretch and change positions as needed throughout the course of an eight-hour day.3 Liberty Mutual subsequently informed Stevens that his condition no longer met the definition of disability and therefore it would not award him additional STD benefits. The termination of Stevens’s eligibility for STD benefits effectively rendered Stevens ineligible for LTD benefits as he could not demonstrate that he was unable to perform his own occupation’s duties throughout the 180-day elimination period. 2 Stevens indicates that he also applied for and received temporary disability benefits from the State of New Jersey at the same time predicated on the same information that he supplied to Liberty Mutual to support his STD claim. (Appellee’s br. 7-8.) 3 Stevens asserts that Dr. Kramer spent a total of one hour and 15 minutes reviewing his case and that Liberty Mutual did not ask Stevens to submit to a physical examination. (Appellee’s br. 11-12.) 6 After Liberty Mutual notified Stevens that he was not eligible for further STD benefits, Stevens filed a series of administrative appeals with Liberty Mutual that he supported with medical records and additional documentation. In response to each of Stevens’s requests for review of additional information, Liberty Mutual enlisted medical professionals to evaluate the information in his record and the new information that he provided. On November 10, 2011, Liberty Mutual made a final determination that Stevens was no longer eligible for STD benefits, and it provided its final recommendation and analysis to that end to Santander, which, in turn, approved the decision a short time thereafter. Liberty Mutual then notified Stevens of the final decision to deny him further STD benefits.