Court Opinion

ID: 2663850
Source: CourtListenerOpinion
Date Created: 2014-04-04 02:45:56.45928+00
Date Added: 2024-06-11T09:17:50.815726
License: Public Domain

UNITED STATES DISTRICT COURT
                        FOR THE DISTRICT OF COLUMBIA

 DENISE KING,                                    )
                                                 )
                      Plaintiff,                 )
                                                 )
               v.                                )   Civil Case No. 09-1539 (RJL)
                                                 )
 LIBERTY LIFE ASSURANCE                          )
 COMPANY OF BOSTON d/b/a/                        )
 LIBERTY MUTUAL,                                 )
                                                 )
                      Defendant.                 )

                              MEMO~UM OPINION
                            (August --1-,2011) [#43 and #44]

       Plaintiff Denise King ("plaintiff' or "King") brought an action for breach of

contract against defendant Liberty Life Assurance Company of Boston, d/b/a! Liberty

Mutual ("defendant" or "Liberty"), seeking withheld long term disability ("LTD")

benefits under an employee welfare benefits plan in which she had enrolled in 2006 while

an employee in the Fairfax County Public School System. Before the Court is plaintiffs

Motion for Summary Judgment and defendant's Cross-Motion for Summary Judgment.

After due consideration of the parties' pleadings, the relevant law, and the entire record

herein, plaintiffs motion is DENIED and defendant's motion is GRANTED.

                                    BACKGROUND

       On July 3, 2003, King underwent bariatric bypass surgery and began experiencing

stomach strictures in August 2003. See Ex. C to Def.'s Cross-Mot. for Summ. J. ("'Def.'s

Cross-Mot.") at 10, July 8, 2010; Ex. H to Def.'s Cross-Mot. at 3. At the time of her

surgery, King was employed by the Leary School in Virginia. Ex. C to Def. 's Cross-Mot

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at 7. After the surgery, she stopped working and ultimately filed a disability claim with

the Leary School's insurer, Hartford Life Insurance Company ("Hartford"). Id. For

twenty-four months, Hartford paid King LTD benefits pursuant to its policy with the

Leary School. See Def.'s Mem. in SUpp. of Cross-Mot. for Summ. J. ("Def.'s Mem.") ~

9, Nov. 8,2010. On August 1,2006, however, Hartford terminated King's benefits

because: (1) Hartford's policy only provided LTD benefits for a maximum twenty-four

month period; and (2) King failed to establish she was unable to perform "Any

Occupation," as required by Hartford's policy. Id.

       On April 18, 2006, King called her primary care physician for a possible follow-

up from the surgery. Ex. D to Def.'s Cross- Mot. at 2. According to her physician's

office note for that visit:

       Patient here for follow up. She continues to feel she cannot work. She
       states she has persistent bowel pain, cramps, vomiting, and is unable to sit
       or work longer than a few minutes. She complains of right hip pain. Is
       worse with prolonged sitting. She still needs to eat on a regular schedule
       and amount. 'I cannot work during shifts or irregular hours.' She still has
       anxiety and needs Xanax daily. She is very anxious and she feels she
       cannot follow specific instructions due to difficulty with concentration.

Id.; see Ex. E to Def.'s Cross-Mot. at 7-8. His diagnosis of King's condition on that date

was "Status post-gastric bypass with multiple somatic complaints. Anxiety." Ex. D to

Def.'s Cross-Mot. at 2; see Ex. E to Def.'s Cross-Mot. at 8.

       Following the April 2006 visit, her doctor renewed the wide array of prescriptions

he had previously prescribed her: Zoloft, Nexium, Aciphex, Xanax, Vicodin, and

Zelnorm. Ex. E to Def. ' s Cross-Mot. at 8.

                                              2
        A few months later, on August 15,2006, King again visited her primary care

physician again for a follow up to her April visit. Id. at 11. According to his office note

for that visit:

        She continues to have recurrent vomiting, nausea, and sudden loss of bowel
        movements. She cannot sit for prolonged periods. She is a special
        education teacher and is unable to teach with her episodes. She has not
        been able to work part time. She takes daily Xanax for anxiety and pain
        meds from chronic abdominal pain. She has difficulty with concentration.

Ex. F to Def.'s Cross-Mot. at 2; see Ex. E to Def.'s Cross-Mot. at 11-12.

        Two days later, on August 17,2006, King began working for the Fairfax County

Public School System ("FCPS") as a special education teacher. l Ex. B to Def. 's Cross-

Mot. at 3. King enrolled in an employee welfare benefits plan-the Group Disability

Income Policy ("Policy")-provided by FCPS and administered by defendant. Id.; see

also Ex. A to Def. 's Cross-Mot. at 2. King's effective date of coverage under the Policy

was September 1,2006. Ex. B. to Def.'s Cross-Mot. at 3.

        During the period from September 1, 2006 to August 31, 2007, King consulted her

primary care physician and several other physicians for a variety of symptoms including

anxiety, chronic pain, tiredness, abdominal pain, and nausea. See Ex. C. to Def.'s Cross-

Mot. at 10; Ex. G to Def. 's Cross-Mot. Also during that period, she continued to take the

same medications that her primary care physician had previously prescribed her. See Ex.

F to Def.'s Cross-Mot. at 2; Ex. G to Def.'s Cross-Mot. at 2-15.

1 Plaintiff contends she began working for FCPS on August 15, 2006. However, she does
not provide any admissible evidence supporting her contention. Defendant, on the other
hand, provides the January 22, 2009 claim denial letter, which indicates that plaintiffs
start date was August 17,2006. See Ex. B to Def.'s Cross-Mot. at 3.
                                             3
       On February 2, 2007, King began taking intermittent leave from work due to her

various medical ailments, including: syncope, chronic abdominal pain, nausea, vomiting,

fatigue, and cognitive difficulties. 2 Ex. B to Def.'s Cross-Mot. at 3. Three days later, on

February 5, 2007, King filed claims for short and long term disability benefits. 3 Id. at 2.

The Policy offers long term disability benefits for employees unable to work because of a

disability, as defined by the Policy's terms. See Ex. A to Def.'s Cross-Mot. For LTD

benefits, the Policy defines "Disability" or "Disabled" as follows:

       a.     if the Covered Person is eligible for the 24 Month Own Occupation
       benefit, "Disability" or "Disabled" means that during the Elimination
       Period and the next 24 months of Disability the Covered Person, as a result
       of Injury or Sickness, is unable to perform the Material and Substantial
       Duties of his Own Occupation; and
       b.     thereafter, the Covered Person is unable to perform, with reasonable
       continuity, the Material and Substantial Duties of Any Occupation.

Id. at 7. The Policy defines "Own Occupation" as follows:

       the Covered Person's occupation that he was performing when his
       Disability or Partial Disability began. For purposes of determining

2 Defendant has submitted a sworn declaration from Dr. Holly R. Dahlman, M.D., a
physician board certified in internal medicine. It is Dr. Dahlman's professional opinion
to a reasonable degree of medical certainty that all of the symptoms, other than short-
term eye pain and gynecological issues, reported by plaintiff during the period of
September 1, 2006, to August 31, 2007, were caused by the conditions for which plaintiff
received treatment from her primary care physicians on August 15, 2006-specifically,
arthritis and post-bariatric surgery complications. See Declaration of Dr. Dahlman
("Dahlman Decl.") ~ 18, Ex. H to Def.'s Cross-Mot. The short-term eye pain and
gynecological issues are not at issue in this case. Subsequent to August 31, 2007,
plaintiff reported symptoms of vasovagal syncope to her primary care physician. Id. ~
19. It is Dr. Dahlman's professional opinion to a reasonable degree of medical certainty
that plaintiff s syncope was caused by multiple factors-including abdominal pain, pre-
existing vomiting, possible dehydration, narcotic pain medications, and later established
                                                                                               •
iron deficiency anemia-all of which resulted from plaintiffs bariatric surgery. Id.
3 Short term benefits are not at issue in this case.

                                              4
        Disability under this Policy, Liberty will consider the Covered Person's
        occupation as it is normally performed in the national economy.

Id. at 9.

        To be eligible for LTD benefits, a claimant must not fall into the Policy's pre-

existing condition exclusion. The relevant terms of the exclusion are as follows:

        Pre-Existing Condition Exclusion:
              the policy will not cover any Disability or Partial Disability:
              1. which is caused or contributed to by, or results from a Pre-Existing
                  Condition; and
              2. which begins in the first 12 months immediately after the Covered
                  Person's effective date of coverage.

Id. at 27. The Policy defines "Pre-Existing Condition" as "a condition resulting from an

Injury or Sickness for which the Covered Person is diagnosed or received Treatment

within three months prior to the Covered Person's effective date of coverage." Id. Under

the Policy, "Treatment" means "consulting, receiving care or services provided by or

under the direction of a Physician including diagnostic measures, being prescribed drugs

and/or medicines, whether the Covered Person chooses to take them or not, and taking

drugs and/or medicines." Id. at 10.

        Although King received short term benefits from February 2, 2007-King's date

of disability-until July 7, 2008, defendant denied LTD benefits on July 7, 2008, finding

that King's medical ailments fell within the Policy's pre-existing condition exclusion.

See ECF No. 35 at 38-39; Pl.'s Mem. in SUpp. of Mot. for Summ. J. ("Pl.'s Mot.") at 12.

Ultimately, King completely ceased working for FCPS on October 29,2007. See Ex. B

to Def.'s Cross-Mot. at 2.

                                              5
       On January 22, 2009, upon King's request for reconsideration, defendant issued a

final denial of LTD benefits. Ex. B to Def.' s Cross-Mot. at 2. Using the February 2,

2007 date of disability, defendant stated that it could not alter its original determination

because it again found King's medical ailments fell within the Policy's pre-existing

condition exclusion. Id. Defendant also considered an alternative date of disability-

October 18, 2007-based on King's attempts to return to work following her temporary

absences. Id. Defendant even denied her LTD benefits under the October 18th date,

finding that King's ailments did not constitute a disability as defined by the Policy. Id.

       On August 8, 2009, King filed this lawsuit, seeking to recover the back-due LTD

benefits denied by defendant. See Complaint ("Compl.") ~ 21. On October 18,2010,

King filed a Motion for Summary Judgment. See Docket Entry 43. On November 8,

2010, defendant filed a Cross-Motion for Summary Judgment. See Docket Entry 44. For

the reasons stated below, King's Motion for Summary Judgment is DENIED and

Defendant's Cross-Motion for Summary Judgment is GRANTED.

                                STANDARD OF REVIEW

       Summary judgment is appropriate when the movant demonstrates that there is no

genuine issue of material fact in dispute and that the moving party is entitled to judgment

as a matter oflaw. Fed. R. Civ. P. 56(a). The moving party bears the burden, and the

court will draw "all justifiable inferences" in the favor of the non-moving party.

Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 255 (1986). Nevertheless, the non-

moving party "may not rest upon the mere allegations or denials of his pleading, but ...

must set forth specific facts showing that there is a genuine issue for trial." Id. at 248

                                              6
(internal quotations omitted). Factual assertions in the moving party's affidavits may be

accepted as true unless the opposing party submits its own affidavits, declarations, or

documentary evidence to the contrary. Neal v. Kelly, 963 F.2d 453,456 (D.C. Cir. 1992).

                                   LEGAL ANALYSIS

   1.      Applicable Law

        Although the Employee Retirement Income Security Act ("ERISA") generally

covers "employee welfare benefit plans," the Act specifically excludes government plans,

including disability policies "established or maintained for its employees by the

Government of the United States, by the government of any State or political subdivision

thereof, or by any agency or instrumentality of any of the foregoing." See 29 U.S.C. §§

1002(32), 1003(b)(1). Both King and defendant agree that because FCPS is a

government entity, ERISA does not apply here. See Compi.       ~   11; PI.'s Mot. at 19; Def.'s

Mem. at 15-16.

        Federal courts sitting in diversity cases ordinarily apply the forum's choice oflaw

principles. See Gray v. Am. Express Co., 743 F.2d 10, 16 (D.C. Cir. 1984). As both

parties agree, the instant case involves a breach of contract. See PI.'S Mot. at 19; Def.'s

Mem. at 18. In our Circuit, parties to a contract may specify the choice of law that they

wish to govern the contract '''as long as there is some reasonable relationship with the

state specified.'" Whiting v. AARP, 637 F.3d 355,361 (D.C. Cir. 2011) (citing Ekstrom

v. Value Health, Inc., 68 F.3d 1391, 1394 (D.C. Cir. 1995)). Here, the Policy expressly

provides a choice of law provision, which states that the Policy is governed by Virginia

law. See Ex. A to Def.'s Mot. at 2. Additionally, the evidence clearly shows that "there

                                              7
is some reasonable relationship" with Virginia. See Whiting, 637 F.3d at 361. First, the

defendant delivered the policy to FCPS in Virginia. See Ex. A to Def.'s Mot. at 2.

Second, the Policy covers employees ofFCPS, including King-a government entity

created by and operating within Virginia. See PI.'s CompI.    ~~   6, 11; see also VA. CODE

ANN. § 22.1-2. Third, King is a Virginia resident. See PI.'s Compi.      ~   6; Pierce v.

Showell, 357 F. Supp. 2d 307,310 (D.D.C. 2005) (holding a choice oflaw provision had

a reasonable relationship with the state chosen because the plaintiff was a citizen of that

state). Further, neither party disputes the applicability of the choice of law provision.

See Mobile Satellite Commc 'n, Inc. v. Intelsat USA Sales Corp., 646 F. Supp. 2d 124, 130

(D.D.C. 2009) (upholding a choice of law provision in a contract where the parties did

not dispute its applicability). Therefore, the Court will apply Virginia law. 4

    II.      Breach of Contract Claim

          King contends that defendant breached the employee welfare benefits contract by

denying her the long term disability benefits she is owed under the Policy. See CompI.       ~~

20-21; PI.'s Mot. at 19. Under Virginia law, "the elements ofa breach of contract action

are (1) a legally enforceable obligation ofa defendant to a plaintiff; (2) the defendant's

violation or breach of that obligation; and (3) injury or damage to the plaintiff caused by

4 Although plaintiff correctly acknowledges that ERISA does not apply to the Policy, she
contends that ERISA caselaw may be used persuasively without providing any relevant
caselaw to support her contention. PI.' s Mot. at 19. In fact, most of plaintiff's
contentions are incorrectly based on ERISA jurisprudence, rather than Virginia contract
law. This Court has not found any binding authority requiring the Court to use ERISA
jurisprudence persuasively. Indeed, Congress specifically created an exception in ERISA
for Government plans established by state and local governments. As both parties agree,
this is a breach of contract case, and as such, this Court will look to Virginia substantive
law, as required by law.
                                              8
the breach of obligation." Sunrise Continuing Care, LLC v. Wright, 671 S.E.2d 132, 135

(Va. 2009) (internal citation and quotation marks omitted). Defendant contends that it

did not breach the contract because it had no legally enforceable obligation to King for

her alleged disability as it was a pre-existing condition and, therefore, was excluded from

coverage under the Policy. Def.'s Mem. at 18. I agree.

       The Policy explicitly excludes from coverage any disability (1) "caused or

contributed by, or resulting from a Pre-Existing Condition," i.e., a condition that

"result[s] from an injury or sickness for which the covered person is diagnosed or

received Treatment within three months prior to the covered person's effective date of

coverage," and (2) that begins in the first twelve months immediately after the person's

effective date of coverage. See Ex. A to Def.'s Cross-Mot. at 27. The Policy defines

"Treatment" as "consulting, receiving care or services provided by or under the direction

of a Physician including diagnostic measures, being prescribed drugs and/or medicines,

whether the Covered Person chooses to take them or not, and taking drugs and/or

medicines." Id.

       King's effective date of coverage under the Policy was September 1,2006. In

April 2006, she consulted her primary care physician for a follow-up from her bariatric

bypass surgery and was prescribed a wide-range of medications to treat her various post-

bariatric ailments. Then, on August 15, 2006-two weeks prior to her effective date of

coverage-King had another follow-up consultation with her primary care physician in

which she complained that she continued to suffer from these various post-bariatric

                                             9
.'

     conditions. 5 Indeed, King continued to take anxiety and pain medications and Dr.

     Dahlman-the only physician expert witness identified by either party-has opined that

     King's symptoms for which she has claimed a disability were caused by the post-bariatric

     condition. See Dahlman Decl. ,-r,-r 18-19, Ex. H to Def.'s Cross-Mot.

            Thus, during the three-month period prior to her September 1,2006 effective date

     of coverage, King was still clearly receiving medical "Treatment" for her post-bariatric

     conditions. Additionally, when King filed her disability claim in February 2007, she was

     well within the twelve month period following her effective date of coverage. Because

     King sought "Treatment" within three months prior to the effective date of coverage and

     her alleged disability began within twelve months of that same date, her alleged disability

     is excluded from coverage as a "Pre-Existing Condition" under the Policy and defendant

     has not breached the contract. 6 Indeed, King admitted in her own deposition in 2010 that

     5  According to Dr. Dahlman's declaration, during that visit, Dr. Perez prescribed King
     with the same medications he had previously prescribed her in April. See Dahlman Decl.
     ~,-r 15,17,18, Ex. H to Def.'s Cross-Mot.
             Plaintiff does not dispute that the symptoms from which she suffers began
     immediately after she underwent bariatric bypass surgery in 2003. Instead, plaintiff
     contends that the February 2007 disability date cannot be used because defendant offered
     a second, alternative date of disability-October 18, 2007-in its final denial letter. See
     PI.'s Mot. at 17; PI.'s Opp'n to Def.'s Cross-Mot. ("PI.'s Opp'n") at 5. In other words,
     plaintiff contends that by including the second date of disability in its final letter,
     defendant has waived the use of the first date of disability that was included in both the
     initial and final denial letter. Plaintiffs argument is unavailing. Defendant has never
     conceded that the first disability date does not apply and has not forfeited that argument.
     Defendant has consistently used the February 2007 disability date in each of its denials.
     Indeed, in its final denial letter, defendant very clearly stated that it could not alter its
     original determination because the conditions for which plaintiff claimed disability "were
     caused, contributed to by, or resulting from a Pre-Existing Condition." Ex. B to Def. 's
     Cross-Mot. at 2. Defendant's final denial of the disability claim based on alternative
     grounds does not preclude defendant from using the February disability date.
                                                  10
she still continues to suffer from various symptoms of her 2003 post-bariatric surgery.

See Ex. C to Def.'s Cross-Mot. at 7-10.

                                      CONCLUSION

       Thus, for all of the foregoing reasons, King's Motion for Summary Judgment,

ECF No. 43, is DENIED and defendant's Cross-Motion for Summary Judgment, ECF

No. 44, is GRANTED.? An appropriate order will accompany this memorandum

OpInIOn.

                                                  United States District Judge

        Similarly, plaintiff contends defendant improperly "mended its hold" by offering
new grounds for which to deny her LTD benefits claim. See Pl.'s Opp'n to Def.'s Cross-
Mot. ("PI.'s Opp'n") at 5-6. For support, plaintiff relies heavily on ERISA caselaw,
which is not applicable in this case. However, plaintiff also cites Railway Co. v.
McCarthy, 96 U.S. 258, 267-68 (1877), for the proposition that a party cannot "mend its
hold," i.e., "[w ]here a party gives a reason for his conduct and decision touching any
thing involved in a controversy, he cannot, after litigation has begun, change his ground,
and put his conduct upon another and a different consideration." Although the Court
need not reach this issue because plaintiff failed to allege it in her complaint, her
contention lacks merit. Here, rather than rely on a new ground, defendant offers the same
rationale in its briefing as it did in its denial letters for why plaintiff is ineligible for
benefits under the Policy. Therefore, defendant did not "mend its hold."
? King's last-ditch effort to bring a bad faith claim is unavailing. See PI's Opp'n at 1-2.
Although the Court need not reach the issue of bad faith because King failed to allege the
issue in her complaint, there is no indication on the record that defendant acted in bad
faith.
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