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LANGLEY v. SEARS

September 27, 2005.

PATTI LANGLEY, Plaintiff,
v.
SEARS, ROEBUCK & COMPANY, Defendant.



The opinion of the court was delivered by: SUSAN WRIGHT, Chief Judge, District

MEMORANDUM OPINION AND ORDER

Plaintiff Patti Langley filed this complaint on January 31, 2005, in the Circuit Court of Pulaski County, Arkansas, seeking a review of a decision denying her claim for Long-Term disability ("LTD") benefits under a plan offered through her employer, defendant Sears, Roebuck & Company ("Sears"). Sears removed the action to federal court on the basis that the claim is covered by the provisions of the Employee Retirement Income Security Act of 1974 (as amended), 29 U.S.C. § 1001 et seq. ("ERISA"). The administrative record has been filed with the Court and the parties have filed their briefs. For the reasons stated below, the Court finds that the decision to deny plaintiff benefits should be reversed.

Background

  Sears provides disability benefits, both short term and long term, to eligible employees through a program funded by Sears and administered by Metropolitan Life Insurance Company ("MetLife"). At the relevant time period, Langley worked as a store general manager. She had been employed at Sears for thirty years. In April 2004, Dr. Jeff Carfagno referred plaintiff to Dr. C. Lowry Barnes, an orthopedist, after plaintiff complained of left knee pain. After their first visit, Barnes reported that plaintiff had been diagnosed by Dr. Michael Jones "as having acute atypical rheumatoid arthritis." Dr. Barnes reported that plaintiff complained of increasing left knee pain over the past 3 months, but that Prozac, prescribed by Dr. Carfagno, "gave her excellent relief from her chronic pain." Dr. Barnes reported that on examination, plaintiff was "neurologically intact distally," "[s]traight leg raising is negative," and [h]ip exam is normal." He noted moderate effusion but indicated her "patella tracks centrally and her knee is stable." Dr. Barnes noted she lacked 15 degrees of extension and flexed to 100. Radiographs showed no acute bony abnormality. She did "have some arthritis in her right knee on the lateral aspect." Dr. Barnes ordered a MRI of her left knee. AR-0258

  On May 5, 2004, following the MRI, plaintiff returned to Barnes. He noted that the MRI showed a "medial and lateral meniscus tear," and reported that "[w]e are going to proceed with arthroscopy of her left knee." AR-0257 Plaintiff had surgery on her left knee on May 14, 2004. AR-00261 She submitted a claim for Short-Term disability ("STD") benefits after her surgery. AR0-005

  On May 18, 2004, plaintiff returned to Barnes for a follow-up after surgery. He reported her knee was stable and in excellent alignment. He recommended an "aggressive therapy program, 3x a week for the next 3 weeks." Dr. Barnes noted plaintiff was working 10 hours per day and was on her feet most of the day. He stated: "I do not think she has a knee that is going to allow her to continue to do that." Dr. Barnes noted he would see plaintiff in three weeks for a re-evaluation. AR-0256 On May 20, 2004, plaintiff visited physical therapist Greg Calaway. He noted plaintiff was "ambulating at this time with no obvious gait deviation," and was "able to do a straight leg raise at this time with no extensor lag seen." He recorded plaintiff had done very well following her surgery, and his long-term goal was to return plaintiff to "full function and activity with no pain or limitations in her left knee within 8 weeks." AR-0273-74

  On May 21, 2004, MetLife wrote plaintiff a letter, approving her claim for STD benefits effective May 14, 2004 through June 17, 2004. MetLife explained what information it would need in order to consider extending her benefits. AR-0005

  On May 24, 2004, plaintiff began physical therapy under the supervision of a number of physical therapists, including Greg Calaway. AR-268-70 On May 24 and 26, the physical therapists reported that plaintiff had no new complaints or increases in pain. During those sessions, plaintiff engaged in a number of exercises including quad sets, straight leg raises, and leg swings. At the May 26 session, plaintiff indicated that she wanted to continue her therapy on her own at home. AR-271-72 On June 2, 2004, plaintiff returned and reported experiencing "some increased discomfort over the weekend when she attempted to do her exercises on her own. For that reason she came back for treatment. She felt she could do her exercises at home but after experiencing problems decided to come back to therapy." She did quad sets, straight leg raises, leg swings for five minutes, and biking for five minutes. Calaway noted she tolerated her treatment well. AR-270 On June 3 and 4, plaintiff engaged in approximately 35 minutes of physical therapy under the supervision of Calaway. Each time he noted she tolerated her treatment well. AR-268-69.

  At some point in late May or early June 2004, Barnes recommended that plaintiff have right knee arthroscopy. On June 8, 2004, Barnes performed the surgery. In his operative notes, he stated that plaintiff had "done well" with her left knee arthroscopy. AR-0259 On June 10, plaintiff returned to Barnes for a follow-up. He noted she was "doing well" and would again undergo "an aggressive therapy program." AR-0255 In a brief note that same day, Barnes said plaintiff should not return to work until September 1, 2004. AR-315

  On June 11, 2004, MetLife wrote plaintiff a letter reminding her that her STD benefits would terminate effective June 17, 2004, if she did not supplement her claim with the following information by June 25, 2004:
1. Copies of the two most recent:
• Office notes.
• Diagnostic test results.
• Operative reports and discharge summaries, if applicable.
• Rehabilitation or therapy notes, if applicable.
2. Names and dosages of all current medications.
3. Functional abilities.
4. Expected return to work date.
AR-0004

  On June 14, 2004, plaintiff returned to physical therapy. She reported to Calaway that her left knee continues to be a little stiff and sore but she had more pain from her right knee having just undergone surgery. She participated in a number of exercises and Calaway indicated plaintiff tolerated her treatment well. AR-0266 On June 16, 2004, plaintiff returned to Calaway and reported no significant problems since her last visit. She participated in exercises and "tolerated her treatment well." AR-0265

  Throughout this time period, plaintiff and MetLife communicated regarding the need for additional medical records. AR-0012-13 However, as of June 21, 2004, plaintiff had not provided MetLife with supplemental information requested in two previous letters. Therefore, on June 21, 2004, MetLife wrote plaintiff explaining that it closed her STD benefit claim as of June 17, 2004. MetLife informed her of her right to appeal the decision. AR-0003

  A few days after writing the June 21 letter, MetLife received up-to-date information from Barnes. The records included information pertaining to plaintiff's June 8 surgery. AR-0014 Based on the new information, MetLife reversed its decision to terminate plaintiff's STD benefits. In a June 30, 2004 letter to plaintiff, MetLife explained that it had approved plaintiff for benefits from May 14, 2004 through July 1, 2004. MetLife again recited the documents needed to extend benefits beyond plaintiff's expected return to work date of July 1, 2004. AR-0002

  Plaintiff returned to Barnes on July 1, 2004. He reported that she was "slowly making progress," "still has crepitance, but less pain," and "good range of motion of her knees today." AR0-253 Also on July 1, 2004, physical therapist Mike Adkins completed a "Progess Report/Plan of Care" pertaining to plaintiff. He noted that plaintiff had a total 14 scheduled physical therapy sessions, 4 of which were cancelled, 2 were no-shows, and 8 were kept. He ...


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