Paquin v. The Prudential Insurance Company of America

          ORDER

          R. BROOKE JACKSON UNITED STATES DISTRICT JUDGE

         This case, which arises under the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq., is a review of defendant Prudential Insurance Company of America's termination of plaintiff Michael J. Paquin's long-term disability benefits. After considering the arguments, applicable law, and administrative record, the Court reverses the termination of Mr. Paquin's benefits for the reasons stated herein, and therefore GRANTS Mr. Paquin's motion for summary judgment, ECF No. 48.

         I. BACKGROUND

         A. Factual and Procedural Background.

         In 2003 Michael Paquin contracted encephalitis from a mosquito infected by the West Nile virus. He sustained brain damage and cognitive difficulties that interfered with his ability to continue his employment as a Business Development Director for Transistor Devices, Inc. ("TDI"). TDI offered an employee benefits plan which was insured and administrated by Prudential Insurance Company of America. The plan states, in relevant part:

You are disabled when Prudential determines that:

• you are unable to perform the material and substantial duties of your regular occupation due to your sickness or injury; and

• you have a 20% or more loss in your indexed monthly earnings due to that sickness or injury.

         After 24 months of payments, you are disabled when Prudential determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training, or experience . . .

         Material and substantial duties means duties that:

• are normally required for the performance of your regular occupation; and

• cannot be reasonably omitted or modified, except that if you are required to work on average in excess of 40 hours per week, Prudential will consider you able to perform that requirement if you are working or have the capacity to work 40 hours per week.

• gainful occupation means an occupation, including self-employment, that is or can be expected to provide you with an income equal to at least 60% of your indexed monthly earnings within 12 months of your return to work.

R. 2163.

         Initially Prudential approved Mr. Paquin for short-term disability benefits in 2003. In 2004 Mr. Paquin's employment ended, and he applied for long-term disability ("LTD") benefits under the company's employee benefits plan. Prudential approved his application and provided him LTD benefits beginning in April 2004. R. 1803. However, when Mr. Paquin attempted (unsuccessfully) to go back to work for a trial period, Prudential terminated Mr. Paquin's LTD benefits in May 2004. Mr. Paquin appealed this decision, and after reviewing his file Prudential reversed its determination in 2006, reinstated Mr. Paquin's benefits, and paid back Mr. Paquin's benefits from May 2004 through January 2006.

         From January 2006 until January 7, 2015-roughly eleven years-Prudential paid Mr. Paquin LTD benefits. It regularly reviewed Mr. Paquin's file throughout the years, and each time it determined that Mr. Paquin's disability warranted LTD benefits.

         However, on January 8, 2015 Prudential terminated Mr. Paquin's LTD benefits, due in large part to one independent neuropsychological test ("NPT") and Prudential's conclusion that there was no valid evidence of a continuing impairment that would prevent Mr. Paquin from performing the duties of his regular occupation. Two internal appeals of that decision were unsuccessful. On August 24, 2016 Mr. Paquin filed this suit challenging the denial of his LTD benefits under the Employee Retirement Income Security Act of 1974, or ERISA. Now before the Court is Mr. Paquin's motion for summary judgment. ECF No. 48. The motion has been fully briefed and is ripe for this Court's review.

         B. Medical Evidence in the Administrative Record.

         The following is a summary of the medical evidence that was before Prudential when it decided to terminate Mr. Paquin's LTD benefits and when it denied Mr. Paquin's subsequent appeals.

• September 2003: Neurologist Janice Miller, MD, treats Mr. Paquin for viral encephalitis and meningitis after exposure to West Nile virus. During this hospital stay, Mr. Paquin is also seen by infectious disease physician Nelson Ganz, MD. R. 22, 117.

• November 2003: Upon referral by Dr. Miller, Mr. Paquin visits Mapletown Rehabilitation Center for cognitive therapy and evaluation. Medical records from these visits indicate notable cognitive impairments. R. 12, 29-65.

• November 21, 2003: Speech language pathologist Melissa Hundley, MS, evaluates Mr. Paquin for neurotrauma speech and language therapy, and she notes that he has "a variety of cognitive deficits which include: decreased short term recall, impaired word finding, impaired processing, impaired executive functioning and an inability to complete multiple tasks." R. 36.

• February 2003: Treating neurologist Michelle Ferguson, MD, certifies Mr. Paquin's West Nile virus exposure as encephalitis. R. 12.

• June 2004: Dr. Ferguson again notes "[p]ersistent and worsening cognitive problems after West Nile encephalitis ...