Director disabled by heart disease takes Prudential to Illinois Court after denial of long-term disability benefits

Alvin Hintz was an employee of CCL Custom Manufacturing, Inc. as Director of Information Systems for more than a decade. The company was purchased prior to Hintz’s termination, by KIK Custom Products, Inc. On August 8, 2005, Hintz was terminated along with eight other employees. In the separation agreement, there was a ‘general release of claims’ that Hintz signed. The long term disability plan was administrated by Prudential.

Before his termination, Hintz was treated for a number of medical conditions. In January of 2003, Dr. Paul R. Wilson at the Carle Foundation Hospital, was treating Hintz. Hintz suffered from suboptimally controlled insulin-dependent diabetes, and significant hyperlipidemia and hypertension. In July of 2003, he saw Dr. Lynette Smith-Caillouet, who was his primary care physician. Baseline fatigue and insomnia were noted, and he was advised to exercise and diet. He saw Dr. Smith-Callouiet again in November of 2003, where it was determined that he had Hypercholesterolemia with high tryglycerides.

In 2003, Mr. Hintz also saw Dr. Malec Mokraoui, who determined that the patient was short of breath, and was experiencing no chest pains at the time. He complained of fatigue. Although no evidence of vascular disease was found, Mr. Hintz was experiencing foot pain. Soon after, he went back to his primary care doctor, with calf-pain.  No swelling was noted. He also claimed to have occasional cramping in the feet. On April 5 of 2004, Hintz saw another doctor whose name is disputed by the parties. The doctor stated that an arterial study revealed claudication in both legs – more in the right than left. In April of 2004, he was diagnosed with vascular disease and mild aortoiliac and infrainguinal disease.

In April 2004, Hintz had a popliteal to perineal bypass, used to bypass diseased blood vessels above or below the knee. In September 2004, Hintz was diagnosed with costochondritis, an inflammation o the cartilage that connects a rib to the breastbone. In October 2004, after a fall from a stepladder, Hintz visited Dr. Smith Caillouet again. He had leg pain and swelling, and was sent to the ER.  Two days later, he went back to Dr. Smith Caillouet for a follow up.  The leg was significantly swollen and had a lot of ecchymosis. The doctor was worried about a possible veinous clot.

In December 2004, it was revealed that Hintz had mild left ventricular hypertrophy and abnormal septal motion in the leg. As his medical conditions became worse, Hintz visited the doctor for angina, wheezing, and congestion. On March 21, 2006, Mr. Hintz had angioplasty and coronary stenting of the saphenous vein. A week later, he was sent to the ER after falling because of lightheadedness.  Unusual palpitations were recorded. The notes included:

By history cerebral TIA x2. Worry about a cardioembolic phenomenon. Patient has enough risk factors. He also has underlying comorbidities including coronary artery disease, peripheral vascular disease, systolic CHF dysfunction, hyperlipidemia, type-2 diabetes, hypertension. Patient will be admitted for IV heparin. Close serial neuro exam, vital exam, and vital monitoring. Admit to Telemetry. Get Neurology consult, TEE, carotid studies, and will go from there. Patient is a full code. He is agreeable with the treatment plan. Continue rest of home medication, including his diabetic meds. Close watch on his blood sugar.

In April of 2006 Hintz submitted his claim for long term disability benefits, stating that congestive heart failure, main right brain artery stenosis, failed bypasses, and diabetes prevented him from working. Hintz also included medical records from April and March of 2006 and a statement from an attending physician, Dr. Mokraoui saying that, “patient is permanent [sic] disabled from his heart condition.” It also stated that his chances of being able to return to work were poor.

Prudential referred Hintz for a clinical review by its clinical department and the conclusion read that Mr. Hintz did not have any cardiac related complaints prior to August of 05. It also stated that there are not enough records at this time to show that Hintz is unable to perform his job.

In June of 2006, Prudential denied the claim, stating that the information indicated that there were no heart problems prior to August of 2005, and that there are no records of treatment during this time frame to support that Hintz was unable to perform the duties of his occupation. In October 2006, Hintz appealed. His appeal included a letter from Dr. Mokraoui stating that Hintz had been a patient since 2003, and in 1998 had undergone coronary bypass surgery as well as suffered from peripheral arterial disease. It further stated:

“It is my opinion to a reasonable degree of medical certainty that Mr. Hintz was only able to perform [*46] the material and substantial duties of his position from April of 2004 to August of 2005 when he was terminated due to the accommodations made by his employer. It was not medically advisable for Mr. Hintz to continue working during that time frame and undoubtedly additional damage was done by doing so, but I understand he was a dedicated employee. I understand that Mr. Hintz had more and more difficulty performing the tasks of his job as time went on and that his attendance suffered over the last several months of his employment. Therefore, as soon as Mr. Hintz’ [sic] employer could not make the accommodations necessary for him to continue working, then in my opinion he was disabled at that moment and would have been previously, but for those accommodations.”

Prudential then asked for all medical records and contacted Hintz’s employer to request copies of accommodation notes or medical restrictions from Hintz’s physicians from April of 2004 through August of 2005.  Hintz then provided four letters from co-workers of the company, stating that the company believed Hintz’s health conditions to be serious and made every effort to accommodate his circumstances. After receiving the medical records, Prudential sent the file to a cardiologist to review. Dr. Dianne L. Zwicke reviewed those records and stated that Mr. Hintz had no medically documented restrictions or physical limitations from 2004 to August of 2005. Also, that the medical records indicate no significant impairment from a cardiac point of view.  The treatment of the chronic underlying illness will be for a lifetime, Dr. Zwicke stated, and that at this point he appears to have a good prognosis.

On January of 2007, Prudential notified Hintz that they were upholding their decision to deny benefits. July of 2007, Hintz appealed again. His appeal was denied again. On January of 2008, Hintz submitted another letter to substantiate his disability claim – this time from Janis M. Wade, senior vice president of human resources and corporate communications at CCL industries, inc.  She states that “I can confirm that [Hintz] suffered from medical issues resulting in heart surgery and I was informed that he continued to have health problems during his employment. It is my understanding that CCL Custom Manufacturing’s management tried to accommodate Mr. Hintz’s health restrictions.”

Hintz felt that he was denied long term benefits improperly, because he suffers from multiple conditions that render him disabled under the terms of the plan. Prudential denies this. The United States District Court for the Northern District of Illinois, Eastern Division denied the parties’ cross motions for summary judgment and did not decide if Hintz’s eligibility should be capped, whether attorney fees should be administered or if Hintz received an appropriate remedy. Since an ERISA summary judgment works like other summary judgments, when there is a doubt about whether there is a genuine issue of material fact, “the summary judgment motion must fail.”  This case will continue and it will be resolved at a non-jury trial, with the decision making the ultimate determination of Mr. Hintz’s eligibility for benefits.

Note from case: The disposition of the parties’ cross motions for summary judgment makes it unnecessary for the Court to decide several other issues that were addressed in the parties’ briefs: (i) whether Hintz’s eligibility for benefits should be capped based on the self-reported symptoms limitation in the Policy, (ii) the appropriate remedy in the event Hintz succeeds, and (iii) attorneys’ fees and prejudgment interest.