Abston v. Sedgwick Claims Management Services Inc

Filing 37

MEMORANDUM OPINION. Signed by Judge Abdul K Kallon on 06/30/2017. (KBB)

FILED
2017 Jun-30 PM 02:17
U.S. DISTRICT COURT
N.D. OF ALABAMA

UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
NORTHWESTERN DIVISION
TAMMY ABSTON,
Plaintiff,

v.
SEDGWICK CLAIMS
MANAGEMENT SERVICES, INC.,
et al.,
Defendants.

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Civil Action Number
3:16-cv-00037-AKK

MEMORANDUM OPINION
Tammy Abston filed this action under the Employee Retirement Income
Security Act of 1974, 29 U.S.C. § 1001 et seq. (“ERISA”), challenging defendants’
decision to deny her long term disability pension benefits. Presently before the
court is defendants’ motion for summary judgment, doc. 24, which is fully briefed,
docs. 24-1; 33; 36, and ripe for review. For the reasons stated below, the motion is
due to be granted.
I.

STANDARD OF REVIEW

Rule 56’s general principle that summary judgment is proper “if the movant
shows that there is no genuine dispute as to any material fact and the movant is
entitled to judgment as a matter of law” has limited application here, because the
district court “sits more as an appellate tribunal than as a trial court” and “evaluates

the reasonableness of an administrative determination in light of the record
compiled before the plan fiduciary.” Leahy v. Raytheon Co., 315 F.3d 11, 18 (1st
Cir. 2002). To that end, the court is guided by the Eleventh Circuit’s six-step
sequential framework for reviewing ERISA benefit denials, which requires the
following:
(1) Apply the de novo standard to determine whether the claim
administrator’s benefits-denial decision was “wrong” (i.e., the
court disagrees with the administrator’s decision); if it is not, then
end the inquiry and affirm the decision.
(2) If the administrator’s decision in fact is “de novo wrong,” then
determine whether he was vested with discretion in reviewing
claims; if not, end judicial inquiry and reverse the decision.
(3) If the administrator’s decision is “de novo wrong” and he was
vested with discretion in reviewing claims, then determine whether
“reasonable” grounds supported it (hence, review his decision
under the more deferential arbitrary and capricious standard).
(4) If no reasonable grounds exist, then end the inquiry and reverse
the administrator’s decision; if reasonable grounds do exist, then
determine if he operated under a conflict of interest.
(5) If there is no conflict, then end the inquiry and affirm the decision.
(6) If there is a conflict, the conflict should merely be a factor for the
court to take into account when determining whether an
administrator’s decision was arbitrary and capricious.
Williams v. Bellsouth Telecommunications, Inc., 373 F.3d 1132, 1138 (11th Cir.
2004), overruled on other grounds by Doyle v. Liberty Life Assurance, 542 F.3d
1352 (11th Cir. 2008). This court’s review of the administrator’s decision is
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limited to “consideration of the material available to the administrator at the time it
made its decision.” Blankenship v. Metro. Life Ins. Co., 644 F.3d 1350, 1355 (11th
Cir. 2011). Moreover, the claimant has the burden of proving entitlement to
ERISA benefits. Glazer v. Reliance Std. Life Ins. Co., 524 F.3d 1241, 1248 (11th
Cir. 2008).
II.

FACTUAL BACKGROUND

Abston worked for SunTrust Bank as an Area Manager 1 Branch Manager, a
position in which she managed eleven branches and conducted annual and midyear reviews.

See doc. 24-7 at 21.

At some point during her employment,

Abston’s treating physician, Dr. David McLain, diagnosed Abston with lupus,
psoriasis, arthritis, and fibromyalgia. See doc. 24-9 at 31. Consequently, Abston
applied for, and received, long term disability benefits beginning August 5, 2013.
Doc. 24-4 at 18. The discontinuation of these benefits is the basis for this lawsuit.
SunTrust Long Term Disability (“LTD”) coverage is part of the SunTrust
Banks, Inc. Employee Benefit Plan (“the Plan”), which is governed by ERISA and
provides financial assistance to eligible employees who are unable to work, as
determined by the claims administrator, due to an illness or injury after 180 days.
Doc. 24-3 at 6, 23. The Benefits Plan Committee has “delegated the ministerial
and discretionary authority and control for the administration of LTD benefit
claims and appeals” to Sedgwick Claims Management. Id. at 21.
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The Plan states that “[m]edical review and approval is required for LTD
benefits,” and obligates the claimant to submit objective medical documentation on
her own behalf in support of “total disability.” 1 Id. at 7. The Plan provides a twotier definition for “total disability” — that is, for the first twenty-four months, a
claimant is disabled if she is “unable to perform each of the material duties of the
occupation [she] regularly perform[s] for SunTrust,” and is “under the regular care
of a physician appropriate to [her] condition.” Id. at 7–8. After twenty-four
months, there is a change in definition (“CID”), which provides that the claimant is
totally disabled if she is “unable to earn at least 60% of [her] pre-disability
earnings while working in any occupation,” “unable to perform each of the
material duties of any occupation for which [she] is reasonably fitted by education,
training, or experience,” and “under the regular care of a physician appropriate to
[her] condition.” Id. at 8. Relevant here, the Plan also provides that the claims
administrator may require claimants to apply for Social Security benefits, as the
LTD benefit plan is designed to “supplement Social Security disability benefits,”
id. at 10, and that a claimant “may be determined to be disabled by the Social
Security Administration and not meet the definition of Total Disability for the LTD
1

See doc. 24-3 at 7 (“It is your responsibility to ensure that any requested medical
information of your condition (objective medical documentation submitted by your physician)
has been submitted including the restrictions and/or limitations precluding you from working in
your own occupation on a full-time basis. The claims administrator will evaluate the medical
documentation submitted on your behalf and determine if your condition meets the Plan’s
definition of Total Disability.”).
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benefits under the Plan,” as “the LTD claims administrator determines [a
claimant’s] eligibility for LTD benefits based on the Plan definition,” id. at 10–11.
After being approved for LTD benefits, the Social Security Administration
also approved Abston for disability benefits beginning August 2013. See doc. 24-5
at 33. Consistent with the Plan, Sedgwick informed Abston that it would monitor
her condition to determine whether she continued to meet the Plan’s definition of
total disability. Doc. 24-4 at 18. Initially, Sedgwick extended Abston’s LTD
benefits based on Dr. McLain’s reports that Abston, in an eight hour day, could sit
for twenty minutes at a time for four hours a day, stand and walk for twenty to
thirty minutes for one hour per day, and occasionally lift/carry up to ten pounds,
and that Abston suffered fatigue from lupus, weakness in both hands, joint pain in
her jaw, and numbness in her right hand. See id. at 18, 32–36.
In accordance with the Plan, see doc. 24-11 at 15, three months prior to the
CID date, Sedgwick initiated the investigation process to determine whether it
should continue Abston’s LTD benefits past the twenty-four month mark, see doc.
24-10 at 38. Consequently, Sedgwick requested a physician advisor review for
rheumatology. Network Medical Review Co., Ltd., a third party independent
medical review company, assigned Abston’s claim to Dr. Rajendra K. Marwah, a
board certified rheumatologist and internal medicine specialist. See doc. 24-8 at
29–34. After his retention, Dr. Marwah contacted Dr. McLain. However, Dr.
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McLain refused to speak to Dr. Marwah, because he was “not being paid for
service and could not waste any more time talking with [Dr. Marwah].” Id. at 29.
Based on his review of Dr. McLain’s records, Dr. Marwah concluded that Abston
“has not had appropriate treatment,” 2 id. at 32, and that, while Abston suffers from
fibromyalgia, rash, psoriasis, and psoriatic arthritis, Abston could perform her job
or any similar job without restrictions or limitations as long as she receives
“ongoing appropriate medical care and follow-up,” id. at 29–30, 33. Based on Dr.
Marwah’s report, Sedgwick informed Abston that it planned to cease her LTD
benefits because she did not qualify for further disability benefits under the Plan:
specifically, “the medical information [did] not support restrictions, limitations, or
impairments that would prevent [Abston] from performing the demands of [her]
own occupation.” Docs. 24-8 at 37; 24-9 at 1.
Abston appealed the denial.

Doc. 24-9 at 5.

To evaluate her appeal,

Sedgwick referred Abston’s claim to Dr. N. Nichole Barry, an independent
physician advisor who also specialized in rheumatology. After reviewing the
entire file, including Dr. McLain’s treatment notes, the SunTrust Branch Manager
job description, Dr. Marwah’s report, Abston’s appeal letter, and the Plan’s
2

For example, Dr. Marwah noted that Rituxan, which Dr. McLain prescribed, “is not
indicated for the treatment of SLE, psoriasis, or psoriatic arthritis.” Doc. 24-8 at 32. Moreover,
Dr. McLain was treating Abston’s psoriasis with Plaquenil and Quinacrine, which are “antimalarial agents . . . known to aggravate psoriasis.” Id. As to Abston’s fibromyalgia, Dr.
Marwah noted that Abston had not been treated with the “FDA approved drug Lyrica” and had
not “been offered physical therapy, occupational therapy, or aquatic therapy.” Id.
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definition of disability, see doc. 24-9 at 30, and unsuccessfully attempting on four
occasions to contact Dr. McLain for a peer-to-peer call, see id. at 31, Dr. Barry
determined that Abston was “not unable to perform each of the material duties of
the occupation she regularly performs as of 06/08/15 through return to work,” id. at
35. Dr. Barry noted that, while Dr. McLain’s July 17, 2015 office visit notes
documented tenderness in multiple joints, Abston did not suffer from swelling,
limited range of motion, or deformities. Id. Dr. Barry further noted that Abston’s
joint pain is non-inflammatory. Id. at 36. For these reasons, Dr. Barry concluded
that “none of [Abston’s] etiologies would prevent [her] from performing her job
duties.” Id. As a result, Sedgwick upheld its denial determination. Id. at 39.
III.

ANALYSIS

Defendants seek summary judgment on the basis that Sedgwick’s denial
decision was de novo correct or, alternatively, that reasonable grounds existed to
deny Abston’s claim. For the reasons stated below, the court agrees and will
affirm the denial of benefits.
A. Sedgwick’s Decision was De Novo Correct
In the first step of the analysis, the court must “review the administrator’s
decision de novo for correctness: based on the evidence before the administrator at
the time it made its decision, the court evaluates whether it would have reached the
same decision.” Melech v. Life Ins. Co. of N. Am., 739 F.3d 663, 673 (11th Cir.
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2014). The evidence here supports such a finding. Specifically, under the Plan,
Abston is eligible for LTD benefits if, among other requirements, she is “unable to
perform each of the material duties of any occupation for which [she] is reasonably
fitted by education, training, or experience.” Doc. 24-3 at 8. During the CID
process, Sedgwick hired an independent reviewer, Dr. Marwah, to evaluate
whether Abston met this standard. Based on Dr. Marwah’s findings that Dr.
McLain had not appropriately treated Abston’s fibromyalgia or provided Abston
an appropriate medication regimen, Sedgwick found that Abston had not sustained
her burden of showing total disability, and decided to cease Abston’s LTD
benefits.
After Abston appealed, Sedgwick hired another consultant to review
Abston’s file. After reviewing the entire file and unsuccessfully attempting to
contact Dr. McLain, Dr. Barry determined that, although Abston experienced
“documented tenderness” in “multiple joints,” Abston nonetheless experienced no
“swelling, limited range of motion, nor any deformities.” Doc. 24-9 at 35. She
added also that Abston did not suffer from any “active or ongoing inflammation.”
Id. at 36. Significantly, like Dr. Marwah, Dr. Barry concluded that Abston could
perform the Area Manager 1 Branch Manager position without any restrictions.
See docs. 24-8 at 29–34; 24-9 at 36.

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In opposing summary judgment, Abston asserts that Sedgwick failed to
consider the entirety of her social security file and did not afford appropriate
weight to the opinions of Dr. McLain. These contentions are unavailing, because
the approval of Social Security benefits is not conclusive on whether a claimant is
also disabled under the terms of an ERISA plan. Whatley v. CNA Ins. Companies,
189 F.3d 1310, 1314 n.8 (11th Cir. 1999).3 Moreover, “courts have no warrant to
require administrators automatically to accord special weight to the opinions of a
claimant’s physician; nor may courts impose on plan administrators a discrete
burden of explanation when they credit reliable evidence that conflicts with a
treating physician’s evaluation.” Black & Decker Disability Plan v. Nord, 538
U.S. 822, 834 (2003). See also Ray v. Sun Life Health Ins. Co., 443 F. App’x 529,
533 (11th Cir. 2011) (“No special weight is to be accorded the opinion of a treating
3

Abston asks the court to find that Sedgwick’s claims process was “procedurally unfair”
in light of the holding in Melech v. Life Ins. Co. of N. Am., 739 F.3d 663 (11th Cir. 2014), that
the failure of the insurance company (that served both as the plan issuer and administrator) to
consider the plaintiff’s SSA file, required remand due to an incomplete record. See doc. 33 at 1.
Melech is distinguishable in two significant regards. First, in Melech, the claims administrator
denied the plaintiff’s claim while her SSDI application was still pending before the SSA. Id. at
665. Here, Sedgwick approved Abston for LTD benefits, and the SSA approved Abston’s SSDI
claim, in August 2013. Second, in Melech, the claims administrator, Life Insurance of North
America (“LINA”) had a “financial stake in the outcome.” Id. at 674. In this case, Sedgwick
had no stake in the outcome, because the LTD benefit funds are paid out of a trust. See docs. 243 at 22; 24-12 at 26. See also HCA Health Servs. of Ga., Inc. v. Emplrs. Health Ins. Co., 240
F.3d 982, 1001 (11th Cir. 2001) (“We find that EHI acted under a conflict of interest because
EHI pays claims out of its own assets.”); Brown v. Blue Cross & Blue Shield, 898 F.2d 1556,
1561–62 (11th Cir. 1990) (“[B]ecause an insurance company pays out to beneficiaries from its
own assets rather than the assets of a trust, its fiduciary role lies in perpetual conflict with its
profit-making role as a business . . . [a] strong conflict of interest [exists] when the fiduciary
making a discretionary decision is also the insurance company responsible for paying the claims
. . . .”). For these reasons, the court is not persuaded by Abston’s argument that remand is
warranted.
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physician” in ERISA cases.). For these reasons, the court finds that Sedgwick’s
decision to deny LTD benefits was de novo correct.
B. Alternatively, Reasonable Grounds Existed to Deny Benefits.
Under the multi-step ERISA framework, the court’s inquiry ends after the
court determines that an administrator’s decision was correct. See Blankenship,
644 F.3d at 1355. However, alternatively, consistent with the analysis above, even
if Sedgwick’s decision was wrong (and this court finds that it was not), reasonable
grounds exist in the record to support Sedgwick’s decision. Additionally, the court
finds that Sedgwick suffered under no conflict of interest. See Gilley v. Monsanto
Co., 490 F.3d 848, 856 (11th Cir. 2007) (“Our circuit law is clear that no conflict
of interest exists where benefits are paid from a trust that is funded through
periodic contributions so that the provider incurs no immediate expense as a result
of paying benefits.”).
IV.

CONCLUSION

Based on a review of the record, the court finds that Sedgwick’s decision
was de novo correct or, alternatively, reasonable, and is due to be affirmed.
Accordingly, defendants’ motion for summary judgment, doc. 24, is due to be
granted. A separate order will be entered contemporaneously herewith.

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DONE the 30th day of June, 2017.

_________________________________
ABDUL K. KALLON
UNITED STATES DISTRICT JUDGE

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