Melech v. Life Insurance Company of North America et al

Filing 162

ORDER granting 109 Motion for Summary Judgment as set out. Signed by Judge Kristi K. DuBose on 9/18/2012. (cmj)

Download PDF
IN  THE  UNITED  STATES  DISTRICT  COURT   FOR  THE  SOUTHERN  DISTRICT  OF  ALABAMA   SOUTHERN  DIVISION     DIANE  G.  MELECH,     )     )     Plaintiff,   )       )             vs.     )   CIVIL  ACTION  NO.:  10-­‐00573-­‐KD-­‐M     )     LIFE  INSURANCE  COMPANY  OF   )   NORTH  AMERICA,  PENSION  AND     )   WELFARE  PLAN  ADMINISTRATION     )   COMMITTEE  –  THE  HERTZ     )   CORPORATION,  HERTZ  CUSTOM     )   BENEFIT  PROGRAM,  AND  THE  HERTZ   )   CORPORATION,   )     )   Defendants.     )       ORDER         This  action  is  before  the  Court  on  motion  for  summary  judgment  filed  by  defendants   Life  Insurance  Company  of  North  America,  Pension  and  Welfare  Plan  Administration   Committee  –  The  Hertz  Corporation,  Hertz  Custom  Benefit  Program,  and  The  Hertz   Corporation  (defendants),  memorandum  in  support, proposed  determinations  of   undisputed  facts  and  conclusions  of  law,  and  evidentiary  submissions  (docs.  109-­‐112);  the   response  and  evidentiary  submissions  filed  by  plaintiff  Diane  G.  Melech  (Melech)  (docs.   143-­‐145);  and  defendants’  reply  (doc.    150).      Upon  consideration  and  for  the  reasons  set   forth  herein,  the  motion  for  summary  judgment  is  GRANTED.  1  2                                                                                                                   1    LINA’s  motion  to  strike  (doc.  151)  Melech’s  Exhibit  2  (Social  Security  claim  file)  and   Exhibit  3  (Melech’s  Declaration)  (doc.  144)  submitted  in  support  of  her  response  is   GRANTED  to  the  extent  that  the  Court  will  not  consider  any  evidence  in  Melech’s  Social   Security  claim  file  that  was  not  before  LINA.      In  Blankenship  v.  Metropolitan  Life  Ins.   Co.    644  F.3d  1350,  1354  (11th  Cir.  2011),  the  Court  of  Appeals  for  the  Eleventh  Circuit   explained  that  “[r]eview  of  the  plan  administrator's  denial  of  benefits  is  limited  to   consideration  of  the  material  available  to  the  administrator  at  the  time  it  made  its   Melech  filed  her  complaint  for  legal  and  equitable  relief  for  violations  of  the   Employee  Retirement  Income  Security  Act  (ERISA),  pursuant  to  29  U.S.C.  §  1132(a)(1).     Initially,  Melech  brought  Count  One  for  failure  to  provide  plan  documents  (doc.  1,  p.  6).     However,  Melech  withdrew  that  claim  for  relief  in  her  response  to  the  motion  for  summary   judgment  (doc.  145,  p.  4).    Melech’s  remaining  Count  2  alleges  a  claim  for  long  term   disability  benefits  pursuant  to  29  U.S.C.    1132(a)(1(B).    Melech  alleges  that  she  is  disabled   under  the  terms  of  the  Hertz  Custom  Benefit  Program  (the  Plan),  an  employee  welfare   benefit  plan  or  an  employee  pension  plan  as  defined  in  29  U.S.C.  §§  1001,  et  seq.     I.  Findings  of  Fact   A.    The  Policy     LINA  issued  Group  Policy  VDT-­‐960024  to  The  Hertz  Corporation.    The  Hertz   Corporation  is  the  Plan  Sponsor  and  the  Plan  Administrator  for  the  Plan.    LINA  serves  as                                                                                                                                                                                                                                                                                                                                                                       decision[.]”  (citations  omitted);  see  also  Ray  v.  Sun  Life  &  Health  Ins.  Co.,  443  Fed.  Appx.  529,   533  (11th  Cir.  2011)  (“Based  on  the  administrative  record  available  to  Sun  Life  when  it   made  its  decision,  .  .  .  we  can  not  say  that  Sun  Life's  denial  of  benefits  was  de  novo  wrong.”)   (citing  Blankenship,  644  F.3d  at  1354    for  the  premise  that  “review  of  benefits  denial  is   limited  to  consideration  of  the  material  available  to  the  administrator  at  the  time  it  made   its  decision”).       2    Melech  moves  the  Court  to  strike  defendants’  argument  at  pages  seven  to  thirteen  of  the   reply  on  the  basis  that  it  is  a  new  ground  for  summary  judgment  which  cannot  properly  be   raised  in  the  reply.  (Doc.  153,  motion;  Doc.  158,  defendants’  response).      Defendants   respond  that  their  arguments  are  not  new  arguments  or  theories  for  relief  but  instead  were   raised  to  address  Melech’s  arguments  in  her  response.    The  motion  to  strike  is  DENIED.      In   Count  II  of  her  complaint,  captioned  “Action  for  Benefits  under  29  U.S.C.  §  1132(a)(1)(B)”,   Melech  made  statements  that  defendants  had  not  complied  with  “29  U.S.C.  §  1133’s   requirement”  regarding  the  wording  of  the  denial  letter  and  that  she  did  not  receive  a  “full   and  fair  review  of  the  decision  denying  the  claim  as  is  required  by  29  U.S.C.  §  1133  and  29   C.F.R.  2560.503-­‐1.”  (Doc.  1,  ¶  48-­‐50,  52).    However,  Melech’s  “Statement  of  Facts”  does  not   contain  any  factual  allegation  to  form  the  basis  of  a  claim  of  violation  of  procedural   requirements  such  as  would  put  defendants  on  notice  of  the  specific  violations  that  were   asserted.    Therefore,  defendants  properly  moved  for  summary  judgment  as  to  Melech’s   “Action  for  Benefits”  asserting  that  Melech  received  a  full  and  fair  review  of  her  claim   initially  and  on  appeal  and  properly  replied  to  Melech’s  response  wherein  she  identified  for   the  first  time  the  underlying  factual  basis  for  her  claim.       2   the  claims  administrator  with  responsibility  for  adjudicating  claims  for  long  term  disability   benefits  made  by  participants  of  the  Plan  (doc.  112-­‐1,  p.  2-­‐3,  Affidavit  of  Kellie  Downey,   Senior  Operations  Representative  at  LINA);  (doc.  112-­‐2,  Administrative  Record).   Under  the  Policy,  the  claimant  Melech  must  provide  proof  of  disability  in  order  for   benefits  to  be  paid.    The  policy  states  as  follows:   The Insurance Company will pay Disability Benefits if an Employee becomes Disabled while covered under this Policy. The Employee must satisfy the Elimination Period, be under the Appropriate Care of a Physician, and meet all other terms and conditions of the policy. He or she must provide the Insurance Company, at his or her own expense, satisfactory proof of Disability before benefits will be paid. The Disability Benefit is shown in the Schedule of Benefits. (Doc. 112-2, p. 125, Copy of Policy). The Policy defines “Total Disability” as follows: Definition of Disability/Disabled The Employee is considered Disabled if, solely because of Injury or Sickness, he or she is: 1. unable to perform the material duties of his or her Regular Occupation; and 2. unable to earn 80% or more of his or her Indexed Earnings from working in his or her Regular Occupation. (Doc. 112-2, p. 110, 118). The Policy also provides that “[a]fter Disability Benefits have been payable for 24 months, the Employee is considered Disabled if, solely due to Injury or Sickness, he or she is: 1. unable to perform the material duties of any occupation for which he or she is, or may reasonably become, qualified based on education, training or experience; and 2. unable to earn 60% or more of his or her Indexed Earnings. The Insurance Company will require proof of earnings and continued Disability.” (Doc. 112-2, p. 110, 118).   3       The  Policy  defines  “Regular  Occupation”  as  “[t]he  occupation  the  employee  routinely   performs  at  the  time  the  Disability  begins.    In  evaluating  the  Disability,  the  Insurance   Company  will  consider  the  duties  of  the  occupation  as  it  is  normally  performed  in  the   general  labor  market  in  the  national  economy.  It  is  not  work  tasks  that  are  performed  for  a   specific  employer  or  at  a  specific  location.”  (Doc.  112-­‐2,  p.  136).       The  terms  and  conditions  of  the  Policy,  provide  that  benefits  become  payable  as   detailed  below:   The  Insurance  Company  will  pay  Disability  Benefits  if  an  employee   becomes  Disabled  while  covered  under  this  Policy.  The  Employee  must   satisfy  the  Elimination  Period,  be  under  the  Appropriate  Care  of  a   Physician,  and  meet  all  the  other  terms  and  conditions  of  the  Policy.  He  or   she  must  provide  the  Insurance  Company,  at  his  or  her  own  expense,   satisfactory  proof  of  Disability  before  benefits  will  be  paid….     The  Insurance  Company  will  require  continued  proof  of  the  Employee’s   Disability  for  benefits  for  continue.     (Doc.  112-­‐2,  p.  125).   B.  The  Claim   Melech  began  working  for  Hertz  Corporation  on  June  3,  1977  and  worked  full  time   as  a  Location  Manager.    Melech  was  responsible  for  managing  the  service  lot  and  its  rental   counter.    (Doc.  145,  p.  5).    Her  duties  required  that  she  be  able  to  sit  for  four  hours,  walk  for   eight  hours,  stand  for  eight  hours,  lift  for  two  hours,  bend  or  twist  for  thee  hours  and  drive   for  eight  hours.  (Doc.  112-­‐2,  p.  354).    Melech’s  last  day  of  employment  was  May  8,  2007.     (Doc.  112-­‐2,  p.  366).    Melech  left  work  with  complaints  of  neck,  shoulder  and  back  pain,   headaches,  and  numbness  in  her  right  arm  and  hand.  (Doc.  112-­‐2,  p.  184).         4   Melech was treated by Dr. Edmund C. Dyas, IV, an orthopedic physician on May 10, 2007, for chronic neck and right shoulder pain.3 Dr. Dyas noted as follows: Patient is having more and more neck and shoulder pain on the right. She’s got bad degenerative disc disease at 5-6, 6-7 with stenosis. She’s also got frank tendinitis in the right shoulder. She works with a computer 50 hours a week, and I think that’s entirely too much for her. We’ll take her off work 2 weeks, put her on PT [physical therapy] and we injected the subscapular bursa today and renewed her Lortab 5. We’ll see her back in 2 weeks. (Doc. 112-2, p. 339). From May 14, 2007 through June 20, 2007, Melech went to physical therapy at Fleming Rehab and Sports Medicine two to three times per week. (Doc. 112-2, p. 249-267). The physical therapists’ assessment notes are generally unreadable either because of poor handwriting or use of symbols and acronyms. However, an overall review indicates that Melech initially had tenderness in the cervical spine, reduced strength (“3” out of “5”) and limited range of motion in her neck and right shoulder. The therapist’s goal was to increase the range of motion and strength and improve Melech’s posture which was initially noted as “head forward”, “shoulders rounded” and “c spine flexed”. (Doc. 112-2, p. 266-267). The notes indicate that Melech attended therapy in May and June 2007, and was to continue treatment for two to three more weeks, but did not, (Doc 112-2, p. 249-250). One readable assessment was written on June 13, 2007, Melech’s next to last session – “Pt. tol therap well. No complaints of pain or discomfort.” (Doc. 112-2, p. 251). Another readable assessment was written on June 11, 2007 –                                                                                                                 3    In  Melech’s  proposed  statement  of  facts,  she  states  that  she  first saw Dr. Dyas on April 1, 2004 with complaints of neck pain radiating down her shoulder into her arm. She provides an insufficient cite to the record for this statement of fact. Melech cites to “Plaintiff’s Evidentiary Submission “Pl’s Evid. Sub.”) D.E. 144 at Exh. 2). Docket entry 144, Exhibit 2 is Melech's Social Security Claim file which consist of 148 pages. The Court has stricken Exhibit 2 to the extent that any evidence therein was not before LINA on the administration of Melech’s claim. Additionally, without a cite to a specific page among the 148 pages, the Court will not search Docket Entry 144 to find Melech’s evidence.     5   “Overall cervical mobility  and  [head  ache]  pain  are  improving.    Though  still  stiff  esp[ecially]   upper  C  &  T  spine.    Needs  to  cont[inue]  to  advance  postural  program  to  help  [decrease]   strain    ___?__  C  spine.”  (Doc.  112-­‐2,  p.  252).       On May 18, 2007, Melech was referred to Dr. Todd Engerson, an orthopedic physician, for a second opinion. Dr. Engerson noted as follows: [Physical Examination] Healthy appearing lady. She has some cervical spasm, some tenderness diffusely in the interscapular region, upper trapezius on the right side. Full [range of motion] of her right shoulder with mild impingement signs. Does have some pain with resisted abduction and forward elevation. Gross motor and sensory testing upper extremities basically [within normal limits]. X-Ray C-spine show significant cervical [degenerative disc disease] at 5-6 and 6-7 with some good sized posterior osteophytes, loss of the normal cervical lordosis associated with spasm. [Impression]: Cervical [degenerative disc disease] with exacerbation. [Recommendation]: I agree with Dr. Dyas’ treatment and have written a note back to that effect. See Dr. Dyas in follow-up (Doc. 112-2, p. 237).   Dr. Dyas saw Melech again on May 24, 2007, he noted as follows: A little better with her physical therapy and rest. We will keep her off until next Tuesday and see her back here in two weeks. (Doc. 112-2, p. 339). On June 7, 2007, Dr. Dyas noted as follows: Patient is having more pain in her neck, shoulder and arm. She is intact neurologically. She is depressed about her job situation and I think that we need to get a MRI scan of her neck to see if it is any worse as it has been over a year. I also think that she can not go back to this job. (Doc. 112-2, p. 339). Also, on June 7, 2007, Dr. Dyas wrote as follows:   6   To Whom it May Concern The above captioned patient is under my care. She is permanently and totally disabled. She can not return to her present job. . . . (Doc. 112-2, p. 340). On June 12, 2007, the MRI of Melech’s cervical spine showed: Clinical History: Neck and Right Upper Extremity Pain. Findings: Spin-echo sagittal, axial and STIR sagittal images were obtained. The cervical spine is in anatomic alignment. There is mild flattening of the C5-6 and C6-7 intervertebral disc without evidence of a disc protrusion and there is also bilateral spondolytic change at these 2 levels with foraminal encroachment. No other abnormality of the cord is seen. Bone marrow signal is within normal limits. Impression: Bilateral spondylosis C5-6 and C6-7 with foraminal encroachment. (Doc. 112-2, p. 339). On September 13, 2007, Melech saw Dr. Dyas again and he noted as follows: Continues to have disabling pain in her neck and shoulder. I injected the trigger area in her neck and renewed her medicine today. We will see her back here as needed. She still can’t work with all of these problems. (Doc. 112-2, p. 311, 339) On or about October 2, 2007, Melech applied for long term disability benefits with LINA and her initial claims manager was Eric Poliziani. (Doc. 112-2, p. 4 “Primary Claim File.”) Melech’s occupation was identified as “Station Manager” with an occupational category of “Office and Clerical”. (Doc. 112-2, p. 66). Her medical condition was identified as “severe degenerative disk disease”. (Id.) On or about October 4, 2007, a letter was mailed to Melech which confirmed receipt of the claim, explained certain aspects of the claims process, and requested additional information. (Doc. 112-2, p. 83-84).   7   On October 12, 2007, Melech saw Dr. Jonathan Miller with complaints of abdominal pain and diarrhea. (Doc. 112-2, p. 192). Dr. Miller noted her history of “some degenerative disk disease, some hand pain, some anxiety and insomnia” and her current medications were “Prevacid, Xanax, Soma, occasional Lortab, fish oils and some vitamin E”. (Id.) On physical examination (relevant to the issues before the Court), Dr. Miller noted that all “[j]oints show full range of motion” and that Melech’s neck was “Supple. No [jugular vein distension]. Nontender.” (Id.) Dr. Miller prescribed Ambien for insomnia instead of Xanax and Nexium for gastroesophageal reflux disease. (Id. p. 193). On October 12, 2007, Poliziani, faxed a letter and form to Dr. Dyas asking that he provide office notes, answer questions regarding prognosis for recovery, return to work, and referral to other specialist, and also asking Dr. Dyas to “help [LINA] understand [Melech’s] current level of functional ability by completing the enclosed Physical Abilities Assessment form.” (Doc. 112-2, p. 342-345). On October 18, 2007, Dr. Dyas faxed the form and letter back to Poliziani. On the face of the letter Dr. Dyas appears to have written “Pt is permanently & totally disabled.” He did not complete the Physical Abilities Assessment form but did sign it. (Doc. 112-2, p. 341-345). On  October  24,  2007,  Poliziani  contacted  Fleming  Rehab.    Poliziani  asked  for   rehabilitation  notes  from  May  2007  to  the  present,  prognosis,  and  any  return  to  work  plan.     (Doc.  112-­‐2,  p.  322-­‐323).    He  also  asked  for  “help  [to]  understand [Melech’s] current level of functional ability by completing the enclosed Physical Abilities Assessment form.” (Id.) Fleming Rehab responded by letter stating that “we have not seen Ms. Melech since June 20, 2007 and cannot make any recommendations or assessments at this time” and that “we will need   8   to re-evaluate her or schedule a functional capacity evaluation (FCE) to determine her work ability.” (Doc. 112-2, p. 321). No FCE was obtained. On November 6, 2007, Melech completed a “Disability Questionnaire & Activities of Daily Living” form. (Doc. 112-2, p. 184-187). Melech stated that “her  neck  hurts  very  badly   when  sitting  at  computer  causing  severe  headaches  and  neck  pain,  right  arm  and  hand  goes   numb.  Lower  back  hurts  when  standing  or  bending.  For  period  of  time  using  phone  causes   pain  in  neck.”  (doc.  112-­‐2,  p.  185).    She  stated  that  she  could  drive  “as  needed”  and   regularly  cooked,  cleaned,  shopped,  did  laundry,  read,  watched  television,  and  attended   church.    (Id.)    For  recreation  she  stated  that  she  “watched  football,  visit  with  family  &   friends,  go  out  to  eat,  lay  on  beach  during  summer”  (Id.)    She  also  reported  that  she   attended  to  all  her  personal  grooming  and  dressing  needs.    (Id.)    As  to  exercise,  she  stated   that  her  therapist  had  told  her  to  “___  with  elastic  bands”  (Doc.  112-­‐2,  p.  186).      Her   medications  were  identified  as  Nexium  once  daily,  Lortab  as  needed,  Soma  as  needed,   Xanax  at  night,  and  Estrace  once  daily.  (Doc.  187).      She  indicated  her  visits  with  Dr.  Dyas   were  on  an  “as  needed”  basis.  (Doc.  187).         Melech  described  the  “Major  Duties”  of  her  job  as  “Doing  reports,  handling   customers,  renting  cars,  making  schedules  for  employees,  safety  issues”  .  (Doc.  112-­‐2,  p.   186).    She  described  the  “Minor  Duties”  of  her  job  as  “Moving  cars,  cleaning  &  vacuuming   cars,  preparing  cars  where  necessary;  inventory.”    (Id).    She  used  a  computer,  copy   machine,  fax  and  a  vacuum.  (Id.)     On  November  13,  2007,  Poliziani  “sent  a  follow  up  request”  to  Dr.  Dyas.    Poliziani   requested  “objective  findings,  copies  of  June  2007  MRI,  [patient]  reports,  medication,  PAA     9   [physical  abilities  assessment]  and  office  visit  notes  beyond  [last  office  visit]  in  file  of   9/13/07.”    (Doc.  112-­‐2,  p.  36).      Dr.  Dyas  did  not  respond  to  the  request.         On  November  20,  2007,  Jeffrey  Weber,  Nurse  Case  Manager,  reviewed  Melech’s   records  and  found  that     [Claimant]  treating  for  neck  pain  due  to  [degenerative  disc  disease].     Cervical  MRI  is  unremarkable.  Dr.  Dyas  states  [claimant]  is  totally  &   permanently  disabled  due  to  pain.    [Record]  does  not  support  no  work.     (Doc.  112-­‐2,  p.  183).       On  November  26,  2007,  Weber  faxed  a  letter  to  Dr.  Dyas  requesting  clarification  as   to  Melech’s  “condition  and  work  status.”  (Doc.  112-­‐2,  p.  79-­‐80).    The  letter  asked  Dr.  Dyas   to  advise  whether  he  had  seen  Melech  since  September  13,  2007,  to  “provide  objective   findings  to  support  Ms.  Melech  being  permanently  and  totally  disabled”,  and  explained  that   “an  ‘off  work’  note  is  not  sufficient  documentation  to  certify  disability.”  (Id.).     On  November  29,  2007,  Poliziani  wrote  Melech  that  LINA  was  unable  to  approve  her   claim.  (Doc.  112-­‐2,  p.  172-­‐176).      Poliziani  explained  that  Melech’s  job  of  Location  Manager   was  categorized  as  Light  Work  in  the  U.S.  Department  of  Labor  Description  of  Occupational   Titles  (DOT)  and  that  LINA  must  look  at  Melech’s  occupation  as  defined  in  the  DOT  and  not   her  specific  job.    He  summarized  the  medical  evidence  including  the  June  12,  2007  MRI   results  and  other  evidence  including  Melech’s  statement  of  daily  activities  that  had  been   reviewed.  Poliziani  explained  as  follows:       Claim  Summary       Upon  review  of  the  documentation  provided,  we  were  unable  to  validate   medical  documentation  which  supported  your  inability  to  perform  the   material  duties  of  your  Regular  Occupation.    In  reviewing  Dr.  Engerson’s     office  notes  ,  no  restrictions  were  noted  and  he  concurred  with  Dr.  Dyas   treatment  plan  at  that  time  of  no  work  for  2  weeks.    A  review  of  the  MRI,   while  noting  some  flattening  of  the  C5-­‐6  and  C6-­‐7,  noted  your  spine  was     10   in  anatomic  alignment  with  no  disc  pertrusion  and  bone  marrow  signal   being  within  normal  limits.  In  reviewing  Dr.  Dyas’  notes,  while   restrictions  and  limitations  were  noted,  no  findings  supporting  a  no  work   restriction  were  documented.    Dr.  Dyas  notes  contained  no  findings  which   support  his  notice  that  you  are  permanently  disabled.       In  an  attempt  to  gather  additional  documentation  from  Dr.  Dyas,  our   Nurse  Case  Manager  contacted  Dr.  Dyas  office  on  November  21,  2007  for   clarification  of  his  findings  as  they  relate  to  your  restrictions.    On   November  26,  2007,  we  also  contacted  Dr.  Dyas  office  and  requested  his   objective  findings  to  support  his  restrictions  and  limitations.  To  date,  Dr.   Dyas  has  not  responded  to  either  request.       As  the  medical  documentation  contained  in  your  file  does  not  support  a   no  work  restriction  we  are  unable  to  approve  your  claim.       Therefore  at  this  time  we  have  closed  your  claim  and  no  benefits  are   payable  as  the  medical  information  does  not  support  how  you  are  unable   to  work.       (Doc.  112-­‐2,  p.  174-­‐175).           Melech’s  was  advised  of  her  right  to  appeal  in  the  denial  letter.    The  letter  explained   that     Appeal  Rights       If  you  disagree  with  our  determination  and  intent  to  appeal  this  claim   decision,  you  must  submit  a  written  appeal    .  .  .       You  have  the  right  to  submit  written  comments  as  well  as  any  new   documentation  you  wish  us  to  consider.    If  you  have  additional   information,  it  must  also  be  sent  for  further  review  .  .  .  .       We  would  be  happy  to  consider  any  medical  evidence  which  supports   your  total  disability.    Medical  evidence  includes,  but  is  not  limited  to:   physician’s  office  notes,  hospital  records,  consultation  reports,  test  result   reports,  therapy  notes,  physical  and/or  mental  limitations  (i.e.,  Functional   Capacities  Testing),  etc.    These  medical  records  should  cover  the  period  of   May  2007  through  the  present.     (Doc.  112-­‐2,  p.  175).         Melech  returned  to  Dr.  Dyas’  on  January  3,  2008.    His  notes  state  that     11   Patient  continues  to  have  disabling  pain  in  her  neck  and  right  shoulder.   She  has  degenerative  disc  disease  in  her  neck  with  cervical  spondylosis.    I   think  she  has  a  rotator  cuff  tear  in  the  right  shoulder.    We  injected  about   the  base  of  her  neck  today.    We  renewed  her  medication  Lortab  and   Soma.       (Doc.  112-­‐2,  p.  170).         On  January  31,  2008,  Melech  appealed  the  decision.  (Doc.  112-­‐2,  p.  168).      She   submitted  office  notes  and  a  letter  from  Dr.  Dyas  dated  January  3,  2008,  wherein  he   explained  as  follows:     This  57  year  old  white  female  has  been  followed  since  she  had  to  stop   working  at  Hertz  Rental  Car  because  of  the  chronic  pain  in  her  neck,  right   shoulder  and  low  back.    She  has  been  worked-­‐up  in  the  past  and  has   cervical  spondylosis  at  C5-­‐6  and  C6-­‐7.    Physical  findings  associated  with   that  are  limited  neck  movement  by  50%.    She  also  has  a  rotator  cuff  tear   in  her  right  shoulder  which  is  chronically  and  intermittently  painful   related  to  activity.    She  also  has  chronic  low  back  pain  with  stiffness.     Neurologic  exam  has  appeared  normal.       X-­‐rays  of  this  lady  show  degenerative  disc  disease  at  C5-­‐6  and  C6-­‐7.     Lumbar  spine  shows  she  has  degenerative  changes  at  L4-­‐5  and  L5-­‐S1.     This  lady’s  job  consisted  of  working  at  Hertz  where  she  was  responsible   for  the  whole  operation  at  times.    She  worked  rotating  shifts  requiring   long  hours  standing  and  walking  in  the  parking  lot  and  cleaning   automobiles,  vacuuming  the  automobiles.    It  has  been  my  opinion  that   this  lady  is  unable  to  do  this  job  and  remains  the  same.       (Doc.  112-­‐2,  p.  169).       On  February  5,  2008,  Senior  Claims  Manager  Marianna  Dileo  acknowledged  receipt   of  the  appeal  and  in  the  box  labeled  “Comment/Review  Outcome/  Rationale/Plan”  stated   as  follows:   2/5/08  New  medical  received  fails  to  conclusively  support  the  RL’s  based   on  [diagnosis]  of  cervical  [degenerative  disc  disease].    Only  new  med   received  per  cm  is  an  1/3/08  [Attending  Physician  (AP)]  ortho  on  where   no  measurable  exam  findings  are  provided  to  clarify  limitations  to   functionality.    AP  only  notes  [complaints]  of  disabling  pain  in  neck  &     12   [right]  shoulder.    Does  not  describe  any  dermatomal  findings,  no  ROM  or   muscle  weakness,  no  sensory  loss  or  gait  defects  noted.     (Doc.  112-­‐2,  p  163).       Also,  on  February  5,  2008,  a  letter  was  sent  to  Melech  acknowledging  receipt  of  the   records  from  Dr.  Dyas.    The  letter  also  explained  that       The  appeal  request  is  being  referred  to  our  Disability  Appeals  Team.    Any   additional  information  submitted  may  impact  the  appeal  decision.     Therefore,  we  ask  that  you  carefully  review  the  enclosed  original  denial   letter  dated  November  29,  2007  to  ensure  that  any  and  all  available   medical  or  other  documentation  related  to  your  claim  has  been   submitted.     (Doc.  112-­‐2,  p.  166).     On  April  16,  2008,  M.J.  Kelly,  RN,  reviewed  the  medical  records.    Kelly  stated  as   follows:   Review  of  medical  [claimant]  saw  2  orthos,  neither  exam  demonstrates   loss  of  strength,  reflexes  or  sensation  of  [upper  extremity].    AP  ortho  Dr.   Dyas  feels  [claimant]  has  [Rotator  Cuff]  tear  but  no  imaging  on  file.     Medical  reviewed  does  not  show  severity  of  symptoms  or  exam  findings   to  support  impairment.     (Doc.  112-­‐2,  p.  160).           On  April  17,  2008,  Tracy  Shimko,  Appeals  Claim  Manager,  wrote  Melech  that  the   denial  had  been  upheld  on  appeal.  (Doc.  112-­‐2,  p.  157-­‐158).    Shimko  identified  Melech’s   occupation  as  Station  Manager  which  “required  light  demand  activities  according  to  the     [DOT]”.  (Id.)      Shimko  explained  as  follows:     To  ensure  appropriate  interpretation  of  medical  documentation,  a  review   was  completed  with  our  Nurse  Case  Manager  (NCM).    The  NCM   commented  that  medical  information  on  file  clearly  documents  your   subjective  complaints  of  pain  in  your  neck,  right  shoulder  and  low  back.     The  MRI  of  your  cervical  spine  performed  June  12,  2007  showed  bilateral   spondylosis  of  C5-­‐C7  with  foraminal  encroachment.    The  exam  findings  of   Dr.  Engerson  and  Dr.  Dyas  fail  to  demonstrate  loss  of  strength,  reflexes  or   sensation  of  your  upper  extremities.    Dr.  Dyas  notes  you  have  a  rotator     13   cuff  tear,  however,  there  is  no  imaging  on  file  to  substantiate  this   diagnosis.    The  medical  reviewed  does  not  show  severity  of  symptoms  or   exam  findings  to  support  a  total  impairment  from  your  own  occupation.         In  summary,  a  review  of  the  medical  information  fails  to  provide  evidence   of  any  clinical  findings  to  negate  your  previously  assessed  level  of   function.    In  addition  the  medical  records  do  not  provide  documentation   to  support  the  restrictions  imposed  by  your  physician  or  your  inability  to   function  in  your  own  occupation.    Therefore,  since  the  medical  on  file   does  not  provide  Disability,  we  must  affirm  our  previous  decision  to  deny   benefits.       (Doc.  112-­‐2,  p.  157-­‐158).           Shimko  also  explained  that  Melech  may  request  a  review  and  that       [i]n  addition  to  any  written  comments,  your  request  for  review  must   include  new  documentation  you  wish  us  to  consider.    This  documentation   includes,  but  is  not  limited  to:  copies  of  office  notes,  test  results,  physical   examination  reports,  mental  status  reports,  consultation  reports,  or  any   other  pertinent  medical    information  from  May  2007  to  the  present.”       (Id.)     Melech  was  seen  by  Dr.  Dyas  on  May  22,  2008.    He  noted  that  Melech  “continues  to   have  increasing  neck  pain”  and  injected  a  sensitive  area  at  the  “lower  cervical  region”.  (Doc.   112-­‐2,  p.  144).    He  noted  that  Melech  was  “intact  neurologically”  but  had  “some  soreness,   pain  and  weakness  in  her  right  shoulder.”  (Id.)       Dr.  Dyas  recommended  another  MRI  of  the  cervical  spine  and  shoulder  which  was   obtained  on  May  23,  2008.      Melech  provided  a  copy  of  the  MRI  results.    The  radiologist   found  that  Melech’s  right  shoulder  did  not  have  a  rotator  cuff  tear  but  did  have  tendinitis  or   tendinopathy  and  “mild  osteoarthritic  spurring  neighboring  the  AC  joint  with  peri-­‐articular   edema.”  (Doc.  112-­‐2,  p.  143).      The  MRI  of  Melech’s  cervical  spine  was  interpreted  as   showing       14   1.    Moderate  degenerative  disc  changes  at  C5-­‐6  and  C6-­‐7  with  broad   based  extruded  disc  resulting  in  mild  central  stenosis  at  each  of  these   levels.     2.  Mild  spondylitic  disc  changes  at  C4-­‐5.     (Doc.  112-­‐2,  p.  143).    The  C4-­‐5  and  C3-­‐4  discs  were  “essentially  unremarkable”  and  the  C7-­‐ T1  showed  “mild  spondylitic  protruding  disc”  but  was  “otherwise  unremarkable.”  (Id.)  4   On  October  10,  2008,  Melech  wrote  LINA  and  requested  another  review  of  the   decision.      Melech  provided  records  from  Dr.  Dyas  and  analyses  from  her  treating   psychiatrist  and  therapist.    She  also  advised  LINA  that  she  was  receiving  Social  Security   Disability  Income  benefits.      Melech  also  explained  that  LINA  had  evaluated  her  claim  based   on  the  occupation  of  Location  Manager  as  described  in  the  DOT  185.167-­‐058  but  that  title   was  Service  Manager  and  had  different  duties.    Melech  asked  that  her  disability  be   evaluated  based  on  the  job  she  actually  performed  as  Location  Manager  for  Hertz  and  not   the  DOT  description  for  “Service  Manager”.5    (Doc.  112-­‐2,  p.  141-­‐142).         Melech  provided  Dr.  Dyas’  notes  from  May  2008  and  also  submitted  psychiatric  and   therapy  records  from  August  and  September  2008  and  an  October  1,  2008  psychiatric   evaluation  report.  (Doc.  112-­‐2,  p.  148-­‐156).    The  records  are  substantially  redacted  or   highlighted  in  a  manner  that  most  are  unreadable.    The  page  captioned  “Current  Diagnosis”   shows  the  principal  diagnosis  as  “mood  disorder  due  to  .  .  .  (indicate  the  general  medic”   (sic)  (Doc.  112-­‐2,  p.  152).                                                                                                                     4    Item  2  of  the  radiologist’s  impression  may  be  incorrect.    In  the  report,  mild  spondyltic   disc  protrusion  was  found  at  the  C7-­‐T1  and  not  at  the  C4-­‐5.    The  C4-­‐5  was  noted  as   “essentially  unremarkable.”    (Doc.  112-­‐2,  p.  143).      The  possible  error,  however,  does  not   affect  the  overall  impression  that  Melech’s  degenerative  disc  disease  was  identified  as   either  mild  or  moderate.     5    LINA  referenced  DOT  185.167-­‐058  which  defines  Service  Manager  (automotive).    The  only  Location  Manager   definition  found  in  the  DOT  refers  to  “Location  Manager  (motion  picture;  radio-­‐tv  broad.)”.         15   On  October  15,  2008,  Tracy  Shimko,  Appeals  Claims  Manager,  wrote  Melech  to   explain  that  accepting  a  second  appeal  is  voluntary  on  the  part  of  LINA  and  that  LINA  had   decided  not  to  accept  Melech’s  second  appeal.    Shimko  discussed  the  psychiatric  records   received  and  concluded  that  the  records  did  not  demonstrate  that  Melech  was   psychiatrically  impaired  from  May  2007  to  the  present.    Shimko  discussed  Dr.  Dyas’   records,  found  that  they  were  “devoid  of  any  physical  exam  findings  demonstrating  the   severity  of  any  motor,  sensory,  vascular  or  neurological  deficits  impairing  [Melech’s]  ability   to  function”  and  stated  that  LINA  was  unable  to  consider  the  second  appeal  because  Melech   had  not  provided  “medical  documentation  that  would  alter  our  previous  decision.”  (Doc.   112-­‐2,  p.  139).      The  letter  also  explained  what  type  of  medical  documentation  was   necessary  for  a  second  appeal.       Melech  did  not  file  another  appeal.    This  action  was  filed  on  October  15,  2010.       II.    Conclusions  of  Law   A.    Summary  Judgment  Standard   Summary judgment should be granted “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.” Fed. R. Civ. P. 56(a). If a party asserts “that a fact cannot be or is genuinely disputed”, the party must (A) cit[e] to particular parts of materials in the record, including depositions, documents, electronically stored information, affidavits or declarations, stipulations (including those made for purposes of the motion only), admissions, interrogatory answers, or other materials; or (B) show[] that the materials cited do not establish the absence or presence of a genuine dispute, or that an adverse party cannot produce admissible evidence to support the fact. Fed. R. Civ. P. 56(c)(1)(A)(B).   16   The party seeking summary judgment bears “the initial burden to show the district court, by reference to materials on file, that there are no genuine issues of material fact that should be decided at trial.” Clark v. Coats & Clark, Inc., 929 F.2d 604, 608 (11th Cir. 1991). The party seeking summary judgment “always bears the initial responsibility of informing the district court of the basis for its motion, and identifying those portions of ‘the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any,’ which it believes demonstrate the absence of a genuine issue of material fact.” Clark, 929 F.2d at 608 quoting Celotex Corp. v. Catrett, 477 U.S. 317, 323, 106 S. Ct. 2548, 2553 (1986). Once the moving party has satisfied its responsibility, the burden shifts to the nonmovant to show the existence of a genuine issue of material fact. Id. “In reviewing whether the nonmoving party has met its burden, the court must stop short of weighing the evidence and making credibility determination of the truth of the matter. Instead, the evidence of the nonmovant is to be believed, and all justifiable inferences are to be drawn in his favor.” Tipton v. Bergrohr GMBH-Siegen, 965 F.2d 994, 999 (11th Cir. 1992) citing Anderson v. Liberty Lobby, 477 U.S. 242, 255, 106 S.Ct. 2505 (1986); Adickes v. S.H. Kress & Co., 398 U.S. 144, 158-159, 90 S.Ct. 1598, 1608-1609 (1970). However, “[a] moving party is entitled to summary judgment if the nonmoving party has ‘failed to make a sufficient showing on an essential element of her case with respect to which she has the burden of proof.’” In re Walker, 48 F. 3d 1161, 1163 (11thCir. 1995) quoting Celotex Corp., 477 U.S. at 323, 106 S. Ct. at 2552. Overall, the Court must “resolve all issues of material fact in favor of the [non-movant], and then determine the legal question of whether the [movant] is entitled to judgment as a matter of law under that version of the facts.” McDowell v. Brown, 392 F.3d 1283, 1288 (11th Cir. 2004) citing Durruthy v. Pastor, 351 F.3d 1080, 1084 (11th Cir. 2003).   17   B.  ERISA  Standard  of  Review  6     ERISA  provides  no  standard  for  courts  reviewing  the  benefits  decisions  of  plan   administrators  or  fiduciaries;  thus,  the  Supreme  Court  established  guidance  for  same  in   Firestone  Tire  &  Rubber  Co.  v.  Bruch,  489  U.S.  101,  109  (1989)  and  Metropolitan  Life  Ins.  Co.   v.  Glenn,  554  U.S.  105  (2008).    More  recently,  the  Eleventh  Circuit  has  reiterated  a  multi-­‐ step  framework  to  guide  lower  courts  when  reviewing  a  plan  administrator's  benefits   decision.    This  framework  consists  of  the  following  “six-­‐step  expanded  Firestone”  test:     (1)  Apply  the  de  novo  standard  to  determine  whether  the  claim   administrator's  benefits-­‐denial  decision  is  “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.     Blakenship  v.  Metropolitan  Life  Ins.  Co.,  644  F.3d  1350,  1355  (11th  Cir.  2011)  (citing  Capone                                                                                                                   6    The  summary  judgment  analysis  is  “applied  in  a  modified  manner  in  an  ERISA  case.”     Rogers  v.  Hartford  Life  and  Accident,  Ins.  Co.,  2012  WL  12883409,  *1  n.2    (M.D.  Ala.    April  16,   2012)  (slip  copy)  (citing  Blankenship  v.  Met.  Life  Ins.  Co.,  644  F.3d  1350,  1354  n.  4  (11th  Cir.   2011)).       18   v.  Aetna  Life  Ins.  Co.,  592  F.3d  1189,  1195  (11th  Cir.  2010)  and  Williams  v.  BellSouth   Telecomms.,  Inc.,  373  F.3d  1132,  1137  (11th  Cir.  2004),  overruled  on  other  grounds  by   Doyle  v.  Liberty  Life  Assurance  Co.  of  Boston,  542  F.3d  1352  (11th  Cir.  2008)).    “All  steps  of   the  analysis  are  ‘potentially  at  issue’  where  a  plan  vests  discretion  to  the  plan   administrator  to  make  benefits  determinations.  See  id,  at  1356  n.7.    Overall,  Melech  has  the   burden  to  establish  that  she  is  entitled  to  benefits  under  the  Plan.    Watts  v.  BellSouth   Telecommunications,  Inc.,  218  Fed.Appx.  854,  856,  (11th  Cir.  2007).     III.    Analysis     A.    Full  and  Fair  Review     In  response  to  the  motion  for  summary  judgment,  Melech  argues  that  LINA  violated   ERISA’s  procedural  requirements  and  therefore  the  action  should  either  be  remanded  to   LINA  for  a  full  and  fair  review  or  LINA  should  be  ordered  to  pay  the  claim.    Specifically,   Melech  argues  that  LINA’s  initial  denial  letter  violated  29  C.F.R  §  2560.503-­‐1(g)(1)(i)   because  LINA  did  not  explain  the  rationale  behind  its  decision  but  instead  stated  only:    “As   the  medical  documentation  contained  in  your  file  does  not  support  a  no-­‐work  restriction   we  are  unable  to  approve  your  claim.”    (Doc.  145,    p.  21).           Title  29  C.F.R  §  2560.503-­‐1(g)  provides  for  the  “[m]anner  and  content  of  notification   of  benefit  determination.”    Paragraph  (g)(1)(i)  states,  in  relevant  part  as  follows:       (1)  Except  as  provided  in  paragraph  (g)(2)  of  this  section,  the  plan   administrator  shall  provide  a  claimant  with  written  or  electronic   notification  of  any  adverse  benefit  determination.  .  .  .    The  notification   shall  set  forth,  in  a  manner  calculated  to  be  understood  by  the  claimant-­‐-­‐       (i)  The  specific  reason  or  reasons  for  the  adverse  determination;       29  C.F.R  §  2560.503-­‐1(g)(1)(i).       19     Review  of  the  initial  denial  letter  shows  that  it  contained  specific  reasons  for  the   decision  and  satisfied  the  requirements  of  the  regulation.    See  Ecklund  v.  Continental  Cas.   Co.,  415  F.Supp.2d  1353,  1376  (N.D.Ala.  2005)  (addressing  a  similar  argument  regarding   lack  of  a  full  and  fair  review  and  finding  that  CAN  clearly  explained  the  reasons  for  denying   the  claim).      After  discussing  the  medical  and  therapy  records,  LINA  explained  as  follows:         Claim  Summary       Upon  review  of  the  documentation  provided,  we  were  unable  to  validate   medical  documentation  which  supported  your  inability  to  perform  the   material  duties  of  your  Regular  Occupation.    In  reviewing  Dr.  Engerson’s     office  notes  ,  no  restrictions  were  noted  and  he  concurred  with  Dr.  Dyas   treatment  plan  at  that  time  of  no  work  for  2  weeks.    A  review  of  the  MRI,   while  noting  some  flattening  of  the  C5-­‐6  and  C6-­‐7,  noted  your  spine  was   in  anatomic  alignment  with  no  disc  pertrusion  and  bone  marrow  signal   being  within  normal  limits.  In  reviewing  Dr.  Dyas’  notes,  while   restrictions  and  limitations  were  noted,  no  findings  supporting  a  no  work   restriction  were  documented.    Dr.  Dyas  notes  contained  no  findings  which   support  his  notice  that  you  are  permanently  disabled.       In  an  attempt  to  gather  additional  documentation  from  Dr.  Dyas,  our   Nurse  Case  Manager  contacted  Dr.  Dyas  office  on  November  21,  2007  for   clarification  of  his  findings  as  they  relate  to  your  restrictions.    On   November  26,  2007,  we  also  contacted  Dr.  Dyas  office  and  requested  his   objective  findings  to  support  his  restrictions  and  limitations.  To  date,  Dr.   Dyas  has  not  responded  to  either  request.       As  the  medical  documentation  contained  in  your  file  does  not  support  a   no  work  restriction  we  are  unable  to  approve  your  claim.       Therefore  at  this  time  we  have  closed  your  claim  and  no  benefits  are   payable  as  the  medical  information  does  not  support  how  you  are  unable   to  work.       (Doc.  112-­‐2,  p.  174-­‐175).           Melech  also  argues  that  LINA’s  denial  letter  violated  29  C.F.R  §  2560.503-­‐1(g)(1)(iii)   because  LINA  failed  to  describe  “what  kind  of  additional  medical  information”  or  additional     20   material  or  information  was  needed  and  failed  to  explain  why  the  material  or  information   was  necessary.       Title  29  C.F.R  §  2560.503-­‐1(g)  provides  for  the  “[m]anner  and  content  of  notification   of  benefit  determination.”    Paragraph  (g)(1)(iii)  states,  in  relevant  part  as  follows:       (1)  Except  as  provided  in  paragraph  (g)(2)  of  this  section,  the  plan   administrator  shall  provide  a  claimant  with  written  or  electronic   notification  of  any  adverse  benefit  determination.  .  .  .    The  notification   shall  set  forth,  in  a  manner  calculated  to  be  understood  by  the  claimant-­‐-­‐             (iii)  A  description  of  any  additional  material  or  information  necessary  for   the  claimant  to  perfect  the  claim  and  an  explanation  of  why  such  material   or  information  is  necessary;       29  C.F.R  §  2560.503-­‐1(g)(1)(iii).         As  stated  above,  the  denial  letter  of  November  29,  2007,  explained  that  Dr.  Dyas   had  not  provided  the  information  requested  by  LINA  and  explained  that  :     In  an  attempt  to  gather  additional  documentation  from  Dr.  Dyas,  our   Nurse  Case  Manager  contacted  Dr.  Dyas  office  on  November  21,  2007  for   clarification  of  his  findings  as  they  relate  to  your  restrictions.    On   November  26,  2007,  we  also  contacted  Dr.  Dyas  office  and  requested  his   objective  findings  to  support  his  restrictions  and  limitations.  To  date,  Dr.   Dyas  has  not  responded  to  either  request.       (Doc.  112-­‐2,  p.  175).       This  statement  was  sufficient  to  put  Melech  on  notice  that  Dr.  Dyas  needed  to  clarify   and  support  his  findings  as  they  related  to  her  restrictions  and  limitations  but  he  had  not   done  so.    Also,  in  the  “Appeal  Rights”  section  of  the  denial  letter,  Melech  was  informed  as   follows:   Appeal  Rights       If  you  disagree  with  our  determination  and  intend  to  appeal  this  claim   decision,  you  must  submit  a  written  appeal    .  .  .         21   You  have  the  right  to  submit  written  comments  as  well  as  any  new   documentation  you  wish  us  to  consider.    If  you  have  additional   information,  it  must  also  be  sent  for  further  review  .  .  .  .       We  would  be  happy  to  consider  any  medical  evidence  which  supports   your  total  disability.    Medical  evidence  includes,  but  is  not  limited  to:   physician’s  office  notes,  hospital  records,  consultation  reports,  test  result   reports,  therapy  notes,  physical  and/or  mental  limitations  (i.e.,  Functional   Capacities  Testing),  etc.    These  medical  records  should  cover  the  period  of   May  2007  through  the  present.     (Doc.  112-­‐2,  p.  175).       The  last  paragraph  plainly  sets  out  the  type  of  medical  evidence  Melech  could   provide  to  LINA  including  a  specific  reference  to  “physical  and/or  mental  limitations”  and     “Functional  Capacities  Testing”  which  may  support  her  claim  of  “total  disability”.    Id.     Overall,  Melech  was  given  sufficient  notice  as  to  the  type  of  medical  evidence  she  could   submit  and  why  it  was  necessary,  i.e.,  to  show  that  she  was  disabled.       Melech  next  argues  that  LINA  violated  29  C.F.R.  §  2560.503(h)(2)(iv)  because  it   failed  to  “take  into  account”  all  the  information  she  submitted  for  her  first  and  second   appeals.      Melech  states  that  LINA’s  nurse  case  manager’s  review  on  appeal  took  two   minutes  and  therefore,  was  not  a  meaningful  review.  7    LINA  responds  that  it  did  not  fail  to   take  into  account  Melech’s  submissions.         Title  29  C.F.R  §  2560.503-­‐1(h)  provides  for  the  “[A]ppeal  of  adverse  benefit   determinations.”    Paragraph  (h)(2)(iv)  states,  in  relevant  part  as  follows:                                                                                                                       7    The  Court  finds  no  merit  to  the  argument  that  LINA’s  Claims  Manager  conducted  a  two   minute  review  on  April  17,  2008,  before  denying  the  appeal.    Melech  acknowledges  that  the   appeal  was  assigned  on  April  15,  2008,  and  that  the  decision  was  made  on  April  17,  2008,   but  she  overlooks  the  date  “April  16,  2008”  in  this  “Appeal  Process”  summary  which  clearly   shows  review  taking  place  on  April  16,  2008.    Also,  it  is  apparent  that  the  time  entry  is   when  the  record  was  created.    (Doc.  112-­‐2,  17)  (“Medical  Investigation  Results  4/16/08   review  of  med  w/NCM  MJ  Kelly  .  .  .”).       22   (2)  Full  and  fair  review.  Except  as  provided  in  paragraphs  (h)(3)  and   (h)(4)  of  this  section,  the  claims  procedures  of  a  plan  will  not  be  deemed   to  provide  a  claimant  with  a  reasonable  opportunity  for  a  full  and  fair   review  of  a  claim  and  adverse  benefit  determination  unless  the  claims   procedures—     (iv)  Provide  for  a  review  that  takes  into  account  all  comments,   documents,  records,  and  other  information  submitted  by  the  claimant   relating  to  the  claim,  without  regard  to  whether  such  information  was   submitted  or  considered  in  the  initial  benefit  determination.     29  C.F.R  §  2560.503-­‐1(h)(2)(iv).         Review  of  the  record  indicates  that  there  is  insufficient  evidence  to  sustain  a  finding   that  LINA  failed  to  provide  a  full  and  fair  review.    The  comments  and  notes  by  the  claims   managers  and  the  nurse  case  managers  provide  sufficient  documentation  that  LINA   adequately  took  into  account  the  information  submitted  by  Melech  in  support  of  her   appeal.     B.    Was  LINA’s  decision  de  novo  wrong?     The  parties  do  not  dispute  that  LINA  is  vested  with  discretionary  authority  to   determine  eligibility  for  benefits.  (Doc.  112-­‐2,  p.  125,  Policy).      Therefore,  the  Court  begins   with  a  de  novo  review  of  LINA’s  decision  based  on  the  evidence  before  LINA  as  found  in  the   administrative  record.    (See  supra  at  note  1)     Defendants  argue  that  LINA  correctly  decided  that  Melech  was  not  disabled  because   the  Administrative  Record  did  not  contain  medical  evidence  of  disability  which  would   preclude  Melech  from  performing  the  material  duties  of  her  light  duty  occupation.   Specifically,  defendants  point  to  the  fact  that  there  is  no  objective  medical  evidence  to   support  Dr.  Dyas’  opinion  that  Melech  was  totally  disabled.8    Defendants  also  argue  that                                                                                                                   8    In  addition  to  the  medical  records  from  Dr.  Dyas  which  contain  his  unsupported  opinion,   defendants  point  out  that  there  was  no  referral  for  pain  management,  no  evidence  of     23   Melech’s  mental  health  treatment  records  did  not  indicate  that  she  was  unable  to  work   because  of  a  mental  impairment.       The  Court  has  reviewed  the  medical  evidence  before  LINA,  and  finds  that  the   decision  was  de  novo  correct.      Therefore,  the  Court  need  not  ascertain  whether  the   decision  was  arbitrary  and  capricious.    Brown  v.  Blue  Cross  &  Blue  Shield  of  Alabama,  898   F.2d  1556,  1566  n.  12  (11th  Cir.1990)  (“It  is  fundamental  that  the  fiduciary's  interpretation   first  must  be  ‘wrong’  from  the  perspective  of  de  novo  review  before  a  reviewing  court  is   concerned  with  the  self-­‐interest  of  the  fiduciary.”)         As  to  clinical  tests  to  support  Melech’s  disability,  on  May  18,  2007,  Dr.  Engerson   obtained  an  x-­‐ray  of  Melech’s  cervical  spine  and  found  “significant  cervical  (degenerative   disc  disease)  at  the  5-­‐6  and  6-­‐7  with  some  good  sized  osteophyties.  Loss  of  the  normal   cervical  lordosis  associated  with  spasm”  (Doc.  112-­‐2,  p.    237).9    On  June  12,  2007,  a  cervical   MRI  was  taken.    The  radiologist  noted  his  impression  that  there  was  now  normal  alignment   of  the  cervical  spine  and  that  Melech’s  cervical  degenerative  disk  disease  was  mild  or   moderate.    (Doc.  112-­‐2,  p.  339).    A  year  later,  on  May  23,  2008,  Melech’s  cervical  MRI  was   interpreted  as  showing  mild  or  moderate  cervical  degenerative  disc  changes  and  mild   central  stenosis.  (Doc.  112-­‐2,  p.  143).         While  Dr.  Engerson  interpreted  the  initial  X-­‐Ray  as  showing  significant  cervical   degenerative  disc  disease  with  loss  of  normal  cervical  lordosis,  the  MRIs  taken  June  12,   2007  and  May  23,  2008,  were  interpreted  to  show  only  mild  or  moderate  cervical  disc                                                                                                                                                                                                                                                                                                                                                                       medication  interfering  with  Melech’s  cognitive  or  functional  abilities,  and  no  evidence  that   she  was  referred  for  surgical  evaluation.   9    Although  the  physical  therapy  notes  are  largely  unreadable,  one  of  the  initial  therapy   goals  was  to  improve  Melech’s  “cervical  stability  posture”.    Limited  range  of  motion  and  fair   strength  in  the  cervical  spine  were  noted.    (Doc.  112-­‐2,  p.    266-­‐267)       24   disease  with  normal  cervical  alignment.  Dr.  Dyas’  opinion  that  Melech  was  totally  disabled   from  her  light  work  occupation  was  not  supported  by  these  tests  without  some  explanation   of  how  the  disease  affected  her  functional  abilities.       As  to  Melech’s  right  shoulder,  there  appears  to  have  been  only  one  test  in  LINA’s   records:  an  MRI  taken  May  23,  2008.    The  MRI  was  interpreted  as  ruling  out  a  rotator  cuff   tear  but  showing  tendinitis  or  tendinopathy  with  “mild  osteoarthritic  spurring  neighboring   the  AC  joint  with  peri-­‐articular  edema.”  (Doc.  112-­‐2,  p.  143).    Dr.  Dyas’  opinion  that  Melech   could  not  work  because  of  a  torn  rotator  cuff  was  not  supported  by  this  test.       As  to  Melech’s  lumbar  disc  disease,  the  only  clinical  test  is  discussed  in  the  January   3,  2008  letter  Dr.  Dyas  wrote  LINA.    He  stated  that  Melech’s  x-­‐ray  showed  “degenerative   changes  at  L4-­‐5  and  L5-­‐S1”.  (Doc.  112-­‐2,  p.  169).    “Changes”  do  not  support  a  finding  of   total  disability  from  light  work.       As  to  functional  limitations  identified  by  the  examining  physicians:10  On  May  10,   2007,  Dr.  Dyas  took  Melech  off  work  for  two  weeks  and  referred  her  for  physical  therapy.   (Doc.  112-­‐2,  p.  339).      On  May  18,  2007,  Dr.  Engerson  found  full  range  of  motion  of  Melech’s   right  shoulder  with  “mild  impingement  signs”,  and  “some  pain  with  resisted  abduction  and   forward  elevation”.    He  also  found  that  Melech’s  “gross  motor  and  sensory  testing  upper   extremities  basically  [within  normal  limits].”    He  agreed  with  Dr.  Dyas’  treatment  plan.     (Doc.  112-­‐2,  p.  237).    On  June  7,  2007,  Dr.  Dyas  noted  that  Melech  was  “intact   neurologically.”  (Doc.  112-­‐2,  p  339).    On  September  13,  2007,  Dr.  Dyas  noted  that  Melech   “still  can’t  work.”  (Doc.  112-­‐2,  p.  339).    On  October  12,  2007,  Dr. Miller found all “Joints                                                                                                                 10  In  a  readable  section  of  their  notes,  the  physical  therapists  indicated  that  Melech’s   cervical  mobility  and  pain  were  improving  although  she  was  still  stiff.    (Doc.  112-­‐2,  p.  252).       25   show full range of motion” and that Melech’s neck was “Supple. No [jugular vein distension]. Nontender.” (Doc. 112-2, p. 193).11 On January 3, 2008, in Dr. Dyas’ letter to LINA, he stated: “Physical findings associated with [cervical spondylosis at C5-6 and C6-7] are limited neck movement by 50%”. He also explained incorrectly that Melech “has a rotator cuff tear in her right shoulder which is chronically and intermittently painful to activity”. As to her lumbar spine, he identified “chronic low back pain with stiffness.” Again, Melech’s neurological exam was normal. (Doc. 112-2, p. 169). On May 22,  2008,  Dr.  Dyas  noted  that  Melech  was  “intact  neurologically”  but  had   “some  soreness,  pain  and  weakness  in  her  right  shoulder.”  (Doc.  112-­‐2,  p.  144).       Despite  Dr.  Dyas’  opinion  that  Melech  was  permanently  and  totally  disabled,  the   only  findings  which  could  reasonably  be  interpreted  as  functional  limitations  are  Dr.   Engerson  finding  of  “mild  impingement  signs”  and  “some  pain  with  resisted  abduction  and   forward  elevation”  in  Melech’s  right  shoulder  (May  18,  2007);    Dr.  Dyas’  finding  of  “some   soreness,  pain  and  weakness”  in  Melech’s  right  shoulder  (May  22,  2008);  and  Dr.  Dyas’   finding  of    “stiffness”  in  the  lumbar  spine,  a  50%  limitation  on  neck  movement  and  pain  in   Melech’s  right  shoulder  related  to  activity  (January  3,  2008).    Dr.  Dyas’  limitations  contrast   with  Dr.  Engerson’s  finding  of  a  full  range  of  motion  in  all  upper  extremities  and  Dr.  Miller’s   finding  of  full  range  of  motion  in  all  joints  and  supple  neck.      Also,  Dr.  Dyas’  finding  of  50%   limitation  on  neck  movement  does  not  explain  how  that  renders  Melech  totally  and   permanently  disabled  or  unable  to  perform  her  job.  12  Therefore,  the  decision  to  deny                                                                                                                   11    The  Court  acknowledges  that  Dr.  Miller  is  not  an  orthopedic  physician.     12    Dr.  Dyas’  opinion  appears  to  be  based  on  two  different  work  descriptions  –  First,  he   stated  that  Melech  worked  at  a  computer  50  hours  per  week  (Doc.  112-­‐2,  p.  339).    Later  he   explained  that  she  “worked  rotating  shifts  requiring  long  hours  standing  and  walking  in  the   parking  lot  and  cleaning  automobiles,  vacuuming  the  automobiles.”    (Doc.  112-­‐2,  p.  169).         26   Melech’s  claim  for  long  term  disability  benefits  is  not  de  novo  wrong  because  Melech  failed   to  sustain  her  burden  to  show  she  could  not,  because  of  functional  limitations,  perform  her   job  as  it  is  normally  performed  in  the  general  labor  market.     IV.  Conclusion       In  accordance  with  the  foregoing,  defendants’  motion  for  summary  judgment  is   GRANTED.     DONE  and  ORDERED  this  the  18th  day  of  September,  2012.   s/  Kristi  K.  DuBose       KRISTI  K.  DuBOSE   STATES  DISTRICT  JUDGE                                                                                                                                                                                                                                                                                                                                                                         Melech  described  her  “Major  Duties”  as  “Doing  reports,  handling  customers,  renting  cars,   making  schedules  for  employees,  safety  issues”.  (Doc.  112-­‐2,  p.  186).    She  described  her   “Minor  Duties”  as  “Moving  cars,  cleaning  &  vacuuming  cars,  preparing  cars  where   necessary;  inventory.”    (Id).    She  used  a  computer,  copy  machine,  fax,  and  a  vacuum.  (Id.)     Thus,  it  appears  that  she  did  not  work  50  hours  per  week  at  the  computer  and  did  not   spend  “long  hours  standing  and  walking  in  the  parking  lot”  or  cleaning  and  vacuuming  cars.           27  

Disclaimer: Justia Dockets & Filings provides public litigation records from the federal appellate and district courts. These filings and docket sheets should not be considered findings of fact or liability, nor do they necessarily reflect the view of Justia.

Why Is My Information Online?