Avery v. International Paper Company Sickness and Accident Plan

Filing 16

MEMORANDUM OPINION AND ORDER. Signed by Honorable Robert T. Dawson on June 21, 2011. (cnn)

IN THE UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF ARKANSAS
EL DORADO DIVISION
RANDALL AVERY

PLAINTIFF

v.

Case No. 09-01010

INTERNATIONAL PAPER COMPANY
SICKNESS AND ACCIDENT PLAN

DEFENDANT

MEMORANDUM OPINION AND ORDER
Plaintiff brings this action pursuant to the provisions of
the Employee Retirement Income Security Act of 1974 (“ERISA”),
29 U.S.C. § 1001 et seq., alleging Defendant‟s decision to deny
his claim for long-term disability benefits was unreasonable.
Before the Court are the Stipulated Administrative Record (Doc.
9), Plaintiff‟s Complaint (Doc. 1), Defendant‟s Answer (Doc. 5),
Plaintiff‟s Motion for Order Directing Administrative Record to
be Augmented and for De Novo Review (Doc. 10), Order Denying
Motion to Supplement Record and for De Novo Review (Doc. 13),
and

Defendant‟s

Motion

for

Memorandum

Judgment

on

Brief
the

in

Support

Administrative

for

Defendant‟s

Record

and

in

Opposition to Plaintiff‟s Memorandum Brief in Support of Claim
of ERISA Benefits (Doc. 15).

Plaintiff‟s claim is DENIED, and

Plaintiff‟s Complaint is DIMISSED WITH PREJUDICE.
I.

BACKGROUND
Plaintiff

International

began

employment

Paper‟s

Fordyce,

as

a

Make

Arkansas

Page 1 of 9

Ready

Ride

Rite

Helper

for

container

plant on August 15, 2005.

(AR-IP000190).

As an hourly employee

and union member, Plaintiff was eligible to apply for the Weekly
Sickness

and

Accident

Plan

benefits

under

the

International

Paper Company Group Health and Welfare Plan (the “Plan”).
IP000016).
human

(AR-

The Plan administrator, the senior vice president of

resources

discretionary

for

International

authority

to

Paper,

interpret

and

is

given

the

administer

the

provisions of the Plan and to decide any claims or disputes that
may

arise

under

administrator
Inc.,

the

Plan.

appointed

(“Sedgwick”)

as

(AR-IP000009-10).

Sedgwick
the

Claims

claims

Management

administrator

The

Plan

Services,
which

is

responsible for the initial Weekly Sickness and Accident benefit
claims

determination

(Exhibit A, ¶ 9).
given

the

and

the

first

appeal

determination.

The Disability Review Committee (“DRC”) is

authority

to

second and final appeal.

decide

benefit

determinations

on

(Exhibit A, ¶ 5).

On May 12, 2006, Plaintiff was absent from work.
IP000097).
Plaintiff

the

(AR-

Consequently, on May 16, 2006, Sedgwick notified
a

claim

for

disability

benefits

was

initiated

for

Plaintiff under the Plan after being notified of his absence.
(AR-IP000097).

On June 5, 2006, Sedgwick notified Plaintiff

that he did not qualify for disability benefits under the Plan
after it reviewed the medical records and a completed disability

Page 2 of 9

form submitted by Plaintiff‟s physician, Dr. Dan A. Martin, M.D.
(AR-IP000082).
On July 10, 2006, Plaintiff faxed Sedgwick his intention to
appeal the denial of his claim for disability benefits.
IP000081).

(AR-

On his appeal form, Plaintiff states he did not

return to work due to “seizures of the brain, dilated (sic)
blood vessels in the head, inflamed liver + hepatitis (sic) have
to have a liver biopsy because it is causing physical problems,
I

can‟t

work

or

drive.”

(AR-IP000081).

Sedgwick

received

additional medical documentation regarding Plaintiff from Dr.
Martin, Dr. Ghulam M. Khaheel M.D., and Dr. Don Greenway M.D.
(AR-IP000085-96, 000117-18).
Sedgwick referred Plaintiff‟s medical records
Medical

Review

Company

(“NMR”)

review.

(AR-IP000107-08).

for

an

to Network

independent

medical

NMR had Plaintiff‟s medical records

reviewed by Dr. Gary P. Greenwood, a board certified physician
in

Internal

Brown,

a

medicine

board

Gastroenterology;

and

physician
and

Dr.

infectious
certified
Joseph

certified physician in Neurology.

diseases;
in

J.

Dr.

Internal
Jares,

James

medicine

III,

(AR-IP000122-33).

a

W.
and

board

The three

physicians concluded that the medical records did not support
restrictions

or

limitations

performing his job duties.

that

would

prevent

(AR-IP000122-133).

Page 3 of 9

him

from

On October 26,

2006, Sedgwick notified Plaintiff the initial denial of benefits
would be upheld.
On

(AR-IP000119).

December

21,

2006,

Sedgwick

received

a

letter

from

Plaintiff‟s attorney expressing Plaintiff‟s desire to appeal the
determination

of

the

disability benefits.

Sedgwick

Appeals

(AR-IP000109).

Unit

regarding

his

Thereafter, Nina Bradley,

Appeals Specialist at Sedgwick proceeded to conduct a review of
the entire administrative record.

(AR-IP000074; Exhibit B, ¶

4).
Sedgwick also had additional independent physicians conduct
another review of Plaintiff‟s medical records.

Those physicians

included Dr. Matthew O. Horowitz, a board certified physician in
internal

medicine

and

gastroenterology;

Dr.

Charles

Brock,

a

board certified physician in neurology and pain management; and
Dr. Joe Maslow, a board certified physician in internal medicine
and

infectious

medical

diseases.

records,

all

(AR-IP000062-72).

three

physicians

Based

determined

on

the

that

no

limitations or restrictions existed to prevent Plaintiff from
performing his regular job duties.
Nina

Bradley

recommended

(AR-IP000062-72).
sustaining

the

denial

of

Plaintiff‟s claim to the DRC because the file did not support a
finding
reviewed

of
the

total

disability.

entire

claim

file

(AR-IP000053-54).
along

with

Nina

The

DRC

Bradley‟s

recommendation and determined the denial of benefits was proper
Page 4 of 9

as

the

Plaintiff

provisions.
II.

was

not

totally

disabled

under

the

Plan

(AR-IP000055).

STANDARD OF REVIEW
Under ERISA, a denial of benefits by a plan administrator

must

be

reviewed

de

novo

unless

the

benefit

plan

gives

the

administrator discretionary authority to determine eligibility
for benefits or to construe the terms of the plan, in which case
the

administrator‟s

discretion.

decision

is

reviewed

for

an

abuse

of

Woo v. Deluxe Corp., 144 F.3d 1157, 1160 (8th Cir.

1998) (citing Firestone Tire & Rubber Co. v. Bruch, 489 U.S.
101, 115 (1989)).

Accordingly, the Court must be guided by the

language of the plan to determine the proper standard of review.
The

Plan

administrator

provides,
has

in

discretion

pertinent
to

part,

“[t]he

Plan

and

administer

the

interpret

provisions of the Plan and to decide any claims or disputes that
may

arise

under

the

Plan.

The

decision

of

the

Plan

administrator with respect to any such matters shall be final
and binding on both the company and the members of the Plan.”
(AR-IP000010).

Therefore, the plan administrator‟s decision may

only be reviewed for an abuse of discretion.
The Eighth Circuit Court of Appeals has “variously defined
. . . an abuse of discretion as being „extremely unreasonable,‟
„virtually‟

the

„extraordinarily

same

as

imprudent.‟”

arbitrary
Shell

Page 5 of 9

and
v.

capricious,
Amalgamated

and

Cotton

Garment, 43 F.3d 364, 366 (8th Cir. 1994) (citations omitted).
“The proper inquiry into the deferential standard is whether
„the

plan

administrator‟s

decision

supported by substantial evidence.‟”

was

reasonable;

i.e.,

Cash v. Wal-Mart Group

Health Plan, 107 F.3d 637, 641 (8th Cir. 1997) (quoting Donaho
v. FMC Corp., 74 F.3d 894, 899 (8th Cir. 1996)).
“While

the

word

„reasonable‟

possesses

numerous

connotations, this court has rejected any such definition that
would

„permit

a

reviewing

court

to

reject

a

discretionary

trustee decision with which the court simply disagrees(.)‟”
(citation omitted).

Id.

A decision is reasonable “if „a reasonable

person could have reached a similar decision, given the evidence
before him, not that a reasonable person would have reached that
decision.‟

If

the

decision

is

supported

by

a

reasonable

explanation, it should not be disturbed, even though a different
reasonable interpretation could have been made.” Id. (citation
omitted).
III. DISCUSSION
Plaintiff

contends

that

the

Court

should

augment

the

administrative record to include supplemental information when
conducting a review of the Plan administrator‟s decision to deny
benefits.

The

Plaintiff

also

contends

that

the

Plan

administrator abused its discretion by denying Plaintiff‟s claim
for disability benefits.
Page 6 of 9

Plaintiff argues that the administrative record should be
augmented to include supplemental information not made available
at the time of the claims procedure.
established

within

the

Eighth

However, “[i]t is firmly

Circuit

that,

under

[the]

deferential standard of review, the Court will only examine the
evidence that was before the administrator when the decision was
made.”

Wakkinen v UNUM Life Ins. Co., 531 F.3d 575, 580 (8th

Cir. 2008).

The Court‟s review in the present case is limited

to the information contained in the administrative record and
supplementing the record with information that was not included,
reviewed, or considered by the plan administrator at the time it
reached its decision to deny coverage would be improper.
Plaintiff argues the medical records of Drs. Martin and
Khaleel

support

a

diagnosis

of

total

duties exist that Plaintiff can perform.
statement

from

Jackie

Hern,

an

disability

and

no

job

Plaintiff highlights a

International

Paper

employee,

which states “[w]e don‟t have a job he could (sic) that would
not

put

him

working.”

in

danger

should

he

experience

a

seizure

while

(Doc. 14, p. 27).

The Plan provides “benefits will be payable if you become
totally disabled, which means that you are unable to perform
your job as a result of a nonoccupational sickness or injury and
are under the regular care of a physician licenses to practice
medicine.”

(AR-IP000010).
Page 7 of 9

Defendant contends the medical records of Drs. Martin and
Khaleel do not support a diagnosis of total disability and do
not suggest Plaintiff is limited or restricted from performing
his daily job duties.

When a difference of opinion between a

claimant‟s

treating

physicians

reviewing

physicians

exists,

and
as

the
in

plan

this

administrator‟s
case,

the

plan

administrator has discretion to find that the employee is not
disabled unless “the administrative decision lacks support in
the record, or . . . the evidence in support of the decision
does

not

ring

evidence.”

true

Donaho,

and

74

is

F.3d

.
at

.

.

overwhelmed

901.

by

Defendant

contrary

utilized

six

independent physicians to review the medical records from Drs.
Martin

and

Khaleel,

and

Plaintiff‟s

laboratory

test

results.

All six reviews concluded that no limitations or restrictions
existed to prevent Plaintiff from performing his job duties.
Defendant

further

contends

that

the

statement

of

Jackie

Hern is taken out of context and the entire correspondence was
merely a simple inquiry to the status of Plaintiff‟s claim.

Dr.

Martin recommended Plaintiff avoid driving, avoid heights, avoid
climbing
harmful

ladders,
to

his

avoid

liver,

ground floor only.

chemicals
and

that

that

his

(AR-IP000184).

could

employment

be

potentially

should

be

on

Plaintiff‟s job duties, as

described in the Job Analysis Form, do not involve any of those
restrictions.

(AR-IP000104-06).

In addition, the six physician

Page 8 of 9

reviews

determined

Plaintiff

to

be

able

to

perform

the

job

duties as described in the Job Analysis Form.
Furthermore,

the

law

requires

administrator be reasonable.

the

decision

of

the

Plan

A decision is reasonable “if „a

reasonable person could have reached a similar decision, given
the evidence before him, not that a reasonable person would have
reached

that

decision.‟

If

the

decision

is

supported

by

a

reasonable explanation, it should not be disturbed, even though
a

different

reasonable

interpretation

could

Cash, 107 F.3d at 641 (citation omitted).
the

Plan

administrator

independent

physician

to

agree

reviews

with

have

been

made.”

It is reasonable for

the

concluding

conclusion

Plaintiff‟s

of

six

symptoms

(based on the available medical records) does not restrict him
from performing his job duties and therefore Plaintiff is not
disabled as defined by the Plan.
IV.

CONCLUSION
For

the

reasons

stated

above,

the

Court

concludes

Defendant‟s decision was supported by substantial evidence and
is AFFIRMED. Accordingly, Defendant‟s Motion for Judgment on the
Administrative

Record

(Doc.

15)

is

hereby

GRANTED,

and

Plaintiff‟s Complaint (Doc. 1) is DIMISSED.
IT IS SO ORDERED this 21st day of June, 2011.
/s/ Robert T. Dawson
Robert T. Dawson
United States District Judge
Page 9 of 9