Oates v. Walgreen Company

Filing 38

ORDER: The Court AFFIRMS the termination of long-term disability benefits in this case. The Clerk is directed to enter JUDGMENT in favor of Defendant and, thereafter, to CLOSE THE CASE. See Order for details. Signed by Judge Virginia M. Hernandez Covington on 4/16/2013. (KAK)

UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF FLORIDA
TAMPA DIVISION
JOHN S. OATES,
Plaintiff,
v.

Case No.

8:12-cv-908-T-33TGW

WALGREEN COMPANY,
Defendant.
______________________________/
ORDER
John Oates, a pharmacist suffering from knee arthritis
and other ailments, claims that his receipt of long-term
disability benefits as provided by his employer, Walgreen Co.
(“Walgreens”)

pursuant

to

an

ERISA

Plan

terminated by the Plan’s Claim Administrator.

was

unlawfully

The Court has

reviewed the 715 page administrative record and, after so
doing, affirms the finding that Oates is no longer entitled to
long-term disability benefits.
I.

Factual Background
A.

Oates Participates in an ERISA Plan

Walgreens offers its pharmacists, including Oates, a
disability plan known as the Walgreens Income Protection Plan
for Pharmacists and Registered Nurses.

It is not disputed

that the Plan is governed by the Employee Retirement and
Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001, et
seq.

The Plan provides short-term and long-term disability
benefits to qualifying employees. (AR 624).1

Only long-term

disability benefits are at issue in this matter. The Summary
Plan Description is before the Court (AR 617-640), and it
defines “disabled” or “disability” as follows:
For the long-term disability period . . . due to
sickness, pregnancy, or accidental injury, you are
prevented from performing one or more of the
essential duties of your own occupation and are
receiving appropriate care and treatment from a
doctor on a continuing basis; and
•
for the first 18 months of long-term benefits,
you are unable to earn more than 80% of your
pre-disability earnings or indexed predisability earnings at your own occupation
from any employer in your local economy; or
•
following that 18 month period, you are unable
to earn more than 60% of your indexed predisability earnings from any employer in your
local economy at any gainful occupation for
which you are reasonably qualified, taking
into
account
your
training,
education,
experience, and pre-disability earnings.
(AR 624).
The costs for the Plan are paid entirely by Walgreens.
(AR 621).

In addition, Walgreens pays the benefits provided

through the Plan, and Walgreens is designated the “Plan
Administrator.” (AR 624, 638).
Sedgwick

Claims

Management

As defined in the Plan,

Services,

Inc.

is

the

“Claim

Administrator,” and makes benefits determinations. (AR 624,

1

References to “AR” are to the administrative record
filed on August 1, 2012.
-2-

638; Craig Decl. Doc. # 37-1 at ¶¶ 3-4).

Sedgwick “has no

corporate relationship to Walgreens.” (Craig Decl. Doc. # 37-1
at

¶

3).

“Under

the

Plan,

Sedgwick

performs

claims

evaluations and makes determinations on specific claims under
the Plan.

Walgreens only provides information regarding the

general eligibility for Plan benefits and regarding the duties
and compensation of Walgreens employees participating in the
Plan

so

as

to

allow

Sedgwick

to

make

claims

decisions

regarding whether an employee is disabled and as to the
amounts of disability benefits.” (Id. at ¶ 3).

In addition,

“[a]ll medical reviews in the claims appeal process are
conducted by independent physicians or other health care
professionals retained by Sedgwick.
the

selection

or

retention

of

Walgreens has no role in
these

reviewing

medical

personnel.” (Id. at ¶ 4).
B.

Oates Receives Disability Benefits for Two Years

Oates, a pharmacist, applied for and was granted shortterm disability benefits due to pain in his knees and back on
May 22, 2009. (AR 541-542). Oates received these benefits for
180 days, which is the maximum duration for such benefits
under the Plan. (AR 541, 542, 529).
On December 16, 2009, Sedgwick long-term disability
examiner Scott Sturm sent Oates a letter advising Oates that

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his claim for long-term disability benefits was approved and
“became payable as of November 18, 2009, through January 31,
2010.” (AR 529-530).

In this letter, Sturm provided Oates

with the Plan’s definition of “disability;” informed Oates
that he was required to apply for Social Security Disability
benefits as outlined in the Plan; and advised Oates that
continued

receipt

contingent

upon

of

long-term

Oates’s

disability

supplying

benefits

additional

was

medical

documentation. Id.
Sedgwick’s approval of Oates’s initial application for
long-term disability benefits was based on the reports of two
independent,

Board

Certified

Mendelssohn and Dr. Jamie Lewis.
Oates

was

not

capable

pharmacist

as

of

of

August

physicians:

Martin

Both physicians found that

performing
22,

Dr.

2009,

his
due

own
to

work

as

a

degenerative

arthritis in his knees and back. (AR 192-205, 529-542). These
physicians noted limitations in walking, standing, bending,
and reaching. Id.
However,

these

physicians

concluded

that

Oates

was

capable of performing a sedentary occupation and was, thus,
not disabled under the any occupation definition of disability
under the Plan. (AR 192-205).

Specifically, Dr. Mendelssohn,

a Board Certified orthopedic surgeon, opined that Oates’s
ailments “would not preclude him from a sedentary occupation.”
-4-

(AR 192). Dr. Lewis, Board Certified in Physical Medicine and
Rehabilitation and Board Certified in Pain Medicine, similarly
determined that Oates “would not be reasonably capable of
performing continuing walking and standing secondary to the
degenerative pathology in the knees, torn meniscus and limited
range

of

motion”

but

limited

his

conclusion

to

Oates’s

“current position” as a pharmacist. (AR 194).
Oates’s

receipt

of

long-term

continued until May 21, 2011.

disability

benefits

During this time period, Oates

submitted medical documentation from his treating physician
Dr. Richard Sweeney, a Family Physician, and Chiropractor
David R. Puentes.

Among other relevant office visit notes,

the record contains Dr. Puentes’ May 18, 2010, note that “with
treatment [Oates] is better however, [he] still fatigues with
weakness into lower extremities [and] is unable to stand for
any period of time without experiencing numbness and weakness
into the lower extremities.” (AR 502).
Dr.

Sweeney’s

September

2,

2010,

office

visit

note

however, states that Oates “suffers from chronic severe pain;
limitations of motion of his knees, back, hands; cognitive
function; and he has had a tender painful left foot which is
chronic.” (AR 480).

Dr. Sweeney remarked that Oates’s

medications include: “Soma, Benicar HCT, Xanax, Protonix,
Celebrex, Synthyroid, Combivent, Nexium, Lortab, and Zoloft.”
-5-

Id.

Dr. Sweeney indicated that Oates’s “restrictions and

limitations”

included

“no

lifting,

critical

thinking

no

standing
due

long
to

term,
side

no

heavy

effects

of

medications, which he takes for his anxiety, depression and
chronic pain.

He cannot do repetitive hand motion due to

severe spasm and pain in his hands.” Id. Dr. Sweeney thus
concluded:

“I

have

declared

him

permanently

and

totally

disabled from any job. He is unable to complete any job at
this time, nor unfortunately do I feel he would be safe to do
any in the future.” Id.
C.

Oates is
Benefits

Awarded

Social

Security

Disability

The Plan contained the requirement that Oates apply for
Social Security Disability Benefits. (AR 625-626).

The Plan

specifically states, “You are required to apply for all other
income benefits for which you are eligible and to appeal any
other income claim denial.

If you fail to do so, your

benefits under the Income Protection Plan will be reduced by
the estimated amount of the Primary Offset Benefit you could
have received if your claim had been approved.

Your benefits

may be withheld entirely until you do apply for the offset
benefit, including appeals.” (AR 626).

The Plan noted “Your

benefits under this plan will be reduced by the amount of

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benefits you are eligible to receive from other sources, such
as Social Security.” Id.
Oates did apply for Social Security Benefits and was in
fact

granted

such

benefits.

The

Social

Security

Administration indicated in a letter to Oates:
You are entitled to monthly disability benefits
beginning November 2009. . . . You will receive
$38,496.00 around March 6, 2011. This is the money
you are due for November 2009 through February
2011. Your next payment of $2,406.00, which is for
March 2011 will be received on or about the fourth
Wednesday of April 2011.
After that you will
receive $2,406 . . each month.
(AR 435).
D.

Oates’s
Long-Term
Terminated

Disability

Benefits

are

As noted, Oates enjoyed a less stringent definition of
“disability” under the Plan for the first 18 months of his
receipt of long-term disability benefits.

However, after the

first 18 months, the Plan definition of “disabled” changed
from

being

“unable

to

earn

more

than

80%

of

your

pre-

disability earnings or indexed pre-disability earnings at your
own occupation” to being “unable to earn more than 60% of your
indexed pre-disability earnings from any employer in your
local economy at any gainful occupation for which you are
reasonably qualified, taking into account your training,

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education,

experience,

and

pre-disability

earnings.”

(AR

624)(emphasis added).
On January 11, 2011, Sturm advised Oates that a change in
the

applicable

definition

of

disability

from

“your

own

occupation” to “any gainful occupation” was on the horizon,
and sent Oates various forms to complete.

On one such form,

Oates indicated that he was able to drive, shop, fish, view
movies, and use a computer on a daily basis. (AR 444-445).
In

addition,

Sturm

referred

Oates’s

file

for

an

independent Transferable Skills Analysis to be performed by
Certified Rehabilitation Counsel James Percic (AR 429-433;
563). Percic considered Dr. Sweeney’s medical opinion as well
as other medical data.

Percic listed Oates’s “transferable

skills” as “knowledge of drugs and drug interactions, basic
medical knowledge, customer service skills, good communication
skills,

supervisory

skills,

good

arithmetic

skills,

organizational ability, computer skills, typing skills, and
good judgment and decision-making skills.” (AR 430).
Percic noted that Oates would be able to “work in a
sedentary or light physical exertion level occupation” and
identified

the

following

as

“vocational

alternatives:”

“Manager, Professional Equipment Sales-and-Service; Manager,
Department; Director, Service; Quality-Control Coordinator;
Pharmaceutical Detailer.” (AR 432).
-8-

The annual salaries for

these

identified

positions

$72,820.80. (AR 433).

ranged

from

$162,510.40

to

Percic based his report on employment

opportunities available in Polk County, Florida where Oates
resides.

Id.

On May 26, 2011, based on Percic’s Transferable Skills
Analysis

and

the

previously

supplied

opinion

of

Dr.

Mendelssohn, Sedgwick terminated Oates’s long-term disability
benefits effective May 22, 2011. (AR 564).
E.

Oates Participates in the Plan Appeals Process

On July 25, 2011, counsel for Oates sent Sturm a letter
stating his disagreement with Sedgwick’s decision to terminate
benefits

and

supplying

Sedgwick

with

additional

medical

documentation, including a letter from Dr. Sweeney and the
Social Security Administration Independent Medical Evaluation
report prepared by Dr. Morris Kutner. (AR 423-428). Sedgwick
construed the July 25, 2011, letter as a request for a firstlevel appeal of the decision to terminate long-term disability
benefits. (AR 567-570).
As a part of that first-level appeal, Regina CrenshawWinfield, Sedgwick Appeals Specialist, referred Oates’s claim
for independent medical review to two physicians: Dr. Siva
Ayyar, Board Certified in Occupational Medicine and Dr. Moshe
Lewis,

Board

Certified

in

-9-

Physical

Medicine

and

Rehabilitation.

Both

of

these

physicians

completed

an

independent review of Oates’s file based on Oates’s entire
medical

file,

including

the

documents

generated

by

Dr.

Sweeney, Dr. Kutner, and Dr. Puentes--the three physicians
Oates relied upon in his attempt to substantiate entitlement
to long-term disability benefits.

Both Dr. Lewis and Dr.

Ayyar filed reports on September 20, 2011, finding that Oates
was not precluded from engaging in gainful employment.
Dr. Lewis specifically noted that Oates was “not disabled
from the ability to perform any occupation for which he may be
qualified

by

education,

05/22/11.” (AR 363).

training,

or

experience

as

of

Dr. Lewis noted that Oates “would be

limited in his ability to stand or walk for prolonged periods”
but found that “there is no evidence to support complete
inability to work.” Id.

Dr. Lewis suggested that Oates

consider sedentary work. Id.
Dr. Ayyar reached the same conclusion:
While [Oates] may indeed have chronic bilateral
knee osteoarthritis that limits his ability to work
in his usual and customary occupation as a
pharmacist, he is certainly not disabled from any
and all occupations for which he may be qualified
by education, training, or experience during the
timeframe in question, 05/22/11 through the
present.
(AR 369).

Dr. Ayyar likewise determined that Oates could

perform sedentary work. Id.
-10-

Based on the reports of Dr. Lewis and Dr. Ayyar, as well
as Percic’s transferable skills analysis, Sedgwick upheld its
termination of Oates’s long-term disability benefits. (AR 336339).

Sedgwick advised Oates that he could request a second-

level appeal of the termination of such benefits. (AR 339).
On January 9, 2012, Oates requested a second level appeal
of Sedgwick’s decision. (AR 310-313).

Through counsel, Oates

submitted additional documentation from Dr. Sweeney and Dr.
Puentes as well as a Vocational Evaluation and Transferable
Skills Analysis from Disability Specialist Gerri Pennachio.
(AR 295-307; 310-313).

Included in

Pennachio’s report is a

notation that Oates spends his days running errands, watching
television, surfing the internet, going fishing and hunting,
drinking 8-10 beers daily and smoking in excess of one pack of
cigarettes daily. Id. (AR 303).
As a part of Oates’s second level appeal, Sedgwick
referred

Oates’s

claim

for

review

by

three

independent

physicians: Dr. Marie-Claude Rigaud, Dr. Richard Kaplan, and
Dr. Phillip Marion. Each of these physicians reviewed Oates’s
entire file and determined that Oates was not disabled.
Specifically, Dr. Rigaud, a Board Certified Psychiatrist,
indicated, “From a strictly psychiatric perspective, it is my
professional opinion, based on available information that the
claimant was not disabled from the ability to perform any
-11-

occupation

for

which

he

may

be

qualified

by

education,

training, or experience as of May 22, 2011.” (AR 257). Dr.
Rigaud also noted that, while Dr. Puentes reported that Oates
was “lethargic” and “loopy,” Dr. Puentes failed to assess “the
possible effects or clinical significance of the consumption
of

eight

to

ten

beers

daily

on

the

claimant’s

overall

functioning.” (AR 259).
Dr. Kaplan and Dr. Marion, both Board Certified in
Physical Medicine and Rehabilitation, likewise determined that
Oates was not disabled.

Dr. Kaplan indicated that “the

records do not indicate that this claimant would be disabled
from doing any occupation.” (AR 267).

Dr. Marion found that

Oates was “not disabled, he is able to work full time at the
sedentary job level.” (AR 276).
Sedgwick thus upheld its decision to terminate Oates’s
benefits at the second-level review phase and communicated the
same to Oates via letter dated February 21, 2012. (AR 239244).
F.

Oates Files his ERISA Complaint

Oates filed an ERISA action against Walgreens on April
25, 2012. (Doc. # 1). Walgreens filed its Answer on June 11,
2012. (Doc. # 12). On July 9, 2012, Walgreens filed its Motion
for an ERISA Scheduling Order “to limit discovery in this

-12-

action to the administrative record.” (Doc. # 16).

This

Court held a hearing on the Motion for an ERISA Scheduling
Order

July

19,

2012.

During that hearing, the parties

addressed the issue of whether a conflict of interest existed
due to Walgreens’s role as the Plan Administrator and the
party paying for disability benefits.
explained

the

separate

role

of

Counsel for Walgreens

the

Plan

Administrator

(Walgreens) and the Claim Administrator (Sedgwick):
The [C]laims Administrator runs the Plan.
If
there’s a unique situation that comes up, like,
well, I don’t know how much this guy worked, maybe
he doesn’t qualify for the Plan. That’s when the
Plan Administrator comes in, and it’s only after
there’s appeals process . . . . It’s only after the
second round.
Here, there’s no allegation in the
complaint that there was a unique situation, [a]
factual scenario that needed the Plan Administrator
to be involved.
Walgreens simply paid, Sedgwick
ran the appeals. And that’s why we believe there’s
no conflict.
(Doc. # 29 at 16).
On July 26, 2012, the Court entered an Order pursuant to
the hearing designating this case as a Track One case,
allowing

limited

discovery,

setting

a

timetable

for

the

parties to file memoranda of law, and directing Walgreens to
file the administrative record. (Doc. # 24). Walgreens filed
the administrative record on August 1, 2012. (Doc. # 27).
Thereafter, on October 5, 2012, Oates filed a Motion for
Clarification (Doc. # 28) regarding the standard of review
-13-

applicable in this ERISA case. On November 6, 2012, the Court
granted the Motion for Clarification as follows: “the Court
now clarifies its conclusion that no conflict of interest
exists and that the arbitrary and capricious standard applies
in

this

case.”

(Doc. # 33).

Each party has filed a

memorandum of law regarding Oates’s entitlement to long-term
disability benefits. (Doc. ## 34, 37).
II.

Legal Standard
As

set

forth

in

Blankenship

v.

Metropolitan

Life

Insurance Company, 644 F.3d 1350 (11th Cir. 2011), the Court
conducts

the

following

review

of

an

ERISA

benefits

determination:
(1)

(2)

(3)

(4)

Apply the de novo standard to determine
whether the claim administrator’s benefitsdenial 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.
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 injury and reverse the
decision.
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).
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.
-14-

(5)
(6)

If there is no conflict, then end the inquiry
and affirm the decision.
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.

Id. at 1355.
The Court’s analysis “centers on assessing whether a
reasonable basis existed for the administrator’s benefits
decision.” Id. See also Conkright v. Frommert, 130 S. Ct.
1640, 1651 (2010)(“the plan administrator’s interpretation of
the plan ‘will not be disturbed if reasonable.’”)(quoting
Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 111
(1989)).
III. Analysis
A.

The Claim Administrator’s Decision was Not Wrong

In determining whether Sedgwick’s decision was “wrong,”
the Court “stand[s] in the shoes of the administrator and
start[s] from scratch, examining all the evidence before the
administrator

as

if

the

issue

had

not

been

decided

previously.” Stiltz v. Metro. Life Ins. Co., No. 105-cv-3052TWT, 2006 U.S. Dist. LEXIS 65394, at *18 (N.D. Ga. Aug. 30,
2006), Aff’d, 244 F. App’x 260 (11th Cir. 2007).
is

‘wrong’

if,

after

a

review

of

the

“A decision

decision

of

the

administrator from a de novo perspective, the court disagrees

-15-

with

the

administrator’s

decision.”

Glazer

v.

Reliance

Standard Life Ins. Co., 524 F.3d 1241, 1246 (11th Cir. 2008).
Furthermore, “[t]he court must consider, based on the record
before the administrator at the time its decision was made,
whether the court would reach the same decision as the
administrator.

If

the

court

determines

that

the

plan

administrator was right, the analysis ends and the decision is
affirmed.”
benefits

Id.

Even if the Court finds that Sedgwick’s

decision

was

wrong,

under

the

arbitrary

and

capricious standard, a decision will still be upheld if it is
grounded in any reasonable basis. Conkright, 130 S. Ct. at
1651.
Oates

asserts

that

the

termination of long-term

disability benefits was wrong because Sedgwick ignored various
doctors’ reports purporting to find Oates totally disabled, as
well

as

the

Social

Security

Administration’s

award

of

disability benefits. Oates also contends that Sedgwick failed
to follow technical Plan requirements regarding the timing of
its decision.

The Court has given careful consideration to

these contentions and determines that they are unavailing as
outlined below.
1.

Treating Physicians

-16-

Oates highlights favorable passages from his treating
physicians’ and Disability Specialists’ reports, and contends
that Sedgwick ignored this information in making its decision
to deny benefits.

As argued by Walgreens, “Oates urges the

Court to simply pick his physicians’ and specialists’ opinions
over those of the independent medical reviewers retained by
Sedgwick.” (Doc. # 37 at 22).
Court.

That is not the role of the

The record reflects that the Claim Administrator

appropriately

relied

upon

the

reports

of

independent

physicians who conducted a complete review of Oates’s file.2
Dr. Mendelssohn determined on November 23, 2009, that
Oates was not precluded “from a sedentary occupation or a
light physical exertion level.” (AR 192). Percic found in his
Transferable Skills Analysis on May 20, 2011, that Oates was
not precluded from gainful employment and that there was “no
documentation beyond Dr. Sweeney’s statement that there are
cognitive

issues

that

would

affect

critical

thinking

sufficiently to negatively impact the performance of a job.”
(AR 429-433).

Dr. Lewis found on September 20, 2011, that

2

These independent experts were not required to
physically examine Oates, and their failure to do so does not
render their opinions invalid. See Richey v. Hartford Life and
Accident Ins. Co., 608 F. Supp. 2d 1306, 1312 (M.D. Fla. 2009)
(“An ERISA administrator is entitled to rely on the opinion of
a qualified consultant who neither treats nor examines the
claimant, but instead reviews the claimant’s medical
records.”).
-17-

Oates “was not disabled from the ability to perform any
occupation

for

which

he

may

be

training, or experience.” (AR 363).

qualified

by

education,

Dr. Ayyar determined on

September 20, 2011, “While [Oates] may indeed have chronic
bilateral knee osteoarthritis that limits his ability to work
in his usual and customary occupation as a pharmacist, he is
certainly not disabled from any and all occupation for which
he may be qualified . . . [he can] do a sedentary type of
work.” (AR 369).

Dr. Rigaud determined on February 7, 2012,

that Oates was not disabled from a “psychiatric perspective.”
(AR 257). Dr. Kaplan found on February 7, 2012, that the
“records

do

not

validate

that

[Oates]

performing any occupation.” (AR 267).

is

disabled

from

Finally, Dr. Marion

indicated on February 7, 2012, that Oates was “able to work
full time at the sedentary job level.” (AR 276).
The

aforementioned

findings,

individually

and

collectively, represent a reasonable basis for the termination
of Oates’s long-term disability benefits.

That Dr. Sweeney,

Dr. Puentes, and Pennachio considered Oates disabled does not
make

Sedgwick’s

reports improper.

reliance

on

the

independent

physician’s

It is well established that a claim

administrator may rely on independent medical examiners, and
there is no requirement that a claim administrator afford
greater weight or deference to treating physicians than to
-18-

independent physician reviewers. See Black & Decker Disability
Plan v. Nord, 538 U.S. 822, 834 (2003)(“[C]ourts have no
warrant to require administrators automatically to accord
special weight to the opinions of a claimant’s physician; nor
may courts impose on administrators a discrete burden of
explanation when they credit reliable evidence that conflicts
with a treating physician’s evaluation.”); Townsend v. Delta
Family-Care Disability & Survivorship Plan, 295 F. App’x 971,
978 (11th Cir. 2008)(“[P]lan administrators are not required
to give greater weight to the submissions of a treating
physician than to other reliable evidence.”); Wilkins v.
Sedgwick Claims Mgmt. Servs., Inc., No. 8:09-cv-1009-T-26TGW,
2010

U.S.

Dist.

LEXIS

42971,

at

*14

(M.D.

Fla.

May

3,

2010)(same); Stenner-Muzyka v. Unum Life Ins. Co. of Am., No.
8:04-cv-984-T-17TBM, 2005 U.S. Dist. LEXIS 23401, at *6 (M.D.
Fla. July 7, 2005)(same).
Furthermore, the record reflects that--far from ignoring
the reports of Oates’s treating physicians--the reviewing
physicians considered the reports supplied by Oates’s treating
physicians and consulted with the treating physicians.

For

instance, the reports of Dr. Ayyar and Dr. Marion reflect that
they each engaged in a telephone call with Dr. Sweeney. (AR
366, 277).

Likewise, Dr. Rigaud’s report indicates that she

personally spoke with Dr. Puentes. (AR 258-261). Furthermore,
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Dr. Kaplan’s report reflects that he spoke with both Dr.
Sweeney and Dr. Puentes. (AR 268-271).
It was soundly within Sedgwick’s discretion to credit the
evidence

from

the

independent

medical

reviwers

over

the

opinions of Oates’s treating physicians and specialists in
denying benefits and throughout the appeal process.
2.
Oates

Social Security Administration Determination
also

contends

that

Sedgwick’s

benefits

determination was wrong because Sedgwick failed to consider
that Oates was found to be disabled by the Social Security
Administration.

Oates specifically asserts that an award of

long-term disability benefits is required based on Metro Life
Insurance Company v. Glenn, 554 U.S. 105, 118 (2008).
In Glenn, a plan participant with a heart condition
appealed

the

plan

administrator’s

denial

of

long-term

disability benefits to the district court. The district court
found in favor of the plan administrator, however, the Sixth
Circuit set aside the plan administrator’s denial of benefits
based on: (1) the plan administrator’s conflict of interest;
(2) the plan administrator’s failure to reconcile its own
conclusion that the plan participant could not work in other
jobs with the Social Security Administration’s determination
that

the

plan

participant

could

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not;

(3)

the

plan

administrator’s focus on one treating physician’s report
suggesting that the plan participant could work, at the
expense of other, more detailed treating physicians’ reports;
(4) the plan administrator’s failure to provide the plan
participant’s

treating

physicians’

reports

to

its

hired

expert; and (5) the plan administrator’s failure to take into
consideration that stress aggravated the plan participant’s
condition.
With respect to the plan participant’s entitlement to
Social Security benefits, the Court indicated: “the [Sixth
Circuit]

found

encouraged

questionable

Glenn

to

the

argue

to

fact
the

that

MetLife

Social

had

Security

Administration that she could do no work, received the bulk of
the benefits of her success in doing so (the remainder going
to the lawyers it recommended), and then ignored the agency’s
finding.” Id. at 118.

The Court found “nothing improper in

the way in which the [Sixth Circuit] conducted its review.”
Id.
The Court agrees with Oates that Glenn is an important
and relevant decision.

Despite some factual similarity with

the present case, however, the Glenn decision does not mandate
an award of long-term disability benefits to Oates. The Glenn
decision does not stand for the proposition that the Social
Security

Administration’s

disability
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determinations

are

binding

on

ERISA

plan

administrators.

The

Glenn

Court

affirmed the Sixth Circuit’s consideration of the Social
Security Administration’s award of benefits as one factor,
among many, that is relevant to the court’s review.
In cases decided after Glenn was handed down and citing
to

Glenn,

approval

the
of

Eleventh

Circuit

has

disability

benefits

by

maintained
the

Social

that

the

Security

Administration is not considered dispositive on the issue of
whether a claimant is disabled under an ERISA plan. See, e.g.,
Ray v. Sun Life & Health Ins. Co., 443 F. App’x 529, 533 (11th
Cir. 2011)(“[W]hile approval of Social Security benefits may
be considered, it is not conclusive on whether a claimant is
also disabled under the terms of an ERISA plan.”).

In

addition, the Eleventh Circuit has affirmed the denial of
disability benefits in the instance of an award of disability
benefits by the Social Security Administration in post-Glenn
ERISA cases. See, e.g., Gipson v. Admin. Comm. of Delta Air
Lines, Inc., 350 F. App’x 389, 392 (11th Cir. 2009); Brannon
v. Bellsouth Telecomms., Inc., 318 F. App’x 767, 770 (11th
Cir. 2009).
This Court has considered all of the relevant factors,
including

the

Social

Security

Administration’s

award

of

benefits to Oates, and determines that Sedgwick’s decision was

-22-

not de novo wrong.3
detailed

and

Sedgwick made its decision based upon the

thorough

reports

of

eminently

qualified

physicians and specialists who opined that Oates was capable
of sedentary work.

In addition, Sedgwick relied upon a

transferable skills analysis showing that, despite Oates’s
knee pain and other conditions, Oates would qualify for and be
able to perform specific jobs with salaries ranging from
$162,510.40 to $72,820.80.

As such, Oates was no longer

disabled as that term is defined in the Plan.

This Court,

standing in the shoes of Sedgwick, would have made the same
determination that Sedgwick made.
Nonetheless,

even

assuming

that

the

termination

of

benefits was de novo wrong, Walgreens would still prevail in
this action.

There is no dispute that Sedgwick, the Claim

Administrator, was vested with discretion in deciding Oates’s
claim.4

And there is no evidence from which to draw any

inference that Sedgwick or Walgreens operated under a conflict
3

The record also reflects that each of the independent
physicians Sedgwick retained gave consideration to Dr.
Kutner’s evaluation. As noted, Dr. Kutner evaluated Oates in
conjunction with the Social Security Administration’s
favorable benefits determination.
4

The Plan states, “The authority granted to the Claim
Administrator and the Plan Administrator to construe the Plan
and make benefits determinations, including claims and appeals
determinations, shall be exercised by them (or persons acting
under their supervision) as they deem appropriate in their
sole discretion.” (AR 635).
-23-

of interest.

The Court decided at a hearing that no conflict

of interest existed.

However, even if a conflict existed in

this case, the Court finds that the decision to deny benefits
would still be upheld.

The record demonstrates that Sedgwick

provided a professional, conscientious, unbiased, and full and
fair review of Oates’s claim.

Had a conflict of interest

existed, that conflict, considered as one of many relevant
factors, would not render the benefits determination at bar
arbitrary and capricious.

Regardless of which standard of

review applies in this case, the Court would reach the same
decision:

that

the

termination

of

long-term

disability

benefits was correct.
3.

Compliance with the Plan

In addition to attacking the substance of the benefits
determination, Oates contends that the Claim Administrator
failed to comply with the technical requirements of the Plan
by failing to issue the denial of benefits determination and
the appeals determinations in a timely manner.

The Court

rejects this argument after giving it due consideration.
The Court determines that Oates received a full and fair
review of his benefits claim, which included a two-level
appeals process and multiple opportunities for Oates to submit
documentation in support of his claim.

-24-

Oates was represented

by counsel throughout the appeals process and the record
reflects that the Claim Administrator cooperated with Oates’s
counsel.

Any delays by the Claim Administrator in providing

written notice to Oates were minor. These purported delays by
the Claim Administrator in providing such written notice to
Oates regarding the denial of his claim are not a basis for
overturning the Claim Administrator’s decision regarding the
denial of long-term disability benefits.
Accordingly, it is
ORDERED, ADJUDGED, and DECREED:
(1)

The Court AFFIRMS the termination of long-term disability
benefits in this case.

(2)

The Clerk is directed to enter JUDGMENT in favor of
Defendant and, thereafter, to CLOSE THE CASE.
DONE and ORDERED in Chambers, in Tampa, Florida, this

16th day of April, 2013.

Copies:

All Counsel of Record

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