Vega v. Carondelet Health Network et al
Filing
66
OPINION, MEMORANDUM AND ORDER re: 57 , 54 ORDERED that Defendant's Motion for Summary Judgment, [Doc. No. 57], is GRANTED. FURTHER ORDERED that Plaintiff's Motion for Summary Judgment, [Doc. No. 54], is DENIED. FURTHER ORDERED that the decision of Defendant to deny Plaintiff's claim for long term disability benefits under the Plan herein is affirmed. A separate judgment in accordance with this Opinion, Memorandum and Order is entered this same date.. Signed by District Judge Henry E. Autrey on 2/6/14. (CEL)
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
EASTERN DIVISION
ROBERT MANUEL VEGA,
)
)
Plaintiff,
)
)
v.
)
)
ASCENSION HEALTH and SEDGWICK )
CLAIMS MANAGEMENT SERVICES,
)
INC.,
)
)
Defendants,
)
Case No. 4:13CV387 HEA
OPINION, MEMORANDUM AND ORDER
This matter is before the Court on Plaintiff’s Motion for Summary
Judgment, [Doc. No. 54], and Defendants’ Motion for Summary Judgment, [Doc.
No.57]. The matter is fully briefed. For the reasons set forth below, Defendant’s
Motion is granted, and Plaintiff’s Motion is denied.
Introduction
Plaintiff seeks to recover benefits pursuant to Section 502(a)(1)(B) of the
Employee Retirement Income Security Act of 1974 (ERISA) , under the long term
disability plan of his employer. Defendant Ascension Health’s Claims
Administrator, Defendant Sedgwick Claims Management Services, Inc. denied
Plaintiff’s application for long-term disability benefits. Plaintiff appealed the
decision. The Claims Administrator’s decision was affirmed. Plaintiff now seeks
review of the denial.
Findings of Fact1
Ascension Health sponsors the self-funded Long-Term Disability Plan
(“LTD Plan”) for the benefit of eligible employees of Carondelet Health Network
in Tucson, Arizona. The LTD Plan is an employee welfare benefit plan governed
by the Employee Retirement Income Security Act. Ascension Health is the LTD
Plan Administrator and LTD Plan Sponsor. The LTD Plan provides that the
administrator “shall have the discretionary authority to decide all questions arising
in connection with the administration, interpretation and application of the Plan.”
The LTD Plan gives Ascension Health the power to delegate its authority to other
administrators. In accordance with the terms of the LTD Plan, Ascension Health
has delegated the discretionary authority with regard to claims administration to
Sedgwick, the Claims Administrator. In this regard, the LTD Plan provides:
Discretionary Authority
In carrying out their respective responsibilities under the Plan, the
Plan administrator and the claims administrator shall have
discretionary authority to interpret the terms of the Plan and to
determine eligibility for and entitlement to Plan benefits in
1
Defendant has filed a Statement of Uncontroverted Facts. Plaintiff, in contravention of
this Court’s Local Rule 7-4.01(E), failed to specifically controvert any of Defendant’s facts.
Likewise, Plaintiff failed to present his own Statement of Uncontroverted Facts. Consequently,
Defendant’s Statement of Uncontroverted Facts is taken as admitted by Plaintiff.
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accordance with the terms of the Plan.
The LTD Plan defines “Disability/Disabled” in relevant part as follows:
Disability/Disabled You are considered to be Disabled or to have a
Disability if due to an Injury or Sickness that is supported by
objective medical evidence, you require and are receiving the regular
care and attendance of a Licensed Physician and you are following
the course of treatment recommended by the Licensed Physician. In
addition, one of the following is true:
! You are unable to perform during the first 24 months of benefit
payments, or eligibility for benefit payments, each of the Material
Duties of your Regular Occupation, and after the first 24 months of
benefit payments, any work or service for which you are reasonably
qualified taking into consideration your training, education,
experience and past earnings …
The term “Material Duties” is defined in the LTD Plan as follows:
Material Duties The essential tasks, functions and operations, and the
skills, abilities, knowledge, training and experience generally
required by employers from those engaged in a particular occupation
that cannot be reasonably modified or omitted.
The term “Regular Occupation” is defined in the LTD Plan as follows:
Regular Occupation The activities that you regularly performed
when your Disability began. In addition to the specific position or job
you hold with your Employer, it also includes other positions and jobs
for which you have training and/or education to perform in your
profession at your Employer or any other employer.
The LTD Plan also provides that it is the participant that has the obligation
to submit ongoing Proof of Disability. Therefore, during the first 24 months of
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receipt of LTD benefit payments, a LTD Plan participant must be unable to
perform the activities that he regularly performed when his Disability began, with
either his own employer or any other employer, whether in the same job capacity
or another for which the Participant has training and/or education.
Plaintiff was 62 years old at the time of filing of his action. Plaintiff was
employed as a Stationary Engineer at Carondelet St. Mary’s Hospital, which is a
part of Carondelet Health Network. In this capacity, Plaintiff was responsible for
operating all equipment and systems central to the distribution of heating, cooling,
steam, water, oxygen and emergency electricity to the main hospital and other
hospital-owned buildings. The physical demands for Plaintiff’s position included:
continuously (67%-100% of the time) - balancing on even indoor surfaces;
handling tools; feeling; functional speech; functional hearing; functional vision;
and cognition; frequently (66% - 34% of the time) - standing; walking; reaching;
lifting less than 10 pounds; and carrying less than 10 pounds while walking
through the facility; occasionally (1% - 33% of the time) - sitting; lifting 10-50
pounds; carrying 10-50 pounds for up to 50 feet; pushing; pulling; climbing
step ladders; stooping/bending; kneeling; and crouching; rarely - crawling;
never – reclining; and tasting/smelling.
Plaintiff’s last day of work was December 10, 2009, making his first day
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absent December 11, 2009. Plaintiff’s Basic Monthly Earnings on his last day of
work were $2849.58.
Plaintiff filed a claim for LTD benefits on or about March 1, 2010, claiming
that he became Disabled on or about December 10, 2009 due to right knee pain.
On December 10, 2009, Sedgwick acknowledged Plaintiff’s claim for LTD
benefits.
On March 5, 2010, Sedgwick requested medical records from Dr. Mark
Senese, the orthopaedic surgeon that Plaintiff identified as his treating physician in
connection with his LTD Application. On March 8, 2010, Sedgwick received an
Attending Physician Statement (“APS”) from Dr. Senese, stating that Plaintiff’s
primary diagnosis was a right knee medial meniscus tear and secondary diagnosis
was joint effusion. The APS reflected that the objective evidence supporting
disability included an arthroscopy on December 23, 2009 and an intra-articular
cortisone injection on the right knee. Dr. Senese opined that Plaintiff did not
“remain/continue to be totally disabled from his occupation as a Stationary
Engineer.” Rather, Plaintiff was able to perform work sitting 8 hours per day,
standing 20 minutes per hour and walking 20 minutes per hour. He was also able
to perform overhead reaching, gross handling, and fine fingering 8 hours per day.
He could lift, carry, push and pull 10 pounds and could perform sustained work for
8 hours per day.
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In spite of this proposed modified work schedule, Plaintiff did not return to
light duty work.
Along with the March 8, 2010 APS, Dr. Senese also submitted progress
notes from Plaintiff’s six visits to Dr. Senese from December 16, 2009 to February
24, 2010. In the December 16, 2009 notes, Dr. Senese observed a right knee with
mild effusion, mild crepitation, and mild joint line tenderness with no instability,
good strength, and neurovascularly intact. Dr. Senese recommended right knee
arthroscopy for a partial meniscectomy.
In the subsequent notes, after the arthroscopic surgery, Dr. Senese observed
mild medial joint line tenderness with no swelling or effusion and attributed his
continued pain to osteoarthritis. Dr. Senese further administered an intra-articular
cortisone injection in Plaintiff’s right knee and opined that Plaintiff could return to
full work status if his symptoms improved after the injection.
In the February 24, 2010 notes, Dr. Senese observed Plaintiff’s right knee
with minimal effusion, minimal swelling and motion without crepitation, but noted
that Plaintiff complained of continued discomfort despite the arthroscopy and
cortisone injection. Dr. Sense opined that Plaintiff could return to light duty work
with no more than 20 minutes of standing or walking per hour in an 8 hour day.
Plaintiff did not return to work.
Dr. Senese submitted more progress notes from a March 24, 2010 visit
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observing tenderness to palpation along the medial femoral condyle, but no
significant effusion, minimal crepitation, and minimal medial joint line tenderness.
He once again recommended light duty work, with a limitation on standing and
walking to 20 minutes each hour. Plaintiff did not return to work.
Sedgwick also requested medical records from Plaintiff’s primary care
physician, Dr. Grinder Singh on March 17, 2010 and March 31, 2010. After
multiple requests, Sedgwick received medical records from Dr. Singh on April 6,
2010. The records included a March 24, 2010 MRI, which revealed a moderatesized joint effusion, complicated popliteal cyst with findings suggesting recent
rupture, tear of the medial posterior horn, extending from the base into the inferior
surface, and partial tear of the femoral insertion of the lateral collateral ligament.
Dr. Singh had referred Plaintiff to Dr. Senese.
On April 20, 2010, Sedgwick initially approved Plaintiff’s claim and
provided LTD benefits to Plaintiff beginning on March 11, 2010, (after exhaustion
of the LTD Plan’s 90-day waiting period). Plaintiff’s monthly long-term disability
(“LTD”) benefit was $1709.75, which was 60% of his Basic Monthly Earnings.
On May 21, 2010 and June 14, 2010, requested medical records from Dr.
John Meaney, who it had learned was also treating Plaintiff. After several
requests, on July 7, 2010, Dr. Meaney submitted several treatment records. All of
Dr. Meaney’s progress notes follow the SOAP method of documentation, which is
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an acronym for Subjective, Objective, Assessment and Plan. The objective
findings documented in Dr. Meaney’s progress notes reflect that at Plaintiff’s May
21, 2010, Plaintiff presented as a “well-nourished male in no distress.” However,
in the treatment plan portion of the progress note, Dr. Meaney concluded that
Plaintiff had failed conservative treatment and would require a total knee
replacement. At the June 10, 2010 visit, Dr. Meaney’s objective findings were
that Plaintiff had an unchanged examination from the May 21, 2010 appointment.
The treatment plan was that Plaintiff would proceed with the knee replacement
pending insurance approval. On June 30, 2010, Plaintiff had total knee
replacement surgery.
At Plaintiff’s July 12, 2010 office visit, Dr. Meaney’s objective findings
reflected that Plaintiff’s staples were removed, and he was Steri-Stripped. No
infection or DVT was noted and he was “Neurovascularly intact distally.” Dr.
Meaney’s treatment plan included physical therapy in a pool. Additionally,
Plaintiff was to continue an “aggressive exercise program.” He was to be
rechecked in a month.
At Plaintiff’s August 2, 2010 visit, Dr. Meaney’s objective findings were:
“Wounds healed. No infection, no DVT. Neurovascularly intact distally. Pretty
much full extension. Flexion to 115 degrees. Ligaments are stable.” Dr. Meaney’s
documented treatment plan was for Plaintiff to continue strengthening exercises.
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He would be rechecked in a month or earlier should the need arise.
On September 15, 2010, Sedgwick requested updated medical records from
Dr. Meaney for Plaintiff’s September 13, 2010 visit and his physical therapy
records from January 1, 2010. On September 28, 2010, Sedgwick still had not
received the requested medical records from Dr. Meaney. Consequently, Sedgwick
sent correspondence to Plaintiff on September 28, 2010, informing him that it
would be forced to deny his LTD claim if records were not received from Dr.
Meaney by October 12, 2010. On October 1, 2010, Dr. Meaney submitted more
progress notes. Plaintiff’s September 13, 2012 progress note reflects the following
objective findings: “Wounds healed. No infection, no DVT. Neurovascularly
intact distally. Full extension. Flexion to 125. Ligaments are stable.” Dr. Meaney’s
treatment plan for Plaintiff was to continue strengthening exercises and be
rechecked in a month.
On October 1, 2010, Sedgwick also received Plaintiff’s physical therapy
initial evaluation and discharge summary. The physical therapy initial evaluation
noted Plaintiff’s increased edema, decreased range of motion, decreased strength,
and increased pain. The evaluation ordered outpatient physical therapy two to
three times a week for six weeks.
The physical therapy discharge summary reflected a treatment period of
July 7, 2010 to August 5, 2010, with Plaintiff having completed nine visits. The
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summary further reported that Plaintiff had “responded well” and had improved
strength, improved range of motion, a decrease in pain, and improved gait. A
continued home exercise program was recommended.
On November 22, 2010, Dr. Meaney submitted progress notes from
Plaintiff’s October 26, 2010 visit, which reflects the following objective findings,
“He has full extension, Flexion to 125. Ligaments are stable. Basically still
working on his quads. Still gets some puffiness periodically, but it is getting
better.” In his treatment plan, the doctor noted that he would see Plaintiff in a
month or earlier, should the need arise. He further noted, “His preoperative
pain is gone. He is trying to work through some surgical discomfort.” Dr.
Meaney’s January 10, 2011 progress notes reflect that subjectively, “He [Plaintiff]
is doing fine.” Dr. Meaney’s objective findings reflect that Plaintiff has, “Full
extension. Flexion to 125. No infection, no DVT. Neurovascularly intact distally.
Still gets some pain in the knee, but it is slowly getting better.” His treatment plan
was for Plaintiff to continue strengthening exercises and to maintain work
restrictions. Plaintiff was to be rechecked in a month. Dr. Meaney’s February 7,
2011 progress notes reflect the following objective findings, “Wounds healed. No
infection, no DVT. Neurovascularly intact distally. Full extension. Flexion to
about 125. Ligaments are stable.” Dr. Meaney’s treatment plan was to check
Plaintiff in two to three months or earlier should the need arise.
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In contrast to his objective findings at the February 7, 2011 appointment and
without citing any medical testing, Dr. Meaney wrote a letter dated February 10,
2011 suggesting that Plaintiff perform sedentary work only for 20 hours per week
with limitations of “no kneeling, crawling, climbing, stooping, or certainly have
any activity around moving machinery or anything of that nature.”
Taking into consideration Dr. Meaney’s objective findings in his progress
notes, Sedgwick concluded that Plaintiff no longer met the definition of Disabled
and therefore no longer qualified for benefits under the LTD Plan.
On March 11, 2011, Sedgwick notified Plaintiff that he no longer qualified
for LTD benefits. The denial notification letter to Plaintiff explained that
Sedgwick fully considered all medical records that it received from Plaintiff’s
treating physicians to make the determination. In an effort to provide a full and
fair evaluation, Sedgwick nurse case manager, Margie Vargo, RN, CCM, CDMS,
reviewed the medical documentation. Nurse Vargo determined that there was no
objective medical evidence to support his inability to work beyond February 28,
2011. Specifically, Nurse Vargo referenced the objective findings in Dr.
Meaney’s progress notes. Specifically, the denial letter states:
You underwent a right knee arthroplasty on 6/30/10. An ex-ray dated
6/30/10 states that the right knee arthroplasty performed was in good
position and alignment of bony structures and hardware apparatus was essentially
anatomical. Dr. Meaney documented in the 2/7/2011 progress note that you are
doing fine. He notes that you have full extension and flexion to 125 degrees. Your
ligaments are stable. You are neurovascularly intact distally. Based on the medical
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information provided, the Nurse Case Manager stated that there is no
documentation of an antalgic gait or need for an assistive device to ambulate.
There is no documentation of effusion, tenderness, or redness. There is no
documentation of infection or DVT. There is no documentation of objective
testing to support your inability to stand, to walk, to carry, to push, to pull, to
kneel, or to climb a ladder. There is no existing data indicating that the knee
prosthesis would be harmed as a result of kneeling. Your position does require
heavy lifting; however it is not done repetitively, it is done occasionally. Based on
this information, there is no objective medical to support your inability to work
and your claim for benefits is denied beyond 2/28/2011.
Sedgwick also advised Plaintiff of his right to appeal the determination
within 180 days, and provided an appeal packet of information.
Prior to proceeding with filing his appeal, Plaintiff’s counsel requested a
complete copy of Plaintiff’s claims file, which was sent to Plaintiff’s counsel on
June 21, 2011.
Plaintiff submitted a written appeal of the denial of additional LTD benefits
on September 12, 2011, five (5) days after the deadline proscribed by the LTD
Plan. Although the appeal was technically untimely, Sedgwick still processed
Plaintiff’s appeal in order to give Plaintiff every opportunity to carry his burden of
establishing that he was entitled to receive additional benefits under the LTD Plan.
Plaintiff’s appeal consisted solely of a letter from his attorney. Plaintiff did
not submit a single medical record or any objective evidence with his appeal.
Plaintiff’s sole argument in the appeal letter for overturning the denial was that
Sedgwick had allegedly failed to speak with Plaintiff’s orthopedic surgeon before
denying additional benefits. In addition, the appeal letter purports to quote a
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statement by Dr. Meaney allegedly made on March 31, 2011; however, no medical
record or progress report dated March 31, 2011 by Dr. Meaney was ever submitted
to Sedgwick either during its initial review or during the appeal review. After
receiving Plaintiff’s appeal letter, Sedgwick reviewed the file and summarized the
history of the claim and the medical that was contained in the file.
Sedgwick then contacted Plaintiff’s counsel to determine whether Plaintiff
intended to submit any medical records or other information in support of the
appeal. Sedgwick left a message for Plaintiff’s counsel on September 19, 2011
and then subsequently spoke with Pam from Plaintiff’s counsel’s office to explain
the medical in the file and ask whether additional information would be submitted.
Pam from Plaintiff’s counsel’s office advised Sedgwick that she would check to
see if additional information would be provided. As no follow-up call was
received, Sedgwick followed up on September 28, 2011. On September 30, 2011,
Pam from Plaintiff’s counsel’s office informed Sedgwick Plaintiff had no
additional information to submit.
Sedgwick then referred Plaintiff’s appeal and the complete claims file to
Network Medical Review, Co., which remitted Plaintiff’s medical records to Dr.
Victor M. Parisien, M.D., a Board Certified Orthopaedic Surgeon, for review.
On October 7, 2011, Dr. Parisien issued findings based on his review of the
medical records, Plaintiff’s job description, and the claims file. Dr. Parisien
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attempted to contact Dr. Senese and Dr. Meaney, but was unable to reach them
despite leaving two separate messages for each physician. Dr. Parisien spoke to
Dr. Singh, who reported that he did not evaluate Plaintiff for any other condition
besides sinusitis, cough, or breathing problems and had no opinion on his
disability. Based on his review of the claims file, Dr. Parisien concluded that
Plaintiff was not Disabled as of March 1, 2011. He further opined that there was
no clinical indication in the medical notes substantiating a finding that the patient
could not do his regular unrestricted work as of March 1, 2011. Specifically, Dr.
Parisien’s report reflects the following:
ORTHOPEDIC SYNOPSIS: Mr. Plaintiff . . . works as a stationary
engineer. This job requires him to lift occasionally 50 to 75 pounds,
to carry 50 pounds occasionally for 50 feet, to use stepladders occasionally to
frequently, to kneel occasionally, and to crouch
occasionally.
...
1. Is the employee disabled from the ability to perform his regular
unrestricted occupation as of 3/1/11?
The employee is not disabled form the ability to perform his regular
unrestricted occupation as of 3/01/11. There is no clinical indication
in the medical notes provided that the patient could not do his regular
unrestricted work as of 03/01/11. The examination on 10/26/10 noted
he had 0 to 125 degrees of flexion of his knee. Examination was unchanged on 01/10/11 a
RATIONALE: This patient underwent a total knee replacement on
06/30/10. He did well postoperatively and as of 10/28/10 he had
recovered a flexion of 125 degrees and had full extension.
Examinations were unchanged on 01/10/11 and 02/07/11. He was
given a note on 02/10/11 for no kneeling, crawling, climbing or
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stooping. There is no clinical information provided to support these
restrictions. There is no indication that he had any complications that
would prevent him from returning to full duty work. As of 03/01/11
he was approximately nine months post total knee replacement and by
this time would have recovered sufficiently to enable him to return to
his regular occupation. There is no indication in the clinical record
that any complications have occurred or that he could not do his
regular job to include kneeling and climbing stepladders and carrying
50-pound weights with occasional lifting of 50-75 pounds. No
clinical information has been provided to support inability to perform
these tasks. The employee is not disabled from the ability to perform
his regular unrestricted occupation as of 03/01/11.
On October 14, 2011, Sedgwick notified Plaintiff that based upon the
medical file review and the independent review of Dr. Parisien, Sedgwick had
determined that Plaintiff was not eligible for additional LTD benefits as of March
1, 2011 because he did not meet the LTD Plan’s definition of Disabled, and denied
his appeal.
On November 28, 2011, Plaintiff’s counsel sent a letter requesting a
complete copy of Plaintiff’s claim file. Sedgwick provided the complete copy of
the claims file on December 29, 2011.
On January 27, 2012, after Plaintiff’s right to an appeal was exhausted and
the administrative record was closed in this matter, Plaintiff attempted to submit
additional information to Sedgwick and asked Sedgwick to reconsider its decision
to deny benefits. Sedgwick responded by letter dated February 29, 2012,
informing Plaintiff that the appeal determination dated January 27, 2012 was final
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and the claim would not be reopened.
Plaintiff filed this lawsuit on August 16, 2012.
Discussion
Standard of Review
In Metropolitan Life Insurance Co. v. Glenn, 128 S.Ct. 2343, 2347-48
(2008), the Supreme Court acknowledged that in Firestone Tire & Rubber Co. v.
Bruch, 489 U.S. 101, 111-13 (1998), the Court set out four principles as to the
appropriate standard of judicial review under ERISA, § 1132(a)(1)(B), as follows:
(1) A court should be “guided by principles of trust law,” analogizing a plan
administrator to a trustee and considering a benefit determination a fiduciary act,
id., at 111-113, 109 S.Ct. 948; (2) trust law principles require de novo review
unless a benefits plan provides otherwise, id., at 115, 109 S.Ct. 948; (3) where the
plan so provides, by granting “the administrator or fiduciary discretionary
authority to determine eligibility,” “a deferential standard of review [is]
appropriate,” id., at 111, 115, 109 S.Ct. 948; and (4) if the administrator or
fiduciary having discretion “is operating under a conflict of interest, that conflict
must be weighed as a ‘facto[r] in determining whether there is an abuse of
discretion,’ “ id., at 115, 109 S.Ct. 948. There is no dispute that the plan gives
Defendant the discretionary authority to determine Plaintiff’s eligibility for long- 16 -
term disability benefits. Thus the standard of review in this matter is for an abuse
of discretion, thus, only if the Defendant’s decision was arbitrary and capricious
will the decision be overturned. Id.
Plaintiff argues that Defendant abused its discretion in failing to give a full
and fair review of Plaintiff’s claim. Initially, it should be noted that Plaintiff
attempts to modify the administrative record by quoting Dr. Meaney’s March 31,
2011 opinion, which was not included in the claims file. Plaintiff argues that the
determination of his treating physician was not given the proper consideration.
However, a plan administrator is not required to give more deference to a treating
physician’s opinion over the reviewing doctor’s opinion. Weidner v. Federal
Express Corp., 492 F.3d 925, 930 (8th Cir. 2007); Black & Decker Disability Plan
v. Nord, 538 U.S. 822, 834 (2003); Cagle v. Unum Life Ins. Co. of America, 2009
WL 995544 (E.D. Mo. 2009).
The record establishes that Defendant considered all of the evidence
presented in support of Plaintiff’s claim. It is undisputed that Dr. Meaney noted
that Plaintiff was improving after his surgery, that an aggressive exercise program
was prescribed and that his extension and flexion were increasing.
Although Dr. Meaney did write a note dated February 10, 2011 suggesting
that Plaintiff perform sedentary work for only 20 hours per week, with the
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limitations of “no kneeling, crawling, climbing, stooping, or certainly have any
activity around moving machinery or anything of that nature,” Dr. Meaney did not
support these limitations with any medical documentation or evidence.
Defendant’s hired consultant, Dr. Parisien, reviewed Plaintiff’s medical
records and attempted to consult with Plaintiff’s treating physicians. They were
unresponsive. Dr. Parisien determined that Plaintiff was not disabled from his job.
Under an abuse of discretion standard, the decision of the Plan
Administrator will not be disturbed if it is “reasonable.” Reasonableness is
measured by whether substantial evidence exists to support the conclusion.
Wakkinen v. Unum Life Insurance Co. of America, 531 F.3d 575, 583 (8th Cir.
2008).
The Administrative Record clearly shows that Defendants considered all of
the medical evidence and opinions offered by Plaintiff and by its consulting
physicians.
Finally, Plaintiff attempts to create an issue with regard to the inherent
conflict by citing Manning v. American Republic Insurance Company, 604 F.3d
1030 (8th Cir. 2010). Manning, however, is inapposite. The record clearly
establishes that the instant case involves a self-funded LTD Plan. As the Plan
reflects, benefits are paid by the Ascension Health Welfare Benefits Trust; claims
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determinations are made by Sedgwick. There can, therefore, be no inherent
conflict of interest as the payor of benefits does not make the determination of
disability.
Conclusions of Law
Based upon the foregoing analysis, the Court concludes the following
conclusions of law:
Defendant’s decision to deny Plaintiff’s claim for long term disability under
the Plan was not an abuse its discretion.
The decision to deny Plaintiff’s claim for long term disability benefits under
the Plan at issue was reasonable.
Because Defendant’s denial of Plaintiff’s claim was not an abuse of
discretion, the decision is affirmed.
Accordingly,
IT IS HEREBY ORDERED that Defendant’s Motion for Summary
Judgment, [Doc. No. 57], is GRANTED.
IT IS FURTHER ORDERED that Plaintiff’s Motion for Summary
Judgment, [Doc. No. 54], is DENIED.
IT IS FURTHER ORDERED that the decision of Defendant to deny
Plaintiff’s claim for long term disability benefits under the Plan herein is affirmed.
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A separate judgment in accordance with this Opinion, Memorandum and
Order is entered this same date.
Dated this 6th day of February, 2014.
_______________________________
HENRY EDWARD AUTREY
UNITED STATES DISTRICT JUDGE
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