Flynn v. Ascension Health Long Term Disability Plan et al

Filing 71

OPINION MEMORANDUM AND ORDER IT IS HEREBY ORDERED that Defendants Motion for Summary Judgment [Doc. No. 58] is DENIED. IT IS FURTHER ORDERED that Plaintiffs Motion for Summary Judgment [Doc. No. 61] is DENIED. IT IS FURTHER ORDERED that this case is REMANDED to Defendant Sedgwick to reopen the administrative record for the limited purpose discussed herein. 58 61 Signed by District Judge Henry Edward Autrey on 7/20/15. (CLA)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
EASTERN DIVISION
DEBRA FLYNN,
Plaintiff,
v.
ASCENSION HEALTH LONG TERM
DISABILITY PLAN, et al.,
Defendants.

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No. 4:13CV2449 HEA

OPINION, MEMORANDUM AND ORDER
This matter is before the Court on the parties’ respective Motions for Summary
Judgment. [Doc. Nos. 58, 61]. The matter is fully briefed. For the reasons set forth below, the
Court will deny both Motions and remand this case to Defendant Sedgwick with directions to
reopen the administrative record.
Introduction
Plaintiff Debra Flynn (“Plaintiff”) was an employee of Providence Hospital and
participated in Defendant Ascension Health’s self-funded Long Term Disability Plan (the “LTD
Plan”), which is administered by Defendant Sedgwick Claims Management Services, Inc.
(“Sedgwick”). Plaintiff brings this action under the Employment Retirement Income Security
Act (“ERISA”), 29 U.S.C. §§ 1001, et seq., alleging that Defendants improperly denied her
claim for long term disability benefits in breach of the terms of the LTD Plan, and Defendants’
fiduciary duties. Plaintiff seeks declaratory relief, an accounting, injunctive relief, and attorneys’
fees.

Facts and Background
A.

The LTD Plan
Plaintiff is a 54 year-old former manager of a radiation oncology clinic for Providence

Hospital. She began working for Providence Hospital in Southfield, Michigan in 1998. She
became the chief radiation therapist at Providence Hospital in July of 2004. Approximately eight
years later, in July of 2012, Plaintiff stopped working due to the disabling effects of a plethora of
diagnosed medical conditions.
According to Defendant Ascension’s job description for Plaintiff, the physical demands
of Plaintiff’s “Regular Occupation” as manager of the radiation oncology clinic required that
Plaintiff be able to walk and stand approximately 80% of the time. The job description also states
that the job required Plaintiff to frequently lift and position patients and/or equipment up to 40
pounds. The material duties of the job include: “Under general supervision, oversees technical
staff and execution of treatment plans. Provides functional supervision over staff therapists.
Oversees daily operations of treatment services.” In addition to the duties described above,
Plaintiff managed a department of 15 employees and assisted therapists where and when needed.
She was also required to audit treatment charts and input billing into the computer, make
monthly schedules, chart rounds with physicians, conduct meetings, and keep track of the
number of patients treated on a daily basis.
Defendant Ascension sponsors the LTD Plan for the benefit of eligible associates of its
affiliated hospitals and health systems, including St. John Providence Health System. The LTD
Plan is an employee welfare benefit plan governed by ERISA. Defendant Ascension 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 Defendant

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Ascension the power to delegate its authority to other administrators. In accordance with the
terms of the LTD Plan, Defendant Ascension has delegated the discretionary authority with
regard to claims administration to Defendant Sedgwick, the Claims Administrator. 1 In this
regard, the LTD Plan provides:
2.8 Authority, Duties and Responsibilities of the Claims Administrator
The Claims Administrator shall have the authority, duties, and responsibilities set forth in
this Section 2.8. The Claims Administrator shall have the discretionary authority to
decide all questions arising in connection with matters set forth in this Section 2.8. Any
such decision by the Claims Administrator shall be conclusive and binding on all persons.
. . . Any interpretations or determinations made pursuant to such discretionary authority
of the Claims Administrator shall be upheld in judicial review unless it is shown that the
interpretation or determination was an abuse of discretion.
The duties of the Claims Administrator shall include but not be limited to
the following:
(a) The Claims Administrator shall have discretionary authority to determine whether a
Participant is eligible to receive or to continue to receive a Benefit under the Plan and to
compute the amount of such Benefit.
(b) The Claims Administrator shall have the discretionary authority to make all claims
determinations in accordance with Section 2.12 and 2.13 of this Plan.
...
(f) In carrying out its duties under Section 2.8, the Claims Administrator shall have the
discretionary authority to interpret and construe all provisions of the Plan.
The LTD Plan defines “Disability/Disabled” in relevant part as follows:
1.11 Disability/Disabled means that due to an Injury or Sickness which is supported by
objective medical evidence,

1

Plaintiff disputes this delegation, arguing that “Defendant [Ascension] retained discretionary authority by
remaining co-plan administrator of the subject plan, as explicitly stated in the plan document.” [Doc. No. 67 at ¶ 6]
[citing AH 0091]. However, Defendants rebut:
Although the Summary Plan Description states that the LTD Plan is jointly administered by Ascension
Health and Sedgwick; the LTD Plan itself details the delegation of authority as between Ascension and
Sedgwick. Sedgwick possesses the sole discretionary authority “to determine whether a Participant is
eligible to receive or continue to receive a Benefit under the Plan” and “to make all claim determinations in
accordance with Sections 2.12 and 2.13 of this Plan.”
[Doc. No. 66 at ¶ 33] [citing AH 0019–20]. Defendants are correct.

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(a) the Participant requires and is receiving from a Licensed Physician regular,
ongoing medical care and is following the course of treatment recommended by
the Licensed Physician; and
(1) The Participant is unable to perform:
(A) during the first 24 months of Benefit payments, or eligibility
for benefit payments, each of the Material Duties of the
Participant’s Regular Occupation.
“Material Duties” is defined in the LTD Plan as:
1.26 Material Duties means 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.
“Regular Occupation” is defined as:
1.40 Regular Occupation means the activities that the Participant regularly performed
when the Participant’s Disability began. In addition to the specific position or job the
Participant holds with the Participant’s employer, Regular Occupation also includes other
positions and jobs for which the Participant has training and/or education to perform in
the Participant’s profession at the Participant’s Employer or any other employer. If the
Participant’s Regular Occupation involves the rendering of professional services and the
Participant is required to have a professional or occupational license in order to work, the
Participant’s Regular Occupation is as broad as the scope of his or her license.
Article 4 of the LTD Plan addresses the timing of the determination of eligibility for LTD
benefits stating:
(a) A determination as to whether a Participant is eligible for LTD benefits shall be made
as of the last day the Participant was actively at work.
(b) When a Participant provides Proof satisfactory to the Claims Administrator that he is
Disabled, the Plan will pay a monthly Benefit to the Participant after completion of the
Elimination Period. This monthly Benefit will be paid as long as the Disability continues,
provided that Proof of continued Disability satisfactory to the Claims Administrator is
submitted to the Claims Administrator upon request.
Elimination Period is defined as:
1.16 Elimination Period means the number of consecutive calendar days of Disability
before Benefits become payable under the Plan. The Elimination Period is specified in
the Adoption Agreement and begins on the first day of Disability.
The Adoption Agreement for St. John Health specifies that “[LTD] Benefits begin on the
181st consecutive calendar day of Disability.” Thus, in order to receive LTD benefit payments,

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an LTD Plan participant must be unable to perform the activities that she regularly performed
when her Disability began, with either her own employer or any other employer, whether in the
same job capacity or another for which the Participant has training and/or education, until the
181st consecutive calendar day after the first day of Disability.
The long-term disability benefit is 70% of the Plaintiff’s former monthly pay minus any
other sources of disability income, including Social Security Disability Income, as long as the
participant remains totally and permanently disabled, through age 65. Plaintiff’s monthly pay
was $6959.33. As such, her gross benefit amount is $4,871.53. The Plan provides that “after the
claim has been submitted, the Claims Administrator may require the Claimant to undergo an
examination by a Licensed Physician and/or vocational assessment by a vocational counselor of
its choice when and as often as it deems necessary in its discretion.”
B.

Plaintiff’s Claim for LTD Benefits
Plaintiff stopped working in July of 2012 due to a Crohn’s disease flare up, for which she

was hospitalized for a week. In October of 2012, Plaintiff applied for long-term disability
benefits under the Plan after exhausting her short-term disability benefits. Plaintiff’s claim was
denied on January 15, 2013, based on a finding that she was not disabled beyond December 4,
2012, and thus did not satisfy the policy’s 180-day elimination period, which would have ended
January 8, 2013. [AH 0913–15]. Plaintiff appealed the benefit denial in a letter dated July 1,
2013, and Defendant Sedgwick upheld the benefit denial in a letter dated September 3, 2013.
[AH 1818–21].
C.

Plaintiff’s Medical History
On February 26, 2008, Plaintiff was diagnosed with Crohn’s disease. Over the next

several years, Plaintiff was seen and treated by several physicians: Dr. David Steinberger
(primary care/internal medicine); Dr. Ellen Zimmerman (gastroenterologist); Dr. Mark

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Silverman (neurologist); Dr. Mark Lebeis (cardiologist); and Dr. Aleem Khan (psychiatry).
Additionally, Plaintiff regularly met with Susan Greenshields, Ph.D (psychology).
In late 2011, Plaintiff was diagnosed with osteoporosis and underwent an MRI which
revealed that Plaintiff was suffering from (1) a rotator cuff tendinosis without tendon tear, and
(2) a joint arthropathy causing encroachment-impingement on the subacromial space and the
musculotendinous junction of the supraspinatus.
In June of 2012, Plaintiff was evaluated for hearing loss, upper airway congestion,
dizziness and cough. The treating physician noted that Plaintiff was aware of ongoing hearing
loss, and a general sense of fatigue and dizziness. Plaintiff underwent an audiogram which
concluded that she suffered from “mild right primarily sensorineural hearing loss; borderline left
hearing level.” [AH 0736]. In July of 2012, Plaintiff reported to Dr. Silverman that she had
suffered from chronic headaches her whole life, but that in April she began to have a different
kind of headache. Further, Plaintiff reported that she had experienced a drooping of her left
eyelid, which did not seem to be going away.
After suffering from a flare up of her Crohn’s disease on July 11, 2012, Plaintiff was
hospitalized for a week. She was noted to have abdominal pain and increased stools upon arrival
to the hospital. While in the hospital, she suffered from several episodes of chest pain. She was
also diagnosed with hyperthyroidism. Plaintiff underwent an MRI of the brain on July 11, and
CT scans of the abdomen and Pelvis on July 14 and 16, 2012. [AH 0726, 0741–42].
Plaintiff was discharged from the hospital on July 18, 2012. In her discharge note, her
treating physicians noted the following:
While in the hospital and on IV steroids, Plaintiff noticed only a modest
improvement in her abdominal pain;
She had several episodes of chest pain during her hospital stay, during which she
was diaphoretic and felt short of breath;

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The hospital’s physical therapy unit did not believe Plaintiff was fit to be
discharged home, which is why they recommended she transition via a subacute
rehab facility:
Physical therapy was recommended.
[AH 0743–45]. She was discharged with the following instructions regarding prednisone:
Take 60 mg daily for 7 days, then 50 mg daily for 7 days, then 40 mg daily for 7
days . . . [then] 35 mg for 7 days, then 30 mg for 7 days, then 25 mg for 7 days,
then stay on 20 mg until told to discontinue.
[AH 0742].
Plaintiff was evaluated by gastroenterologist Dr. Ellen Zimmerman, gastroenterologist,
on July 26, 2012. In her treatment note, Dr. Zimmerman observed:
[Plaintiff] developed worsening diarrhea and chest pain that she feels ultimately
was dyspepsia. She was admitted on July 11th to July 18th. . . . She was weak and
her balance was not normal and she was admitted. She was sent to a nursing home
in Allen Park after discharge. Plan is for her to be there until August 7th.
Currently, she has five bowel movements a day, half of which are formed. She
has rare blood. She has epigastric pain and pain is in her RUQ and RLQ.
[AH 0243–44]. Dr. Zimmerman noted that Plaintiff was taking 50 milligrams per day of
prednisone, and recommended tapering by10 milligrams per day every week until she was down
to 40 milligrams per day, and then tapering by 5 milligrams per day every week until she was
down to 20 milligrams per day, and then tapering by 5 milligrams per day every week until she
was off. [AH 0243–44]. Dr. Zimmerman instructed Plaintiff not to return to work until she was
below 20 milligrams per day. [AH 0244].
Plaintiff was evaluated by psychologist Dr. Greenshields for the first time on August 13,
and again on August 21, 23, and 30, 2012. Plaintiff reported feelings of sadness, anxiety,
depression, lack of concentration, low self-esteem, and not being well enough to work. 2

2

In September, Plaintiff met with Dr. Greenshields on the 13th and 20th, 2012. Plaintiff met with Dr. Greenshields
on October 4, 18, and 25, as well as November 1, 8, 13, and 29. Plaintiff additionally met with Dr. Greenshields on
December 6, 13, 17, 20, 27, and 31. In January of 2013, Plaintiff met with Dr. Greenshields on the 3rd, 7th, 10th,
14th, 17th, 21st, and 24th. Plaintiff met with Dr. Greenshields February 7, 11, 14, 18, 21, 26, and 28 of 2013. In
March of 2013, Plaintiff met with Dr. Greenshields on the 6th, 7th, 18th, 21st, 25th, 28th, and 30th. In April,
Plaintiff met with Dr. Greenshields on the 4th and 25th.

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Plaintiff was evaluated by psychiatrist Dr. Khan on August 14, 2012. Dr. Kahn
determined Plaintiff is clinically depressed with Generalized Anxiety Disorder, noting:
51 year old lady with history of depression and suicidal attempt in the past. Came
for psych due to increased depression and constant anxiety. Patient reported
recent flare up of her Crohn’s disease, was hospitalized and reported worsening of
her mood. Feels sad, has crying spells, feels helpless, lots of worries, has anxietylike butterflies in stomach all the time, worried about different things, always a
worrier.
[AH 0162]. On August 20, 2012, Plaintiff saw Dr. Steinberger for her GERD. Plaintiff met again
with Dr. Khan on September 4, 2012.
On September 5, 2012, Plaintiff went to the St. Mary Mercy Hospital Emergency
Department upon experiencing left facial numbness and left lip droop. The ER physicians
determined she had sustained a “cerebrovascular accident,” noting that she presented with “left
facial numbness and left lip droop.” [AH 0685–89]. In a treatment note from the same day, the
examining physician who performed a history and physical on Plaintiff noted that Plaintiff’s
chief complaint was left facial numbness, that she was currently on a prednisone taper at 20
milligrams daily for a flair up of her Crohn’s disease in July, that she had photophobia and some
blurring in her left eye, and that she denied any other neurologic deficits. [AH 0668–74]. In the
physical examination, it was noted: “Moon face secondary to prednisone use; left cheek appears
swollen with a slight droop to left side of mouth, drooping of both eyelids, appears worse on
left.” On September 6, 2012, Dr. Sonia Fernando, neurologist, noted Plaintiff had most likely
suffered a TIA in the right middle cerebral artery distribution. Dr. Fernando opined that her daily
headaches are muscle contractions. [AH 0676].
Plaintiff underwent an Echo exam on September 7, 2012. The results of the exam showed
that she has a PFO (patent foramen ovale), which is a hole in the heart. [AH 0681]. This was
confirmed by a transesophageal echocardiogram on September 11, 2012. [AH 0227].

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On September 14, 2012, Dr. Steinberger evaluated Plaintiff. He encouraged her to
continue physical therapy to improve her strength and balance. He expressed hope that she
would improve enough to return to work on October 17, 2012. [AH 0203].
On September 17, 2012, Dr. Zimmerman noted that Plaintiff was experiencing four to
five bowel movements a day, and worse associated pain than she previously experienced. Dr.
Zimmerman noted that Plaintiff was taking 20 milligrams of prednisone per day, and instructed
Plaintiff to taper her prednisone by 5 milligrams a week until she was off of it, and to not return
to work until she was below 20 milligrams per day. [AH 0239–41].
Dr. Lebeis, a cardiologist, evaluated Plaintiff for the first time on September 24, 2012.
On October 2, 2012, Dr. Khan evaluated Plaintiff. Dr. Steinberger noted on October 10, 2012,
that Plaintiff began showing symptoms of a recurrent bladder infection six weeks prior and that
such an infection generally lasts six weeks. The symptoms were reported as being severe.
Dr. Steinberger noted on October 19, 2012 that, despite trying to return to work, the physical
demands and psychological strain had “caused incapacitating anxiety and flare of colitis.” [AH
0830]. Accordingly, Dr. Steinberger stated that Plaintiff would “need to go of work again[.]” He
also noted that she had a migraine and her depression continued.
Plaintiff met with Drs. Steinberger and Khan on November 6, 2012. Dr. Steinberger
noted:
ASSESSMENT AND PLAN:
Anxiety and depression – continue prozac and trazadone. We also ordered a TSH
to rule out thyroid problems which could be causing your condition. –.
Colitis – continue your current medications, if symptoms worsen, please give us a
call. –.
Hypertension –.
Arthropathy –. You can take Tylenol for your pain. Refrain from other NSAIDs
like
ibuprofen. If your pain persists or worsens, please call us. Also continue your
daily
exercises. –. * * *
HISTORY OF PRESENT ILLNESS:
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1. Colitis
Admitted in July 2012 for an exacerbation of colitis at U of M, spent 8 days in
hospital for Crohn’s disease. She spent 3 weeks in the nursing home.
Due to patient’s stress and anxiety, she noted that her symptoms were getting
worse. She noted severe nonradiating abdominal pain (severity 5/10) and on and
off diarrhea. She takes Norco sometimes motrin which provides modest relief.
Symptoms began on October 15th when she lost her job. Symptoms associated
with nausea, no vomiting, no blood in stools.
2. Anxiety (followup).
The patient presents with anxious/fearful thoughts, depressed mood, difficulty
concentrating, difficulty falling asleep, difficulty staying asleep, diminished
interest or pleasure, easily startled, excessive worry, fatigue, feelings of guilt,
feelings of invulnerability and loss of appetite but denies compulsive thoughts,
decreased need for sleep, increased energy, increased libido, paranoia, poor
judgment, racing thoughts of death or suicide.
3. Depression.
4. Migraine.
5. Hypothyroidism.
6. Joint pain.
Associated symptoms include difficulty initiating sleep. Additional information:
one month ago patient developed difficulty ambulating. She mentions that all of
her joints are stiff. She notes pain and tenderness in hand joints as well as her
knees and elbows. –
She performs exercises which makes her pain worse. No relief from meds.
[AH 0834–36]. Dr. Khan noted:
“Depression.
Patient was tearful, frustrated, depressed, complaining of poor sleep, feels
helpless, sad and depressed. She reported that she lost her job, she was the main
breadwinner for her household and these stressors are making her depression
worse.
ASSESSMENT:
Exacerbation of mood problems, probably due to recent loss of job and financial
concerns.”
[AH 1483].
On November 9, 2012, Dr. Silverman wrote a letter to Dr. Steinberger, noting:
Unfortunately, it sounds as if she is losing her job at Providence Hospital. We did
get the results of the transcranial Doppler and this was negative. – She has had no
recurrence of any TIA or stroke-like symptoms. There is no plan to close her PFO
at this time. She is somewhat depressed now and is seeing a psychiatrist. * * *
Neurologically, Debra seems to be doing well. She has had no recurrence of any
TIA or stroke-like symptoms. She has not had any significant migrainous
symptoms. I will see her back in three to four months.

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[AH 1503].
On November 21, 2012, Dr. Greenshields completed a “Disability Mental Health
Certificate” for Defendant Sedgwick on Plaintiff’s behalf, noting: “This [patient] is unable to
work and there is no evidence as to when/if she can work.” [AH 1612]. On December 2, 2012,
Dr. Zimmerman completed a form provided by Defendant Sedgwick, explaining that Plaintiff’s
Crohn’s disease was “objective medical evidence” supporting her disability, and that she would
be able to return to work when her prednisone dose decreased to less than 20 milligrams. [AH
1618].
On December 4, 2012, Dr. Khan noted:
Depression, anxiety.
Patient reported feeling little better, sleep better, less crying spells, but reported
feeling
tired and drained and wants to stay in bed all the time.
ASSESSMENT:
Mood is improved but still has depressive symptoms.
DIAGNOSES:
Major depressive disorder, recurrent episode, moderate degree
Generalized anxiety disorder.
[AH 0336]. The same day Dr. Steinberger noted:
Myalgia and arthralgia.
Continues to have joint and muscle pain. ‘Every joint’ hips, knees, shoulders,
fingers, elbows. Improves with rubbing sometimes. Heat helps when applied.
Sleeps well with trazadone and Xanax. Sometimes sleeps all day. Psychiatrist
changed medication today
feeling that this could be related to depression.”
[AH 0377]. Dr. Steinberger also noted: “Still agree with disability plan for long term.” [AH
0375].
On December 17, 2012, Defendant Sedgwick received from Dr. Steinberger a completed
form Sedgwick has sent him, in which Dr. Steinberger opined that Plaintiff should “never” return
to work on account of her disability. [AH 0897].

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Dr. Khan met with Plaintiff on January 15, 2013 and noted that she was clinically
depressed, had experienced a flare up of her Crohn’s disease, and was sleeping poorly. On
January 28, 2013, Dr. Steinberger noted:
ASSESSMENT PLAN:
Crohn’s disease:
Continue current medications. Follow up at U of M. If it keeps getting worse than
we may have to start steroid.
Migraine:
Continue depakote and follow up with neurologist to see if we can change it to
something else as you did not have migraine attack in a while.
Arthritis due to inflammatory bowel.
Limitation due to disability
HISTORY OF PRESENT ILLNESS:
1. Disability:
Location of pain was upper back. Additional information: she was denied her
disability. Still having severe fatigue, diarrhea, abdominal pain due to Crohn’s
disease. Having “a lot of nausea.” Still having joint pain diffusely but hands and
knees are worst. Has a difficult time lifting grandson who weighs 22 lbs.
Functional limitations were reviewed.
2. Crohn’s disease:
She states the symptoms are acute, her crohn’s disease is acting up and she
follows up at U of M for that. She does not want to go on steroids. She is stressed
out because of disability and that is why her crohn’s is acting up.
FUNCTIONAL LIMITATIONS:
Patient reports: is able to go up stairs, perform activities of daily living, walk,
walk 10 blocks, walk an unlimited distance and walk 5 to 10 blocks. Patient
reports: finds it difficult to climb stairs, exercise, get in and out of car, go down
stairs, kneel and put on socks and shoes.
[AH 0846–47].
On February 12, 2013, Dr. Khan noted:
Follow up visit for mood and anxiety. Reported feeling better than before. Started
taking Cymbalta 60 mg for the last two weeks and reported less pain in joints and
better mood, still complaining of increased sleep, takes Xanax 0.5 mg three times
a day.
[AH 0770]. On February 13, 2013, Plaintiff saw Dr. Silverman. [AH 0722].
Plaintiff saw Dr. Zimmerman on March 4, 2013 for a follow up appointment. Dr.
Zimmerman noted: “In regards to her medical disability, we did let her know that she would not
qualify for medical disability based on the severity of her Crohn’s disease.” [AH 1779].
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On March 13, 2013, Dr. Steinberger saw Plaintiff and noted:
HISTORY OF PRESENT ILLNESS:
Chronic conditions –.
Hypertension –; Hypothyroidism –; inflammatory bowel disease crohn’s
diagnosis –chronic stable headaches. Having a headache daily. Wakes up every
morning feeling poorly. Head pounding, upset stomach, feet and shoulders hurt.
Hard to walk. Low back pain.
[AH 0854]. On March 28, 2013, Plaintiff saw Dr. Silverman again. [AH 0724]. On April 23,
2013, Dr. Khan noted that Plaintiff reported feeling better than before.
In a July 1, 2013 statement submitted in support of Plaintiff’s administrative appeal, Dr.
Steinberger listed Plaintiff’s diagnoses to include: Crohn’s disease, Debility, Right shoulder cuff
tendinosis, Right shoulder AC joint arthropathy, Myalgia and arthralgia, Arthritisdue to
inflammatory bowel disease, Chronic pain, Vertigo, Transient ischemic attach (TIA),
Gastroesophageal reflux disease (GERD), Migraine headaches, Anemia, Hypertension,
Hypothyroidism, Depression due to physical conditions, and Generalized anxiety disorder. [AH
0904]. Dr. Steinberger explained that the above-described medical conditions caused Plaintiff to
experience diarrhea and abdominal pain due to Crohn’s disease, flare ups of
Crohn’s disease due to stress and anxiety from physical conditions, no energy, difficulty
concentrating, pain and stiffness in all joints including hands, hips, knees and elbows, severe
fatigue, and pain in the upper back. Dr. Steinberger further stated that Plaintiff has difficulty
climbing stairs, going down stairs, exercising, getting in and out of a car, cannot kneel and is not
able to put on her socks and shoes. Dr. Steinberger explained that he previously stated, in an
October 29, 2013 letter to “Whom It May Concern,” that Plaintiff was unable to work, and it was
unknown when she would be able to return to work. Dr. Steinberger further stated that when
asked to complete Defendant Sedgwick’s December 17, 2012 form letter, he indicated that
Plaintiff would never be released to return to work full-duty. Dr. Steinberger concluded: “It is
my medical opinion that Debra Flynn is totally and permanently disabled from her regular
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occupation as Manager, Radiation Oncology Department, and all full time employment at this
time.” 3
D.

Sedgwick’s Review of Plaintiff’s Claims
Plaintiff’s claim was reviewed by Margie Vargo, a “Nurse Case Manager,” employed by

Defendant Sedgwick. Nurse Vargo determined that Plaintiff was disabled from July 12, 2012
through December 4, 2012, but not beyond that date. Nurse Vargo found that there was
“insufficient objective information to support a continued period of disability” beyond December
4, 2012. [AH 409–11]. Defendant Sedgwick initially denied Plaintiff’s claim for benefits in a
letter dated January 15, 2013. In the denial letter, a Sedgwick claims examiner, Lanette Morrow,
reiterated Vargo’s conclusions that there was “insufficient objective information to support a
continued period of disability beyond 12/5/12” and that because of this, Plaintiff did not satisfy
the Plan’s 180-day elimination period, which would have ended January 8, 2013. [AH 0913–15].
The letter explained:
The medical record noted your complaints of joint and muscle pain, however
laboratory reports indicated that your CPK and RA factor were within normal
limits. There is no documentation of an elevated sedimentation rate or c-reactive
protein. Dr. Steinberger’s progress note dated 12/4/12 did not provide any
documentation of swollen joints or tenderness in joints. There is no
documentation of restricted range of motion in joints, decreased strength or
muscle spasms. The record did not note any objective testing to support your
inability to lift, to carry, to push, to pull, to walk or to stand.
Dr. Khan’s note dated 12/4/12 indicated your depressive symptoms but also noted
that they are improved. There is no documentation of poor hygiene, poor eye
contact, stiffness in posture or poor articulation of speech such as stammering,
mechanical or stuttering. There is no documentation of abnormal phraseology
such as being slow, sluggish, halting, pressured or being rapid. You were noted to
be alert and oriented x 4. Your recent and remote memory was intact and your
thoughts were coherent and logical. There is no documentation of suicidal or
homicidal ideation. There is no documentation that you are unable to perform
3

Plaintiff submitted a Social Security Administration decision regarding her disability status dated August 21, 2014.
Because this decision was not contained in the administrative record, it has no bearing on the question at bar:
whether Defendants’ decision to deny Plaintiff’s claim for LTD benefits was arbitrary and capricious. Accordingly,
the Court will disregard it.

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activities of daily living. Accordingly, we reached the decision that you do not
qualify for benefits under the terms of the Ascension Health Long-Term
Disability Plan.
[AH 0914].
Plaintiff appealed the benefit denial in a letter dated July 1, 2013. Plaintiff submitted a
copy of the relevant Plan documents, prior correspondence, updated medical records, medical
literature about Plaintiff’s disabling conditions, and Dr. Steinberger’s sworn statement attesting
to Plaintiff’s total disability and inability to work. Plaintiff’s attachments contained information
ranging from medical records to Wikipedia entries regarding medical conditions.
Defendant Sedgwick referred Plaintiff’s claims file to Reliable Review Services, which
remitted Plaintiff’s medical records to three independent reviewers. Dr. Alan Altman, Board
Certified in Gastroenterology and Internal Medicine, completed an independent review from a
gastroenterology perspective. [AH 1698–1711]. Dr. Altman was paid $475 for his review, and
$237.50 for an addendum he later submitted after reviewing additional records. Dr. Gary Nudell,
Board Certified in Internal Medicine, completed an independent review from an internal
medicine perspective. [AH 1721–28]. Dr. Nudell was paid $525 for his review. Dr. Warren Tuff,
Board Certified in Psychiatry, completed an independent medical review from a psychiatric
perspective. [AH 1730–36]. None of the three independent reviewers contacted or examined
Plaintiff. Instead, their respective reviews were limited to medical records, the claims file, and, in
some instances, speaking with Plaintiff’s treating physicians. Dr. Nudell spoke with Dr. Lebeis.
He could not reach Dr. Silverman, or set a time to speak with Dr. Steinberger, who advised Dr.
Nudell to rely on Dr. Steinberger’s records. Dr. Nudell concluded that Plaintiff was not disabled
as of December 5, 2012, finding:
None of claimant’s internal medicine conditions, including but not limited to
hypertension, migraine headaches, patent foramen ovale (PFO), preventricular
contractions (PVCs), or hypothyroidism would otherwise restrict work function.
…
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The claimant reported joint pain, thought to be secondary to Crohn’s disease.
Physical examinations however, did not document any significant synovitis or
significant musculoskeletal abnormalities that would otherwise restrict work
function following December 05, 2012.
…
The claimant was hospitalized for a possible TIA, though overall imaging was
normal, and again there were no lingering neurologic deficits that would
otherwise restrict work function. The claimant has a history of hypothyroidism,
without documentation of any work restriction based on this chronic condition.
Ultimately, I would opine that form an internal medicine perspective only, the
claimant’s chronic medical conditions would not restrict the claimant from
returning to her prior occupation as of December 05, 2012.
[AH 1723–25].
Dr. Altman attempted to contact Dr. Zimmermann and Dr. Steinberger, but was
unable to reach them. He issued his report without speaking with them. [AH 1707]. Dr.
Altman concluded that Plaintiff was not Disabled as of December 5, 2012, stating:
The documentation establishes a hospitalization in July of 2012, with symptoms
of abdominal pain and diarrhea, but without evidence of active mucosal Crohn’s
disease…The claimant had a partial response to prednisone, which was tapered
over time.
…
Her gastroenterologist felt she could return to work when her prednisone dosage
was tapered to less than 20 mg/day and this occurred well before December of
2012. There is no documentation to support the presence of an active
inflammatory arthropathy associated with irritable bowel disease as multiple
examinations of her extremities reported only edema. From a gastrointestinal
disease perspective and consistent with the recommendation of Dr. Zimmermann
the claimant had the functional capacity to return to work as of December 05,
2012 going forward.
[AH 1706–08].
After having received additional medical records from Dr. Zimmerman, Dr. Altman
supplemented his review with an addendum on August 20, 2013. [AH 1803–05]. Upon review of
those records, Dr. Altman concurred with Dr. Zimmerman’s March 4, 2013 conclusion that
Plaintiff “would not qualify for medical disability based on the severity of her Crohn’s disease.”
[AH 1805].

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In connection with Dr. Tuff’s review of Plaintiff’s psychiatric condition, Dr. Tuff spoke
with Dr. Kahn and Dr. Greenshields by telephone. According to Dr. Tuff, Dr. Kahn opined that
Plaintiff “d[id] not have any mental health issues that would disable her as he [was] of the
opinion that it [was] her medical problems that [were] paramount.” [AH 1732]. Dr. Tuff
unsuccessfully attempted to reach Dr. Steinberger. Based on his conversations with Plaintiff’s
treatment providers and upon a review of Plaintiff’s records, Dr. Tuff concluded:
The claimant has multiple chronic physical illnesses, which combined with her
characteristic tendency to over-react to things, produced symptoms of anxiety and
depression. There is no objective evidence of how her mental health symptoms
would directly adversely impact her work performance.
[AH 1733].
On September 3, Sedgwick upheld the benefit denial in a letter to Plaintiff from appeals
specialist Kim Pirok. [AH 1818–21].
Legal Standards
A.

Summary Judgment Standard
The standards for summary judgment are well settled. In determining whether summary

judgment should issue, the Court must view the facts and inferences from the facts in the light
most favorable to the nonmoving party. Matsushita Elec. Indus. Co., Ltd. v. Zenith Radio Corp.,
475 U.S. 574, 587, 106 S. Ct. 1348, 89 L. Ed. 2d 538 (1986); Woods v. DaimlerChrysler Corp.,
409 F.3d 984, 990 (8th Cir. 2005); Littrell v. City of Kansas City, Mo., 459 F.3d 918, 921 (8th
Cir. 2006). The moving party has the burden to establish both the absence of a genuine issue of
material fact and that it is entitled to judgment as a matter of law. Fed. R. Civ. P. 56(c); Anderson
v. Liberty Lobby, Inc., 477 U.S. 242, 247, 106 S. Ct. 2505, 91 L. Ed. 2d 202 (1986); Celotex
Corp. v. Catrett, 477 U.S. 317, 322, 106 S. Ct. 2548, 91 L. Ed. 2d 265 (1986); Enterprise Bank v.
Magna Bank, 92 F.3d 743, 747 (8th Cir. 1996). Once the moving party has met this burden, the
nonmoving party may not rest on the allegations in his pleadings but by affidavit or other
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evidence must set forth specific facts showing that a genuine issue of material fact exists. Fed. R.
Civ. P. 56(e); Anderson 477 U.S. at 256; Littrell, 459 F.3d at 921. “The party opposing summary
judgment may not rest on the allegations in its pleadings; it must ‘set forth specific facts showing
that there is a genuine issue for trial.’” United of Omaha Life Ins. Co. v. Honea, 458 F.3d 788,
791 (8th Cir. 2006) (quoting Fed. R. Civ. P. 56(e)). “‘Only disputes over facts that might affect
the outcome of the suit under the governing law will properly preclude the entry of summary
judgment.’” Hitt v. Harsco Corp., 356 F.3d 920, 923 (8th Cir. 2004) (quoting Anderson v.
Liberty Lobby, Inc., 477 U.S. 242, 248, 106 S. Ct. 2505, 91 L. Ed. 2d 202 (1986)). An issue of
fact is genuine when “a reasonable jury could return a verdict for the nonmoving party” on the
question. Anderson, 477 U.S. at 248; Woods, 409 F.3d at 990.
To survive a motion for summary judgment, the “nonmoving party must ‘substantiate his
allegations with sufficient probative evidence [that] would permit a finding in [his] favor based
on more than mere speculation, conjecture, or fantasy.’” Wilson v. Int'l Bus. Machs. Corp., 62
F.3d 237, 241 (8th Cir. 1995) (quoting Putman v. Unity Health System, 348 F.3d 732, 733–34
(8th Cir. 2003). A plaintiff may not merely point to unsupported self-serving allegations, but
must substantiate allegations with sufficient probative evidence that would permit a finding in
the plaintiff's favor. Wilson v. Int’l Bus. Mach. Corp., 62 F.3d 237, 241 (8th Cir. 1995). “The
mere existence of a scintilla of evidence in support of the plaintiff’s position will be insufficient;
there must be evidence on which the jury could reasonably find for the plaintiff.” Anderson, 477
U.S. 242 at 252, 106 S. Ct. 2505, 91 L. Ed. 2d 202; Davidson & Associates v. Jung, 422 F.3d
630, 638 (8th Cir. 2005).
Summary Judgment will be granted when, viewing the evidence in the light most
favorable to the nonmoving party and giving the nonmoving party the benefit of all reasonable
inferences, there are no genuine issues of material fact and the moving party is entitled to

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judgment as a matter of law. Samuels v. Kansas City Mo. Sch. Dist., 437 F.3d 797, 801 (8th Cir.
2006). “Mere allegations, unsupported by specific facts or evidence beyond the nonmoving
party’s own conclusions, are insufficient to withstand a motion for summary judgment.” Thomas
v. Corwin, 483 F.3d 516, 526–27(8th Cir. 2007). “Simply referencing the complaint, or alleging
that a fact is otherwise, is insufficient to show there is a genuine issue for trial.” Kountze ex rel.
Hitchcock Foundation v. Gaines, 536 F.3d 813, 818 (8th Cir. 2008).
B.

ERISA Standard
Under ERISA, “[a] civil action may be brought by a participant or beneficiary . . . to

recover benefits due to him under the terms of the plan, to enforce his rights under the terms of
the plan, or to clarify his rights to future benefits . . . .” 29 U.S.C. § 1132(a)(1)(B). A denial of
benefits under a plan governed by ERISA is to be reviewed de novo, “unless the benefit plan
gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or
to construe the terms of the plan.” Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115
(1989).
If an ERISA plan grants the administrator discretion to construe the plan and to determine
benefits eligibility, as in this case, the Court must apply a deferential abuse-of-discretion
standard in reviewing the plan administrator’s decision. Jessup v. Alcoa, Inc., 481 F.3d 1004,
1006 (8th Cir. 2007). Under the abuse of discretion standard applicable in this case, the Court
will “reverse the plan administrator’s decision ‘only if it is arbitrary and capricious.’” Groves v.
Metro. Life Ins. Co., 438 F.3d 872, 874 (8th Cir. 2006) (quoting Hebert v. SBC Pension Benefit
Plan, 354 F.3d 796, 799 (8th Cir. 2004)). “To determine whether a plan administrator’s decision
was arbitrary and capricious, ‘we ask whether the decision to deny . . . benefits was supported by
substantial evidence, meaning more than a scintilla but less than a preponderance.’” Schatz v.
Mut. of Omaha Ins. Co., 220 F.3d 944, 949 (8th Cir. 2000) (quoting

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Health Plan, 107 F.3d 637, 641 (8th Cir. 1997)). “Provided the decision ‘is supported by a
reasonable explanation, it should not be disturbed, even though a different reasonable
interpretation could have been made.’” Id. (quoting Cash, 107 F.3d at 641. “The requirement that
the [plan administrator’s] decision be reasonable should be read to mean that 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.” Midgett v.
Washington Group Intern. Long Term Disability Plan, 561 F.3d 887, 896–97 (8th Cir. 2009)
(internal citation and quotation marks omitted).
Discussion
The questions before the Court are whether genuine issues of material fact exist, based on
the administrative record, as to the reasonableness of Defendants’ decision to deny Plaintiff’s
claim for long term disability benefits and, if not, whether one party is entitled to judgment as a
matter of law. The parties’ competing Motions for Summary Judgment each argue that there is
no genuine issue of material fact with respect to this decision, but differ in their conclusion—
with Plaintiff asserting that she is entitled to judgment as a matter of law because the denial was
clearly arbitrary and capricious, and Defendants arguing that they are entitled to judgment as a
matter of law because the denial was clearly reasonable and supported by substantial evidence
such that it was not an abuse of discretion.
For the reasons that follow, the Court finds that genuine issues of material fact do exist
and, accordingly, will deny the parties’ competing Motions. Further, the Court will remand this
case to Defendant Sedgwick with directions to reopen the administrative record.
A.

Conflict of Interest
Plaintiff argues that, despite hiring Defendant Sedgwick to administer the claims brought

under the Plan, Defendant Ascension retained discretionary authority to determine eligibility for

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benefits and therefore acted under a conflict of interest in terminating Plaintiff’s benefits. [Doc.
No. 62 at 4–5] [citing Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105 (2008)]. However, the
record clearly establishes that, under the Plan, benefits are paid by Defendant Ascension and
claims determinations are made by Defendant Sedgwick. Therefore, as this Court has previously
determined with regard to Ascension’s self-funded LTD Plan administered by Sedgwick, “there
can . . . be no inherent conflict of interest as the payor of benefits does not make the
determination of disability.” Vega v. Ascension Health, 997 F. Supp. 2d 1000, 1009 (E.D. Mo.
2014).
B.

Medical Opinions
1.

Internal Medicine

Plaintiff’s internist, Dr. Steinberger, opined that Plaintiff was disabled and could not
return to work beyond December 5, 2012, or the elimination date of January 8, 2013. [AH 0375,
0897, 0904–05]. 4 Dr. Nudell—the internist who conducted an independent medical review of
Plaintiff’s file—considered Dr. Steinberger’s notes, medical records, and opinions, and
expressed a different opinion: “Ultimately I would opine that from an internal medicine
perspective only, the claimant’s chronic medical conditions would not restrict the claimant from
returning to her prior occupation as of medical conditions would not restrict the claimant from
returning to her prior occupation as of December 5, 2012.” [AH 1725]. The Court cannot find
that it was unreasonable for Defendants to credit the opinion of Dr. Nudell over Dr. Steinberger.
See Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003); Weidner v. Fed. Express

4

Plaintiff’s psychologist, Dr. Greenshields, opined similarly that “[t]his [patient] is unable to
work and there is no evidence as to when/if she can work.” [AH 1612]. However, Dr.
Greenshields, as a psychologist, and not a licensed physician, cannot certify Plaintiff as disabled
under the plan. [See AH 0012–13] [“A licensed psychiatrist must supervise all treatment of
Disabilities related to Mental Illness. . . . psychologists cannot certify disability under the Plan.”]
[emphasis added]. Accordingly, the Court will not consider the opinions of Dr. Greenshields.

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Corp., 492 F.3d 925, 930 (8th Cir. 2007). Despite Plaintiff’s arguments to the contrary, the fact
that Dr. Nudell did not examine Plaintiff does not alter this conclusion. See Dillard’s Inc. v.
Liberty Life Assurance Co. of Boston, 456 F.3d 894, 899–200 (8th Cir. 2006).
2.

Gastroenterology

Plaintiff was discharged from the hospital on July 18, 2012 with instructions to take 60
milligrams of prednisone daily, and to taper the amount week by week. When Plaintiff saw Dr.
Zimmerman, her gastroenterologist, on July 26, 2012, she was down to 50 milligrams of
prednisone per day. Dr. Zimmerman instructed Plaintiff to taper her prednisone use by10
milligrams per day every week until she was down to 40 milligrams per day, and then taper by 5
milligrams per day every week until she was down to 20 milligrams per day, and then taper by 5
milligrams per day every week until she was off of prednisone. [AH 0243–44]. Dr. Zimmerman
instructed Plaintiff not to return to work until she was below 20 milligrams per day. [AH 0244].
Based on this schedule, Plaintiff would have been down to 15 milligrams per day by the
week of September 6, 2012 and thus ready to return to work pursuant to Dr. Zimmerman’s
instructions. However, when Dr. Zimmerman saw Plaintiff on September 17, 2012, she noted
that Plaintiff was currently taking 20 milligrams a day. [AH 0314]. Dr. Zimmerman again
instructed Plaintiff to taper by 5 milligrams per week, and not to work until she was below 20
milligrams. [Id.]. Based on Dr. Zimmerman’s September 17, 2012 note, Defendants extrapolate
that “Plaintiff’s gastroenterologist released her to work on or around September 24, 2012 (once
her prednisone dosage was below 20 milligrams per day)[.]” [Doc. No. 65 at 7] [citing AH
1779].
However, despite Dr. Zimmerman setting the taper schedule at the July 26, 2012 visit,
and reinforcing it at the September 17, 2012 visit, the record far from reflects that Dr.
Zimmerman “released [Plaintiff] to work on or around September 24, 2012.” Rather, the record

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contains a form Dr. Zimmerman completed for Sedgwick on December 2, 2012 explaining that
Plaintiff’s Crohn’s disease was “objective medical evidence” supporting her disability, and that
she would be able to return to work when her prednisone dose decreased to less than 20
milligrams. [AH 1618]. The existence of this form in the record, when viewed in a vacuum,
would clearly demonstrate that Dr. Zimmerman had not cleared Plaintiff to return to work as of
December 2, 2012 or, likely, December 4, 2012.
The Court, of course, does not consider Dr. Zimmerman’s December 2, 2012 form in a
vacuum, but rather in the context of the record. Defendants correctly note that, prior to December
2, 2012, Plaintiff’s last visit with Dr. Zimmerman reflected in the record was on September 17,
2012. From this, Defendants conclude that on the December 2, 2012 form, Dr. Zimmerman
“noted the most recent (but outdated) restriction on Plaintiff’s activities, from September 17,
2012: ‘patient can return to work when prednisone dose is <20 mg.’” [Doc. No. 69 at 4].
Defendants argue that the record demonstrates that Plaintiff was off of prednisone well before
December 2, 2012. In support of this contention, Defendants note that “Prednisone is not listed
among current medications in reports from Plaintiff’s November 6, 2012 or December 4, 2012
office visits with Dr. Steinberger.” [Doc. No. 69 at 4] [citing AH 1531, 1667].
The Court finds Defendants’ conclusion regarding when Plaintiff went off prednisone to
be pure speculation. Although Defendants are correct that Dr. Steinberger’s notes from
Plaintiff’s November 6 and December 4, 2012 office visits did not list prednisone as a current
medication, Dr. Steinberger’s notes from Plaintiff’s August 20, September 14, October 10, and
October 19, 2012 office visits similarly do not list prednisone as a current medication. Based on
Dr. Zimmerman’s September 17, 2014 notes, Plaintiff would have still been on the initial taper
schedule on August 20 and September 14, 2012. This fact obviates the import of the absence of
reported prednisone usage in Dr. Steinberger’s November 6 and December 4, 2012 notes.

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Further, records from many of Plaintiff’s other visits reflect continuing use of prednisone:
September 24, 2012 (Dr. Lebeis) [AH 0692]; September 28, 2012 (Dr. Silverman) [AH 0236];
October 11, 2012 (Dr. Silverman) [AH 0235]; November 5, 2012 (Dr. Lebeis) [AH 0696]; and
November 9, 2012 (Silverman) [AH 0719]. When viewed in this context it appears equally
plausible, if not more plausible, that Dr. Zimmerman’s December 2, 2012 form was meant to be
read just as it was written: Plaintiff’s Crohn’s disease was “objective medical evidence”
supporting her disability, Plaintiff was still on at least 20 milligrams prednisone as of December
2, 2012, and Plaintiff was not to return to work until her prednisone dose decreased to less than
20 milligrams. [AH 1618]. At the very least, disputed issues of material fact exist as to the
import of Dr. Zimmerman’s December 2, 2012 form. 5 See Hitt, 356 F.3d at 923.
Defendants credit the report of Dr. Altman—the gastroenterologist who conducted an
independent medical review of Plaintiff’s file—which concluded that Plaintiff was not disabled
from a gastroenterology perspective. However, Dr. Altman’s conclusions rested heavily upon his
understanding of Plaintiff’s medical record as demonstrating that Plaintiff was taking less than
20 milligrams per day of prednisone “well before December of 2012,” and Dr. Altman’s possibly
mistaken belief that Dr. Zimmerman had concluded that Plaintiff could work as of December 5,
2012. Dr. Altman wrote:
Prednisone was to be decreased by 5 mg/week until off completely. At the time
[(September 17, 2012)] she was taking 20 mg/day.
Dr. Zimmerman felt the claimant could return to work when she is below 20 mg
of prednisone/day. . . .

5

Defendants further contend that if Plaintiff was still on prednisone by December of 2012, more than 11 weeks after
her September visit with Dr. Zimmerman, it could only mean that she did not follow Dr. Zimmerman’s tapering
instructions, which is required by the Plan. [Doc. No. 69 at 3 n.1] [“Pursuant to Section 4.5(e) of the LTD Plan,
monthly Disability benefits terminate on ‘[t]he date the Participant . . . is not following the course of treatment
recommended by the Licensed Physician.’”] [citing AH 0029]. However, this requirement is irrelevant here, because
if Dr. Zimmerman’s December 2, 2012 form is read to mean that Plaintiff was still on prednisone as of that date, it is
reasonable to infer that Dr. Zimmerman so instructed her.

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Therefore, as of December 5, 2012 going forward she was on less than 20
mg/prednisone . . . . Consistent with the recommendation of Dr. Zimmerman she
had the capacity from a gastrointestinal disease perspective to perform her usual
occupational tasks.
Her gastroenterologist felt she could return to work when her prednisone dosage
was tapered to less than 20 mg/day and this occurred well before December of
2012. . . . From a gastrointestinal disease perspective and consistent with the
recommendation of Dr. Zimmerman the claimant had the functional capacity to
return to work as of December 05, 2012 going forward.
[AH 1706–08] [emphasis added]. Although Dr. Altman did attempt to telephone Dr. Zimmerman
three times between July 31 and August 2, 2013, he was unsuccessful and, accordingly, could
not verify his belief that Dr. Zimmerman no longer had Plaintiff on prednisone as of December
5, 2012. [AH 1707].
Given the disputed issues of material fact concerning Plaintiff’s prednisone usage on
December 5, 2012, the Court cannot at this time adjudicate whether Defendants’ decision to deny
Plaintiff’s claim for long term disability benefits was arbitrary and capricious. See Samuels, 437
F.3d at 801 (“Summary Judgment will be granted when, viewing the evidence in the light most
favorable to the nonmoving party and giving the nonmoving party the benefit of all reasonable
inferences, there are no genuine issues of material fact and the moving party is entitled to
judgment as a matter of law.”). The Court will therefore deny both Motions for Summary
Judgment.
A reviewing court must remand a case when the court or agency fails to make adequate
findings or explain the rationale for its decision. Mayo v. Schiltgen, 921 F.2d 177, 179 (8th Cir.
1990). This course of action is appropriate in ERISA cases. Abram v. Cargill, Inc., 395 F.3d 882,
887–88 (8th Cir. 2005) superseded by regulation on other grounds in Midgett v. Wash. Group
Int’l Long Term Disability Plan, 561 F.3d 887 (8th Cir. 2009); see also Harden v. Am. Express
Fin. Corp., 384 F.3d 498, 500 (8th Cir.2004) (per curiam) (remanding to the plan administrator
where the plan failed to obtain and consider social security records, which the plan implied it
- 25 -

would consider); Gaither v. Aetna Life Ins. Co., 388 F.3d 759, 773–76 (10th Cir. 2004)
(remanding where the plan failed to obtain or consider information about the claimant’s
termination for use of narcotic painkillers); Gallo v. Amoco Corp., 102 F.3d 918, 923 (7th Cir.
1996) (noting that remand is appropriate when an ERISA plan does not make adequate findings
or adequately explain its reasoning)).
Accordingly, the Court will remand this case to Sedgwick with directions to reopen the
administrative record to either determine the status of Plaintiff’s prednisone use as of December
5, 2012, and Dr. Zimmerman’s opinions thereon, or to request a revised report from Dr. Altman
which does not rely on his previous assumption that Plaintiff was off of prednisone per Dr.
Zimmerman’s instructions as of December 5, 2012.
Conclusion
Based on the foregoing, the Court will deny the parties Motions for Summary Judgment.
Accordingly,
IT IS HEREBY ORDERED that Defendant’s Motion for Summary Judgment [Doc. No.
58] is DENIED.
IT IS FURTHER ORDERED that Plaintiff’s Motion for Summary Judgment [Doc. No.
61] is DENIED.
IT IS FURTHER ORDERED that this case is REMANDED to Defendant Sedgwick to
reopen the administrative record for the limited purpose discussed herein.
Dated this 20th day of July, 2015.

HENRY EDWARD AUTREY
UNITED STATES DISTRICT JUDGE

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