Presi v. Alexian Brothers Health System

Filing 71

MEMORANDUM AND ORDER IT IS HEREBY ORDERED that Defendants Motion for Summary Judgement (ECF No. 55) is GRANTED, and Plaintiffs Motion for Judgement on the Administrative Record or in the Alternative Motion for Summary Judgement (ECF No. 58) is DENIED. An appropriate Judgement will accompany this Memorandum and Order. 58 55 Management Services, Inc. Signed by District Judge Jean C. Hamilton on 3/14/19. (CLA)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
EASTERN DIVISION
JACQUELINE E. PRESI,
)
)
Plaintiff,
)
)
v.
)
Case No. 4:16CV01857JCH
)
ASCENSION HEALTH ALIANCE, et al.
)
)
Defendants.
)
MEMORANDUM AND ORDER
This matter is before the court on Defendants Ascension Health Alliance (“Ascension”),
Ascension Long Term Disability Plan (“LTD Plan”), Ascension Short-Term Disability Plan
(“STD Plan”), and Sedgwick Claims Management Services, Inc.’s (“Sedgwick”)(collectively
“Defendants”) Motion for Summary Judgement filed November 6, 2018. (ECF No. 55). This
matter is also before the Court on Plaintiff Jacqueline E. Presi’s Motion for Judgement on the
Administrative Record or in the Alternative Motion for Summary Judgement, filed November 6,
2018. (ECF No. 58). The Court will take up both motions together. The motions are fully briefed
and ready for disposition.
BACKGROUND1
Plaintiff was employed by Alexian Brother’s Health System (“Alexian”) as a Unit
Secretary, which required clerical duties, reception functions, training new unit secretaries and
other staff, and ensuring that the department operated effectively. (Defendants’ Statement of
Uncontroverted Material Facts (“Defendant Facts”) ¶ 22; and see, Plaintiff’s Statement of
Uncontroverted Material Facts (“Plaintiff Facts”) ¶ 5). At all times relevant hereto, Plaintiff was

1

Citation is primarily to the Defendants’ Statement of Uncontroverted Facts or the Administrative Record itself.
Defendant’s statement of facts provided a more complete record and was primarily uncontested by the Plaintiff.
1

an employee of Alexian.2 (Plaintiff Facts ¶ 4). Alexian by written agreement adopted a welfare
benefit plan through Acension, which offered short-term disability benefits (“STD benefits”) and
long-term disability benefits (“LTD benefits”) for the benefit of some or all of its employees
including the Plaintiff. (Plaintiff Facts ¶¶ 1, 8). Ascension delegated the discretionary authority
to make claims determinations to Sedgwick, the Claims Administrator. As such, Sedgwick
possessed discretionary authority to make benefit determinations. (Defendant Facts ¶¶ 14-15,
citing AR AH1226, AR AH1288).
Plaintiff filed the present lawsuit on November 22, 2016, seeking STD benefits pursuant
to the STD Plan. (ECF No. 55 ¶1). Plaintiff amended her claim on May 7, 2018, to include a
claim for LTD benefits pursuant to the LTD Plan.3 Id.
I.

Plaintiff’s STD claim

Plaintiff first missed work due to her alleged Disability on or about May 20, 2015.4
(Defendant Facts ¶ 23). Plaintiff alleges that she has a history with osteochondroma (benign
tumors of the bones), muscle spasm, shoulder pain, and anxiety disorder, and had some
osteochondroma surgically removed from her shoulder in May of 2012.5 (Defendant Facts ¶ 23,
citing AR AH0205). Plaintiff submitted a claim for STD benefits at which time Sedgwick
requested medical documentation to evaluate her claim. (Defendant Facts ¶ 24, citing AR

2

Plaintiff states in her facts that the Plaintiff was an employee of Alexian and/or Ascension. (Plaintiff Facts ¶ 4).
The Defendants state that Alexian constituted the Plaintiff’s employer as defined in 29 U.S.C. § 1002(5) and (6); and
denies that Plaintiff was ever employed by Ascension.
3
Both the STD Plan and the LTD plan are employee welfare plans governed by the Employee Retirement Income
Security Act of 1974, 29 U.S.C. 1001 et seq. (“ERISA”).
4
Plaintiff states that she last worked in late April or May of 2015. (Plaintiff Facts ¶ 5).
5
Plaintiff asserts that the primary medical conditions that form the basis of her claim are “multi-factorial and
include without limitation the following: complex hereditary osteochondroma, snapping scapula syndrome,
osteopenia, muscle spasms and weakness, along with chronic associated pain and migraines. Plaintiff also has two
bulging disks in her neck (cervical spine). She also suffers with significant problems with her right hand which is
her dominant hand. Given her problems, injections to her body parts have been required. She also has problems with
her vision” (Plaintiff Facts ¶ 13). Defendant objected to Plaintiff’s support for these facts in the Administrative
Record and alleges that the Plaintiff impermissibly relies on a summary provided by counsel rather than the medical
records included in the Administrative Record. (ECF No. 62 at 7).
2

AH0156-165). The STD Plan requires that Plaintiff submit proof, in the form of objective
medical evidence to substantiate the existence of Plaintiff’s alleged Disability. (Defendant Facts
¶¶ 9-10, citing AR AH0074).
The STD Plan defines “disability” and “disabled” for the purposes of STD benefits as follows:
[D]ue to an Injury or Sickness which is supported by objective medical
evidence (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 (b) either (1) or
(2) below is satisfied. (1) the Participant is unable to perform each of the
Material Duties6 of the Participant’s Regular Occupation;7 or (2) while
unable to perform each of the Material Duties of the Participant’s Regular
Occupation on a full-time basis and while eligible for Rehabilitative
Employment, (A) the Participant is performing at least one of the Material
Duties of Regular Occupation or any other work or service on the parttime or full time basis; and (B) the Participant’s earning from work while
Disabled does not exceed 80% of the Participant’s Basic Weekly
Earnings.
(Defendant Facts ¶ 6).
a. Plaintiff’s Initial STD Claim
In September of 2014, the Plaintiff visited the emergency room due to severe headache
with facial numbness, and a CT scan was performed. The CT scan was normal and the Plaintiff
was discharged the next day. (Defendant Facts ¶29, citing AR AH0189-93). The records state
that Plaintiff had “complete near resolution of her migraine, was able to tolerate her meal,
ambulate, and tolerate light noise without difficulty. Patient was then released from the hospital
discharged home.” (AR AH0189). On December 12, 2014, Plaintiff visited Dr. Danielle

6

Material duties are defined as 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.” (Defendant Facts ¶7).
7
Regular Occupation is defined as 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 another employer. If the Participant’s
Regular Occupation involves rendering of professional services and the Participant is required to have a professional
or occupational license to work, the Participant’s Regular Occupation is as broad as the scope of his or her license.”
(Defendant Facts ¶ 8).
3

Anderson8 for a follow-up after her hospital visit to discuss persistent facial pain. Dr. Anderson
prescribed Tegretol RX tabs (seizure control medicine), and instructed the Plaintiff to continue
her other medications including Lyrica (pain medication to treat pain caused by nerve damage),
Norco (pain medication), and Mortin (pain medication). (Defendant Facts ¶ 30, citing AR
AH0197-99).9 Dr. Anderson in her record states:
The patient tells me that it onsent of the left maxillary region
shooting/stabbing pains May 2014 at the time she was diagnosed with a
sinus infection treated by an ENT, Dr. Dreitch with antibiotics. This did
resolve the pain temporarily, but pain resumed, she describes the pain as
lightning bolts in nature, 8/10 severity at times, occurring on a daily basis,
episodically, throughout the day but still severe to this date. She has seen
Dr. Rosenblatt, neurosurgery and diagnosed her with a left-sided atypical
facial pain and instructed her to come here for medical treatment….she
denied any weakness of face or extremities.
(AR AH0197).

Dr. Anderson additionally determined that the Plaintiff had, “no drift or

asymmetry in the upper or lower extremities; strength symmetrical and full in all four
extremities…range of motion at the left shoulder joint is normal.” (AR AH0198).
On December 30, 2014, Plaintiff visited Dr. Anderson again and stated that the new
medication provided good relief for her facial pain. (Defendant Facts ¶ 31, citing AR AH019496). The record goes on to state that the Plaintiff experiences some “break through pain” and that
the “Patient does have some dizziness and lightheadedness on her current medication regimen
but is slowly getting used to it. She denies any new focal neurological deficits.” (AR AH0194).
On May 20, 2015, and on June 3, 2015, the Plaintiff visited Dr. Sood for
complaints of shoulder pain and for assistance completing paperwork for disability and
FMLA leave. (Defendant Facts ¶ 34, citing AR AH0210-15). Dr. Sood noted that on May
20, 2015, the Plaintiff complaint included pain management. Dr. Sood stated that,
8

Northwest Neurology
Plaintiff disputes the date of her appointment with Dr. Anderson and claims that the appointment took place on
December 18, 2014. (ECF No. 64).

9

4

Patient uses strong opiate pain medications and muscle relaxant to control
her pain and muscle tightness. The side effects impair her ability to
perform her work in a safe and effective manner. The over use of her
shoulder and arms with repetitive movement can exacerbate her condition
and is presenting today for further evaluation.
(AR AH0213).
Sedgwick also received records from Dr. Sanjay Patari’s10 office which reflected that on
June 10, 2015, the Plaintiff complained of pain in her left scapula. (Defendant Facts ¶ 25, citing
AR AH0184-88). Plaintiff received six series of corticosteroid injections from one of her other
treating physicians, Dr. Rajiv Sood. Id. Dr. Patari’s physical examination indicated some crepitus
(grating, crackling or popping sounds) in Plaintiff’s shoulder and “some atrophy of the
surrounding fat musculature.” (AR AH0167). Dr. Patari recommended that the Plaintiff receive
corticosteroid between the scapula and the ribs as well as physical therapy to improve her
strength. Id.
On July 13, 2015, Sedgwick spoke with the Plaintiff who explained her medical history
with osteochondromas and noted prior medical issues including glaucoma and migraines. The
Plaintiff further stated that although she was unable to vacuum, lift or clean, she could do lots of
things with her left arm and could write with both hands. (Defendant Facts ¶ 31, citing AR
AH0201-03). On July 20, 2015, Dr. Sood completed an Attending Physician Statement, in which
he made an objective finding of osteochondroma and subjective systems of pain, muscle spasms,
increased anxiety and weakness. (Defendant Facts ¶ 33, citing AR AH0205). Dr. Sood noted that
the Plaintiff was ambulatory but also noted his belief that the Plaintiff could not return to her
regular occupation without restrictions or without restricted light duty. (Defendant Facts ¶ 33,
citing AR AH0205). In his Attending Physician Statement, Dr. Sood marked that on May 20,
2015, he advised the Plaintiff to discontinue her job duties. Id.
10

The Center for Sports Orthopedics, S.C.
5

Nurse Case Manager Jennifer Jansen RN,11 reviewed the medical documentation and
found Dr. Sood’s examination to be normal with no indication of limited range of motion or
decreased strength resulting from Plaintiff’s complaints of pain. (Defendant Facts ¶ 33, citing
AR AH1188-89). Nurse Jansen further found that there was no swelling or muscle spasms, and
no increase in medications over the last three appointments with Dr. Sood. The Plaintiff had only
received refills on her medication. Nurse Jansen also reviewed the diagnostic imaging contained
in the Plaintiff’s claim file and determined that all of the tests were unremarkable and within
normal limits or unchanged from previous imaging. Based on her review, Nurse Jansen
recommended that STD benefits be denied. Id.
On July 31, 2015, the Plaintiff was notified by letter that her claim for STD benefits had
been denied. (Defendant Facts ¶ 36, citing AR AH0230-31). In its denial letter, Sedgwick
explained that its decision to deny Plaintiff’s claim was based on the physical examinations of
Dr. Sood between May and July of 2015, which appeared normal and did not indicate a limited
range of motion or decreased strength, swelling or spasm and because the Plaintiff did not
receive any dosage increases on her medications. Sedgwick looked at the MRI, EKG and CT
scans provided, all of which were in normal ranges, unremarkable or did not show a change from
prior imaging. (Defendant Facts ¶ 37). Sedgwick also relied upon a record from Dr. Patari, from
June 10, 2015 which reflected that a recent CT scan showed no obvious impingement or
recurrence of osteochondroma of Plaintiff’s scapula. Id., citing AR AH0230-31. The letter also
advised the Plaintiff of her right to appeal. Id.
b. Plaintiff’s Appeal of Her STD Claim

11

Plaintiff specifically takes issue with the review of Plaintiff’s medical records by an on-staff RN employed by
Sedgwick and that she is not an MD, NP, or PA. (ECF No. 64 at 16).
6

On August 6, 2015, the Plaintiff requested a copy of her claims file which was provided
to her on August 25, 2015. (Defendant Facts ¶ 38). On January 26, 2016, the Plaintiff appealed
the initial denial of her STD benefits and submitted her medical records, biographical
information, and curriculum vitae documentation for her providers. (Defendant Facts ¶¶ 39-40,
citing AR AH0454-064). Additional documentation included records from Dr. Sood and Dr.
Chintalben Shah for visits in 2012 and 2013 for shoulder pain and steroid injections. (Defendant
Facts ¶ 41, citing AR AH0539-553). On April 12, 2015, Dr. Sood recommended that Plaintiff
undergo a functional capacity evaluation to which the Plaintiff declined.12 (Defendant Facts ¶
43, citing AR AH0531-33). On August 12, 2015, Plaintiff visited Dr. Sood again to review
FMLA papers and was physically examined. The examination was normal except for bilateral
shoulder popping in Plaintiff’s upper extremities and facial pain. (Defendant Facts ¶ 44, citing
AR AH0520-21). Dr. Sood notes that “[p]atient has had multiple growths on her shoulder that
keep growing back.” (AR AH0521).
On August 21, 2015, the Plaintiff saw Melissa Swierad, APN for continued headaches
and shoulder pain; and to complete paperwork for time off of work. At this appointment Ms.
Swierad physically examined the Plaintiff and noted normal findings except for shoulder pain
and popping. (Defendant Facts ¶ 45, citing AR AH0514-16). On September, 9, 2015, the
Plaintiff went back to Dr. Sood and sought further evaluation. Dr. Sood’s report stated that the
Plaintiff is “severely impaired, can’t live with the pain but can’t live with the side effects caused
by the pain medications. It was recommended that Plaintiff to follow up with her rheumatologist
and pain specialist for chronic pain.” (Defendant Facts ¶ 46, citing AR AH0514-16).

12

In a medical note from Dr. Sood dated June 10, 2015 Dr. Sood notes that the Plaintiff was instructed to have a
Functional Capacity Evaluation done but that the Plaintiff was unable to go for this due to lack of insurance
coverage and inability to financially afford it. (AR AH0532).
7

A letter from Dr. Bigol dated January 22, 2016, indicated that on December 10, 2015, the
Plaintiff came in for persistent left scapular pain, radiating to the left shoulder and neck region.
(AR AH0494). The letter contains a review of Plaintiff’s conditions. Dr. Bigol had been treating
the Plaintiff for osteochondroma of the left scapula which was resected in May of 2012. Dr.
Bigol’s letter explains that the Plaintiff experienced a complication of “reversible mild brachial
plexus traction injury, manifested by left shoulder numbness and tingling…[and] snapping
scapula which worsened and persisted after the procedure.” Dr. Bigol states that:
She continued to be symptomatic of left periscapular pain, which was described
as sharp and radiating to the left shoulder and left neck areas. It is also
accompanied with constant tingling and numbness, and with the sensation of
muscular fatigue and upper extremity instability. This is more apparent during
repetitive movement. It results in her dropping things due to momentary loss of
movement control, loss of strength and weakness. The pain is felt at all times even
at rest and becomes worse with activities. She had undergone several steroid
injections without success. Treatment modality such as local heat, topical over the
counter medications and massage offered minimum relief. The only medication
that helps are narcotics…[t]his has allowed her to perform the activities of daily
living but has limitations due to side effects, such as drowsiness. Over time she
required higher doses of medication with increasing side effects…this is not
compatible for her to maintain livelihood.
(AR AH0494). Dr. Bigol also included his physical examination findings while the patient was
on pain medication. Upon physical examination Plaintiff was deemed to have full range of
motion of the left shoulder with pain and clicking or snapping sounds and experienced localized
pain around the surroundings of left scapula. (Defendant Facts ¶ 51, citing AR AH0504; and see,
AR AH0494). The documentation from Dr. Bigol also referenced an initial evaluation at Alexian
Rehabilitation, at which time it was determined that the Plaintiff, not on pain medication during
the evaluation, experienced decreased range of motion and pain upon movement. (AR AH0494;
but see, Defendant Facts ¶ 51 citing, AR AH0504). These records state that medical and surgical
treatments have not been successful and that the Plaintiff’s “complicated osteochondroma is a

8

debilitating illness. It limits her control and ability to perform the lightest duties inclusive of her
left upper extremity and movements requiring pivoting at the lumbar (abdomen or lower spine),
thoracic (mid-spine) and cervical spine (neck) regions with associated pain” the Plaintiff “would
have difficulty functioning with activities of daily living and will be unable to fulfill her
professional duties at work” and her condition is likely to be permanent with the only viable
treatment being pain control. (Defendant Facts ¶ 51, citing AR AH0504).
On December 15, 2015, the Plaintiff sought a second opinion from Dr. Gregory Drake
regarding the pain in her left neck, shoulder and periscapular region. (Defendant Fact ¶ 47, citing
AR AH0485-87). At that appointment the Plaintiff states that her,
“[p]ain is severe with a rating of 10/10. She describes the symptoms as
constant, sharp, stabbing, throbbing, aching, pressure and radiating. The
symptoms worsen as the day progresses. The symptoms are worse in the
evening. Additional symptoms include numbness, stiffness, tingling,
weakness, swelling, instability, fatigue, ROM (range of motion) limitation,
radiation of pain on the involved side, sleep disturbances and loss of
feeling. Since the onset, the symptoms have been worsening. Symptoms
are made worse with rest, activity, lifting and movement.”
(AR AH0485). Upon examination, Dr. Drake notes that, “[t]here is no deformity, swelling
ecchymosis (bruising), or atrophy present,” that Plaintiff’s right and left neck were pain free with
a full range of motion, but there was tenderness in the left bicipital groove but no swelling ,
ecchymosis or deformity. Dr. Drake goes does note that Plaintiff experiences pain with 160
degrees of right abduction and with 90 degrees of right external rotation. Id. Dr. Drake stated that
there was no evidence of rotator cuff tear, nor was this a recurrence of the Plaintiff’s
osteochondroma. (Defendant Facts ¶ 47, citing AR AH0485-87). Dr. Drake recommended
physical therapy and further recommended dry needling for periscapular pain. Id.
On January 5, 2016, the Plaintiff visited Dr. Matthew Jiminez with complaints of pain
and popping in her shoulder and cervical spine. (Defendant Facts ¶ 48, citing AR AH0505-07).
9

Dr. Jiminez observed the popping on range of motion, but also observed a full range of motion.
Id. Dr. Jiminez ordered x-rays which showed that the glunohumeral joint was well located and
confirmed Plaintiff’s diagnosis of multiple osteochondromatosis. Id. On January 12, 2016,
Plaintiff described her pain as “involving mainly the L (left) periscapular region radiating to L
(left) shoulder and neck area” which was “reduced by narcotics from 10/10 to tolerable intensity
of 4-5/10…nothing helps her except medications.” (AR AH0894). The Plaintiff then saw Dr. Jay
Joshi on January 20, 2016, for left shoulder pain aggravated by weather. Dr. Joshi prescribed left
thoracic medial beta block injections. (Defendant Facts ¶ 49, citing AR AH0499-500).
On February 10, 2016, Plaintiff saw Dr. Joshi for a post procedure follow up. Her
diagnosis at this time was, unspecified thoracic, thoracolumbar, and lumbosacral intervertebral
disc disorder; pain in the thoracic spine, intercostal neuropathy, other disorders of the peripheral
nervous system, osteochondropathy, unspecified of unspecified site, hyperesthesia, neuropathic
pain, intercostal neuralgia, and osteochondritis. (AR AH0899-900). Plaintiff reported that her
pain was felt when using her left arm and that right scapula popping was extremely painful, she
stated that actions such as bending backwards, exercise, lifting and any repetitive movement
using the left arm aggravated her pain; and that she was experiencing a dizzy or high feeling
from her Lyrica medication.13 (AR AH0900-01).
A letter dated March 14, 2016, from Dr. Bigol provided a clinical status update stating
that the Plaintiff was diagnosed with, Osteochonfromatosis left upper and lower extremities;
thoracic spondylosis without myelopathy; and thoracolumbar intervertebral disk disease; that the
“[p]atient continues to experience recurrent left scapular pains and also has developed right
scapular pains since February 2016” that “[o]n February 4th, 2016, she received her first steroid

13

Plaintiff also reported feeling a dizzy side effect from the Lyrica to Dr. Joshi on January 20, 2016. (AR AH090405).
10

injections over the left T4-T8 facet medial branch block under fluoroscopic guidance. Anesthesia
mild sedation. She had great but temporary relief.” (AR AH0897). “On March 31, 2016, she is
scheduled to receive her second steroid injections over the T4-T8 level at Alexian Brother’s
Medical Center, she also has an appointment to see a rheumatologist on March 17, 2016.” Id.
On April 21, 2016, Dr. Carol Hullet submitted her independent medical analysis of
Plaintiff’s claim of disability between the dates of April 17, 2015 through October 13, 2015. Dr.
Hullet concludes that although the Plaintiff has multiple osteochondroma, “[t]here has not be a
recurrence of the osteochondroma” nor any “significant complaint due to any other
osteochondromas.” (AR AH0941). Dr. Hullet goes on to say that, “[p]ain, however, is described
as 10/10 and only partially relieved by pain medication. Other treatments have been largely
unsuccessful” and concludes that, “there are no clinical findings indicating any functional
limitation from any orthopedic condition” and then states that “there are no findings that are not
clinically significant” when asked to explain why certain findings in the record are not clinically
significant. (AR AH0942).
Also on April 21, 2016, Dr. Mahajan submitted his independent medical analysis of
Plaintiff’s disability claim and concludes that the Plaintiff was not disabled between April 17,
2015 and October 13, 2015. Dr, Mahajan states:
The provided medical records do not include any clinical abnormalities to
substantiate the need for work or activity restrictions. The claimant’s
examination findings by various physicians do not reveal any evidence of
abnormalities consistent with an ongoing active process, such as malignant
neoplasm. The need to assess a patient as being unable to perform usual
and customary work-activities needs to be based on clinical examination
or clinical abnormalities as opposed to self-reported complaints.
(AR AH0946). When asked what findings were not clinically significant, Dr. Mahajan
states that “[f]rom a pain management perspective, the claimant is not disabled.” Id.

11

On May 16, 2016, Dr. Hulett and Dr. Mahajan were asked to review Plaintiff’s
medical evidence with regard to the possible side effects she may have experienced from
her prescribed medications. (AR AH0961) Dr. Hullet indicates that “there are no side
effects other than drowsiness mentioned by her (Plaintiff’s) internist. This side effect
would not result in her inability to safely perform her own regular unrestricted job.”
(AH0968). In contrast, Dr. Mahajan states that “the medical records reviewed do not
contain any indication that the claimant is experiencing side effects from her current
medications.” (AR AH0976). He continues stating that Dr. Sood and Ms. Swierad, ARNP
document that “the claimant was taking strong opiate medications and muscle relaxants
for pain and the side effects of medications impaired her (Plaintiff’s) ability to perform
her work in a safe and effective manner. While the medications can potentially have
adverse effects, bi adverse effects were documented. There are no changes in mentation,
muscle weakness or any other objective findings documented…[i]n this case, no findings
related to the side effects from medication are documented. (AR AH0976).
On May 26, 2016, Sedgwick informed the Plaintiff that the denial of her STD
benefits would be upheld on appeal. (Defendant Facts ¶¶ 68-69, citing AR AH0979-980).
The letter advised Plaintiff that this decision was final and binging, and explainted that
Plaintiff would be provided with reasonable access and copies to documents relevant to
her claim, and that she had a right to bring an action under ERISA. (Defendant Fact ¶ 70,
citing AR AH0979-0980).

12

II.

Plaintiff’s LTD Benefits Claim

In addition to its STD Plan, Ascension also sponsors a self-funded LTD Plan14 for
eligible employees of Alexian Brothers Health System. (Defendant Facts ¶ 11, citing AR
AH1214, 1219). Ascension is the LTD Plan Sponsor and Plan Administrator and delegated its
discretionary authority to make claims determinations to Sedgwick. (Defendant Facts ¶¶13-14,
citing AR AH1226, AR AH1288). Under the terms of the LTD Plan a Disabled employee is
required to complete an Elimination Period before benefits become payable. (Defendant Facts ¶
16, citing AR AH 1240). The LTD Plan defines the Elimination Period as “‘the number of
consecutive calendar days of Disability before benefits become payable under the Plan…’”
subject to conditions.15 (Defendant Facts ¶ 17, citing AR AH1219). The LTD Plan Elimination
Period is 180-days; therefore the LTD benefits begin on the 181th consecutive day of Disability.
(Defendant Facts ¶¶19-20, citing AR AH1289, AR AH1291).
On or about September 28, 2016, the Plaintiff requested that Sedgwick open a claim for
LTD benefits. (Defendant Facts ¶ 72, citing AR AH2671). Plaintiff maintains that prior to this
date, on or about April 9, 2016, Plaintiff, or her husband acting or her behalf, sought to initiate
an LTD claim on April 9, 2016. (ECF No. 64 at 31, citing AR AH1090-91). On November 4,
2016 the Plaintiff’s claim for LTD benefits was denied because Sedgwick believed that the
Plaintiff had failed to timely elect LTD coverage. (Defendant Facts ¶ 73, citing AR AH1298-99).
On January 13, 2017, Plaintiff appealed the decision and provided documentation that the

14

The LTD Plan is an employee welfare benefits plan governed by ERISA.
The Elimination Period accrual is subject to the following conditions:
“During the Elimination Period a Total Disability that temporarily ceases for not more than thirty
(30) days, whether consecutive or intermittent, will be considered continuous for the purpose of
accumulating the Elimination Period. Any days that the Participant is not disabled will not be
counted toward the completion of the Elimination Period…If during the Elimination Period a
Participant becomes eligible for coverage under any other group long-term disability plan/policy,
the terms of the above… shall not apply.”
(Defendant Facts ¶ 18,citing AR AH1240-41).

15

13

Plaintiff had elected LTD coverage. (Defendant Facts ¶ 74, citing AR AH1319-362). On
February 7, 2017, Sedgwick informed the Plaintiff that the denial of her claim would be
overturned. (Defendant Facts ¶ 75). To make a determination, Sedgwick requested medical
evidence and completed LTD forms from Plaintiff’s treating providers, Dr. Anderson, Dr. Bigol
Dr. Drake, Dr. Jiminez, Dr. Patari and Dr. Sood. (Defendant Facts ¶ 76, citing AR AH13961429).
On March 14, 2017, Nurse Case Manager Jennifer Jansen reviewed Plaintiff’s LTD claim
file and recommended that the LTD claim be denied.16 (Defendant Facts ¶ 84, citing AR
AH2595-97). Nurse Jansen concluded that the information provided to her did not substantiate a
finding of disability and that there were insufficient exam findings to show that Plaintiff was
unable to perform her job demands. (Defendant Facts ¶ 85, citing AR AH2596-97). On March
15, 2017, Sedgwick denied Plaintiff’s claim and apprised her of her appeal rights. (Defendant
Facts ¶ 86). Plaintiff appealed on September 11, 2017, (Defendant Facts ¶ 88, citing AR
AH2174-2360). In her appeal Plaintiff included additional medical records from her treating
physicians. Id. Additionally on appeal, Plaintiff challenged the weight Sedgwick gave to the side
effects that she claimed to be experiencing from her medications. (AR AH2163).
On January 24, 2018, Sedgwick held a round table to discuss the review of Plaintiff’s
appeal. (Defendant Facts ¶ 97). The round table was tasked with first determining if the Plaintiff
was eligible for LTD benefits. If Plaintiff was determined to be eligible then Sedgwick intended
to send Plaintiff’s claim for rheumatology, orthopedic, and psychology independent medical
reviews followed by a cumulative review. (Defendant Facts ¶ 97, citing AR AH2554). On
January 30, 2018, Sedgwick determined that the Plaintiff was not eligible for LTD benefits

16

Plaintiff takes specific issue with the review by Ms. Jansen because she is an on-staff RN employed by Sedgwick
and is not an MD, NP or PA. Plaintiff however does not make a claim for conflict of interest.
14

because she had not been approved for STD benefits. (Defendant Facts ¶ 98). Approval for the
maximum 180-day elimination period is required for LTD eligibility. (Defendant Facts ¶ 98,
citing AR AH2551). Sedgwick remanded Plaintiff’s claim for an eligibility review. Id.
On February 7, 2018, Plaintiff was informed of the denial of her LTD claim due to her
failure to complete the elimination period. (Defendant Facts ¶ 99, citing AR AH2483-85). On
March 13, 2018, Plaintiff appealed. (Defendant Facts ¶ 100, citing AR AH2494). The denial was
upheld on March 19, 2018. (Defendant Facts ¶ 101, citing AR AH2506-07). On May 7, 2018,
Plaintiff amended her present lawsuit to include a claim for LTD benefits.
SUMMARY JUDGEMENT
The Court may grant a motion for summary judgment if, “the pleadings, depositions,
answers to interrogatories, and admissions on file, together with the affidavits, if any, show that
there is no genuine issue as to any material fact and that the moving party is entitled to judgment
as a matter of law.” Fed. R. Civ. P. 56(c); Celotex Corp. v. Catrett, 477 U.S. 317, 322 (1986).
The substantive law determines which facts are critical and which are irrelevant. Only disputes
over facts that might affect the outcome will properly preclude summary judgment. Anderson v.
Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). Summary judgment is not proper if the evidence
is such that a reasonable jury could return a verdict for the nonmoving party. Id.
A moving party always bears the burden of informing the Court of the basis of its motion.
Celotex, 477 U.S. at 323. Once the moving party discharges this burden, the nonmoving party
must set forth specific facts demonstrating that there is a dispute as to a genuine issue of material
fact, not the “mere existence of some alleged factual dispute.” Fed. R. Civ. P. 56(e); Anderson,
477 U.S. at 247. The nonmoving party may not rest upon mere allegations or denials of its
pleadings. Anderson, 477 U.S. at 256. In passing on a motion for summary judgment, the Court

15

must view the facts in the light most favorable to the nonmoving party, and all justifiable
inferences are to be drawn in its favor. Anderson, 477 U.S. at 255. The Court’s function is not
to weigh the evidence, but to determine whether there is a genuine issue for trial. Id. at 249.
DISCUSSION
The Eight Circuit has held that, “[u]nder ERISA, a plan participant may bring a civil
action to ‘recover benefits due to him under the terms of his plan, to enforce his rights under the
terms of the plan, or to clarify his rights to future benefits under the terms of the plan.’”
Pralutsky v. Metropolitan Life Ins. Co., 435 F.3d 833, 837 (8th Cir. 2009), quoting 29 U.S.C. §
1132(a)(1)(B), cert denied, 549 U.S. 887 (2006). “[T]he district court reviews de novo a denial
of benefits in an ERISA case, unless a plan administrator has discretionary power to construe
uncertain terms or to make eligibility determinations, when review is for abuse of discretion.”
Risttenhouse v. UnitedHealth Group Long Term Disability Ins. Plan, 476 F.3d 626, 628 (8th Cir.
2007)(emphasis omitted)(citation omitted).
In the instant case, Plaintiff does not dispute that the Plan granted Sedgwick discretionary
authority to determine eligibility for benefits and construe terms of the Plan, (ECF No. 59 at 4;
ECF No. 64, 2-3,8). The standard of review for this Court thus is abuse of discretion.
Under the abuse of discretion standard, the proper inquiry is whether the
plan administrator’s decision was reasonable; i.e., supported by substantial
evidence. In considering the reasonableness of a plan administrator’s factbased disability determination, courts should consider whether the
decision is supported by substantial evidence. Substantial evidence is
more than a mere scintilla. It means such relevant evidence as a
reasonable mind might accept as adequate to support a conclusion.
Fletcher-Merrit v. NorAm Energy Corp., 250 F.3d 1174, 1179 (8th Cir. 2001) (internal quotation
marks and citations omitted). In making its determination “a reviewing court must focus on the
evidence available to the plan administrators at the time of their decision and may not admit new
16

evidence or consider post hoc rationales.” King v. Hartford Life and Acc. Ins. Co., 414 F.3d 994,
999 (8th Cir. 2005) (internal quotation marks and citation omitted). In light of this standard, the
Court will not consider medical records attached to Plaintiff’s claim for LTD benefits in
evaluating Plaintiff’s claim for STD benefits.
Finally, “[a] decision supported by a reasonable explanation will not be disturbed even if
another reasonable interpretation could be made or if the court might have reached a different
result had it decided the matter de novo.” Phillips-Foster v. UNUM Life Ins. Co. of America, 302
F.3d 785, 794 (8th Cir. 2002)(citation omitted); see also, Midgett v. Washington Group Intern,
Long Term Disability Plan, 561, F.3d 887, 897 (8th Cir. 2009)(emphasis in original)(internal
quotation marks and citation omitted)(“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.”).
I.

Plaintiff’s claim for STD benefits.

In their Motion for Summary Judgement the Defendants argue that the Plaintiff is not
entitled to the benefits that she seeks under the STD plan. (ECF No. 56 at 1). Defendant argues
that the Plaintiff had the burden to and has failed to provide adequate “proof” or “objective
medical evidence” required to be eligible for STD benefits. Id. at 2, 4. Defendant asserts that the
Plaintiff did not submit medical records that contained clinical findings supporting functional
limitations or work activity restrictions. Id. at 2. In response, the Plaintiff argues that the quality
and quantity of Plaintiff’s medical reports and documentation amount to proof of the Plaintiff’s
disability. (ECF No. 63, 3-4). Plaintiff asserts that Defendant Sedgwick’s review denying STD
benefits failed to consist of a full and fair review under ERISA because the decision was based

17

on the opinion of an on staff nurse case manager and doctors employed by Sedgwick who did not
examine the Plaintiff. Id., 5-6.17 Plaintiff also contends that Sedgwick ignored the medical
findings of the Plaintiff’s treating physicians. Id., at 8 (stating that Sedgwick has “improperly
‘cherry-picked’ the medical proof of Ms. Presi’s disability”).
On her Motion for Judgement on the Administrative Record or in the Alternative Motion
for Summary Judgment, the Plaintiff argues that Plaintiff’s STD claim should have been
approved as evidenced by the documents submitted on behalf of the Plaintiff which evidence that
she had disability. (ECF No. 59, 5-6). Additionally, Plaintiff argues that the Defendants’ support
for their denial was insufficient. Id. Plaintiff argues that Sedgwick could have had the Plaintiff
examined by a physician of its choice to assess her physical condition but did not and therefore
disregarded reliable medical information. Id. at 8.

In response, the Defendants argue that

reliance on the claims file and reports by peer-review physicians is reasonable. (ECF No. 61, 89). Defendants further argue that they were under no obligation to have the Plaintiff examined by
the other physicians and that there “is no documented objective medical evidence to support that
Plaintiff’s diagnoses render [her] functionally incapable of working as a unit secretary. Id., 1011.
Plaintiff cites to Sixth Circuit cases, Kalish v. Liberty Mutual/Liberty Life Assur. Co., 18
and Niswonger v. PNC Bank Corp. & Affiliates Long Term Disability Plan,19 for the proposition

17

Plaintiff does not clearly raise a conflict of interest issue in this case.
See, Kalish v. L Liberty Mutual/Liberty Life Assur. Co., 419 F.3d 501(6th Cir. 2005)(when plan administrator’s
explanation with some skepticism…Physicians repeatedly retained by benefits plans may have incentive to make a
finding of “not disabled” in order to save their employers’ money and preserve their own consulting
arrangements…Whether a doctor has physically examined claimant is one factor that a court may consider in
determining whether plan administrators acted arbitrarily and capriciously in giving greater weight to opinion of its
consulting physician. The failure to conduct a physical examination may, in some cases, raise questions about the
thoroughness and accuracy of the benefits determination…).
19
See, Niswonger v. PNC Bank Corp. & Affiliates Long Term Disability Plan, 612 Fed. Appx 317,323 (6th Cir.
2015)(holding that Liberty’s denial of benefits was arbitrary and capricious because of its disregard of reliable
18

18

that the Court ought to view the independent medical examinations conducted by Sedgwick with
skepticism. These cases however are not binding and run contrary to Eighth Circuit Precedent.
The Eighth Circuit has found that there is no abuse of discretion in cases where an administrator
could order an independent medical examination and declined to do so. Rutledge v. Liberty Life
Assur. Co. of Boston, 481 F.3d 655, 661 (8th Cir. 2007). Therefore, defendant’s decision to not
have the Plaintiff examined independently does not amount to abuse of discretion. This Court is
bound by the United States Court of Appeals for the Eighth Circuit (“Eighth Circuit”) precedent
and will not apply the law from another circuit where the Eighth Circuit has been clear. See,
Hood v. United States, 342 F.3d 861,864 (8th Cir. 2003)(holding that a district court in the
Eighth Circuit is bound to apply Eighth Circuit precedent); see also, Hull v. Stevens Transp.,
Inc., 2015 WL 3454512 at *2 (E.D. Mo. May 29, 2015). This Court can find an abuse of
discretion only where the evidence relied upon in rendering a claims determination is matched by
overwhelming contrary evidence. See, Whitler v. Standard Ins. Co., 815, F.3d. 1134, 1140 (8th
Cir. 2016)(citing Coker v. Metro Life Ins. Co., 281 F.3d 793,799 (8th

Cir. 2002)).

The

foregoing arguments asserted by the Plaintiff based on cases from the Sixth circuit are therefore
without merit. Even if the Court were to give weight to these arguments, Plaintiff’s medical
documentation is not overwhelmingly contrary to the conclusions drawn by Sedgwick.
Yet the Plaintiff further argues that the initial STD denial letter of July 31, 2015, was not
based on the full documented medical proof submitted on behalf of the Plaintiff. (ECF No. 59 at
8). Sedgwick’s initial denial of Plaintiff’s STD benefits was based on the physical examinations
of the Plaintiff by Dr. Sood, between May and July of 2015. Nurse Jansen stated that these
examinations appeared normal and did not indicate a limited range of motion or decreased

evidence, e.g. ignoring objective medical tests and opinions of treating physicians for no reason, failing to rebut
medical evidence, and not requesting an independent examination.
19

strength, swelling or spasm and because the Plaintiff did not receive any dosage increases on her
medications; the MRI, EKG and CT scans provided, all of which were in normal ranges,
unremarkable or did not show a change from prior imaging; a record from Dr. Patari, from June
10, 2015, which reflected that a recent CT scan showed no obvious impingement or recurrence
of osteochondroma of Plaintiff’s scapula. (AR AH0230). The Plaintiff asserts that Defendant
failed to acknowledge the following evidence:
Dr. Sood’s April 15, 2015, observation that the Plaintiff has a history of chronic pain
due to growing of back bone tremors on right shoulder and after surgery has found
limitations in what she can do due to the return of pain from the regrowth of bone
tremors.
Dr. Sood’s May 20, 2015, observation that the Plaintiff “uses strong opiate pain
medications and muscle relaxants to control her pain and muscle tightness. The side
effects impair her ability to do her work in a safe and effective manner. The over use
of her shoulder and arms with repetitive movement can exacerbate her condition.”
(AR AH0213).
Dr. Sood’s June 3, 2015, observation that the Plaintiff’s musculoskeletal review noted
that she was positive for joint pain or joint swelling and positive for muscle pain. (AR
AH0210)
Dr. Sood’s December 18, 2015, report stating that the Plaintiff stay off of work with
short term disability due to her medical condition and side effects from the
medication.
Dr. Jiminez’s January 5, 2016, diagnostic x-ray showing that the Plaintiff has
multiple osteochondromatosis.20 (AR AH0505-07).
Dr. Drake’s December 17, 2015, X-ray of Plaintiff’s left shoulder revealing moderate
a.c. joint arthritis/osteochondroma and his impression of osteochodropathies in the
left shoulder and left shoulder pain.
Dr. Bigol’s January 22, 2016, letter stating that the Plaintiff will have great difficulty
functioning with activities of daily living and will be unable to fulfill her professional
duties; that her condition is likely permanent; and that the only viable treatment is
pain control. (AR AH0494).
Dr. Patari’s June 10, 2015 record indicating that while there was no obvious
impingement there was crepitus in the superior border of the scapula with some
atrophy of the surrounding fat musculature. A corticosteroid was given between the
scapula and ribs. (AR AH0167).
With regard to Dr. Sood’s May 20, 2015, observations, the information referenced by the
Plaintiff is found under Plaintiff’s general complaint in her medical records. (AR AH0213). It is
20

At this appointment, Dr. Jiminez also observed popping on range of motion but full range of motion. (AR
AH0505-07).
20

not clear to the Court to what extent the statement is self-reported by the Plaintiff or an objective
medical finding by Plaintiff’s treating physician. Additionally, Dr. Sood’s December 18, 2015,
observations; Dr. Jiminez’s January 5, 2016, diagnostic X-ray; Dr. Drake’s December 17, 2015,
X-ray and Dr. Bigol’s January 22, 2015, letter were not submitted until after the initial claims
decision was rendered on July 31, 2015. (AR AH0230). These documents were provided as
supplemental material to Plaintiff’s claim on appeal and therefore were not before the
adjudicator at the time the initial denial of STD benefits was made. As stated previously, it is not
for the Court to review information not available to the plan administrators at the time of their
review. See, King v. Hartford Life and Acc. Ins. Co., 414 F.3d 994, 999 (8th Cir. 2005).
Although Plaintiff submitted medical records documenting her numerous complaints to
her medical providers and her diagnoses, the Defendants contest the Plaintiff’s claim that she has
submitted proof of functional limitations demonstrating that she is disabled. Defendant argues
that diagnoses alone do not prove that Plaintiff had a disability. (ECF No. 61 at 11). Absent proof
of impairments or restrictions, diagnoses simply do not equate to objective medical Proof of
Disability.” Id., and see, Pralutsky v. Metropolitan Life Ins. Co., 435 F.3d 833, (In which a
diagnosis of fibromyalgia could not be substituted for proof of the extent of the plan participant’s
disability).
Nurse Jansen and both of the physicians reviewing Plaintiff’s claim file on appeal
concluded that she was not so disabled as to require STD benefits. They did so after noting there
was little or no objective evidence of impairment. Requiring objective medical proof of
Plaintiff’s disability is not unreasonable. See Coker v. Metropolitan Life Ins. Co., 281 F.3d 793,
799 (8th Cir. 2002) (holding that providing only subjective medical opinions, which were

21

unsupported by objective medical evidence, did not suffice to prove a claim for benefits); see
also Prezioso v. Prudential Ins. Co. of America, 748 F.3d 797, 806 (8th Cir. 2014) (same).
For the Court to find in favor of the Plaintiff, the Court must determine that it was
unreasonable for the Claims Administrator to preference the reviews of independent medical
examiners over Plaintiff’s self-reported conditions and the opinions of her doctors. “When there
is a conflict of opinion between a claimant’s treating physicians and the plan administrator’s
reviewing physicians, the plan administrator has discretion to deny benefits unless the record
does not support denial.” Johnson v. Metropolitan Life Ins. Co., 437 F.3d 809, 814 (8th Cir.
2006) (citation omitted). The opinions of treating physicians are not entitled to deference over
the opinions of reviewing physicians. See, Black and Decker Disability Plan v. Nord, 538 U.S.
822, 834 (2003)(“courts have no warrant to require administrators to automatically accord
special weight to the opinions of a claimant’s physician; not many courts impose on plan
administers a discrete burden of explanation when they credit reliable evidence that conflicts
with a treating physician’s evaluation.”); Weidner v. Fed. Express Corp., 492 F.3d 925, 930 (8th
Cir. 2007)(“a plan administrator does not abuse its discretion in denying claimant total disability
benefits despite a treating physician’s opinion that claimant was ‘fully disabled.’”); Dillard’s Inc.
v. Liberty Life Assurance Co. of Boston, 456 F.3d 894, 899 (8th Cir. 2006)(rejecting contention
that the plan administrator abused its discretion when in “credited a reviewer’s analysis over a
primary care physician’s conclusions because the reviewer did not physically examine the
claimant”).
Upon review of the Administrative Record, no consensus arises between Plaintiff’s
treating physicians with regard to Plaintiff’s functional capacity. While Dr. Sood is adamant that
the Plaintiff cannot work and repetitive movements will exacerbate Plaintiff’s condition, other

22

treating physicians provide a more complex picture of Plaintiff’s ability. (AR AH0213). Dr.
Anderson found the Plaintiff’s strength to be symmetrical and determined that the Plaintiff had a
full range of motion at the left shoulder. (AR AH0189). Dr. Patari found some atrophy
surrounding the Plaintiff’s musculature of her shoulder and some crepitus and recommended that
the Plaintiff be treated with a corticosteroid and physical therapy (AR AH0167). Ms. Swierad,
APN observed shoulder pain and popping but stated that her findings regarding the Plaintiff were
otherwise normal. (AR AH0514-16). Dr. Bigol noted drowsiness from medication and that
Plaintiff’s shoulder and neck showed muscle fatigue and her upper extremities showed
instability, but also noted that on her pain medication the Plaintiff had full range of motion. (AR
AH0494, AH0504). Conversely, Dr. Drake observed no deformity, swelling, bruising or atrophy
but noted that the Plaintiff had range of motion limitations. (AR AH0485-87). Confusingly he
also stated that the Plaintiff had full range of motion with 160 degrees right abduction and 90
degrees of right external rotation. Finally, Dr. Jiminez noted that the Plaintiff had popping on
range of motion but full range of motion. (AR AH0505-07).
In making a decision on Plaintiff’s claim for STD benefits, Sedgwick states:
The Unit reviewed medical records from Rajiv Sood, MD, Chintalben
Shah, MD, Alexius Medical Center, Alexian Brother’s Hospital Network,
Jefferey Freihage, MD, Jordan Samuels, MD, Danielle Anderson, MD,
Gregory Drake DO, Matthew Jiminez, MD, Percival Bigol, MD, and Jay
Joshi, MD, dated March 21, 2012 through February 4, 2016.
Ms. Presi’s file was reviewed by independent specialist, Carol Hulett, MD,
who is board certified in Orthopedic Surgery and Nakul Mahajan, MD,
who is board certified in Pain Management. Dr. Hulett and Dr. Mahajan
performed an independent review of all available medical documentation
and outlined in detail the medical finding upon which the recommendation
was made.
Dr. Hulett completed peer contact with Rajiv Sood, MD, on April 19,
2016. Dr. Sood indicated that disability is due to recurrent

23

ostrochondromas/nerve pressure and headaches with high doses of pain
management. No further information was provided.
Dr. Hulett made attempts to complete a peer to peer teleconference with
Dr. Sanjay Patari, Dr. Gregory Drake, Dr. Percivol Bigol, and Dr.
Matthew Jiminez on April 19, 2016. Messages were left for the physicians
requesting a return call. No return call was received from either provider;
therefore the teleconference was unsuccessful.
Dr. Mahajan made attempts to complete a peer to peer teleconference with
Rajiv Sood, MD, Dr. Percival Bigol, and Dr. Jay Joshi, on April 19, 2016
and April 20, 2016. Messages were left for the physicians requesting a
return call. No return call was received from either provider; therefore the
teleconference was unsuccessful.
Based on the review of medical information, Ms. Presi was diagnosed
with pain in the joint of the shoulder region, osteopenia, chondrodystrophy
migraine with aura, benign neoplasm of the bone, and articular cartilafe,
spasm of the muscle, and cervicalgia. Ms. Presi’s treatment has consisted
of physical therapy, injections, and medications. It is documented that Ms.
Presi has had an osteochondroma surgically removed from the left scapula
in 2012. However, her pain never resolved and she is being treated for
chronic pain. Ms. Presi’s range of motion and strength are normal and
crepitation only. There has been no recurrence of the ostrochondroma. A
functional capacity evaluation was suggested at one point in mid-2015 but
never done.
From an Orthopedic Surgery perspective, Dr. Hulett opined that the
clinical examination of the left shoulder does not demonstrate any positive
clinical findings indicating functional limitation. Additionally there are not
side effects from medication other than drowsiness, mentioned. This side
effect would not result in an inability to safely perform in her own regular
unrestricted job.
From a Pain Management perspective, Dr. Mahajan opined that the
provided medical records do not include any clinical abnormalities to
substantiate the need for work or activity restrictions. Examination
findings by various physicians do not reveal any evidence of abnormalities
consistent with an ongoing active process, such as malignant neoplasm.
Also, there are no medication side-effects reported that would justify and
substantiate the need for any work or activity restrictions. Additionally,
there are no changes in mentation, muscle weakness or any other objective
findings documented regarding taking the medication.
(AR AH0979-980).

24

While the Court’s interpretation of the submitted medical evidence may not have
been identical to that of the adjudicators for Sedgwick, it is not required for it to be the
same. This Court “may not simply substitute its opinion for that of the plan
administrator.” Fletcher-Merrit 250 F.3d 1174, 1180 (8th Cir 2001).

In this case,

Sedgwick gave detailed reasons for denying Plaintiff’s STD claim, clearly pointed to the
basis for its decision, and declined to rely on Plaintiff’s lack of objective support for her
claimed disability. Upon consideration of the record before it, the Court cannot say that
Sedgwick abused its discretion in denying the Plaintiff’s claim for STD benefits and the
denial of benefits based upon lack of objective evidence of the Plaintiff’s disability is not
unreasonable.
II.

Plaintiff’s claim for LTD benefits.

In her Motion for Summary Judgement Plaintiff contends that her LTD claim should
have been approved by Sedgwick. The Defendant argues that the Plaintiff is not entitled to LTD
benefits because Plaintiff failed to satisfy a condition precedent to receive them. Id. at 2. Plaintiff
contends that Defendant’s proffered reason for denying her LTD benefits is deceptive because
the Plaintiff had already filed a lawsuit regarding her denial of STD benefits when the Defendant
concluded that the denial of STD benefits precluded her from being eligible for LTD benefits.
(ECF No. 63, 9-11). Plaintiff further asserts that the documentation that was provided along with
her claim for LTD benefits was sufficient to present a valid claim for LTD benefits. Id., 9-13.
Defendant argues that the Plaintiff has not offered any evidence to support her claim that the
Plaintiff’s lawsuit for STD benefits had any impact on the administrative decision making
process for Plaintiff’s claim for LTD benefits. Id. at 12. The Court agrees. The LTD Plan
explains that the completion of a 180-day elimination period is necessary for the Plaintiff to seek

25

LTD benefits. Plaintiff does not argue that she has completed the elimination period. Plaintiff
only argues that the documentation submitted ought to demonstrate that she is disabled. Since the
completion of the elimination period is necessary for the Plaintiff to seek LTD benefits, the
Court will uphold the Defendant’s denial of LTD benefits for the Plaintiff’s failure to satisfy a
condition precedent.
CONCLUSION
Accordingly,
IT IS HEREBY ORDERED that Defendants’ Motion for Summary Judgement (ECF
No. 55) is GRANTED, and Plaintiff’s Motion for Judgement on the Administrative Record or in
the Alternative Motion for Summary Judgement (ECF No. 58) is DENIED. An appropriate
Judgement will accompany this Memorandum and Order.

Dated this 14th day of March 2019.

/s/ Jean C. Hamilton
UNITED STATES DISCTIRT JUDGE

26