JONES v. CHARTER COMMUNICATIONS SHORT TERM DISABILITY PLAN
Filing
36
MEMORANDUM OPINION AND ORDER signed by JUDGE WILLIAM L. OSTEEN, JR on 3/28/2019; that Plaintiff's Motion for Judgment, (Doc. 22 ), is DENIED, that Defendant's Motion for Summary Judgment, (Doc. 23 ), is GRANTED, and that this case is DISMISSED. A judgment in accordance with this Memorandum Opinion and Order will be entered contemporaneously herewith. (Sheets, Jamie)
IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF NORTH CAROLINA
ERIC JONES,
Plaintiff,
v.
CHARTER COMMUNICATIONS
SHORT TERM DISABILITY PLAN,
Defendant.
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1:17CV863
MEMORANDUM OPINION AND ORDER
OSTEEN, JR., District Judge
Plaintiff Eric Jones (“Jones”) brings this action pursuant
to 29 U.S.C. § 1132(a)(1)(B) of the Employee Retirement Income
Security Act (“ERISA”), 29 U.S.C. § 1001 et seq., seeking this
court’s review of a denial of short-term disability benefits.
(Complaint (“Compl.”) (Doc. 1) ¶ 10.) Presently before this
court are cross-motions for summary judgment filed by Jones,
(Doc. 22), 1 and Defendant Charter Communications Short Term
Disability Plan (the “STD Plan”), (Doc. 23). Each party has
filed a brief in support of its motion. (Doc. 22-1 (Jones); 2 Doc.
1
Though styled as a “Motion for Judgment,” Jones moves
pursuant to Federal Rule of Civil Procedure 56, (see Doc. 22 at
1), and the court construes Jones’s motion as one for summary
judgment.
2
Jones refiled his memorandum in support of his motion to
include a certificate of word count. (See Doc. 25.)
24 (STD Plan).) Defendant has responded to Plaintiff’s motion,
(Doc. 26), and the parties agree that this matter can be
resolved on summary judgment, (see Doc. 10 at 2). 3 For the
reasons that follow, Plaintiff’s motion will be denied, and
Defendant’s motion will be granted.
I.
FACTUAL BACKGROUND AND PROCEDURAL HISTORY
A.
The STD Plan
Jones is a former employee of Charter Communications, Inc.
(together with Time Warner Cable (“TWC”), which Charter
Communications acquired in 2016, “Charter”). Charter has an
employee benefit program called the Charter/TWC Benefits Plan
(the “Benefits Plan”). (See A.R. at 2459-91.) 4 The STD Plan is a
self-funded component program of the Benefits Plan. (See A.R. at
3
All citations in this Memorandum Opinion and Order to
documents filed with the court refer to the page numbers located
at the bottom right-hand corner of the documents as they appear
on CM/ECF.
4
Citations to the “A.R.” refer to the Administrative Record
filed by Defendant and the Bates numbers located at the bottom
of the documents. (Def.’s Mem. in Supp. of Mot. for Summ. J.
(“Def.’s Br.”) (Doc. 24), Ex. 1, Parts 1 to 20 (Docs. 24-1 to
24-20).)
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2496-2501.) 5 As an employee, Jones was a beneficiary of the STD
Plan.
The STD Plan provides eligible employees up to twenty-six
weeks of short-term disability benefits, which cover a
percentage of an eligible employee’s compensation when he is
unable to perform his job duties. (A.R. at 2497.) To receive
short-term disability benefits, claimants must be “totally” or
“partially” disabled, as defined by the STD Plan. (A.R. at
5
The STD Plan asserted in its Answer that it is not a
proper defendant because Sedgwick Claims Management Services,
Inc. administers the STD Plan. (Def.’s Br. (Doc. 24) at 7;
Answer (Doc. 4) at 5 (citing Gluth v. Wal-Mart Stores, Inc., No.
96-1307, 1997 WL 368625 (4th Cir. July 3, 1997)).) In Gluth, the
Fourth Circuit found that a trust that was merely funding a
benefits plan, with no administrative control, was an improper
defendant. 1997 WL 368625, at *6. The Fourth Circuit, however,
cited a Ninth Circuit case, Gelardi v. Pertec Comput. Corp., 761
F.2d 1323, 1324-25 (9th Cir. 1985), that said: “ERISA permits
suits to recover benefits only against the employee benefits
plan as an entity.” Gluth, 1997 WL 368625, at *6 n.8 (citing
Gelardi, 761 F.2d at 1324-25; Daniel v. Eaton Corp., 839 F.2d
263, 266 (6th Cir. 1988)). Given the court’s ultimate
disposition of Plaintiff’s claim, the court will not endeavor to
make a finding one way or the other, though it views the STD
Plan as a proper defendant. See Larson v. United Healthcare Ins.
Co., 723 F.3d 905, 916 (7th Cir. 2013) (“[A] claim for benefits
ordinarily should be brought against the plan because the plan
normally owes the benefits,” except under an insurance-based
ERISA plan where the insurer decides eligibility questions); see
also McRae v. Rogosin Converters, Inc., 301 F. Supp. 2d 471, 475
(M.D.N.C. 2004) (citing Gluth, 1997 WL 368625, at *6) (“Although
the Fourth Circuit has not published a decision that expressly
holds who is a proper defendant . . . [it] appears to be aligned
with those circuits that permit a plaintiff to bring an
action . . . against the pension plan itself as an
entity . . . .”).
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2499.) An employee is “totally disabled” if he “cannot perform
the Essential Duties of [his] own occupation” and is “earning
less than 20% of [his] pre-disability Covered Compensation due
to an injury or illness (including Mental Illness . . . ).” (See
A.R. at 2499.) An employee is “partially disabled” if he is
“able to work part-time for any employer performing some, but
not all, of the Essential Duties of [his] own occupation” and
“cannot earn more than 80% of [his] pre-disability Covered
Compensation.” (A.R. at 2499.) “Essential dut[ies]” are “the
important tasks, functions and operations generally required by
employers from those engaged in their usual occupation that
cannot be reasonably omitted or modified.” (A.R. at 2505.) A
grant of short-term disability benefits lasts until the earliest
of the date a beneficiary is no longer disabled, his failure to
furnish satisfactory proof of continued disability, or the
exhaustion of his twenty-six weeks of short-term disability
benefits. (See A.R. at 2498-99.)
A third party may administer the Benefits or STD Plans. The
Benefits Plan defines the “Administrator” as the “Committee”
and, in turn, the “Committee” as at least three members
appointed by Charter and receiving no compensation for such
services. (A.R. at 2463, 2476.) Importantly, the Committee has:
[T]otal and exclusive responsibility to control,
operate, manage, and administer the [Benefits] Plan in
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accordance with its terms. The Committee shall have
the authority that may be necessary or helpful to
enable it to discharge its responsibilities with
respect to the [Benefits] Plan. Without limiting the
generality of the preceding sentence, the Committee,
or its delegate, if any, shall have the exclusive
right to interpret the [Benefits] Plan, to determine
eligibility for coverage under the [Benefits] Plan, to
determine eligibility for benefits under the
[Benefits] Plan, to construe any ambiguous provision
of the [Benefits] Plan, to correct any default, to
supply any omission, to reconcile any inconsistency,
and to decide any and all questions arising in
administration, interpretation, and application of the
[Benefits] Plan.
(A.R. at 2476.) The Committee’s decisions, as well as those by
the Claims Administrator, are conclusive and binding. (A.R. at
2476, 2478.) And the Committee’s authority does not extend to
“any matter as to which a Claims Administrator or another
designated party under any Component Program is empowered to
make determinations.” (A.R. at 2477.)
The Committee “delegated its authority to determine
benefits under the [Benefits] Plan to the Claim Administrators.”
(A.R. at 2476.) The STD Plan then provides that the Claims
Administrator “is the claims fiduciary with sole authority to
determine benefit claims under the terms of the [STD Plan].”
(A.R. at 2501.) The STD Plan allows the Claims Administrator to
request that an employee receiving short-term disability
benefits be examined to verify continued disability and to
request that a beneficiary provide it with “other satisfactory
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proof of [the beneficiary’s] continued disability.” (A.R. at
2499; see also A.R. at 2502.) 6 Finally, the STD Plan provides
that any appeal of a denied claim will be reviewed by the Claims
Administrator and conducted by a person not involved in the
initial determination. (See A.R. at 2503.)
Charter partnered with Sedgwick Claims Management Services,
Inc. (“Sedgwick”) to administer the STD Plan. (A.R. at 2508.) 7
B.
Jones’s Mental Illness and the Short-Term Disability
Benefits at Issue
Jones was a Customer Care Rep I (“CSP 1”) at Charter, (A.R.
at 1900-01), providing “customer sales and service support by
telephone for the high-speed data broadband product, digital
phone and cable television[,]” (A.R. at 1410). His job
responsibilities included interacting with customers and
coworkers positively and empathetically, performing mathematical
calculations, providing expertise on products and services,
problem solving, and other sedentary tasks. (A.R. at 2402-06.)
6
This court is unclear as to which party pays for
verification examinations. (Compare A.R. at 2499 (stating that
they are at the Claims Administrator’s expense), with A.R. at
2502 (stating that periodic reexaminations are at the
beneficiary’s expense).)
7
The Administrative Record contains no written agreement
between the STD Plan and Sedgwick, and Sedgwick is not defined
as the Claims Administrator, but it is clear to the court, and
the parties do not argue otherwise, that Sedgwick is the Claims
Administrator under the STD Plan.
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Jones’s job required concentration, stable mood, multitasking,
and the ability to handle high call volume. (A.R. at 116-17.)
Jones has a history of mental health issues, stemming in
part from a traumatic burn he suffered as a child. (See A.R. at
1426, 1431.) He has received therapy since he was young and
started taking medications in 1999. (A.R. at 117.) Jones was
diagnosed with bipolar disorder in 2008. (A.R. at 117.)
Jones first applied for short-term disability benefits
under the STD Plan on or around May 18, 2015, due to psychiatric
issues, including his bipolar disorder. (A.R. at 4, 9.) His
treating physician at the time, Dr. M. Chan Badger, noted in a
June 3, 2015 attending physician statement that Jones was “not
stable to perform his current job functions.” (A.R. at 9-10.) In
the attending physician statement, Dr. Badger noted a projected
return to work date of August 18, 2015. (A.R. at 10.) Sedgwick
ultimately approved Jones’s claim for short-term disability
benefits through August 9, 2015, and Jones returned to work on
or around August 10, 2015. (See A.R. at 11, 36.)
In late 2015, Jones switched medical providers and began
seeing Dr. Chris Aiken and Nurse Practitioner Sara Robertson
(“N.P. Robertson”) at the Mood Treatment Center. (A.R. at 1499.)
Jones first visited the Mood Treatment Center on December 17,
2015, and N.P. Robertson diagnosed him with bipolar type II
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disorder, obsessive-compulsive disorder (“OCD”), attentiondeficit/hyperactivity disorder (“ADHD”), remissive cocaine use,
and also noted post-traumatic stress disorder (“PTSD”). (14991508.) Jones regularly received treatment at the Mood Treatment
Center over the following months, including on December 30,
2015, (A.R. at 1498); January 14, 2016, (A.R. at 1495);
February 19, 2016, (A.R. at 1492); March 10, 2016, (A.R. at
1489); March 24, 2016, (A.R. at 1486); and May 5, 2016, (A.R. at
1483).
Jones’s treatment continued through the summer of 2016.
Jones saw N.P. Robertson on July 20, 2016. (A.R. at 1480-83.)
N.P. Robertson’s psychiatric progress notes from that visit,
signed by Dr. Aiken, indicate that Jones endorsed high-tomoderate depressed mood, mild problems with concentration,
anxiety, and no suicidal ideations. (A.R. at 1481.) Jones
reported feeling well four of the previous seven days. (A.R. at
1482.) The notes also state that Jones was “[u]nhappy at his job
– wants to do PR work.” (A.R. at 1481.) The notes do not
indicate whether Jones was unable to perform any job functions,
(see A.R. at 1480-83), but state that his “judgment may be
impaired depending on the task/setting[,]” (A.R. at 1483).
On August 17, 2016, Jones applied for the short-term
disability benefits relevant here. (A.R. at 1689-94.) On
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August 19, 2016, Jones saw N.P. Robertson. (A.R. at 1478-80.)
Her psychiatric progress notes from that visit, signed by Dr.
Aiken, indicate that Jones was depressed, anxious, and had
developed mild insomnia since his last visit on July 20, 2016.
(See A.R. at 1478-80.) Jones endorsed high-to-moderate depressed
mood, anxiety, concentration problems, and he denied suicidal
ideations; N.P Robertson again noted Jones’s bipolar disorder,
PTSD, OCD, ADHD, and remissive cocaine use. (A.R. at 1478-80.)
Jones reported feeling well zero of the previous seven days and
wanted to go on short-term disability. (A.R. at 1478-79.) The
notes do not indicate that Jones was unable to perform any job
functions and state that Jones had no functional impairment from
his depression. (See A.R. at 1478-80.) N.P. Robertson continued
Jones’s current medications. (A.R. at 1480.)
Shortly thereafter, on August 26, 2016, Dr. Aiken and N.P.
Robertson indicated in a statement of incapacity/attending
physician statement (“SOI”) that Jones was incapacitated until
September 22, 2016, due to his bipolar type II disorder, PTSD,
and ADHD. (A.R. at 1646.) The SOI also indicates that Jones had
visited the emergency room at Novant Health. (A.R. at 1647.) The
Mood Treatment Center appears to have faxed this SOI to Sedgwick
on August 29, 2016 and September 8, 2016. (A.R. at 1645-46.) On
September 6, 2016, Sedgwick approved Jones’s short-term
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disability benefits from August 22, 2016 through September 6,
2016, effective after an elimination period of August 22, 2016
to August 28, 2016. (A.R. at 1662-63.)
On September 6, 2016, Jones visited N.P. Robertson, who
noted that Jones’s mood had improved. (A.R. at 1474.) N.P.
Robertson’s notes state that Jones endorsed very mild symptoms
of depressed mood, anxiety, and problems with concentration.
(A.R. at 1474.) Jones reported feeling well five of the seven
previous days and had no suicidal or impulsive thoughts. (A.R.
at 1474-75.) N.P. Robertson did not indicate whether Jones was
unable to perform his job functions. (See A.R. at 1474-75.)
Thereafter, in an SOI dated September 26, 2016, Dr. Aiken
indicated that Jones was unable to perform his job functions due
to his condition. (A.R. at 1627.) Dr. Aiken recommended that
Jones not return to work until October 25, 2016, because of his
bipolar type II disorder, PTSD, ADHD, as well as four panic
attacks in the prior month. (A.R. at 1627-28.) Attached to the
SOI was a September 26, 2016 “summary of disability” form in
which N.P. Robertson and Dr. Aiken specifically noted that they
had advised Jones to stop working. (A.R. at 1630-31.) They noted
Jones’s full impairment in certain of his job functions,
including the inability to: “maintain a work pace appropriate to
a given workload”; “perform complex or varied tasks”; “make
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generalizations, evaluations or decisions”; and “relate to other
people beyond giving and receiving instructions.” (A.R. at 163132.) The Mood Treatment Center faxed the SOI and disability
summary to Sedgwick on September 26, 2016. (A.R. at 1624-32.)
On September 29, 2016, a Sedgwick employee reviewed Jones’s
file and recommended extending Jones’s short-term disability
benefits until October 21, 2016, based on an expected return-towork date of October 25, 2016. (A.R. at 1144-45.) Sedgwick’s
internal documentation summarizes the approval rationale and
notes that Jones needed “additional time for symptoms to
stabilize prior to [return to work] as a CSP 1.” (A.R. at 359.)
On September 30, 2016, Sedgwick extended Jones’s short-term
disability benefits through October 21, 2016. (A.R. at 1620.)
On October 12, 2016, Dr. Aiken and Jones spoke on the phone
regarding Jones’s treatment and response to his medications.
(A.R. at 1472-73.) Dr. Aiken’s notes of that call do not
indicate whether Jones was unable to perform his job duties.
(See A.R. at 1472-73.) On October 21, 2016, Jones visited N.P.
Robertson. (A.R. at 1469-71.) Her notes, signed by Dr. Aiken,
indicate that Jones’s mood had improved, that he felt well six
of the prior seven days, and suggest no functional impairment.
(See A.R. at 1469-71.) Jones still exhibited mild symptoms of
depressed mood, hypoactivity, concentration problems, and
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anxiety. (A.R. at 1469.) But he showed no signs of psychosis or
suicidal thoughts. (A.R. at 1469-71.) The notes state that Jones
“had 2 interviews – on STD – extended 1 more month.” (A.R. at
1469.) The notes also indicate that Jones would see a new
therapist, Ms. Barbara Farran, ASCW, LCSW. (See A.R. at 1469.)
N.P. Robertson did not indicate whether Jones was unable to
perform his job duties. (See A.R at 1469-71.)
Sedgwick attempted to call Jones on October 15, 2016 before
his grant of short-term disability benefits expired on
October 21, 2016. (A.R. at 340.) Sedgwick did not immediately
cut Jones’s benefits off on October 21st. Sedgwick attempted to
contact Dr. Aiken’s office to get an update on Jones’s
condition. On October 26, 2016, Sedgwick spoke with Jones and
told him that no updated information had been received from the
Mood Treatment Center. (A.R. at 352.) On October 27, 2016,
Sedgwick faxed the Mood Treatment Center requesting updated
medical information on Jones and again called Jones. (A.R. at
340, 350.) On October 28, 2016, the Mood Treatment Center faxed
Sedgwick Jones’s updated medical records, including a list of
current medications and the notes from Jones’s October 12, 2016
telephone conference and October 21, 2016 office visit. (See
A.R. at 346-48; 1598-1608.) A Sedgwick form document requesting
medical information was also filled out by someone at the Mood
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Treatment Center and indicates that Jones’s next treatment was
on November 18, 2016 and that his estimated return to work date
was November 25, 2016. (A.R. at 1599.)
Sedgwick spoke to Jones on November 1, 2016 and advised him
that it was reviewing the additional information from the Mood
Treatment Center. (See A.R. at 343-44.) On November 2, 2016,
after reviewing the additional office visit notes, Sedgwick left
a voicemail with the Mood Treatment Center seeking to clarify
“what provider saw on exam that is preventing [employee] from
working, examples how those symptoms were observed to be severe,
and if [employee] could [return to work] with restrictions.”
(A.R. at 1776.) Sedgwick left another voicemail with Dr. Aiken
and N.P. Robertson on November 3, 2016. (A.R. at 1776.) The
voicemails apparently went unreturned. Later that day,
November 3, 2016, one of Sedgwick’s registered nurses reviewed
Jones’s file, including Dr. Aiken’s notes from his October 12,
2016 telephone conference with Jones, N.P. Robertson’s
psychiatric notes from Jones’s October 21, 2016 treatment, and
Jones’s medication list. (See A.R. at 1775.) Sedgwick’s nurse
concluded that Jones’s “[m]edical information does not support
severity that [he] is disabled still because exam findings are
minimal and do not indicate that [he] has a cognitive
impairment.” (A.R. at 1776.) The nurse was unable to tell
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whether Dr. Aiken and N.P. Robertson had cleared Jones to return
to work as there was “no visible indication that [he] need[ed]
more time off of work[,]” and it looked to the nurse as if
Jones’s symptoms were more in control and his mood had improved.
(A.R. at 342, 1776.)
For those reasons, on November 3, 2016, Sedgwick denied a
continuation of Jones’s short-term disability benefits,
effective October 22, 2016, and notified Jones in writing. (A.R.
at 315, 1463-65.) Sedgwick’s denial letter states that it had
“received medical information from Dr. [sic] Sara Robertson &
Dr. Chris Aiken on 09/26/2016, which confirmed [Jones’s]
disability through 10/21/2016. The determination to deny an
extension of benefits is based on a review of medical
documentation provided by Amanda Kirby [sic] & Dr. Badger [sic]
on 10/28/2016.” (A.R. at 1464.) 8 The letter continues that those
records did not “support severity of disability due to exam
findings being minimal and do not indicate that the [employee]
has a cognitive impairment. Attempts to gather additional
information were unsuccessful.” (A.R. at 1464.)
8
Sedgwick mistakenly referenced Dr. Badger and Ms. Kirby
(Jones’s previous therapist). Sedgwick later explained to Jones
between November 8 and 9, 2016, that the documentation it
received on October 28, 2016, and reviewed prior to denying
continuation of his benefits was from the Mood Treatment Center,
had an e-signature from Dr. Aiken, and only mentioned Ms. Kirby
as another provider. (See A.R. at 324-28.)
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On November 4, 2016, Dr. Aiken faxed Jones’s medical
records to Sedgwick, with an “urgent” notation. (A.R. at 158788.) These documents included the October 12, 2016 and
October 21, 2016 psychiatric progress notes, (A.R. at 1587-95),
which Sedgwick had already reviewed after Dr. Aiken sent them on
October 28th, (A.R. at 1598-1608). Jones also called Sedgwick
several times between November 4, 2016 and November 9, 2016 to
dispute the denial. (A.R. at 325-26, 332-36.)
C.
The Administrative Appeal
On November 10, 2016, Jones appealed Sedgwick’s denial
through a faxed letter dated November 9, 2016, from Dr. Aiken to
Sedgwick’s National Appeals Unit. (A.R. at 1461-62, 1466 (STD
Appeal Form signed by Jones on November 7, 2016).) Dr. Aiken
requested that Sedgwick reconsider its denial because Jones’s
medical condition “impair[ed] his ability to work in any
capacity.” (A.R. at 1462.) In his cover letter, Dr. Aiken
reiterated that Dr. Badger and Ms. Kirby were “not affiliated
with Mood Treatment Center” in any way. (A.R. at 1462.) Dr.
Aiken provided Jones’s psychiatric progress notes from
December 17, 2015 through October 21, 2016. (A.R. at 1461-1508.)
On November 15, 2016, Sedgwick’s Appeals Unit notified
Jones of its receipt of his appeal, which Sedgwick assigned to
Appeals Specialist Tricia Pike. (A.R. at 1457-58.) On
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November 17, 2016, Sedgwick contacted Jones to explain the
appeal process and told him that an independent physician would
review Jones’s file and contact N.P. Robertson and Ms. Farran to
discuss Jones’s medical issues. (A.R. at 309-12.) Jones stated
that no other providers needed to be contacted. (See A.R. at
310.) Sedgwick told Jones which medical documents it currently
had for review, including the Mood Treatment Center’s notes from
August 19, 2016 and September 16, 2016, as well as the
associated SOI from September 26, 2016, and notes from Jones’s
October 12, 2016 telephone conference with Dr. Aiken and his
October 21, 2016 office visit. (A.R. at 310.) Jones told
Sedgwick that there would be additional information submitted
from a forthcoming treatment on November 18, 2016, and possibly
information from Ms. Farran. (See A.R. at 310-11.) On
November 17, 2016, Sedgwick tolled Jones’s appeal through
November 30, 2016, to allow Jones time to perfect his appeal.
(A.R. at 309-11, 1434).
On November 18, 2016, Jones saw N.P. Robertson. (A.R. at
1432.) Her psychiatric progress notes from that visit, signed by
Dr. Aiken, state that Jones’s short-term disability benefits
were denied and that Jones was now extremely depressed,
“[t]earful, not sleeping, [and] hopeless.” (A.R. at 1430-32.)
Jones reported feeling well zero of the prior seven days, and
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N.P. Robertson noted “passive suicidal thoughts without
plan/intent (low-moderate).” (A.R. at 1430-31.) The notes
describe Jones’s mental status as “[m]arkedly ill, with
functional impairment from symptoms,” and judgment impairment
depending on the task or setting. (A.R. at 1431-32.) The notes
do not specifically indicate that Jones was unable to perform
his job functions. (See A.R. at 1431-32.) N.P. Robertson
increased Jones’s dosage of Klonopin due to his anxiety. (A.R.
at 1432.)
On or around November 28, 2016, Sedgwick received N.P.
Robertson’s notes from the November 18, 2016 visit and Jones’s
updated prescription list. (A.R. at 299-04, 1427-32.) On
November 30, 2016, Ms. Pike left a voicemail with the Mood
Treatment Center, asking if more time was needed to submit
additional information. (A.R. at 299.) Thereafter, Sedgwick
tolled Jones’s appeal through December 18, 2016. (A.R. at 1423.) 9
On December 5, 2016, Ms. Farran faxed Sedgwick a letter
stating that she had been seeing Jones since October 27, 2016.
(A.R. at 1424-26.) Ms. Farran’s diagnosis was for PTSD “based on
9
Ms. Pike informed Jones incorrectly on December 9, 2016
that Sedgwick was still missing the November 18, 2016 visit
notes, (A.R. at 292-93), which misbelief might have caused this
tolling, (see A.R. at 665-66). By December 13, 2016, Ms. Pike
had informed Jones that Sedgwick did have the November 18th
notes. (A.R. at 288-89.)
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[Jones’s] trauma of being a burn victim, a former Marine, and
the subsequent bullying he encountered,” (A.R. at 1426), but she
did not opine on his disability status.
On December 13, 2016, Jones told Sedgwick that, if the
November 18, 2016 documents included the information “about the
hopelessness, suicidal tendencies and significant increase in
Klonopin dosage,” then his file was complete. (A.R. at 1748-49.)
Later that day, Ms. Pike referred Jones’s appeal to an
independent physician for review (“IPA review”). (A.R. at 1748.)
The referred file included Sedgwick’s November 3, 2016 denial
letter, Dr. Aiken’s November 9, 2016 appeal letter with the
supporting medical records from December 2015 through October
2016, N.P. Robertson’s November 18, 2016 office visit notes and
Jones’s prescription list, Jones’s job description, and all
“juris notes.” (A.R. at 1748-49.) In her referral for IPA
review, Ms. Pike specifically requested that a specialist in
psychiatry conduct the review. (A.R. at 1748.)
Dr. Patrick Young, a board-certified psychiatrist retained
through Dane Street LLC, conducted the review of Jones’s appeal
and his file, including: Sedgwick’s internal file and
communications with Jones; Jones’s job description; Dr. Aiken’s
November 9, 2016 appeal letter; Jones’s medical records from the
Mood Treatment Center, including the psychiatric notes from
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December 2015 through November 18, 2016, and the SOIs from
August 26, 2016 and September 26, 2016; Ms. Farran’s December 5,
2016 letter; and other miscellaneous records and correspondence.
(See A.R. at 1408.) As part of his review, Dr. Young conducted a
peer-to-peer phone discussion on December 20, 2016 with N.P.
Robertson. (A.R. at 274-75, 1408-09.) N.P. Robertson told Dr.
Young that she saw Jones on October 21, 2016 and November 18,
2016. (A.R. at 275-76.) She said Jones was doing reasonably well
and improving on October 21st but had gotten more depressed by
November 18th. (A.R. at 276.) N.P. Robertson did not change
Jones’s medications after the October 21, 2016 visit, and she
only increased his Klonopin dosage after the November 18, 2016
visit. (A.R. at 276, 1410.) 10 N.P. Robertson told Dr. Young that
she was unsure if Jones’s change in mood related to the denial
of his short-term disability benefits. (A.R. at 276.) N.P.
Robertson could not identify what specific impairments Jones had
that would have caused an inability to function. (A.R. at 276,
1410.) Dr. Young also requested peer-to-peer discussion with
Jones’s therapist, Ms. Farran, who declined to opine on Jones’s
10
Dr. Young’s review documentation refers to another anxiety
drug, Clonazepam. (A.R. at 1410.) The Mood Treatment Center’s
documents refer to Klonopin. (A.R. at 2399.) It appears to this
court that Clonazepam is the generic form of the brand-name drug
Klonopin.
- 19 -
disability status because she was not qualified to make those
determinations. (A.R. at 275-78, 1410.)
Dr. Young concluded in his IPA review that Jones was not
impaired from October 22, 2016. (A.R. at 1413.) He noted the SOI
from September 26, 2016, which clearly indicated that Jones was
unable to perform any of his job functions and that he had
experienced four panic attacks in a month. (A.R. at 1411.) Dr.
Young also relied on the notes from Jones’s October 21, 2016
visit, where N.P. Robertson noted mild symptoms and an improved
mood and did not indicate that Jones was impaired as of that
date. (A.R. at 1413.)
Dr. Young’s review states that Jones got worse by
November 18, 2016, but Dr. Young felt that the decline was
“directly related to his disability denial.” (A.R. at 1413.) 11
Jones’s “[m]ental status exam showed depressed mood, constricted
affect, low tone speech, negative thought content and impaired
judgment . . . and passive suicidal thoughts.” (A.R. at 1411.)
Nevertheless, the November 18th notes revealed “normal thought
11
The court notes that Dr. Young wrote in his review that
“the treating provider said in the [November 18th] note” that
Jones’s increase in depression “was related to his denial of
disability.” (A.R. at 1414.) While the conclusion that Dr. Young
drew from N.P. Robertson’s note is reasonable, her note states
that Jones had been “[d]enied for short term disability & pt is
appealing. Extremely depressed . . . .” (A.R. at 1430.) That is,
it does not explicitly state that Sedgwick’s denial caused
Jones’s increased depression.
- 20 -
process and content.” (A.R. at 1414.) Dr. Young found that, even
on November 18, 2016, when Jones was extremely depressed, Jones
had “no issues with cognition, and was able to think clearly.”
(A.R. at 1413.) While Jones did express some suicidal ideations
at the November 18th treatment, “he was not considered suicidal,
as no plan of action was taken.” (A.R. at 1413.) The only change
to Jones’s prescriptions was an increased dosage of Klonopin.
(A.R. at 1413.) To Dr. Young, the “findings for the days in
question [did] not support impairment.” (A.R. at 1413.)
On December 22, 2016, Sedgwick received Dr. Young’s IPA
review upholding the denial of Jones’s short-term disability
benefits. (A.R. at 645.) Sedgwick’s internal documentation notes
that Dr. Young’s rationale was that “[t]here [was] no clear
clinical documentation submitted for review that is found to be
supportive of any continued condition of disability or resulting
functional impairment of any severity to support disability from
their job as a CSP 1.” (A.R. at 645.) And “[t]here were no
medical findings associated with any abnormality and no evidence
of functional impairment that would support disability.” (A.R.
at 645.) Sedgwick’s internal review of Dr. Young’s rationale
noted that Sedgwick agreed with the decision due to a “lack of
objective clinical findings.” (A.R. at 270.)
- 21 -
On December 28, 2016, Sedgwick denied Jones’s
administrative appeal. (A.R. at 1403-05.) Sedgwick’s denial
letter states that Sedgwick’s Appeals Unit had reviewed medical
records from Dr. Aiken, N.P. Robertson, and Ms. Farran, dated
December 17, 2015 through December 5, 2016. (A.R. at 1404.) 12 The
denial letter provides that Jones’s file was reviewed by an
independent specialist, Dr. Young, a board-certified
psychiatrist. (A.R. at 1404.) The letter continues that Dr.
Young had performed a comprehensive review of the available
medical documentation, received a message from Ms. Farran on
December 19, 2016, and spoken with N.P. Robertson on
December 20, 2016. (A.R. at 1404.) The denial letter recounts
Dr. Young’s conversation with N.P. Robertson on December 20,
2016, during which N.P. Robertson said that Jones was doing
reasonably well on October 21, 2016, and that a few weeks later,
during a November 18, 2016 treatment visit, Jones “had gotten
more depressed and anxious, however, the remainder of the exam
was unremarkable.” (A.R. at 1404.) The denial letter states that
Jones’s “symptoms were mild during [his] October visit and
although [his] symptoms worsened during [his] November visit,
this appeared to be related to [Jones’s] disability denial as
12
The letter states December 17, 2016 through December 5,
2016, an obvious error.
- 22 -
there were no issues noted with cognition or [his] ability to
think clearly.” (A.R. at 1404.) Further, Dr. Young found during
his review “that the medical information provided [did not]
support impairment for the dates in question.” (A.R. at 1404.)
The denial letter concludes: “[a]s the medical information in
the file does not support your inability to perform your own
occupation, as defined by the [STD] Plan . . . , we have no
alternative other than to reaffirm the denial of benefits for
the period of October 22, 2016 to your return to work.” (A.R. at
1404.)
D.
Subsequent History
Jones visited the Mood Treatment Center on January 5, 2017,
and, on January 6, 2017, Sedgwick received N.P. Robertson’s
clearance for Jones to return to work on January 6th. (A.R. at
495, 1402.) The relevant period for Jones’s claim, therefore, is
October 22, 2016 through January 5, 2017.
It appears that Jones returned to work on January 7, 2017,
went back out on January 10th, returned on January 14th, (A.R.
at 1827), and again requested short-term disability benefits on
or around January 10, 2017. (Pl.’s Mem. in Supp. of Mot. for
Summ. J. (“Pl.’s Br.”) (Doc. 22-1) at 6; see A.R. at 264.)
Jones initiated care with a new psychiatrist, Dr. Subedi,
on or around January 19, 2017. (A.R. at 483.) In support of
- 23 -
Jones’s January claim for short-term disability benefits, Dr.
Subedi submitted an SOI dated February 2, 2017, (A.R. at 138082), and later submitted one dated April 4, 2017, (A.R. at 133537). In the February 2nd SOI, Dr. Subedi noted Jones’s inability
to multi-task, interact appropriately with others, concentrate
on tasks, and Jones’s incapacitation from January 19, 2017
through March 13, 2017. (A.R. at 1381-82.) Dr. Subedi later
extended that incapacitation until April 14, 2017. (A.R. at
1335.) In late January and early February 2017, Jones also
participated in a partial hospitalization program. (A.R. at
625.)
On or around March 20, 2017, a registered nurse at Sedgwick
reviewed Jones’s claim, including the SOI from February 2, 2017,
and noted Jones’s bipolar disorder, poor concentration,
psychiatric treatment, and that his “sedentary occupation []
does require concentration, stable mood, and ability to
multitask high volume of calls.” (A.R. at 1720-21.) On March 21,
2017, Sedgwick approved Jones’s short-term disability benefits
through March 31, 2017, (A.R. at 1719-1720), later extending
them until April 16, 2017. (A.R. at 2430.) Jones returned to
work on or around April 17, 2017, (A.R. at 453), but his
- 24 -
employment with Charter was then terminated, effective May 30,
2017, (A.R. at 2422). 13
Jones filed this lawsuit on September 27, 2017, pursuant to
29 U.S.C. § 1132(a)(1)(B), seeking reversal of Sedgwick’s denial
of his short-term disability benefits from October 22, 2016
through January 5, 2017, and a declaration from this court that
he is entitled to those benefits. (See Compl. (Doc. 1) at 1, 3;
Pl.’s Br. (Doc. 22-1) at 13.) In the alternative, Jones asks
this court to remand his claim for a “full and fair review.”
(Compl. (Doc. 1) ¶ 10.)
II.
STANDARD OF REVIEW
Summary judgment is appropriate when “there is no genuine
dispute as to any material fact and the movant is entitled to
judgment as a matter of law.” Fed. R. Civ. P. 56(a); see Celotex
Corp. v. Catrett, 477 U.S. 317, 322–23 (1986). This court’s
summary judgment inquiry is whether the evidence “is so onesided that one party must prevail as a matter of law.” Anderson
v. Liberty Lobby, Inc., 477 U.S. 242, 252 (1986). The moving
party bears the initial burden of demonstrating “that there is
an absence of evidence to support the nonmoving party’s case.”
Celotex Corp., 477 U.S. at 325. If the “moving party discharges
13
The Complaint appears to mistakenly allege that Jones was
employed by Charter until August 2016. (Compl. (Doc. 1) ¶ 5.)
- 25 -
its burden . . . , the nonmoving party must come forward with
specific facts showing that there is a genuine issue for trial.”
McLean v. Patten Cmtys., Inc., 332 F.3d 714, 718-19 (4th Cir.
2003) (citing Matsushita Elec. Indus. Co. v. Zenith Radio Corp.,
475 U.S. 574, 586-87 (1986)). Summary judgment should be granted
“unless a reasonable jury could return a verdict for the
nonmoving party on the evidence presented.” McLean, 332 F.3d at
719 (citing Liberty Lobby, 477 U.S. at 247–48).
When facing cross-motions for summary judgment, this court
reviews “each motion separately on its own merits to determine
whether either of the parties deserves judgment as a matter of
law.” Rossignol v. Voorhaar, 316 F.3d 516, 523 (4th Cir. 2003)
(citations and internal quotation marks omitted). “When
considering each individual motion, the court must take care to
resolve all factual disputes and any competing, rational
inferences in the light most favorable to the party opposing
that motion.” Id. (citation and internal quotation marks
omitted).
When reviewing a claims administrator’s determination of
eligibility for benefits under ERISA, the standard that this
court applies depends on whether the claims administrator is
vested with discretion in making the determination. If it is
not, then this court reviews the claim administrator’s decision
- 26 -
de novo. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115
(1989). If it is, then this court reviews the decision “for
abuse of discretion, and [this court] will not disturb such a
decision if it is reasonable.” Booth v. Wal-Mart Stores, Inc.
Assocs. Health & Welfare Plan, 201 F.3d 335, 342 (4th Cir. 2000)
(certain citations omitted) (citing Firestone Tire & Rubber Co.,
489 U.S. at 111). A claims administrator’s decision is
reasonable when it is the result of a “deliberate, principled,
reasoning process and [is] supported by substantial evidence.”
Williams v. Metro. Life Ins. Co., 609 F.3d 622, 630 (4th Cir.
2010) (citations and internal quotation marks omitted).
When analyzing the reasonableness of a claim
administrator’s denial of benefits, courts in the Fourth Circuit
generally consider some of the following factors:
(1) the language of the plan; (2) the purposes and
goals of the plan; (3) the adequacy of the materials
considered to make the decision and the degree to
which they support it; (4) whether the fiduciary’s
interpretation was consistent with other provisions in
the plan and with earlier interpretations of the plan;
(5) whether the decisionmaking process was reasoned
and principled; (6) whether the decision was
consistent with the procedural and substantive
requirements of ERISA; (7) any external standard
relevant to the exercise of discretion; and (8) the
fiduciary’s motives and any conflict of interest it
may have.
Booth, 201 F.3d at 342–43.
- 27 -
Finally, this court generally limits its consideration of
evidence to the administrative record. Helton v. AT & T Inc.,
709 F.3d 343, 352 (4th Cir. 2013) (citations omitted). But the
more specific and pertinent consideration is of the evidence
within the administrative record that was known to the claims
administrator when it rendered its decision. See id. With these
principles in mind, this court turns to Sedgwick’s denial of
Jones’s short-term disability benefits from October 22, 2016
through January 5, 2017.
III. ANALYSIS
A.
Abuse of Discretion Standard is Applicable
Taken together, the language of the STD and Benefits Plans
grants Sedgwick the sole discretion to determine eligibility for
short-term disability benefits.
The language of the Benefits Plan grants the Committee, or
its delegate, the exclusive right to interpret the Benefits Plan
and to determine eligibility for benefits thereunder. The
Committee, whose decisions are final and binding, delegated its
authority to the Claims Administrators generally under the
Benefits Plan. Under the STD Plan specifically, a component
program of the Benefits Plan, the Claims Administrator has sole
authority to decide claims for short-term disability benefits.
And it is evident to this court that Charter partnered with
- 28 -
Sedgwick to administer the STD Plan, i.e., to be the Claims
Administrator for the STD Plan. And the parties agree. (See
Pl.’s Br. (Doc. 22-1) at 7; Def.’s Br. (Doc. 24) at 5.) In
addition, the fact that Sedgwick is responsible for reviewing
and managing appeals of claim denials further evidences its
discretion with respect to eligibility determinations. See
Starnes v. Gen. Elec. Co., 201 F. Supp. 2d 549, 556 (M.D.N.C.
2002).
Relatedly, Sedgwick serves as a third-party claims
fiduciary free of any conflict of interest. Charter self-funds
its Plan, and Sedgwick “does not act as an insurer of the Plan;
therefore, neither it nor the doctor[] it retained had any
direct financial stake in the determination of [the
beneficiary’s] eligibility.” Sheppard & Enoch Pratt Hosp., Inc.
v. Travelers Ins. Co., 32 F.3d 120, 126 (4th Cir. 1994); (see
A.R. at 1414-15 (Dr. Young’s attestation to no conflict of
interest)). Sedgwick had no conflict of interest or any ulterior
motive influencing its determination. That Booth factor,
therefore, does not weigh in favor of finding Sedgwick’s denial
unreasonable. See Booth, 201 F.3d at 343.
B.
Denial was Supported by Substantial Evidence
This court has little trouble finding that Sedgwick
reviewed an adequate universe of documents. Sedgwick ensured
- 29 -
that it had up-to-date medical records at each step of its
review process. Most importantly, it verified that it had up-todate medical records prior to denying Jones’s claim on
November 3, 2016, and upholding that decision on December 28,
2016. Sedgwick specifically indicated which documents it had
reviewed in its November 3, 2016 letter and which documents Dr.
Young and Sedgwick had reviewed in its December 28, 2016 letter.
This court’s review of the administrative record suggests, and
this court finds, that Sedgwick based its determination on an
adequate consideration of all relevant materials obtained at its
own effort and provided to it by Jones and his medical
providers. Further, that universe of documents substantially
supports Sedgwick’s determinations.
Sedgwick’s September 6, 2016 grant of short term-disability
benefits was supported by the August 26, 2016 SOI, in which Dr.
Aiken and N.P. Robertson clearly provided that Jones was unable
to perform his job functions until September 22, 2016, due to
his bipolar type II disorder, PTSD, and ADHD. That SOI also
states that Jones had visited the emergency room at Novant
Health. By so indicating, the SOI made up for the fact that the
August 19, 2016 office visit notes, while noting that Jones felt
well zero of the prior seven days, do not indicate that Jones
was unable to perform any job functions.
- 30 -
The same is true of Sedgwick’s extension of Jones’s shortterm disability benefits on September 30, 2016. The
September 26, 2016 SOI clearly indicates what the September 6,
2016 office visit notes do not – that Jones was unable to
perform his job functions. Although Dr. Aiken did not identify
specific job functions Jones was unable to perform, he did note
that Jones’s four panic attacks in the prior month prevented him
from completing basic tasks, and he indicated an expected
return-to-work date of October 25, 2016. In addition, attached
to that SOI was a summary-of-disability form, in which Dr. Aiken
and N.P. Robertson noted that they had advised Jones to stop
working. In that form, Jones’s providers wrote that Jones was
fully impaired in his ability to maintain an appropriate work
pace, perform complex tasks, relate to others, make decisions
without supervision, and influence people.
Sedgwick denied Jones’s short-term disability benefits on
November 3, 2016, after undertaking to obtain Jones’s most
recent medical records. On October 28, 2016, before making its
decision, Sedgwick received Dr. Aiken’s notes from his October
12, 2016 telephone conference with Jones and the notes from
Jones’s October 21, 2016 visit to the Mood Treatment Center.
Sedgwick determined that those notes – which do not indicate
Jones’s inability to perform his job functions and were not
- 31 -
accompanied by an SOI – did not support a finding of continued
disability. The October 21st office visit notes indicate that
Jones’s mood had improved and that he felt well six of the seven
prior days. Jones was coherent, experiencing very mild
depression, and alert and oriented. N.P. Robertson only
indicated that Jones’s judgment “may be impaired depending on
the task/setting.” (A.R. at 1471.) When Sedgwick attempted to
gather further information as to what Jones’s providers saw that
would support continued disability, it was unable to do so.
Therefore, Sedgwick denied continuation of Jones’s short-term
disability benefits shortly after Jones failed to furnish
satisfactory proof of continued disability, as it has the
discretion to do under the STD Plan.
While Sedgwick’s denial letter to Jones contains an obvious
error – i.e., that Dr. Badger and Ms. Kirby provided the updated
records to Sedgwick – this court finds that Sedgwick considered
the proper documents from the Mood Treatment Center before
denying Jones’s claim (and advised Jones of the same). See Judge
v. Metro. Life Ins. Co., 710 F.3d 651, 658-60 (6th Cir. 2013)
(collecting cases) (finding administrator’s “recital of an
incorrect standard of ‘total disability’ in its initial denial
letter,” later corrected upon review, harmless error when
documentation evidencing disability was insufficient throughout
- 32 -
the administrative-review process). Even though Sedgwick’s
attempts to contact the Mood Treatment Center after reviewing
Jones’s medical records were unsuccessful, the record is clear
that Sedgwick had Jones’s most up-to-date medical records as of
November 3, 2016. Sedgwick therefore had the documents necessary
to make a determination and did in fact properly consider those
records when it denied Jones’s benefits. The court therefore
finds that Sedgwick’s November 3rd denial of Jones’s short-term
disability benefits, effective October 21, 2016, was based on
adequate materials that substantially support Sedgwick’s
discretionary determination.
As to Dr. Young’s IPA review, it is clear to this court
that Dr. Young reviewed adequate materials, and Sedgwick’s
decision to uphold the denial was supported by substantial
evidence. Dr. Young reviewed Jones’s job description; Dr.
Aiken’s appeal letter; the Mood Treatment Center’s psychiatric
progress notes from December 17, 2015 through November 18, 2016;
the August 26, 2016 SOI; and the September 26, 2016 SOI and the
attached form summarizing Jones’s disability. He also reviewed
Sedgwick’s communications with Jones and his providers from
August 18, 2016 through December 5, 2016; correspondence from
Ms. Farran; Sedgwick’s “juris notes”; and miscellaneous
documents. (A.R. at 1408.) For many of the same reasons that the
- 33 -
court finds Sedgwick’s initial denial reasonable, the court
finds that Dr. Young’s conclusion, and Sedgwick’s denial of
Jones’s appeal on December 28, 2016 reasonable. Two facts,
however, warrant additional discussion.
First, in his November 9, 2016 appeal letter, Dr. Aiken
wrote: “Eric Jones has a medical condition which currently
impairs his ability to work in any capacity.” (A.R. at 1462.)
Second, Jones’s condition had deteriorated by the time of his
November 18, 2016 office visit, as N.P. Robertson’s notes
reflect. Dr. Young reviewed both Dr. Aiken’s appeal letter and
N.P. Robertson’s notes from Jones’s November 18, 2016 office
visit.
Jones points to Dr. Aiken’s November 9, 2016 appeal letter
in arguing that Dr. Aiken “continued to opine several times
after October 21, 2016 that Plaintiff was disabled and unable to
work, including submitting an appeal . . . on his behalf.”
(Pl.’s Br. (Doc. 22-1) at 9.) This court does not find that Dr.
Aiken “continued to opine several times” that Jones was disabled
and unable to work as argued by Jones. In fact, it appears that
Dr. Aiken’s opinions were limited to his cover letter to Jones’s
appeal and perhaps in signing off on N.P. Robertson’s
November 18, 2016 patient notes. But when Dr. Young conducted a
peer-to-peer discussion with N.P. Robertson, she could not tell
- 34 -
Dr. Young whether Jones was unable to perform his job duties or
what specific impairments would cause, or would have caused at
the time, an inability to perform his job functions. In the
absence of evidence that Dr. Aiken had information over and
above that which was available through N.P. Robertson, the facts
support a conclusion that Dr. Young’s recommendation was not
inconsistent with the opinions of Jones’s own providers. (Ms.
Farran declined to opine on Jones’s disability status.)
Even so, as Defendant argues, ERISA “do[es] not command
plan administrators to credit the opinions of treating
physicians over other evidence relevant to the claimant’s
medical condition.” Black & Decker Disability Plan v. Nord, 538
U.S. 822, 825 (2003); see also Matos v. Lorillard Tobacco Co.
Grp. Disability Ins. Plan, 391 F. Supp. 2d 392, 400 (M.D.N.C.
2005) (citing Nord, 538 U.S. at 834) (“[It is] clearly
established that no treating physician rule exists in ERISA
cases.”). The Fourth Circuit has been equally clear that a
claims administrator does not abuse its discretion when it
credits a retained, independent, reviewing physician’s
recommendation that disagrees with a beneficiary’s medical
provider. See, e.g., Booth, 201 F.3d at 345 (citing Elliott v.
Sara Lee Corp., 190 F.3d 601, 606 (4th Cir. 1999); Ellis v.
Metro. Life Ins., 126 F.3d 228, 234 (4th Cir. 1997)) (reversing
- 35 -
district court and finding no abuse of discretion by
administrative committee where evidence from two treating
providers conflicted with the opinions of two reviewing
physicians).
Second, Jones argues that “Plaintiff’s condition continued
to deteriorate after the October 21, 2016 denial.” (Pl.’s Br.
(Doc. 22-1) at 9.) Pointing to the November 18, 2016 office
visit note, which indicates that Jones was extremely depressed
and had some functional impairment, Jones argues that Dr. Young
offered no support for the “blanket and generic statement” that
he believed Jones’s symptoms were caused by Sedgwick’s denial of
short-term disability benefits. (Id.) Defendant argues that Dr.
Young’s conclusion was supported by Jones’s “self-proclaimed
hatred of working at Charter.” (Def.’s Resp. in Opp’n to Pl.’s
Mot. for Summ. J. (“Def.’s Resp.”) (Doc. 26) at 11; see also
A.R. at 1500, 1506.) It is apparent from this record that Jones
was unhappy at Charter and interviewing for other jobs. (See,
e.g., A.R. at 1469, 1481, 1489.) But the court declines to
credit Defendant’s argument because there is no indication that
Dr. Young or Sedgwick took that fact into consideration in
reaching their respective recommendation or determinations.
Nevertheless, Dr. Young’s conclusion regarding Jones’s
deterioration was reasonable.
- 36 -
The November 18, 2016 office visit note does not
specifically indicate an inability to perform job functions and
was not followed by an SOI clearly stating Jones’s disability,
in marked contrast to the August and September office visits,
which were followed by SOIs which in turn supported Sedgwick’s
decisions to grant the short-term disability benefits. While the
November 18, 2016 notes state that Jones was “[m]arkedly ill,
with functional impairment from symptoms[,]” (A.R. at 1431), Dr.
Young found that the note also shows Jones’s “normal thought
process and content[,]” (A.R. at 1414). In addition, Dr. Young
appears to have inferred from the fact that N.P. Robertson did
not change Jones’s medication, except for an increase to his
Klonopin dosage, that Jones’s symptoms were under control.
Further, the court finds it a fair inference that Dr. Young drew
from the content of the November 18, 2016 note, as well as the
timing of Jones’s deterioration, that Jones’s symptoms related
to the benefits denial. Dr. Young’s peer-to-peer discussion with
N.P. Robertson did not diminish Dr. Young’s suspicion in that
regard, specifically because of N.P. Robertson’s inability to
tell Dr. Young that Jones’s deterioration was unrelated to
Sedgwick’s denial.
Taking into consideration the peer-to-peer discussion that
Dr. Young initiated, the court does not find Dr. Young’s
- 37 -
conclusion unreasonable. Even if contradictory to the
November 18, 2016 note (which the court does not find), the
court again notes that “it is not an abuse of discretion for a
plan fiduciary to deny benefits where conflicting medical
reports were presented.” Booth, 201 F.3d at 345 (alterations,
citations, and internal quotation marks omitted).
That Sedgwick chose to rely on Dr. Young’s conclusion that
Jones was not disabled rather than Dr. Aiken’s opinion (voiced
only once) is not an abuse of discretion. The court finds that
Sedgwick’s denial is supported by substantial evidence.
C.
Charter did not Abuse its Discretion
Jones argues specifically that Charter abused its
discretion in two ways: (i) by not engaging in a reasoned and
principled review process, (Pl.’s Br. (Doc. 22-1) at 8-11), and
(ii) by failing to request that Jones attend an “Independent
Medical Examination,” (id. at 11-13). The court will consider
each in turn.
1.
Reasoned and Principled Decision-making Process
Jones’s fundamental argument as to the reasonableness of
Sedgwick’s decision-making process is that it was inconsistent.
(See Pl.’s Br. (Doc. 22-1) at 8-11.) That is, because Sedgwick
approved Jones’s short-term disability benefits from August 22,
2016 through October 21, 2016, and then again beginning on or
- 38 -
around January 10, 2017, it was unreasonable to deny them in the
interim absent evidence that Jones’s disability had ceased. (Id.
at 9.)
The administrative record contradicts Jones’s assertion
that Sedgwick’s decision-making process was inconsistent;
rather, Sedgwick’s decision-making process was consistent – it
granted Jones’s claims when supported by an SOI satisfactorily
indicating Jones’s disability on September 6, 2016,
September 30, 2016, and March 20, 2017, and denied his claim on
November 3, 2016 when not supported by an SOI or any other
satisfactory proof of continued disability. Jones argues that
the “most glaring” of Defendant’s failures to engage in a
principled review is that Sedgwick denied Jones’s claim from
October 22, 2016 through January 5, 2017 and then granted his
claim again on March 20, 2017, effective on or around
January 10, 2017, based on the “exact same diagnoses, symptoms,
and limitations” as before. (Id. at 10.) But the March 20, 2017
grant was supported by Dr. Subedi’s SOI, and Jones ignores the
fact that, in late January and early February 2017, he
participated in a partial hospitalization program, during which
time he “would not able to fulfill the work required” of him, as
Sedgwick explicitly noted in its review. (A.R. at 625.) The
limitations on Jones’s ability to work were not, in fact, the
- 39 -
exact same. His condition had rapidly deteriorated, perhaps best
evidenced by the fact that his own provider, N.P. Robertson had
just cleared Jones to return to work without restriction on
January 6, 2017. Further, as Defendant suggests, (Def.’s Resp.
(Doc. 26) at 10-11), if Sedgwick’s subsequent grant of benefits
contributed to an abuse-of-discretion finding by this court,
claims administrators might be faced with the perverse decision
to deny a claim for consistency reasons and in an effort to
avoid having a grant used against them at a later time. This
court, therefore, finds that Sedgwick engaged in a reasoned and
principled decision-making process in denying continuation of
Jones’s short-term disability benefits. Nevertheless, the court
will briefly address Jones’s cited authority.
Jones relies primarily on another district court’s
unpublished opinion, Thomas v. Alcoa Inc., for the proposition
that a claim administrator’s inconsistent eligibility
determinations indicate an abuse of discretion. (Pl.’s Br. (Doc.
22-1) at 8-11 (citing Thomas, Civil Action No. RDB-07-1670, 2008
- 40 -
WL 4164156, at *10 (D. Md. Sept. 5, 2008)). 14 This court does not
find Thomas persuasive.
In Thomas, the district court found that Alcoa’s denial of
a beneficiary’s long-term disability benefits was not the result
of a deliberate and principled review process where Alcoa had
granted the benefits two years earlier. See 2008 WL 4164156, at
*9, *15. In Thomas, the district court’s conclusion depended on
several factors not present here. Most significantly, the court
found that plaintiff’s employer, Alcoa, was both the benefit
plan’s administrator and insurer, meaning that Alcoa had a
financial stake in the eligibility decision that it made. Id. at
*8. The court, therefore, applied a less-deferential modified
abuse-of-discretion standard applicable to conflicted
administrators, id. at *10, which might have caused the court to
14
Plaintiff also cites Anderson v. Reliance Standard Life
Insurance Co., Civil No. WDQ-11-1188, 2013 WL 1190782 (D. Md.
Mar. 21, 2013), in arguing that a denial without “new medical
information to justify that decision [should be treated with]
significant skepticism.” (Pl.’s Br. (Doc. 22-1) at 8 (quoting
Anderson, 2013 WL 1190782, at *9).) The district court in that
case cited two out-of-circuit and unreported cases for that
proposition, and Jones selectively quotes the court, which
limited that skepticism to the “termination of long term
disability benefits . . . .” Anderson, 2013 WL 1109782, at *9
n.26 (citations omitted). Sedgwick terminated Jones’s short-term
disability benefits. Further, the district court in Anderson
continued, as Jones acknowledges, (Pl.’s Br. (Doc. 22-1) at 8),
that “the Fourth Circuit has stated that the administrator need
not show a change in condition to justify a termination of
benefits.” Anderson, 2013 WL 1190782, at *9 & n.27 (citations
omitted). This court does not find Anderson persuasive.
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find the denial unreasonable on its own, see id. at *15 (“The
administrator could only have reached this peculiar result by a
selective and incomplete review of the record – a review that
was likely distorted by Alcoa’s motivations to reduce the
expense to its bottom line.”). The court in Thomas actually
double counted the conflict of interest by applying the lessdeferential standard of review and finding that the conflict, as
an independent Booth factor in the reasonableness analysis,
weighed against a finding that the denial was reasonable. Id. at
*9. 15 Neither fact is present here.
Further, while Alcoa retained ultimate discretionary
authority for eligibility determinations, Alcoa employed a
third-party administrator to make an initial eligibility
determination. Thomas, 2008 WL 4164156, at *9. Alcoa replaced
the third-party administrator that initially granted plaintiff’s
disability benefits and, shortly thereafter, the new third-party
administrator denied them. Id. at *10. The timing and
15
In light of the Supreme Court’s decision in Metropolitan
Life Insurance Co. v. Glenn, 554 U.S. 105 (2008), decided
shortly before Thomas, the district court’s double counting and
application of a modified abuse-of-discretion standard was
perhaps improper. See Champion v. Black & Decker (U.S.) Inc.,
550 F.3d 353, 358 (4th Cir. 2008) (citations omitted) (“[A]fter
Glenn, . . . courts are to apply simply the abuse-of-discretion
standard . . . even if the administrator operated under a
conflict of interest. . . . And any conflict of interest is
considered as one factor, among many, in determining the
reasonableness of the discretionary determination.”).
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circumstances of that replacement in Alcoa’s review process
“further stoke[d] th[e] Court’s suspicion.” Id. at *9-10.
Finally, the eligibility reversal was not supported by
substantial evidence considering plaintiff’s “undeniable
deterioration” in the interim between the approval and denial.
Id. at *10-11 (noting physician statement that, “[t]he thought
that [plaintiff] could do any type of repetitive actions or even
work again in the future with all of [his] issues is absolutely
unheard of”; noting another physician’s statement that the
third-party administrator’s “distasteful report . . . has the
appearance of being contrived to circumvent or obscure the
obvious and create artificial and inappropriate barriers to the
ultimate and inescapable conclusion that [plaintiff is]
irrefutably 100% disabled”). Ultimately, the district court
found it “impossible . . . to ascertain how Alcoa reached its
eligibility decision . . . or what evidence it relied upon.” Id.
at *12.
This court has already found that Sedgwick is not
conflicted and has sole discretion to make eligibility
determinations. Therefore, Sedgwick’s role does not weigh
against a finding of reasonableness as it did (twice) in Thomas.
In addition, Sedgwick was the third-party administrator
throughout the relevant time here. This court has also found
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that Sedgwick’s decision was supported by substantial evidence,
the most relevant of which was N.P. Robertson’s notes from
October 21, 2016 indicating Jones’s improvement – not an
undeniable deterioration as in Thomas. While Jones’s condition
had worsened by November 18, 2016, Dr. Young found that Jones’s
increase in depression was related to his disability denial;
whereas, in Thomas, the beneficiary’s deterioration occurred
after a grant and before a denial. Id. at *15.
This court also notes that Sedgwick’s appeals specialist,
Ms. Pike, specifically sought out a psychiatrist to review
Jones’s denial, evincing a principled approach by Sedgwick in
reviewing the merits of Jones’s appeal. See Gluth, 1997 WL
368625, at *5 (finding that seeking out and obtaining an opinion
from a medical professional with specific and relevant
experience “evince[d] a principled approach”).
It is well settled “that no vested right to benefits
accrues under an employee welfare benefit plan absent a clearly
stated obligation to this effect in the plan’s policies.”
Webster v. Black & Decker (U.S.) Inc., 33 F. App’x 69, 75 (4th
Cir. 2002) (citing Gable v. Sweetheart Cup Co., Inc., 35 F.3d
851, 855 (4th Cir. 1994)). Here, the Benefits Plan provides that
“[t]he benefits under the Plan and the Component Programs [e.g.,
the STD Plan] are not vested benefits, and in no event shall any
- 44 -
person have any vested rights with respect thereto.” (A.R. at
2486.) Sedgwick’s denials of Jones’s short-term disability
benefits on November 3, 2016, and his appeal on December 28,
2016 were the result of a reasoned and principled decisionmaking process.
2.
Independent Medical Examination Not Required
Jones’s other argument is that Sedgwick abused its
discretion by failing to request an independent medical
examination. (Pl.’s Br. (Doc. 22-1) at 11-13.) Jones relies
almost exclusively on another district court’s decision in Zhou
v. Metropolitan Life Insurance Co. for the proposition that,
“[w]here a claimant suffers from a disability condition
encompassing subjective complaints, an independent medical
examination is appropriate.” (Pl.’s Br. (Doc. 22-1) at 11
(quoting Zhou, 807 F. Supp. 2d 458, 471 (D. Md. 2011).) Yet,
Plaintiff concedes that neither Defendant nor Sedgwick was
obligated to request an independent medical examination. (See
Pl.’s Br. (Doc. 22-1) at 11.) 16 Nevertheless, Sedgwick upheld the
16
Nor does the law provide a per se rule requiring a claims
administrator to conduct an independent medical examination
before denying benefits, as Defendant argues. (See Def.’s Resp.
(Doc. 26) at 14 (certain citation omitted) (citing Piepenhagen
v. Old Dominion Freight Line, Inc. Emp. Benefit Plan, 640 F.
Supp. 2d 778, 792 (W.D. Va. 2009)).)
- 45 -
denial here based in part on a “lack of objective clinical
findings,” (A.R. at 270), and, under these circumstances, the
court’s decision in Zhou does suggest an examination is
appropriate, see 807 F. Supp. 2d at 474. A brief discussion,
therefore, is warranted.
The court in Zhou found it “inappropriate” for the
defendant to deny the plaintiff’s long-term disability claim
“based solely on the opinions of psychiatrists who merely
reviewed Plaintiff’s file, to the exclusion of statements and
diagnoses by Plaintiff’s treating physicians, and without an
independent medical examination supporting the view of [the
claims administrator’s] psychiatrists.” Id. at 474. The court in
Zhou then cited to non-binding decisions as examples of courts
holding that an independent medical examination is appropriate
“where the claimant suffers from a disability condition
encompassing subjective complaints[,]” such as depression. Id.
(citing Smith v. Cont’l Cas. Co., 450 F.3d 253, 263-64 (6th Cir.
2006); Schwarzwaelder v. Merrill Lynch & Co., 606 F. Supp. 2d
546, 560 (W.D. Pa. 2009); Zanny v. Kellogg Co., No. 4:05-CV-74,
2006 WL 1851236, at *9 (W.D. Mich. June 30, 2006)).
Plaintiff again overlooks that Zhou involved a conflicted
administrator, one serving as both the insurer and administrator
of the long-term disability plan at issue. Zhou, 807 F. Supp. 2d
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at 470. In Thomas, which Jones also relies upon heavily in his
other argument, the court wrote that, “[w]hile independent
examinations are not required, they are common in ERISA cases,
and courts are wary of conflicted administrators who deny
benefits without utilizing them.” 2008 WL 4164156, at *11
(emphasis added) (citing Laser v. Provident Life & Accident Ins.
Co., 211 F. Supp. 2d 645, 649-50 (D. Md. 2002) (applying
modified abuse-of-discretion standard); Watson v. UnumProvident
Corp., 185 F. Supp. 2d 579, 581-82 (D. Md. 2002) (weighing
conflict and applying less deferential standard of review)). 17
Again, Sedgwick has no conflict when making its eligibility
determinations under the STD Plan.
In addition, the eligibility determinations at issue in
Thomas and Zhou, and the cases cited therein, usually involved
the denial of long-term disability benefits, not short-term
disability benefits. See Zhou, 807 F. Supp. 2d at 473; Thomas,
2008 WL 4164156, at *1; Laser, 211 F. Supp. 2d at 647; Watson,
185 F. Supp. 2d at 581; Schwarzwaelder, 606 F. Supp. 2d at 548;
17
The district court’s review in Zanny was actually de novo
because the plan language did not grant the claims administrator
discretionary authority in making eligibility determinations.
2006 WL 1851236, at *1, *9. The district court there also found
that the administrator “regularly reviewed the client’s file
with an open intention to deny benefits despite profound and
compelling evidence of serious and prolonged mental illness.”
Id. at *9. Sedgwick acted with no such intention here.
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Zanny, 2006 WL 1851236, at *1. 18 A plan administrator’s decision
to order an independent medical examination in the context of a
claim for long-term disability benefits involves different costanalyses and standard-of-care considerations than those involved
in a claim for short-term disability benefits.
Here, unlike in Zhou, Jones’s own medical records failed to
establish his disability, and Dr. Young’s peer-to-peer
discussion with N.P. Robertson confirmed Dr. Young’s
recommendation. Sedgwick fully and fairly considered the medical
opinions and diagnoses of Jones’s treating physicians. There was
not satisfactory information available to support incapacity at
the time of Sedgwick’s November 3, 2016 denial or during the
appeal process. Dr. Young made the effort to discuss Jones’s
treatment with his providers. Any inference of continued
impairment that could have been gleaned from the November 18,
2016 medical records had to be discounted after Dr. Young’s
peer-to-peer discussion with N.P. Robertson. Sedgwick exercised
its discretion in not requesting an independent medical
18
The Sixth Circuit’s decision in Smith involved a denial
of short-term disability benefits. 450 F.3d at 254. The Sixth
Circuit remanded the case for a full and fair review of the
disability claim where an administrator’s peer-review doctor
never consulted with the insured’s primary provider, never fully
reviewed the insured’s job description, and the court was unable
to determine whether the administrator artificially altered
medical records for review. Id. at 261-64. Similar facts are not
present here.
- 48 -
evaluation in addition to Dr. Young’s review – and that decision
was reasonable. Sedgwick used a deliberate, principled, and
reasoned decision-making process in denying Jones’s request for
continued short-term disability benefits. It was a decision
supported by substantial evidence, and it was a decision the STD
Plan allowed Sedgwick to make in its sole discretion.
IV.
CONCLUSION
For the reasons stated herein, IT IS THEREFORE ORDERED that
Plaintiff’s Motion for Judgment, (Doc. 22), is DENIED, that
Defendant’s Motion for Summary Judgment, (Doc. 23), is GRANTED,
and that this case is DISMISSED.
A judgment in accordance with this Memorandum Opinion and
Order will be entered contemporaneously herewith.
This the 28th day of March, 2019.
____________________________________
United States District Judge
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