Corey v. Sedgwick Claims Management Services et al
Filing
47
Memorandum of Opinion and Order: Defendants' Motion for Judgment on the Administrative Record (Doc. 40 ) is GRANTED, and plaintiff's motion (Doc. 39 ) is DENIED. Plaintiff's Motion for Leave to File Reply Brief (Doc. 45 ) is GRANTED, and Defendant's Motion to Strike (Doc. 46 ) is GRANTED. Judge Patricia A. Gaughan on 6/28/16. (LC,S)
UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF OHIO
EASTERN DIVISION
Bruce Corey,
Plaintiff,
vs.
Sedgwick Claims Management
Services, et al.,
Defendants.
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CASE NO. 1:15 CV 1736
JUDGE PATRICIA A. GAUGHAN
Memorandum of Opinion and Order
INTRODUCTION
This matter is before the Court upon the parties’ cross-motions for judgment on the
administrative record (Docs. 391 and 40). This case arises under the Employee Retirement
Security Act of 1974 (“ERISA”). For the reasons that follow, defendants’ motion for judgment
on the administrative record is GRANTED, and plaintiff’s motion is DENIED. Also pending
before the Court are Plaintiff’s Motion for Leave to File Reply Brief, which is GRANTED, and
Defendant’s Motion to Strike, which is GRANTED.
1
Plaintiff’s motion, entitled “Plaintiff’s Brief on the Record,” is not captioned as a
motion, but the Court will treat it as such.
1
FACTS
Plaintiff was a machine operator at Eaton Corporation from July 20, 1987, until April of
2014. Defendants are Eaton Corporation Disability Plan for U.S. Employees (the “Plan”) and
Eaton Corporation Health and Welfare Administrative Committee (the “Benefits Committee”).
As an employee, plaintiff is entitled to participate in the Plan.
A. Plan Terms
The Plan consists of a general plan description, referred to as the Wrap Document, and
Operative Documents, which include the Summary Plan Descriptions (“SPDs”) for the Short and
Long Term Disability Plans. The SPDs for both plans designate the Benefits Committee as the
Plan Administrator. Sedgwick Claims Management Services, Inc. (“Sedgwick”) is the third party
that administers benefits claims and appeals.2 The Wrap Document provides that the “Plan
Administrator and its delegate...shall have the sole and absolute authority and responsibility for
construing and interpreting the provisions of the Plan, subject to any applicable requirements of
law.” (AR 9). Similarly, the Short and Long Term Disability Plan SPDs both confer discretion on
the Plan Administrator: “The Plan Administrator and/or Claims Administrator has discretionary
authority to determine eligibility for benefits and to construe any and all terms of the Plan,
including but not limited to, any disputed or doubtful terms.” (AR 1080, 1102).
A Plan participant is eligible for short term disability benefits “if an occupational or nonoccupational illness or injury prevents [the participant] from performing the essential duties of
[his or her] regular position with the Company or the duties of any suitable alternative position
with the Company.” (AR 1087). The participant must also be “under the care of a health care
2
The Court dismissed Sedgwick as a defendant on February 29, 2016.
2
practitioner who verifies, to the satisfaction of the Claims Administrator,” that the participant is
unable to perform his or her essential duties because of the disability. (AR 1089).
To be eligible for long term disability benefits, a participant must have a “covered
disability” that prevents him from working for longer than six months and be under the
continuous care of a physician. (AR 1063). The Long Term Disability Plan defines “covered
disability” as follows:
You are considered to have a covered disability ... under the Plan if, as the result
of an occupational or non-occupational illness or injury:
During the first 24 months, including any period of short term disability, you are
totally and continuously unable to perform the essential duties of your regular
position with the company, or the duties of any suitable alternative position with
the Company; and
Following the first 24 months, you are totally and continuously unable to engage
in any occupation or to perform any work for compensation or profit for which
you are, or may become, reasonably well fit by reason of education, training or
experience at Eaton or elsewhere.
(AR 1063).3
Both the Short and Long Term Disability Plans require a participant to provide objective
findings of a disability to substantiate the claimed period of disability. (AR 1063, 1091). Both
Plans define “objective findings” as findings that “your health care practitioner observes through
objective means, not your description of the symptoms.” Objective findings include:
• Physical examination findings (functional impairments/capacity);
• Diagnostic test results/imaging studies;
• Diagnoses;
• X-ray results;
3
Under both the Short and Long Term Disability Plans, Eaton has the sole
discretion to determine the availability and suitability of alternative positions at
Eaton.
3
• Observation of anatomical, physiological or psychological abnormalities and
• Medications and/or treatment plan.
(AR 1063, 1091).
B. Plaintiff’s STD Benefits
Plaintiff’s physician, Dr. John Tumbush, diagnosed him with cluster headaches on
February 14, 2014. Dr. Tumbush noted that the headaches were “incapacitating,” occurred every
four hours, and precluded plaintiff from working or operating machinery. (AR 394). Plaintiff was
treating the headaches with 100 percent oxygen, which Dr. Tumbush noted he would not be able
to do at work. (AR 34). As a result, the doctor stated that plaintiff “was not able to return to work
until headache cycle is resolved.” Plaintiff filed a short term disability claim, which Sedgwick
approved from February 10, 2014, through March 2, 2014. Plaintiff returned to work at full duty
on March 3, 2014. (AR 56).
Plaintiff stopped working on April 28, 2014, and again sought short term disability
benefits. Plaintiff’s physician, Dr. Mark Rorick, diagnosed him with cluster headaches and issued
a “Certificate to Return to Work,” which stated that plaintiff could return to work on May 7,
2014, with no restrictions. (AR 60). Sedgwick approved plaintiff’s short term disability benefits
claim for the period April 28, 2014, through May 7, 2014. (AR 109).
On May 12, 2014, Dr. Rorick provided Sedgwick with a Family and Medical Leave Act
certification form and his report from plaintiff’s examination on May 2, 2014. In these
documents, Dr. Rorick noted that plaintiff’s pain from the headaches was “very severe and
incapacitating,” that plaintiff was unable to perform his work duties because he could not drive to
and from work while he was suffering a headache, and that plaintiff was taking multiple
4
medications for his condition. (AR 96, 101, 105). Dr. Rorick’s visit summary, however, stated
that plaintiff “will return to work on May 7th.” (AR 105).
Sedgwick denied plaintiff’s claim for a continuation of short term disability benefits after
May 7, 2014. (AR 123). The denial letter stated that the claim was denied because it did not meet
the Short Term Disability Plan provisions requiring objective findings of a disability and the
requirement that a physician verify to Sedgwick’s satisfaction that plaintiff could not perform the
essential duties of his position because of his disability. It informed plaintiff that the denial was
based on a review of the documentation that Dr. Rorick had provided and stated:
The received medical information does not document the severity of your
condition(s) to support STD benefits effective May 8th 2014. Medical records
obtained for date of service May 5th 2014 indicated that Dr. Rodrick has released
you to return to work on May 7th 2014. At this time objective clinical findings to
support the severity of your condition as of May 7th 2014 and beyond have not
been received.
(AR 118).
On May 27, 2014, plaintiff requested a First Level Appeal. In support of his appeal,
plaintiff submitted a summary of his examination by Dr. Eric Baron, a neurologist. Dr. Baron’s
visit summary indicated that plaintiff had cluster headaches, but it did not state whether plaintiff
was unable to work because of the headaches. (AR 125-132). Plaintiff also submitted a return-towork form dated June 5, 2014, from Dr. Rorick. Dr. Rorick stated that it was “unknown” when
plaintiff could return to work because he suffered from “incapacitating cluster headaches” that
caused nausea, dizziness, and occasional loss of consciousness. He noted that, once plaintiff
returned to work, he would be able to perform his regular duties “as long as headaches are gone.
During cluster headache exacerbation, he needs to be off work.” (AR 135). Dr. Rorick also
5
submitted medical records from his examination of plaintiff on June 12, 2014. In these records,
Dr. Rorick concluded that plaintiff “cannot return to work at this time” and noted that plaintiff
had reported having three to four headaches of varying duration per day, with an average pain
score of four out of ten, and that the pain is made worse by noise and light. (AR 149, 152).4 Dr.
Rorick stopped plaintiff’s prescription for prednisone, but did not explain why. (AR 152).
As part of its first-level review, Sedgwick sent plaintiff’s file to Dr. Steven Graham, a
board-certified neurologist, for review. Dr. Graham reviewed plaintiff’s entire claim file and also
spoke with Dr. Rorick on the telephone. He unsuccessfully attempted to contact Dr. Baron three
times between June 19 and 20; he left a message each time and twice explained the nature of his
call, once to a nurse and once to a receptionist. Dr. Rorick reported to Dr. Graham that plaintiff
suffered from cluster headaches, often more than once a day, despite taking prednisone,
sumatriptan, and oxygen therapy.5 He noted that the cluster headaches last approximately 45-60
minutes and that it is difficult for plaintiff to function when he has a headache. He did not relate
any adverse side effects from the medication and did not mention any neurological exam
abnormalities. (AR 154).
Based on Dr. Graham’s review of the file and his conversation with Dr. Rorick, he
concluded that plaintiff was “not disabled from his regular unrestricted job as of 05/07/14.” He
4
On May 2, 2014, when Dr. Rorick noted that plaintiff was returning to work on
May 7, plaintiff had reported an average pain score of eight out of ten.
5
Defendants’ own notes about plaintiff’s claim state that a “major drawback of
oxygen [therapy] is the need to carry an oxygen cylinder and regulator.” (AR
499-500). The notes also identify that plaintiff’s headaches are worsened by noise,
bending, and exertion. (AR 504). Plaintiff was a machine operator, which is rated
as heavy exertion work (AR 438, 458).
6
noted that plaintiff’s primary diagnosis is cluster headaches, which are episodic in nature and
may require medication for control. He acknowledged that “[s]ignificant impairment in activities
do occurred [sic] during cluster headache attacks.” But he noted that “this does not result in any
neurological, physical exam abnormalities,” that “[n]eurological examinations have been normal
in the records supplied,” and that “[o]ther than complaints of headache pain preventing return to
work, there are no physical abnormalities, which would prevent return to work.” He concluded:
“Therefore, from a neurological perspective, the medical evidence does not support that there is a
neurological disability; the employee is not disabled from his regular unrestricted job as of
05/07/2014 to return to work.” (AR 156).
On July 7, 2014, Sedgwick upheld its decision to deny plaintiff’s short term disability
claim after May 7, 2014. The denial letter informed plaintiff of the relevant Plan provision and
that the decision was based on Sedgwick’s review of the entire claim file, including the reports
from Drs. Rorick, Baron, and Graham. The letter contained a summary of plaintiff’s diagnosis
and then stated that “[t]here are no neurological or physical examination abnormalities noted.” It
concluded: “As there are no objective findings contained in the medical documentation that
support an impairment that would preclude you from performing your job duties as of May 7,
2014, we have no alternative than to reaffirm the decision to deny benefits for the period of May
7, 2014 through your return to work date.” (AR 159). The letter notified plaintiff of his right to
appeal and informed him that he could submit additional medical evidence in support of the
appeal. (AR 159). It also stated that, upon written request and free of charge, plaintiff would be
“provided reasonable access to, and copies of, all documents, records, and other information
relevant to [his] claim for benefits.” (AR 159).
7
Plaintiff requested a Final Level Appeal on August 1, 2014. According to the Plan, the
review on appeal is a “‘fresh’ look at the claim [by the Plan Administrator] without deference” to
Sedgwick’s denial decision. (AR 1024). Additional evidence was available for the final appeal.
Specifically, Dr. Baron provided more documents related to his examination of plaintiff on May
19, 2014. In these documents, Dr. Baron noted that “the condition for which [plaintiff] [sought]
leave” was “chronic cluster headache with frequent exacerbation which impair working ability.”
Dr. Baron indicated that plaintiff’s condition would cause periodic flare-ups that would prevent
him from performing his job functions and that it would be necessary for him to be absent from
work during the flare-ups. (AR 285). He estimated that the flare-ups would occur once or twice a
week and last 0-24 hours. Nevertheless, Dr. Baron also noted that plaintiff’s condition did not
render him unable to perform any of his job functions. (AR 284). Moreover, he noted that the
plaintiff had not been incapacitated and would not be incapacitated “for a single continuous
period of time, including any time for treatment and recovery.” (AR 285).
Plaintiff also submitted the records of his examination on July 30, 2014, by Dr. Andre
Machado, a neurologist with the Cleveland Clinic. Plaintiff reported to Dr. Machado that his
headaches occurred two to six times a day and that the severity of his headaches could go to a ten
on a zero to ten scale but were an average of five. Plaintiff described his pain level as
“moderate.” Dr. Machado noted that the plaintiff’s headaches were located in his right jaw,
forehead, and temple, and radiated posteriorly to the occipital region. Imitrex typically abated the
headaches within two to three minutes, but Dr. Machado indicated that plaintiff was trying to
reduce his use of the medication because he experienced associated chest pain. Plaintiff also
reported using supplemental oxygen two to three times a day, which usually helped if he did it
8
early enough, and that prednisone had worked well in the past. During the visit, Dr. Machado
performed a focused neurologic exam. Most of the results of this exam appear to be normal, but
plaintiff highlights the doctor’s notes regarding the trigeminal nerve (“CN V”). The neurology
report states: “CN V: Diminished sensation to pinprick in the entire right side of the face,
diminished to light touch in right cheek and jaw, but normal in right forehead, masseter 5/5.”
(AR 541-42). Dr. Machado concluded that plaintiff had a “history of chronic, severe cluster
headaches.” (AR 542). Although Dr. Machado stated that “[plaintiff] reports associated disability
and [that he] has not been able to work due to the pain in recent months,” the doctor did not
reach any conclusions about whether the headaches rendered plaintiff disabled or unable to
perform his duties at Eaton. (Id.).
Finally, the Plan Administrator asked a physician from an independent medical review
organization, Medical Review Institute of America (“MRIoA”), to conduct a file review. The
physician is certified in general neurology but defendants have not identified him by name
because MRIoA’s policy is to keep the names of its reviewing physicians confidential. (AR
1112). The physician reviewed plaintiff’s job description, the medical records of his treating
physicians, the results of neurological tests, and Dr. Graham’s review. He also attempted to
contact Drs. Rorick and Baron on September 10, 11, and 12. Each time, he left a message with
his name and reason for the call but was unsuccessful in reaching them. Dr. Machado declined to
speak with the reviewer because plaintiff “was being seen only for the occipital nerve stimulator
and headaches.” (AR. 1107). The reviewing physician acknowledged that plaintiff has a history
of cluster headaches that occur two to six times a day, but noted that he takes Imitrex and oxygen
to abort the headaches and that he is asymptomatic between headaches. He also indicated that
9
“there is no evidence of any side effects from medication that would prevent [plaintiff] from
doing his job.” He concluded that there were “no objective findings that would support the
presence of an impairment that would result in any restrictions or limitations” and “no objective
evidence that [plaintiff] is unable to perform his job as of 5/7/14 to the present.” (AR 11091110).
The Plan Administrator conducted its review of plaintiff’s claim and issued a denial letter
on September 26, 2014. The letter identified the relevant plan provisions (e.g., definition of
“covered disability” and requirement of objective findings) and informed plaintiff that “[t]he
substantial weight, of the medical documentation provided by you, your treating health care
providers and the independent physician reviewers, supports the conclusion that for the time
period from May 7, 2014 to present your disability is not covered as required by the Plan.” (AR
551). The letter noted that the review by the Plan Administrator had been a “fresh” look at the
evidence without any deference to the prior denial decisions. It also informed plaintiff that he
could request, free of charge, any documents, records, or other information that were submitted
or considered in the benefits determination, and explained that he had a right to file a civil action
under ERISA. (AR 552).
C. Plaintiff’s Request for a Long Term Disability Benefit Application
One month later, plaintiff called to request a long term disability information package
from the Claims Administrator. The Claims Administrator informed plaintiff that he was not
eligible for long term disability benefits because his short term disability benefit claim had been
denied. (AR 686). Plaintiff responded that he “just wanted to have the packet.” The Claims
Administrator informed plaintiff that “we do not just send out the packets and if there is
10
something about LTD that he needed to know he could ask me or look in his handbook.” (AR
686).
STANDARD OF REVIEW
Normally, a district court applies a de novo standard of review to a plan administrator’s
denial of benefits. Evans v. UnumProvident Corp., 434 F.3d 866, 876 (6th Cir. 2006). But when
a plan administrator is given discretionary authority to determine eligibility for benefits or to
construe the plan terms, the court applies “the highly deferential arbitrary and capricious standard
of review.” Id. (internal quotations omitted). Here, the Plan vested the Plan Administrator with
discretionary authority to determine eligibility for benefits and to construe the terms of the Plan.
The arbitrary and capricious standard is the “least demanding form of judicial review of
administrative action....When it is possible to offer a reasoned explanation, based on the
evidence, for a particular outcome, that outcome is not arbitrary and capricious.” Id. at 877. A
federal court, however, may not merely “rubber stamp[]” the administrator’s decision. Moon v.
UnumProvident Corp., 405 F.3d 373, 379 (6th Cir. 2005). Instead, it must consider the evidence
and determine if the decision was based on a “principled reasoning process” and “substantial
evidence.” Evans, 434 F.3d at 876. “[T]he ultimate issue in an ERISA denial of benefits case is
not whether discrete acts by the plan administrator are arbitrary and capricious but whether its
ultimate decision denying benefits was arbitrary and capricious.” Spangler v. Lockheed Martin
Eergy Sys., Inc., 313 F.3d 356, 362 (6th Cir. 2002). In evaluating a plan administrator’s decision,
the court’s review is limited to the administrative record, and its job is to determine whether, in
light of the record as a whole, the explanation for the decision to deny benefits is rational. Moon,
405 F.3d at 381; Wilkins v. Baptist Healthcare Sys., Inc., 150 F.3d 609, 615 (6th Cir. 1998).
11
The Sixth Circuit recognizes that “a conflict of interest exists when the insurer both
decides whether the employee is eligible for benefits and pays those benefits.” Evans, 434 F.3d at
876. The conflict of interest does not displace the arbitrary and capricious standard. Instead, it is
a factor that the court considers when deciding if the administrator's decision was arbitrary and
capricious. Id. In addition to the existence of any conflicts of interest, the Sixth Circuit considers
these other factors in an arbitrary and capricious review: the quality and quantity of the medical
evidence; whether the administrator considered any disability finding by the Social Security
Administration; and whether the administrator contracted with physicians to conduct a file
review as opposed to a physical examination of the claimant. Fura v. Fed. Exp. Corp. Long Term
Disability Plan, 534 Fed. Appx. 340, 342 (6th Cir. 2013). Applying these factors, defendants'
denial of STD benefits was not arbitrary and capricious.
ANALYSIS
A. Denial of Short Term Disability Benefits
1. Quality and Quantity of the Medical Evidence
Courts must evaluate the quality and quantity of the medical evidence and the opinions on
both sides in reviewing ERISA claims. DeLisle v. Sun Life Assur. Co. of Canada, 558 F.3d 440,
446 (6th Cir. 2009). In conducting this review, a plan’s requirements bind participants and the
court. See Cooper v. Life Ins. Co. of N. Am., 486 F.3d 157, 166 (6th Cir. 2007). In this case,
plaintiff is bound by the Plan’s requirement that he produce “objective findings” of a disability,
which include findings that his health care providers “observe[] through objective means, not
[his] description of the symptoms.”
The Sixth Circuit has consistently recognized that “[g]enerally, when a plan administrator
12
chooses to rely upon the medical opinion of one doctor over that of another in determining
whether a claimant is entitled to ERISA benefits, the plan administrator’s decision cannot be said
to have been arbitrary and capricious because it would be possible to offer a reasoned
explanation, based upon the evidence, for the administrator's decision.” McDonald v.
Western-Southern Life Ins. Co., 347 F.3d 161, 169 (6th Cir. 2003). In evaluating competing
physicians’ opinions, a plan administrator is not required to accord special weight to a claimant’s
treating physician; “nor may courts impose on plan administrators a discrete burden of
explanation when they credit reliable evidence that conflicts with a treating physician’s
evaluation.” Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834, 123 S. Ct. 1965 (2003).
Plan administrators, however, “may not arbitrarily refuse to credit a claimant's reliable evidence,
including the opinions of a treating physician.” Id.
Here, the quality and quantity of the evidence show that defendants’ denial of plaintiff’s
short term disability benefits claim was not arbitrary and capricious. To be eligible for short term
disability benefits, plaintiff had to show, with objective findings, that his headaches prevented
him from performing the essential duties of his regular position at Eaton or the duties of any
suitable alternative position. The Plan Administrator’s determination that plaintiff failed to
produce such objective findings is supported by several physicians’ opinions. Both of the
independent physician file reviewers determined that plaintiff had no neurological abnormalities
and that the headaches did not render him unable to perform his regular duties. Moreover, in Dr.
Baron’s summary of his examination of plaintiff, he indicated that, while plaintiff’s headaches
would cause periodic flare-ups that prevented him from performing his job functions, plaintiff
had not been incapacitated, nor would he be incapacitated “for a single continuous period of
13
time, including any time for treatment and recovery.” Ultimately, Dr. Baron concluded that
plaintiff’s condition did not render him unable to perform any of his job functions. These
conclusions alone are evidence that the Plan Administrator’s decision was based on substantial
evidence and a reasoned explanation. McDonald, 347 F.3d at 169 (6th Cir. 2003).
It is true that Dr. Rorick’s June 5, 2014 return-to-work form stated that it was “unknown”
when plaintiff could return to work because his headaches were “incapacitating.” But Dr.
Rorick’s conclusion regarding the nature of plaintiff’s headaches is based exclusively on
plaintiff's self-reported symptoms regarding the severity and frequency of his pain. Brown v. Fed.
Exp. Corp., 610 Fed. Appx. 498, 504 (6th Cir. 2015) (holding that administrator’s determination
that plaintiff’s subjective reports of pain and fatigue did not constitute objective evidence as
required by the plan was not arbitrary and capricious). As defendants point out, it is also curious
that Dr. Rorick released plaintiff to return to work on May 7, 2014, when plaintiff reported a pain
level of eight out of ten, yet he changed his opinion several weeks later and determined that
plaintiff was unable to return to work even though his average pain level had dropped to four out
of ten.
Plaintiff argues that defendants’ conclusion that no objective evidence of disability exists
is inconsistent with the Plan’s definition of “objective findings,” which includes medication and
treatment plans as examples of objective findings. There is no dispute that plaintiff was on
several forms of medication and that he was receiving treatment for his chronic headaches. But
the record does not support a finding that this medication or any treatment plan prevented
plaintiff from performing the essential duties of his position, i.e., rendered him disabled under the
14
Plan’s definition.6 In fact, the evidence is to the contrary. Indeed, Dr. Graham noted in his report
that Dr. Rorick did not relate any adverse side effects from the medication, and the MIRoA
physician specifically found that the medications did not interfere with plaintiff’s ability to work.
To the contrary, the evidence suggests that the medication was often successful in abating the
headaches, sometimes quite quickly. Dr. Rorick’s notes from his May 2, 2014 examination of
plaintiff indicate that prednisone alleviated plaintiff’s headaches. On July 30, 2014, Dr. Machado
similarly noted that “prednisone ... works well.” He also noted that Imitrex typically abated the
headaches within two to three minutes, that a recent greater occipital nerve block had provided
headache relief for seven to ten days, and that oxygen two to three times per day “usually helps if
[plaintiff] does it early enough.” Though plaintiff experienced some chest pain with Imitrex and
oxygen was difficult to administer at work, the record does not support that these, or other
medications, rendered him unable to perform his duties.
Plaintiff also cites Dr. Machado’s notes regarding plaintiff’s trigeminal nerve as evidence
of objective findings of a disability. Dr. Machado reported that plaintiff had “diminished
6
Plaintiff apparently interprets the Plan to mean that any medication constitutes
objective evidence of a disability, whether or not the medication causes side
effects that render a claimant unable to perform the essential functions of his or
her position. On the other hand, defendants implicitly interpret the Plan to mean
that medication only constitutes objective evidence of a disability if it renders the
claimant unable to perform his or her position. The Plan Administrator had
discretion to interpret all Plan terms, and its interpretation is not unreasonable
given that the ultimate issue in determining whether a claimant is entitled to
benefits is whether he or she is unable to perform the essential duties of his or her
position. Other courts reviewing Eaton’s disability plan have considered the side
effects of a claimant’s medication in determining whether the medication
constituted objective evidence of a disability under the plan. See, e.g., Scott v.
Eaton Corp. Long Term Disability Plan, 454 Fed. Appx. 154, 158, 161 (4th Cir.
2011); McGruder v. Eaton Corp. Short Term disability Plan, 2006 WL
3042798,at **10, 13 (D.S.C. Oct. 23, 2006).
15
sensation to pinprick in the entire right side of the face, diminished to light touch in right cheek
and jaw, but normal in right forehead, masseter 5/5.” To support his argument that this notation
is objective evidence of a disability, plaintiff relies on evidence outside the administrative record,
specifically, a medical journal article and a fact sheet from the National Institute of Health
regarding the trigeminal nerve. As an initial matter, the Court grants defendants’ Motion to Strike
plaintiff’s new evidence because the Court’s review is limited to the material in the
administrative record at the time the Plan Administrator made its decision denying plaintiff’s
benefits. See Evans v. Metro Life Ins. Co., 190 Fed. App’x 429, 434 (6th Cir. 2006). Moreover, as
defendants point out, Dr. Machado’s report does not connect plaintiff’s diminished sensation in
his trigeminal nerve to plaintiff’s headaches or to his ability to work. In fact, while Dr. Machado
stated that “[plaintiff] reports associated disability and [that he] has not been able to work due to
the pain in recent months,” the doctor did not reach any conclusions about whether the headaches
rendered plaintiff disabled or unable to perform his duties at Eaton. Nor did any of plaintiff’s
other treating physicians conclude that this diminished feeling caused or exacerbated plaintiff’s
cluster headaches or affected his ability to work. Contrary to plaintiff’s assertion, the MIRoA
neurologist did not “cherry pick” which evidence he or she relied on in concluding that the record
contained no objective evidence that plaintiff was unable to perform his job. While the
neurologist did not specifically mention the notation regarding the trigeminal nerve, he reviewed
Dr. Machado’s report and noted that the “examination revealed normal mental status, cranial
nerve, motor, cerebellar and reflex examinations.” (AR 1108). In short, a conclusion that Dr.
Machado’s notation regarding plaintiff’s trigeminal nerve constitutes objective evidence of a
disability would be based on mere conjecture.
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Finally, plaintiff complains that, although the MIRoA neurologist accepted that plaintiff
had “debilitating headaches” two to six times a day, defendants never ordered a vocational
analysis to determine plaintiff’s ability to perform his duties in light of the symptoms from his
headaches. First, plaintiff mischaracterizes the neurologist’s statement in his report. The
neurologist did not state that the headaches were “debilitating”; he stated only that “th[e]
patient has a history of cluster headaches that are occurring on a daily basis.... In between attacks,
which occur two to six times per day, he is asymptomatic.” Second, the severity of plaintiff’s
headaches is supported in the record only by plaintiff’s own subjective complaints. Third,
nothing prohibited plaintiff from seeking his own vocational analysis. Lastly, plaintiff cites no
case law that would require the Plan Administrator to perform a vocational analysis, particularly
in light of a record containing substantial evidence that plaintiff was not disabled according to the
Plan’s definition.
2. Conflict of Interest
As noted above, an inherent conflict of interest exists when a plan administrator both
pays benefits and is vested with discretion to determine eligibility for benefits. Such a conflict
“prove[s] more important…where circumstances suggest a higher likelihood that it affected the
benefits decision.” Metro Life Ins. Co. v. Glenn, 554 U.S. 105, 117 (2008). When a claimant
“offers more than conclusory allegations of bias,” a court should give greater weight to the
conflict. DeLisle v. Sun Life Assurance Co. of Canada, 558 F.3d 440, 445 (6th Cir. 2009). Here,
the record is devoid of any evidence that the conflict affected the Plan Administrator’s
determination that plaintiff’s headaches did not render him unable to perform the regular
functions of his job. Rather, as discussed above, the benefits determination was based on a
17
thorough review of the record, which included substantial evidence that plaintiff's condition was
not objectively disabling. See Schwalm v. Guardian Life Ins. Co. of Am., 626 F.3d 299, 311-312
(6th Cir. 2010) (finding that conflict did not render decision arbitrary and capricious where the
administrator “provided a thorough review of the record and there [was] no indication that the
review was improperly influenced by the inherent conflict of interest”).
3. File Review
The Sixth Circuit has consistently held that there is “nothing inherently objectionable
about a file review by a qualified physician in the context of a benefits determination.” Calvert v.
Firstar Fin., Inc., 409 F.3d 286, 296 (6th Cir. 2005). Still, “an administrator’s decision to conduct
a file-only review might raise questions about the benefits determination, particularly where the
right to conduct a physical examination is specifically reserved in the plan. Judge v. Metropolitan
Life Ins. Co., 710 F.3d 651, 663 (6th Cir. 2013). In evaluating the propriety of an administrator’s
reliance on a file review, a court should consider whether the file review takes into account the
employee’s entire file, provides reasons for rejecting the opinions of treating physicians, and
makes credibility determinations. Id.; Calvert, 409 F.3d at 296-97; Fura v. Fed. Exp. Corp. Long
Term Disability Plan, 534 Fed. App’x 340, 343 (6th Cir. 2013).
Here, the Plan reserves the right to conduct a physical examination, but the file review
conducted by the two independent neurologists is of the kind that the Sixth Circuit deemed
acceptable in Judge. Like in Judge, the neurologists reviewed all of the evidence in the file, made
no credibility determinations about plaintiff, and made note of where plaintiff’s treating
physicians’ reports lacked objective medical evidence. See Judge, 710 F.3d at 663. Indeed, as
plaintiff notes, the reviewers accepted plaintiff’s statements about the severity and frequency of
18
his headaches. In coming to a different conclusion than plaintiff’s treating physicians about
whether he was disabled, however, the reviewers explained that: the results of his neurological
examinations were normal; his record showed no evidence of physical abnormalities other than
his own complaints of headache pain; there was no evidence of any side effects from medication
that would prevent him from doing his job; some medication had been successful in abating the
headaches; and, ultimately, there was no objective evidence in the record to support a finding of
disability. Moreover, both reviewers made reasonable attempts to talk with plaintiff’s treating
physicians, calling several times and leaving messages about the nature of their phone calls, and,
in fact, Dr. Graham spoke with Dr. Rorick, who did not report any neurological exam
abnormalities or adverse side effects from medication. For these reasons, it was not arbitrary and
capricious for the Plan Administrator to rely on the file review in making its determination that
plaintiff was not entitled to short term disability benefits.
4. Social Security Determination
There is no evidence in the record of any disability finding by the Social Security
Administration.
For the foregoing reasons, the Court concludes that defendants’ decision to deny plaintiff
short term disability benefits was not aribitrary and capricious because it gave due weight to
plaintiff’s evidence and was supported by a deliberate, principled reasoning process and
substantial evidence.
B. Denial of Long Term Disability Benefits
Plaintiff argues that defendants wrongfully denied him long term disability benefits when
they refused to provide him with the long term disability application. As noted above, “the
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ultimate issue in an ERISA denial of benefits case is not whether discrete acts by the plan
administrator are arbitrary and capricious but whether its ultimate decision denying benefits was
arbitrary and capricious.” Spangler v. Lockheed Martin Eergy Sys., Inc., 313 F.3d 356, 362 (6th
Cir. 2002). Here, defendants’ decision to deny plaintiff long term disability benefits was not
arbitrary and capricious. To be eligible for long term disability benefits, a participant must have a
“covered disability” that prevents him from working for longer than six months and be under the
continuous care of a physician. A participant has a covered disability under the Plan, if, as the
result of an illness or injury, during the first twenty-four months, the participant is “totally and
continuously unable to perform the essential duties of [his or her] regular position with the
company or the duties of any suitable alternative position with the Company.” Once the Plan
Administrator determined that plaintiff was not entitled to short term disability benefits after May
7, 2014, plaintiff necessarily failed the test for long term disability benefits because he could not
show that he had a covered disability that prevented him from working for longer than six
months. Thus, even if it would have been more appropriate for the defendants to provide him
with a copy of the application packet, defendants did not wrongfully deny him long term
disability benefits.
C. Adequacy of the denial letter
Plaintiff complains that the final denial letter is deficient because it contains “no actual
explanation or analysis.” (Pl.’s Br. at 21). 29 U.S.C. § 1133 requires that a plan administrator
provide adequate notice to the claimant of the specific reasons for a claim denial and an
opportunity for the claimant to have the decision reviewed by the fiduciary. The Sixth Circuit
applies a “substantial compliance” test in determining whether an administrator has complied
20
with the notice requirements of § 1133. This test “considers all communications between an
administrator and plan participant to determine whether the information provided was sufficient
under the circumstances.” Wenner v. Sun Life Assur. Co. of Canada, 482 F.3d 878, 881 (6th Cir.
2007) (quotations omitted). If, as a whole, the communications between the administrator and
participant fulfill § 1133’s purposes, an administrator’s decision will be upheld even where the
“particular communication does not meet those requirements.” Id. (quotations omitted).
When all of the communications between defendants and plaintiff are taken into account,
the Court finds that they meet § 1133’s notice requirements. The initial denial letter informed
plaintiff that his claim was denied because he did not meet the Short Term Disability Plan
provisions requiring objective findings of a disability or the requirement that a physician verify to
Sedgwick’s satisfaction that plaintiff could not perform the essential duties of his position
because of his disability. It informed plaintiff that the denial was based on a review of the
documentation that Dr. Rorick had provided, summarized the deficiencies in Dr. Rorick’s report,
and noted that Dr. Rorick had released plaintiff to work on May 7, 2014. The letter also
explained the process for appealing and included an appeal form. (AR 118). The initial appeal
denial letter informed plaintiff of the relevant plan provisions and noted that the decision was
based upon a review of the entire file, including the reports from Drs. Rorick, Baron, and
Graham. It explained that plaintiff was being denied benefits because the record did not contain
any neurological or physical abnormalities or any objective findings that would support an
impairment that precluded him from performing his job duties as of May 7, 2014. The letter
explained his right to appeal, his right to submit additional medical evidence, and that he could
receive free copies of all documents, records, and other information relevant to his claim for
21
benefits. Lastly, the final denial letter identified the relevant plan provisions and explained that
the substantial weight of all of the medical documentation supported the conclusion that
plaintiff’s condition was not covered by the Plan. It also informed plaintiff that he could request
free copies of the documents and records that were considered in the benefits determination and
explained his right to file a civil action under ERISA. Taken together, these letters gave plaintiff
a consistent and sufficiently thorough explanation of why his claim was being denied such that
he would understand the defects he needed to cure and the process he needed to follow in order
to be entitled to benefits.
Plaintiff further argues that defendants’ reliance on the review of an anonymous physician
from MRIoA deprived him of a full and fair review of his claim. He argues that “[t]he
thoroughness of the review by Defendants comes into question as they rely nearly exclusively on
the previously hidden file review by MRIoA.7 The [independent medical examination] is not
even signed by a doctor, nor is there an actual examination.” (Pl.s Br. at 22). As an initial matter,
plaintiffs’ characterization that defendants’ final denial is based “nearly exclusively” on the
report from the anonymous MRIoA physician is not supported by the record. As just noted,
defendants informed plaintiff that the denial was based on a review of the entire record;
moreover, the denial would have been supported by substantial evidence even without the
anonymous physician’s review. With respect to plaintiff’s objection that the anonymous
physician did not examine plaintiff, the Court has already addressed the defendants’ decision to
7
Plaintiff asserts that defendants intentionally withheld the MRIoA physician
report but provides no evidence of this other than the fact that it was not included
in the Administrative Record when defendants initially provided it to plaintiff in
November of 2015. But once defendants were aware of the omission, they
provided the report to plaintiff.
22
conduct a file review and concluded that it was not arbitrary and capricious. Finally, the fact that
the report is not signed by a doctor is immaterial. The report identifies the physician’s
qualifications, and the denial letter informed plaintiff that “[his] identify may be forwarded to
[plaintiff] upon written request to the Plan Administrator.” (AR 551). Plaintiff does not provide
any evidence that he submitted such a written request. See Houser v. Alcoa, Inc. Long Term
Disability Plan, No. CIV.A. 10 160, 2010 WL 5058310, at *11 12 (W.D. Pa. Dec. 6, 2010)
(rejecting claimant’s argument that denial was arbitrary and capricious because administrator
relied in part on review by anonymous physician from MRIoA and noting that ERISA “does not
prohibit plans from consulting with an unidentified medical expert in connection with the grant
or denial of benefits”); McGruder v. Eaton Corp. Short Term Disability Plan, No. CIVA 3:06
418 CMC, 2006 WL 3042798, at *13) (finding that administrator’s denial decision, which was
based in part on review by anonymous physician from MRIoA, was not arbitrary and capricious).
D. The Administrative Record
In his brief, plaintiff complains that defendants have not provided a complete
administrative record. As support, he notes that the record “has a number of omissions or
redacted pages.” (Pl.’s Br. at 25) (citing pages 422, 430, 444, 451, and 820 of the record).
Plaintiff’s argument is not well-taken. On March 23, 2016, plaintiff’s counsel raised the concern
about these pages with defendants’ counsel and asked defendants’ counsel to provide the pages
in unredacted form or to provide a privilege log. On March 25, 2016, defendants’ counsel
emailed plaintiffs’ counsel a declaration from Matthew Wicklander, the Assistant Vice President
of Operations and Client Services at Sedgwick, which states that no pages were redacted from
the administrative record. Specifically, Wicklander states: “I have reviewed pages 422, 430, 444,
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451, and 820 of the Administrative Record.... The pages have not been redacted and no
information has otherwise been removed. The phrase ‘Restricted Proprietary Information’ is used
by Sedgwick on certain notifications. It is a legend to identify information restricted from further
disclosure; it does not indicate that information has been redacted or otherwise removed from the
document(s).” (Def.’s Mem. in Opp., Ex. A-4). Plaintiff offers no reason that the Court should
question the veracity of Wicklander’s declaration, and the Court finds that the administrative
record is complete.
CONCLUSION
For the foregoing reasons, defendants’ Motion for Judgment on the Administrative
Record (Doc. 40) is GRANTED, and plaintiff’s motion (Doc. 39) is DENIED. Plaintiff’s Motion
for Leave to File Reply Brief (Doc. 45) is GRANTED, and Defendant’s Motion to Strike (Doc.
46) is GRANTED.
IT IS SO ORDERED.
/s/ Patricia A. Gaughan
PATRICIA A. GAUGHAN
United States District Judge
Dated: 6/28/16
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