Hagerman v. Prudential Life Insurance Co. of America
Filing
31
OPINION and ORDER granting 22 Defendants' Motion for Judgment on the Administrative Record and denying 24 Plaintiff's Motion for Judgment on the Administrative Record. Signed by Judge George C. Smith on 2/22/18. (sem)
UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF OHIO
EASTERN DIVISION
STANLEY A. HAGERMAN,
Plaintiff,
v.
Case No.: 2:16-cv-932
JUDGE GEORGE C. SMITH
Magistrate Judge Jolson
AMERICAN ELECTIC POWER
SERVICE CORPORATION, et al.,
Defendants.
OPINION AND ORDER
Plaintiff Stanley A. Hagerman brings this action pursuant to the Employee Retirement
Income Security Act of 1974 (“ERISA”), as amended, 29 U.S.C. § 1132. On August 25, 2017,
Hagerman and Defendants American Electric Power Service Corporation and AEP Long-Term
Disability Plan (collectively, “AEP”) each moved for judgment on the administrative record.
(Docs. 22 and 24). Responses have been filed and these motions are now ripe for review. For
the following reasons, Hagerman’s motion is DENIED and AEP’s motion is GRANTED.
I.
BACKGROUND
Plaintiff Stanley Hagerman was employed as a senior generation dispatcher by Defendant
American Electric Power Service Corporation (“AEP”) until February 23, 2015. (Doc. 23,
Administrative Record (“AR”) 4, 94–98). His position included the following responsibilities:
Dispatching AEP’s generation assets; communication with power plant operators,
and other personnel; monitor, record, and report on emission information;
directing power plant control room operators to take appropriate action to ensure
units are operated to support reliable operation of the Bulk Electric System.
(AR 660).
Hagerman was a participant in the long-term disability plan (the “Plan”) offered by AEP.
The Plan was administered by AEP and Prudential Insurance Company of America
(“Prudential”) performed claims administration services for AEP’s Plan. The relevant provisions
of the Plan are set forth in the AEP Long-Term Disability Plan in the Administrative Record
(“AR”), pages 101 through 120. Under the terms of the Plan, long-term disability benefits
become available after a participant has been disabled for 1,040 hours of regularly scheduled
work (this waiting period is called the “elimination period”), until 24 months following the date
of disability, if the participant can establish that she had “an illness or injury that requires the
regular treatment of a duly qualified physician that may reasonably be expected to prevent you
from performing the material duties of your own occupation with AEP” (the own occupation
standard). (Doc. 23, AR 106). If the employee continues to be disabled after the first 24 months
(the conclusion of the Plan’s “own occupation” period), to continue receiving long-term
disability benefits, the Plan requires the participant to establish that he had “an illness or injury
that requires the regular treatment of a duly qualified physician and that may reasonably be
expected to prevent you from performing the duties of any occupation for which you are
reasonably qualified by your education, training and experience” (the any occupation standard).
(AR 107).
Pursuant to the Plan, it is Plaintiff’s burden to provide proof of his disability. (AR 113)
(“When you apply for benefits, you must provide proof of your disability.”). The Plan requires
“satisfactory, written proof of objective medical information relating to [the applicant’s] illness
or injury which supports a functional impairment that renders [the applicant] to be disabled.” (Id.
at 111).
2
The Plan sets forth the rights and responsibilities of Prudential, as the claims
administrator responsible for determinations under the Plan’s claims and appeals procedures,
which include reviewing and processing LTD claims by eligible participants. (AR 113). As
claims administrator, Prudential’s decisions are final and binding. (AR 117).
A.
Hagerman’s medical conditions
Hagerman suffered a traumatic head injury in a motor vehicle accident in 1984 when he
was 18 years old. (AR 311). He had a seizure shortly following the accident, but was able to
prevent further seizures with medication (Tegretol) for about twenty years. (AR 311–12). He
experienced a handful of seizures during 2010–13, and then in December 2014, he requested to
change to an extended release form of his medication. (AR 126). Hagerman suffered another
seizure in January 2015 and was admitted to Mount Carmel East Hospital for several days in
February 2015 for Tegretol toxicity resulting from his medication change.
(AR 430).
Hagerman has not returned to work since his hospital admission on February 23, 2015.
From then on, Hagerman has not experienced any further seizures, but has “zoning out”
or “staring” spells and reports problems with his memory. (AR 343). Hagerman has several
other chronic conditions, including diabetes, hyperthyroidism, obstructive sleep apnea, epilepsy,
and facial swelling and hives caused by allergic reactions. (AR 127, 265).
On March 12, 2015, Hagerman was seen by his primary care physician, Dr. Randolph
Schultz, whose progress notes indicate that Hagerman was “to return to work pending next
Tegretol level being in therapeutic range. Patient agrees with plan.” (AR 358). However, on
March 24, 2015, Dr. Schultz issued an Attending Physician’s Statement (“APS”) stating that
Hagerman was disabled for the period of March 23–May 25, 2015, due to “mild cognitive
impairment since 2 seizures Feb 2015.” (AR 100). In the space for the date Hagerman was
released to return to work, Dr. Schultz wrote “N/A.” (Id.).
3
Dr. Schultz referred Hagerman for a neurological assessment of his epilepsy. (AR 342).
The neurological assessment was completed by Dr. Imad Najm on May 11, 2015. (Id.). Dr.
Najm noted Hagerman’s history of seizures and staring spells, describing the latter as “zones and
stares off with no associated [loss of consciousness], he can still hear and see what is going on
around him and is unable to respond.”
(AR 343).
Dr. Najm’s notes also indicate that
Hagerman’s seizures were now well-controlled with medication, and that “[a]s for the zoning out
spells, we are at this time unclear of the etiology of these events. They could be dialeptic
seizures, or possibly brief microsleep episodes as a result of his sleep apnea.” (AR 346). The
staring spells were occurring every day. (Id.). Dr. Najm instructed Hagerman not to drive until
he was seizure-free for at least six months, and that he should not engage in unsupervised
bathing or swimming, use of heavy machinery, or use of sharp moving objects. (AR 346–47).
Hagerman also underwent EEG monitoring for several days from May 7 to May 12,
2015, under the supervision of Dr. Andreas Alexopoulos. (AR 125). During this period, he
reported experiencing three seizures, but no change in EEG activity was observed. (AR 128).
Hagerman also underwent an MRI, the results of which were normal. (AR 131). In his
discharge instructions, Dr. Alexopoulos stated, “[Hagerman] was not cleared to return to work.”
(Id.).
On June 9, 2015, Susan Rojc, PA-C, issued an APS stating that Hagerman was disabled
for the period of May 7–August 20, 2015, “at least,” and that his return to work date would be
determined after an upcoming follow up appointment with Dr. Najm on August 20, 2015. (AR
99). Ms. Rojc left blank the section of the form to explain the reasons for Hagerman’s work
restrictions, but noted a primary diagnosis of “spells” and a subjective finding of “seizures.”
(Id.).
4
Hagerman saw Dr. Najm for a follow up appointment on August 20, 2015, at which time
Hagerman reported continued staring spells and speech problems.
(AR 298).
Dr. Najm
discussed with Hagerman the possibility that his symptoms were caused by conversion disorder.
(Id.). Dr. Najm also recommended that Hagerman be seen by the Center for Brain Health for
further evaluation. (Id.).
B.
Initial denial of disability benefits
Prudential’s claims manager referred Hagerman’s file to Dr. Jonathan Mittelman, a
board-certified specialist in occupational and environmental medicine, for review on September
25, 2015. (AR 667–69). Dr. Mittelman reviewed the medical records that had been provided to
Prudential at that time: records from his February 2015 hospitalization at Mount Carmel East for
Tegretol toxicity; Dr. Schultz’s progress notes and March 2015 APS; Dr. Najm’s May 2015
neurological assessment; records from Dr. Alexopoulos’s EEG monitoring in May 2015; Rojc’s
June 2015 APS; Dr. Najm’s notes from the August 2015 follow up appointment. (Id.).
Dr. Mittelman concluded that standard post-seizure diagnosis restrictions (including no
unsupervised bathing or swimming, no use of heavy machinery, no use of sharp moving objects,
and avoidance of heights) were supported by Hagerman’s currently available medical records;
but the same did not disclose any cognitive testing that would speak to Hagerman’s self-reported
cognitive changes. (Id.). Dr. Mittelman determined that Hagerman’s physicians’ basis for
keeping Hagerman off work was the unclear cause of Hagerman’s staring or zoning out spells.
(AR 669). In Dr. Mittelman’s opinion, Hagerman would be limited in performing his job duties
only during his brief staring spells, and although these spells are unpredictable in their frequency,
it was unclear whether they would “prevent[ ] him from performing sustainable job duties.”
(Id.). Therefore, “there appears to be no support for it need for such restriction [sic].” (Id.).
5
Dr. Mittelman also noted that Hagerman had recently undergone a neurological
assessment with Dr. Jagan Pillai and was scheduled to undergo neuropsychological testing in
November. He listed obtaining records from these assessments as a next step. (Id.).
Based on Dr. Mittelman’s file review, Prudential denied Hagerman’s claim for long-term
disability benefits on October 1, 2015. (AR 626–29). In its denial letter, Prudential noted that it
had reviewed the medical information from Dr. Schultz and Drs. Najm, Alexopoulos, and Pillai
of the Cleveland Clinic. (AR 627). Prudential summarized the contents of these medical
records, concluding that Hagerman’s medical records did not support impairment that would
prevent Hagerman from performing the material and substantial duties of his own occupation.
(AR 627–28). Rather, Prudential concluded that the available medical information supported
that Hagerman would be limited only during his brief staring spells. (AR 627).
C.
Hagerman’s first appeal
On December 11, 2015, Hagerman sent a letter to Prudential appealing the denial of
disability benefits and enclosing additional medical records for Prudential’s review.
Hagerman had undergone a further neurological assessment with Dr. Jagan Pillai at the
Center for Brain Health on September 10, 2015. (AR 328). Hagerman’s main concerns at this
time were “if he can return to work in a power plant and if his speech changes will improve.”
(Id.). Dr. Pillai administered several tests, including the Montreal Cognitive Assessment (on
which he scored 22/30), a dementia mental status exam, and a neurological exam. (AR 329–31).
Dr. Pillai concluded that Hagerman had deficits in working memory and attention and
recommended “neuropsychologic testing to help determine level of disability/ability to work.”
(AR 331).
On September 25, 2015, Dr. Najm issued an APS stating that Hagerman was disabled for
the period of May 7, 2015 to November 30, 2015. (AR 295). By way of explanation, Dr. Najm
6
stated, “cognitive changes being evaluated, work ability to be determined after 11/6/15 testing.”
(Id.). Dr. Najm stated that Hagerman’s return to work date would was “to be determined after
testing in Nov.” (Id.).
Hagerman underwent a neuropsychological evaluation with Dr. Aaron Bonner-Jackson at
the Center for Brain Health on November 11, 2015.
(AR 311).
Dr. Bonner-Jackson
administered several stand-alone and embedded indices of performance validity and task
engagement, which indicated Hagerman “put forth a consistent and credible effort on the
evaluation.” (AR 313). While Dr. Bonner-Jackson did observe cognitive deficits, he classified
them as mild:
Taken together, results of this exam are suggestive of fairly mild weaknesses
primarily affecting frontal-executive cognitive skills. . . . With regard to work,
the patient’s cognitive profile suggests some inefficiencies that may hinder his
performance, and he will likely be more effective with better control of his mood
symptoms. As such, he may consider returning to work on a part-time basis (if
possible). Should he return to work, he is advised to use any memory and
organizational strategies at his disposal to remind him of tasks to complete.
Focusing on one task at a time and limiting potential distracters will also be
important.
(AR 314).
Hagerman was seen again by Dr. Pillai on November 17, 2015. (AR 332). Dr. Pillai
reviewed Dr. Bonner-Jackson’s November 11, 2015 neuropsychological evaluation, and, noting
the mild cognitive impairments observed in that assessment, stated that “[Hagerman] is cleared
to work in some occupations or part time in others for which he has to discuss with occupational
medicine at his place of work.” (Id.).
Contemporaneous with his neurological and neuropsychological assessments, Hagerman
was also being seen by Dr. Philip Berger, a family physician, and Premier Allergy for serious
allergic reactions including facial swelling and chronic hives. (AR 466–81, 513–35; AR 372–92,
537–86). On December 8, 2015, Dr. Philip Berger issued an APS stating that Hagerman’s return
7
to work date was “N/A” due to impairments of “breathing, weakness” and “shortness of breath.”
(AR 303). Progress notes from a visit with Dr. Berger of the same date noted that Hagerman had
recently visited the emergency room due to facial swelling. (AR 513).
Prudential arranged for an independent neuropsychologist to review Hagerman’s file
(including the new records received in December 2015 and Hagerman’s job description) and
answer questions about his functional limitations. (AR 634–36). On February 15, 2016, Dr.
Glen Getz, a board-certified neuropsychologist, submitted a neuropsychology file review in
response to Prudential’s referral questions. (AR 180–87). Dr. Getz concluded that, “[t]aken as a
whole, the medical records reviewed do not support the claim of the presence of validated mental
health difficulties that would have a significant psychological or cognitive impact and result in
any medically necessary restrictions and/or limitations from February 2015 through the present
time.” (AR 185).
Based on Dr. Getz’s file review, Prudential sent a letter to Hagerman on February 18,
2016. (AR 639–44). The letter reviewed in detail all of the records reviewed by Dr. Getz and
the specific conclusions he reached with respect to those records. (Id.). In particular, both Dr.
Getz in his file review and Prudential in its February 18, 2016 letter addressed Dr. BonnerJackson’s neuropsychological evaluation at length, including the raw data from the 12 different
cognitive tests administered by Dr. Bonner-Jackson. As noted by Dr. Getz and Prudential, all of
Hagerman’s scores were in the low-average to average range. (AR 641). Even Dr. BonnerJackson, Hagerman’s own doctor who determined Hagerman had “mild” cognitive impairments,
did not conclude that those impairments required work restrictions. (AR 314). For these
reasons, Prudential upheld its initial denial of disability benefits. (AR 643).
8
D.
Hagerman’s Second Appeal
On April 12, 2016, Hagerman’s counsel sent a letter to Prudential providing notice of
Hagerman’s second-level appeal of the denial of benefits and requesting an extension of time for
submission of additional medical records for Prudential’s review. (AR 337).
On June 14, 2016, Hagerman’s counsel submitted a large volume of medical records to
Prudential, which largely appeared to be either duplicative of, or providing further detail
regarding, Hagerman’s February 2015 hospitalization at Mount Carmel for seizures; his May
2015 hospitalization and EEG monitoring at the Cleveland Clinic; progress notes from
Hagerman’s primary care physician, Dr. Schultz; and Hagerman’s treatment by Dr. Berger and
Premier Allergy for facial swelling and hives. (AR 210–586).
Hagerman’s counsel also
submitted records indicating that Hagerman was seen by Rachel Falsone, CNP, and Dr. James
Fagan beginning in January 2016 for issues related to his obstructive sleep apnea, chronic cough,
and allergic reactions. (AR 443–49; AR 450–51, 482–511). Falsone noted that Hagerman’s
sleep was interrupted frequently, causing excessive daytime sleepiness. (AR 444).
On June 22, 2016, Hagerman’s counsel also submitted records related to Hagerman’s
visit to the Mount Carmel emergency room on March 2, 2106 for facial swelling (which
triggered Dr. Berger’s initial referral to Premier Allergy). (AR 256–84).
On June 23, 2016, Prudential arranged for an independent panel, consisting of a
neurologist with a specialty in sleep medicine and a neuropsychologist, to undertake a file review
of all records submitted by Hagerman, as well as Hagerman’s job description. (AR 653–55).
Prudential specifically requested that the neuropsychologist undertake a further review of the raw
data from Dr. Bonner-Jackson’s neuropsychological testing. (Id.).
The panel review was conducted by Dr. Nick DeFilippis, a board-certified
neuropsychologist, and Dr. Len Grinman, who is board-certified in neurology and sleep
9
medicine. On July 13, 2016, after discussing Hagerman’s file with each other, Dr. DeFilippis
and Dr. Grinman each submitted separate written evaluations of Hagerman’s medical records.
(AR 593–611). In particular, Dr. DeFilippis reviewed the raw data from Dr. Bonner-Jackson’s
neuropsychological assessment and concluded that this assessment “only identified a few
scattered low-average/borderline scores with most neuropsychological testing in the average to
above average ranges.” (AR 598). Dr. DeFilippis further noted it was unfortunate that “Dr.
Bonner-Jackson had not administered a measure of personality functioning that could have
possibly identified somatization. This was mentioned by the Cleveland Clinic as a possibility
after the claimant had video monitoring that did not show EEG changes when the claimant was
exhibiting seizure-like activity.” (Id.).
For his part, Dr. Grinman concluded that Hagerman’s “staring episodes” “are not seizures
and are not formally impairing” because they “last for seconds and do not preclude working.”
(AR 610–11). While Dr. Grinman recommended continuation of general seizure precautions (no
driving, swimming, use of heavy machinery, etc.), he found “no other evidence of
impairment/limitation.” (AR 611). Both reviewers ultimately concluded that the records did not
support a physical or cognitive impairment that would prevent Hagerman from working for the
period of February 24, 2015 onward. (Id.).
On July 21, 2016, Prudential sent a letter to Hagerman’s counsel informing her that
Prudential had once again upheld its denial. (AR 658–61). Prudential concluded that job
restrictions related to the seizure diagnosis (no climbing, no working at unenclosed heights, no
commercial driving, no sharp objects, and no operation of heavy machinery) were warranted.
(Id.) However, Hagerman’s job description indicated that his occupation is sedentary and does
not involve any of the restricted duties. (Id.). “Therefore, the medically supported restrictions
10
and limitations would not prevent him from performing the material duties of his own
occupation. As a result, he does not meet the plan’s definition of disability . . . .” (AR 661).
On September 27, 2016, Hagerman commenced this action. Both parties have now
moved for judgment on the administrative record. (Docs. 22 and 24).
II.
STANDARD OF REVIEW
Hagerman’s claim for benefits is governed by ERISA, as amended, 29 U.S.C. § 1132.
Section 502(a)(1)(B) gives Hagerman the right, as a participant of the Plan, to bring a civil action
“to recover benefits due to him under the terms of his plan, to enforce his rights under the terms
of the plan, or to clarify his rights to future benefits under the terms of the plan.” 29 U.S.C.
§ 1132 (a)(1)(B). The Court reviews a challenge to a denial of ERISA plan benefits under a de
novo standard “unless the plan provides to the contrary.” Metro. Life Ins. Co. v. Glenn, 554 U.S.
105, 111 (2008).
Under circumstances where the “benefit plan gives the administrator or
fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of
the plan,” the more deferential “arbitrary and capricious” standard of review applies. McCartha
v. Nat’l City Corp., 419 F.3d 437, 441 (6th Cir. 2005) (citing Firestone Tire & Rubber Co. v.
Bruch, 489 U.S. 101, 115 (1989)).
Prudential argues that the Court should review under the arbitrary and capricious
standard, and Hagerman concedes as much. The Plan at issue in this case specifically states:
[AEP] has delegated its claims administration authority for reviewing and
processing LTD claims by eligible participants to a claims administrator. As of
January 1, 2009, the Prudential Insurance Company of America (“Prudential”) is
the plan’s claims administrator.
(AR 113).
This Court has previously found that the aforementioned language sufficiently delegates
discretionary authority to determine eligibility for benefits. See Milam v. Am. Elec. Power Long
11
Term Disability Plan, No. 2:11-cv-77, 2012 WL 4364304, *3 (S.D. Ohio Sept. 24, 2012)
(Marbley, J.) (“the benefit plan gives the administrator discretion to determine eligibility for
benefits or to construe the terms of the plan”). There is no question that Prudential made the
final decision regarding Plaintiff’s long-term disability benefits. Accordingly, the Court will
apply the arbitrary and capricious standard to this case.
The arbitrary and capricious standard is the least demanding form of judicial review of
administrative action. Evans v. UnumProvident Corp., 434 F.3d 866, 876 (6th Cir. 2006).
Under this standard, a court will uphold an administrator’s decision if it is rational in light of the
plan’s provisions. McDonald v. Western-Southern Life Ins. Co., 347 F.3d 161, 169 (6th Cir.
2003) (citation omitted). “[W]hen it is possible to offer a reasoned explanation, based on the
evidence, for a particular outcome, that outcome is not arbitrary and capricious.” Id.; see also
Baker v. UMWA Health & Ret. Funds, 924 F.2d 1140, 1144 (6th Cir. 1991) (“Applying the abuse
of discretion standard in this context requires that the [administrator’s] decision be upheld if it is
the result of a deliberate, principled reasoning process and if it is supported by substantial
evidence.”). The arbitrary and capricious standard, however, does not require a court to merely
rubber stamp the administrator’s decision; instead, a court “must exercise review powers.” Jones
v. Metro. Life Ins. Co., 385 F.3d 654, 661 (6th Cir. 2004).
When conducting its review of a denial of benefits claim, the Court is generally “limited
to consideration of the information actually considered by the administrator.” Killian v.
Healthsource Provident Adm’rs, Inc., 152 F.3d 514, 522 (6th Cir. 1998); see also Marks v.
Newcourt Credit Grp., Inc., 342 F.3d 444, 457 (6th Cir. 2003). The Court is required to review
the plan administrator’s decision based on the administrative record and render findings of fact
and conclusions of law accordingly. Wilkins v. Baptist Healthcare Sys., Inc., 150 F.3d 609, 619
12
(6th Cir. 1998). In reviewing the record and the administrator’s determination, however, the
Court will take into consideration (if present) the fact that a defendant is acting under a conflict
of interest based on being both the decision-maker, who determines which claims are covered,
and the payor of those claims. Glenn, 554 U.S. at 115–16; Johnson v. Conn. Gen’l Life Ins. Co.,
324 F. App’x 459, 465 (6th Cir. 2009). The weight that a conflict of interest receives is
determined by case-specific factors. Glenn, 554 U.S. at 116–17 (“[C]onflicts are but one factor
among many that a reviewing judge must take into account.”); Johnson, 324 F. App’x at 465–66.
III.
DISCUSSION
Hagerman asserts that he was and is disabled “primarily due to his cognitive
impairments, his seizure and staring spell disorders, and in part due to the medications he is
required to take.” (Doc. 24, Hagerman’s Mot. at 18). He argues that he was wrongfully denied
long-term disability benefits by Prudential because: (1) the medical and vocational evidence
supports the existence of a cognitive impairment that limited Hagerman’s ability to perform the
material duties of his occupation; and (2) Hagerman was not afforded a full and fair review.
Prudential counters these arguments by asserting the medical evidence does not support
Hagerman’s claim, and that Prudential afforded Hagerman a full and fair review when it had his
medical records reviewed by three independent physicians (Drs. Getz, DeFilippis, and Grinman).
The Court will address each argument in turn.1
A.
The medical and vocational evidence
Hagerman contends “[t]here is no dispute that Mr. Hagerman suffers from: 1) random
seizures; 2) epilepsy; 3) cognitive impairments, which affect his judgment, speech and ability to
think clearly; and 4) staring spells.” (Doc. 24, Hagerman’s Mot. at 13). Hagerman also asserts
1
Hagerman also included a count in his Amended Complaint alleging that AEP failed to produce a complete claim
file in response to a demand by Hagerman’s counsel. (Doc. 11, Am. Compl. ¶ 13). Hagerman has indicated to the
Court and AEP’s counsel that he no longer intends to pursue this count and therefore it is DISMISSED.
13
that his job “required mental acuity, alertness and the ability to focus. The wide range of
symptoms he suffered from multiple disorders prevented him from performing these important,
mentally challenging functions.” (Id.). But unfortunately for Hagerman, his medical records do
not support this conclusion—not even according to Hagerman’s own treating physicians, Dr.
Pillai and Dr. Bonner-Jackson, who both determined that Hagerman’s mild cognitive
impairments did not prevent him from performing his job.
Further, the Attending Physician Statements asserting that Hagerman was disabled and
unable to work during the relevant period lack support. Rojc’s APS of June 9, 2015 left blank
the section of the form to explain the reasons for Hagerman’s work restrictions, stating that his
ability to return to work would be evaluated after a follow up appointment with Dr. Najm. (AR
99). Dr. Najm’s September 25, 2015 APS stated only that Hagerman’s “cognitive changes
[were] being evaluated, work ability to be determined after 11/6/15 testing.” (AR 295). These
two APSs, therefore, do not actually document any occupational impairments, but merely defer
any analysis of occupational impairments until further testing could be undertaken. Finally, Dr.
Berger’s APS of December 8, 2015 based Hagerman’s inability to work on “shortness of breath”
and “weakness” that were linked to Hagerman’s allergy-related conditions, but does not explain
how or why shortness of breath or weakness would limit Hagerman’s ability to perform his
sedentary occupation. (AR 303–05). These conclusory statements that a claimant is disabled
without supporting documentation are insufficient to qualify for benefits under the Plan. Boone
v. Liberty Life Assur. Co. of Boston, 161 F. App’x 469, 473–74 (6th Cir. 2005) (claims
administrator did not “arbitrarily” discredit claimant’s doctors’ findings of disability when such
findings were unsupported by objective medical evidence, as required by the plan); Jackson v.
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Metro. Life, 24 F. App’x 290, 293 (6th Cir. 2001) (“the district court did not err in rejecting the
treating physician’s conclusory opinion that Jackson could not work again.”).
Hagerman further asserts that he told Prudential in his first appeal letter that “AEP HR [ ]
notified me that I wouldn’t be allowed to return to work” and that Prudential disregarded this
information.
It is Hagerman’s “belief” that, had Prudential followed up with AEP for
clarification, AEP “would have advised that Mr. Hagerman’s condition created a safety hazard.”
(Id. at 14). But it is Hagerman’s responsibility to submit documentation of his inability to work
or that his condition created a safety hazard, and he has submitted no evidence from AEP to that
effect. As it stands, Hagerman’s assertion that his medical conditions created a safety hazard is
supported only by his attorney’s arguments, and not by the medical records and job descriptions
submitted for Prudential’s review. The Court therefore cannot consider these arguments at this
stage. Strickrath v. Hartford Ins. Co., No. C2-06-1080, 2008 WL 835686, at *1 (S.D. Ohio Mar.
28, 2008) (Sargus, J.) (court could not consider counsel’s representations regarding claimant’s
job duties without documentation in the administrative record); Madaffari v. Metrocall
Companies Grp. Policy GL, H-21163-0, Plan No. 501, No. 02 C 4201, 2005 WL 1458071, at
*12 (N.D. Ill. June 15, 2005) (counsel’s letter contained arguments, not undisputed facts, and
could not be considered by the court when unsupported in the administrative record).
Hagerman further argues that Prudential “gave insufficient consideration to the possible
effects of the medications Mr. Hagerman was taking,” which, “at least at some point in time,”
numbered as high as 20. (Doc. 24, Hagerman’s Mot. at 16). But as correctly pointed out by
Prudential, the medical records submitted by Hagerman do not speak to any impairment caused
by his medications. Nor did Hagerman or his counsel raise the possibility of medication-induced
side effects at any point during the administrative process.
15
Based on the records submitted by Hagerman, the Court does not find that Prudential’s
substantive evaluation of the available objective, medical evidence was arbitrary or capricious.
B.
Full and fair review
In addition to the substance of Prudential’s decision that Hagerman was not disabled,
Hagerman also challenges the procedural aspects of Prudential’s benefits denial. Hagerman
contends that his disability, which he characterizes as “primarily due to his cognitive
impairments, his seizure and staring spell disorders, and in part due to the medications he is
required to take,” presents itself in an inherently subjective manner “that [is] not verifiable from
a review of records, reports, or test results.” (Doc. 24, Hagerman’s Mot. at 18–19). As a result,
Hagerman argues, Prudential was required to arrange an independent in-person medical
examination—not merely have independent physicians review Hagerman’s file. (Id. at 19).
In making this argument, Hagerman attempts to transform a dispute over objective
medical evidence into one of credibility. Because the independent physicians who reviewed
Hagerman’s files determined he was not disabled, Hagerman concludes that, “[p]ut simply, these
physicians did not believe Mr. Hagerman.” (Id. at 20). While it is true that the Sixth Circuit has
raised concerns about physicians making credibility determinations about claimants without ever
personally examining them, it does not follow that every file review involves a credibility
determination. Javery v. Lucent Techs., Inc. Long Term Disability Plan for Mgmt. or LBA
Employees, 741 F.3d 686, 702 (6th Cir. 2014) (“[R]eliance on a file review is inappropriate
where a claims administrator disputes the credibility of a claimant’s complaints.”). Indeed,
accepting Hagerman’s argument that every adverse benefit determination involves a credibility
issue would mean that a claims administrator would never be able to rely on a file review in
denying benefits. The Sixth Circuit has expressly rejected this result. McKenna v. Aetna Life
Ins. Co., 620 F. App’x 445, 450–51 (6th Cir. 2015) (“[T]here is nothing inherently improper with
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relying on a file review, even one that disagrees with the conclusions of a treating
physician.”) (quoting Calvert v. Firstar Fin., Inc., 409 F.3d 286, 297 n.6 (6th Cir. 2005)).
In this case, all treating and reviewing physicians agree on the extent of Hagerman’s
impairments: he has a seizure disorder, and he has mild cognitive impairments. As to the former,
all treating and reviewing physicians agree that general seizure restrictions (no driving, climbing,
using heavy machinery, etc.) should be followed. As to the latter, all treating and reviewing
physicians (who provided more than a conclusory statement that Hagerman was disabled) agreed
these impairments would not materially interfere with the performance of his occupation as
senior generation dispatcher.
No one has suggested that Hagerman is malingering or
exaggerating the extent of his impairments; the treating and reviewing physicians simply do not
think that the impairments, as reported by Hagerman, will interfere with Hagerman’s job duties.
Therefore, this case does not involve a credibility dispute that requires an in-person independent
medical examination.
Finally, Hagerman argues that “it appears that Defendants were operating under a conflict
of interest. [AEP] is the plan administrator of the self-insured Plan, and is also responsible for
funding the Plan.” (Doc. 24, Hagerman’s Mot. at 21). If a conflict of interest were present, then
it would be a factor for the Court to consider in deciding whether Prudential’s determination was
arbitrary and capricious. Glenn, 554 U.S. at 115–16; Johnson v. Conn. Gen’l Life Ins. Co., 324
F. App’x 459, 465 (6th Cir. 2009). But Hagerman fundamentally misunderstands the type of
conflict courts are concerned with. While AEP funds the Plan, and makes determinations about
which employees are eligible to participate in the Plan, it has delegated the claims administration
process—i.e., the determination of which eligible claimants meet the Plan’s definition of
disability, thereby entitling them to financial benefits—to Prudential. (AR 113). Thus, it is not
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the case that AEP is both the decision-maker, who determines which claims are covered, and the
payor of those claims, and therefore no conflict of interest is present.
Accordingly, the Court finds no deficiencies with the procedures used by Prudential in
denying Hagerman’s claim for benefits.
IV.
CONCLUSION
For the foregoing reasons, the Court GRANTS AEP’s Motion for Judgment on the
Administrative Record and DENIES Hagerman’s Motion for Judgment on the Administrative
Record.
The Clerk shall remove Documents 22 and 24 from the Court’s pending motions list and
close this case.
IT IS SO ORDERED.
/s/ George C. Smith
GEORGE C. SMITH, JUDGE
UNITED STATES DISTRICT COURT
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