Brooks v. AT&T Umbrella Benefit Plan No. 1

Filing 27

OPINION AND ORDER, FINDINGS OF FACT AND CONCLUSIONS OF LAW. Signed by Honorable Cameron McGowan Currie on 11/5/2013. (cbru, )

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF SOUTH CAROLINA
COLUMBIA DIVISION
ANGELA BROOKS,

)
)
Plaintiff,
)
)
vs.
)
)
AT&T UMBRELLA BENEFIT PLAN
)
NO. 1,
)
)
Defendant.
)
___________________________________ )

C/A No. 3:13-CV-0610-CMC

OPINION AND ORDER
FINDINGS OF FACT AND
CONCLUSIONS OF LAW

Through this action, Plaintiff Angela Brooks (“Brooks”), seeks a determination that she is
entitled to both short-term disability (“STD”) and long-term disability (“LTD”) benefits under the
AT&T Umbrella Benefit Plan No. 1 (“Plan”). The matter is before the court for a decision on the
merits based on the parties’ written submissions.1
The parties disagree as to the standard of review to be applied (de novo or abuse of
discretion) as well as the proper result under either standard of review. They also disagree as to
whether Brooks has exhausted plan remedies as to LTD benefits.
For the reasons set forth below, the court concludes that the denial of Brooks’ claim for STD
benefits should be reviewed under the abuse of discretion standard and, under that standard, should
be upheld. Because an award (and exhaustion) of STD benefits is a prerequisite to an award of LTD

1

It is undisputed that the benefits at issue were provided as part of an employee welfare
benefit plan and that Brooks’ sole remedy arises under the Employee Retirement Income Security
Act of 1974 (“ERISA”). See, e.g.,29 U.S.C. § 1002(1) (defining employee welfare benefit plan); 29
U.S.C. § 1003 (providing ERISA’s scope of coverage); 29 U.S.C. § 1132(a)(1)(B) and (g) (ERISA”s
remedial provisions). The parties have consented to resolution of this action on the merits based on
their written submissions. See Dkt. No. 24 (Joint Stipulation).

benefits, this determination precludes any claim for LTD benefits. The court, therefore, directs entry
of judgment for the Plan.
DECISION OF THE COURT
Having fully considered the administrative record, relevant Plan documents, and the
memoranda of the parties, the court enters the following Findings of Fact and Conclusions of Law
pursuant to Rule 52(a) of the Federal Rules of Civil Procedure. To the extent any findings of fact
represent conclusions of law, or vice-versa, they shall be so regarded.
FINDINGS OF FACT
Brooks was employed by AT&T Mobility, LLC (“AT&T Mobility”) from March 2002 until
February 23, 2012. As an employee of AT&T Mobility, Brooks participated in the Plan, which
included a Disability Income Program (“DIP”) component. E.g., Dkt. No. 10 ¶ 5 (Am. Complaint);
Dkt. No. 12 ¶ 5 (Answer to Am. Complaint ); Dkt. No. 24-4 (Plan documents).
The Plan was administered by AT&T Inc. (“Plan Administrator”). As explained in more
detail below, the Plan Administrator delegated certain decision-making authority to a third-party
Claims and Appeals Administrator. Dkt. No. 12 ¶ 5; DIP 43-44, 46.2 The entity that filled both
roles was Sedgwick Claims Management Service, Inc. (“Sedgwick”). See infra at 5 n. 3.

2

The record of Brooks’ claim and related plan documents have been filed as two collective
exhibits in three electronic case filing (“ECF”) attachments. See Dkt. Nos. 24-2, 24-3, 24-4. The
first two of these ECF attachments (Dkt. Nos. 24-2 and 24-3) contain the administrative record
(“AR”). The court identifies these documents by referring to the AR page number in the lower right
hand corner of each page. Plan documents are contained in Dkt. No. 24-4. The most critical of the
Plan documents consists of the Summary Plan Description for the DIP, which the court identifies
by the DIP page number in the lower right-hand corner of each page.
2

A.

Relevant Plan Provisions
1.

Overview of Benefits

The DIP provides ongoing income (ranging from 60 to 100% of pay) to eligible employees
who become partially or totally disabled (as defined in the DIP) due to illness or injury. DIP 6. STD
benefits begin on the eighth consecutive calendar day of full or partial absence from work as a result
of an approved partial or total disability and continue for up to twenty-six weeks, provided the
eligible employee remains partially or totally disabled. Id. If the disability continues beyond twentysix weeks, the employee may be eligible for LTD benefits. Id. Thus, qualification for and
exhaustion of STD benefits is a prerequisite to an award of LTD benefits. See DIP 23 (to be
considered for LTD Benefits, an eligible employee must first “[r]eceive the maximum amount (26
weeks) of Short-Term Disability Benefits under the Program”).
2.

Definition of Disability

The DIP defines disability as follows:
When You Are Considered Disabled
You are considered disabled for purposes of Short-Term Disability
Benefits if you are found by the Claims Administrator to be Totally
Disabled or Partially Disabled.
...
You are considered Totally Disabled when, because of Illness or
Injury, you are unable to perform all of the essential functions of your
job or another available job assigned by your Participating Company
with the same full-time or part-time classification for which you are
qualified.
...
You are considered Partially Disabled when, because of Illness or
Injury, you are unable to perform all of the essential functions of your
job or another available job assigned by your Participating Company
3

within the same full-time or part-time classification for which you are
qualified, for the same number of hours that you were regularly
scheduled to work before your Partial Disability. No Short-Term
Disability Benefits will be paid if you do not return to work when you
are approved as Partially Disabled.
DIP 14-15.
In order to be considered for Short-Term Disability Benefits under the Program, an eligible
employee must: “Be under the care of a Physician and follow his or her recommended treatment
plan. The Claims Administrator will require that you periodically furnish satisfactory Medical
Documentation of your Partial or Total Disability from your Physician.” DIP 15.
3.

Plan Administration and Grant of Discretion

The DIP provides as follows regarding plan administration:
The Program is administered by AT&T. However, AT&T has contracted with third
parties for certain functions associated with this Program.
...
The Claims Administrator has been delegated authority by the Plan Administrator to
determine whether a particular Eligible Employee who has filed a claim for benefits
is entitled to benefits under the Program.
The Appeals Administrator has been delegated authority by the Plan Administrator
to determine whether a claim was properly decided by the Claims Administrator.
...
The Plan Administrator (or, in matters delegated to third parties, the third party that
has been so delegated) will have sole discretion to interpret the Program, including,
but not limited to, interpretation of the terms of the Program, determinations of
coverage and eligibility for benefits, and determination of all relevant factual matters.
Any determination made by the Plan Administrator or any delegated third party will
not be overturned unless it is arbitrary and capricious.

4

DIP 44 (emphasis added). The Plan Administrator, AT&T, Inc., delegated its decision-making
authority to third-party Claims and Appeals Administrator Sedgwick, which administered the AT&T
Integrated Disability Services Center (“IDSC”). DIP 31-33, 42-46.3
B. Brooks’ Claim and Medical Records
Brooks’ first day of absence relevant to her STD claim was May 5, 2011, thereby making her
potential “first day of disability” May 12, 2011. AR 47. Brooks remained out of work for a little
over eight months, returning to work full time and for full duty on January 17, 2012. Id.
On May 10, 2011, Sedgwick sent a letter and packet of documents to Brooks, confirming that
her claim had been initiated and explaining, in detail, the standards and documentation necessary to
support an award of benefits. AR 57-86. The letter advised Brooks as follows: “medical
information to substantiate your disability is due . . . by 05/20/2011.” AR 57. It also advised Brooks
that, “[t]o qualify for benefit payments under the AT&T disability plans, your medical condition
should involve a sickness or injury, supported by medical documentation that prevents you from
performing the duties of your job with or without reasonable accommodations.” AR 57. The
necessity for documentation of the disabling condition was emphasized including through the
following statement:

3

Sedgwick is not named in the DIP Summary Plan Description. That document does,
however, clearly indicate that the Plan Administrator has delegated its authority to resolve claims
and appeals (as well as its related discretion) to one or more third-party Claims and Appeals
Administrators. DIP 43-44. It is beyond dispute that Sedgwick fulfilled both roles, receiving claims
and appeals through the address provided for the AT&T Integrated Disability Service Center
(“IDSC”) and responding using correspondence reflecting that letterhead and identifying Sedgwick
as administrator of the IDSC. See, e.g., DIP 46 (directing participants to send claims and appeals
to the IDSC and providing an address); AR 57-66 (benefit application packet with multiple
documents bearing the letterhead “AT&T Integrated Disability Service Center . . . as administered
by Sedgwick CMS”); AR169 (denial letter to Brooks bearing same letterhead).
5

It is important that both you and your treating provider understand that these forms,
along with chart notes, diagnostic test results, hospital summaries, etc. specifically
related to the reason [for] your absence should be returned regardless of the length
of your disability. It is critical that your physician demonstrates by his/her
observations and clinical findings that you are unable to perform your work with or
without accommodations. This is the information, which will allow the case
manager to make a determination of your eligibility for benefit payments under the
AT&T disability plans.
AR 57.
On May 13, 2011, Brooks’ supervisor, Sheila Crisostomo (“Crisostomo”), sent an e-mail to
the Sedgwick employee handling Brooks’ claim, Disability Specialist Ruben Mortera (“Disability
Specialist Mortera” or “Mortera”). The e-mail contained information regarding Brooks’ duties as
a Retail Account Executive including a description of the physical requirements, which were
classified as “moderate.” AR 9-10.
On May 20, 2011, Brooks’ primary care physician, Dr. David Fisher, sent an eleven-page
facsimile to Sedgwick.

AR 93-103.

The facsimile contained only two pages of medical

documentation: a one-page “Initial Physician Statement” dated May 19, 2011, and a one-page office
note reflecting an doctor’s visit on May 6, 2011. AR 100, 101.4
On the Initial Physician Statement, Dr. Fisher indicated that the “Diagnosis current and
contributing” for Brooks was “Sjogren’s Syndrome 710.2; Hypothyroidism 244.9; Raynaud’s 433;
[and] Fatigue 780.79.” AR 100. The form listed the following symptoms reported by the patient:
“profound fatigue; slowed mentation.” Under “Observed clinical findings[,]” Dr. Fisher listed
“depressed mood.” Dr. Fisher indicated that the current plan of treatment was “Prednisone, B12
injections,” and a possible prescription of Plaquenil. In response to a query whether the plan of
4

The remaining pages consisted of multiple copies of instructions and signed and unsigned
authorization forms.
6

treatment was expected to improve Brooks’ condition, Dr. Fisher wrote: “yes, but may take 4-6 wks
to elicit improvement in symptoms.” AR 100. In response to a request for “date and description of
treatment during the past three months[,]” Dr. Fisher wrote “5/19/11, 5/6/11[.]” He provided no
response to the query: “Are there current functional restrictions? If yes, what are they and what is
the anticipated duration of the restrictions?” Under a section for “Additional Comments,” Dr.
Fisher wrote: “OOW 5/6/11 - 6/21/11.” In context, the letters “OOW” appear to stand for “out of
work,” as the dates indicated are consistent with Dr. Fisher’s statement that improvement might be
expected within four to six weeks. AR 100.
The office note from Brooks’ visit to Dr. Fisher on May 6, 2011, thirteen days before the
Initial Physician’s Statement was completed, provides little additional information. AR 101. It
reads, in full, as follows:
S:
Ms. Brooks is a 28-year-old who presents today to follow up on her history
of Sjogren’s syndrome and hypothyroidism with previous thyroiditis. She stopped
taking Plaquenil from Dr. Fant, her rheumatologist, because of adverse side effects,
but she is having what she feels like is an exacerbation of Sjogren’s or thyroiditis
with profound fatigue.
O:
BP 112/66, pulse 74, WT 120. Her mood and affect are appropriate. No
thyromegaly. Heart is RR. Lungs are clear.
LABS:
A:

I am checking her thyroid and antibodies.
Sjogren’s syndrome and hypothyroidism with previous thyroiditis.

P:
Armour Thyroid 120 mb one q.d. #90 x 1 refill. Armour Thyroid 30 mg q.d.,
#90 x 1 refill, and I put her on a Sterapred 5 mg 6-day dosepak for Sjogren’s flare.
I will notify her if her thyroid hormones or antibodies are abnormal. Otherwise, We
will see her back in six months with fasting labs a week prior and p.r.n.
AR 101.

7

Thus, like the May 19, 2011 Initial Physician Statement, this May 6, 2011 office visit note
primarily documents Brooks’ subjective (“S:”) report of what she believed was an exacerbation of
Sjorgen’s syndrome with “profound fatigue.” The objective (“O:”) and assessment (“A:”) sections
do not mention any functional limitations or necessity for an absence from work. Neither does the
May 6, 2011 office note refer to observation of a depressed mood (as noted on the Initial Physician
Statement). Instead, the note of the May 6, 2011 office visit refers to Brooks’ mood and affect as
“appropriate.” Further, while the May 6, 2011 office visit note refers to requested laboratory work,
no results were provided with the claim. Neither are any laboratory results mentioned in the
accompanying May 19, 2011, Initial Physician Statement.
C.

Initial Claim Review and Denial

On or about May 25,2011, Sedgwick assigned medical review of Brooks’ claim to David L.
Hinkamp, M.D., a board-certified occupation/environmental medicine physician.5 AR 15-17. Dr.
Hinkamp completed his review of Brooks’ record and claim by May 31, 2011, and summarized his
conclusions as follows:
The medical notes document that the [employee] was seen 05/06/11 with a history
of Sjogren’s syndrome and hypothyroidism. Reportedly, the [employee] stopped
taking plaquenil that was prescribed by her Rheumatologist because of adverse side
effects, but she was having what she felt was an exacerbation of Sjogren’s or
thyroiditis with profound fatigue. On examination there were no abnormalities
noted. Dr. Fisher then noted that he was checking her thyroid and antibodies.
No results from those evaluations or follow up are found. There are no activity
cautions or orders for bed rest. I was unable to speak with Dr. Fisher to obtain
further information.

5

For purposes of this order, the court assumes Dr. Hinkamp was an employee of Sedgwick.
8

AR 000016. Dr. Hinkamp concluded that there was justification for Brooks’ absence from work
from May 5-11, 2011, “to allow time for planned evaluation of [her] chronic disorders” but
“insufficient objective medical findings to support an inability to perform moderate work activities
05/12/11 through present.” AR 16-17.6
As reflected in his above-quoted statement, Dr. Hinkamp did not consult with Dr. Fisher
before concluding that Brooks’ medical record did not “support an inability to perform moderate
work” during the relevant period. Disability Specialist Mortera had, however, made several
unsuccessful attempts to set up such a call.7 Contrary to Brooks’ argument, the court does not find
any statement by Dr. Hinkamp constitutes an intentionally false statement regarding these
unsuccessful attempts.8
6

Dr. Hinkamp had only the note of the May 6, 2011 office visit and the May 19, 2011 Initial
Physician’s Statement when he prepared this report. He did not have the note of Brook’s May 19,
2011 office visit, which includes an observation of some depression and includes an assessment of
“fatigue and concentration difficulties.” See AR 142 (discussed infra n. 11). That document was
not submitted to the Plan until after the initial denial of the claim.
7

Computer notes refer to this individual as “MORTERAR.”

8

Brooks argues that Dr. Hinkamp’s review was “neither reasoned or principled” because he
“made up a reason to justify not making a phone call to Ms. Brooks’ physician[.]” Dkt. No. 26 at 6.
The alleged “made up . . . reason” is a statement found in a May 31, 2011, computer note that reads
as follows: “Date and Time calls made to [treating physicians]: No call made. The [Claim Manager]
noted that the [treating physician] is not willing to speak with the [physician advisor].” AR 15
(emphasis added). This notation is entered by “STWARD[,]” and may or may not represent a direct
statement from Hinkamp. Language later in the same entry does, however, appear to represent a
personal statement by Hinkamp on the subject: “I was unable to speak with Dr. Fisher to obtain
further information.” AR 16 (emphasis added).
In light of the evidence discussed below, the court does not find Dr. Hinkamp’s statements
(assuming both are attributable to him) regarding the reason for his failure to speak to Dr. Fisher to
be intentionally false or suggestive of an improper motive. At worst, they suggest an incomplete
understanding of what transpired during one of the unsuccessful attempts by the Disability Specialist
to arrange a telephone conference between Dr. Hinkamp and Dr. Fisher.
Notes of activity on the claim predating Dr. Hinkamp’s determination that Brooks was not
disabled indicate attempts were made by Disability Specialist Mortera to arrange a teleconference
(continued...)
9

On June 8, 2011, Sedgwick sent Brooks a letter which stated that “after a careful and
thorough review of your request for payment of short term disability benefits under the AT&T
Disability Income Program (DIP), it has been determined that your claim does not qualify for
payment. As a result, benefits are denied effective 05/12/2011 through your return to work date.”
AR 104. The letter advised Brooks that the decision to deny benefits was based on a review of
medical documentation provided by Dr. Fisher dated May 6, 2011, and May 19, 2011, and an
unsuccessful attempt by the Physician Advisor (Dr. Hinkamp) to contact Dr. Fisher to discuss
Brooks’ medical information. It also indicated that the Physician Advisor determined, based on the
available records, that the clinical information lacked clear findings that Brooks was prevented from
performing the essential functions of her occupation. AR 104-05. Finally, the letter informed
Brooks both of her right to appeal (and how to do so) and her right to seek judicial review if the
appeal was denied. AR 105. Appeal forms were included with the denial letter. AR 107-10.9

8

(...continued)
between Dr. Fisher and the physician advisor. The notation of the first call to Dr. Fisher’s officeeads
as follows: “spoke to Janet, no info over phone, need to send formal request to fax[.]” AR 8 (May
11, 2011 call). A note relating to a subsequent call to see if the faxed request was received resulted
in no answer after fifteen rings and no option to leave a voice mail. AR 9 (May 13, 2011 call). A
May 23 note indicates records were received on May 20. AR 12. Notes on the following day, May
24, indicate the phone rang fifteen times without answer or option to leave a voice mail. AR 13.
The note on which Brooks relies to argue that Dr. Hinkamp misrepresented what occurred was
entered the following day and states that Mortera “spoke with Chris office manager and advised
attempt to schedule teleconference, she stated Dr. Fisher is not in the office and will be out until next
Tuesday 05/31. DS asked if anyone else could participate in teleconference and she stated no, it
would have to be Dr. Fisher.” AR 13-14 (May 25 note). This notation leaves open the possibility
that Dr. Fisher would have discussed Brooks’ condition with Dr. Hinkamp if he had called on or after
May 31, 2011.
9

It appears Brooks was advised of the denial by phone before the date referenced on this
letter. See AR 19 (computer note of June 2, 2011 telephone conversation between Disability
Specialist Mortera and Brooks, indicating Brooks was informed of the denial, the reasons for the
denial, and the type information needed for a successful appeal).
10

On or about June 20, 2011, Brooks filled out and signed the “IDSC Quality Review Unit
Appeal Form” and returned it soon thereafter, along with supporting documents, to the IDSC Quality
Review Unit (run by Sedgwick). AR 119. The supporting documents included the following:
•

a five-page letter from Brooks describing significant difficulties she was experiencing
performing daily tasks (AR 120-24);

•

a one-page letter from Brooks to Dr. Fant advising what she needs from him for the
appeal (AR 125);

•

Dr. Fant’s one-page responsive letter (AR 126 – discussed below);

•

Dr. Fant’s records of Brooks’ visits on July 6, 2010, November 8, 2010, May 9,
2011, and June 9, 2011 (AR 127-35);

•

Laboratory reports for July 9, 2010, and June 10, 2011 (AR 136-39) (presumably
ordered by Dr. Fant as they correspond with dates of Brooks’ office visits with
him)10;

•

Dr. Fisher’s office notes for Brooks’ visits on January 27, 2011, May 6, 2011, and
May 19, 2011 (AR 142-43, 145)11;

10

The June 10, 2011 laboratory report relates to the relevant period and reflects a low TSH
level, which a hand notation indicates shows “over replacement of thyroid hormone.” AR 136.
11

Of Dr. Fisher’s records, only the notes of the May 6 and 19, 2011 office visits and a May
6, 2011 lab report fall within the relevant period. The notes of the May 6, 2011 visit were previously
provided to the Plan and are discussed above. The notes of the May 19, 2011 visit state Brooks
reported “feel[ing] like she cannot perform her job duties without errors. So, she is here to discuss
having short-term out-of-work forms completed.” AR 142. Observations include “BP 112/66, pulse
74, WT 120. She is alert but seems a bit depressed or down, mainly because she said she is so
fatigued. She has no thyromegaly. Heart is RR. We gave her a B12 shot today.” Id. The remaining
sections read as follows:
A:

Sjogren’s syndrome exacerbation with fatigue and concentration difficulties.

P:
Out-of-work from 05/06/11 through 06/21/11. I would like her to return in
a month to recheck labs after she completes Prednisone 10 mg taper of four pills q.d.
x 5 days, then three pills q/d/ x 5 days, then two pills q.d. x 5 days, and one pill q.d.
x 2 weeks.
(continued...)
11

•

A laboratory report prepared by Dr. Fisher’s practice for May 6, 2011 (AR 144)12;

•

Several laboratory reports and one radiology report from 2010 and earlier (AR 14649).

AR 119-50.
The most critical of these documents is Dr. Fant’s June 24, 2011 letter, which is addressed
to Brooks but advises her to use it as she sees fit.13 AR 126. The letter states that Dr. Fant had seen
Brooks on four occasions: July 6, 2010; November 8, 2010; May 9, 2011; and June 9, 2011. AR
126.14 It also confirms that Dr. Fant was treating Brooks “for a systemic autoimmune disorder,
Sjogrens syndrome, which has resulted in dry eyes, salivary gland enlargement, and severe fatigue.”
Id. (also noting that Sjogrens syndrome “nearly always results in fatigue which, not uncommonly,
can be debilitative.”). Id. It concludes by “request[ing] that those who will be examining your

11

(...continued)
Id. Thus, this note is consistent with Dr. Fisher’s Initial Physician’s statement in suggesting that
Brooks needed to be out of work from May 6, 2011, to June 21, 2011. It also includes an assessment
of “Sjogren’s syndrome exacerbation with fatigue and concentration difficulties.”
12

This report addresses thyroid function and indicates three thyroid measures which were
out of the normal range including TSH III of .20 (with a normal range listed as .27 to 4.20). AR 144.
A metabolic panel performed a month later (presumably for Dr. Fant) reports TSH of .045 (with a
normal range listed as .35 to 4.5). AR 136. Hand written notes on the later report state the report
indicates an over replacement of thyroid.
13

In her memorandum, Brooks specifically refers to three medical records: Dr. Fant’s letter
and two laboratory reports, AR 140 and AR 144. The first of the two referenced laboratory reports
(AR 140) is dated July 9, 2010 (ten months prior to her claimed disability period), and is relevant
only in that it supports Brooks’ diagnosis for Sjogren’s syndrone. The second referenced laboratory
report (AR 144) covers the thyroid panel performed for Dr. Fisher on May 6, 2011. As noted above,
any thyroid deficiency reflected in this report was overcorrected by June 10, 2011. Thus, AR 144
suggests a thyroid deficiency that was correctable with medication. No physician has, in any event,
opined that Brooks was disabled by her thyroid condition.
14

Only the visits in May and June 2011 occurred during the period for which disability
benefits are sought (or the immediately preceding sick leave period).
12

appeal for short term disability give favorable consideration to your request.” He also states he is
available “to answer questions regarding your case that these examiners may have[.]”
Corresponding notes relating to Brooks’ June 9, 2011 office visit with Dr. Fant refer to
Brooks’ complaints of fatigue, mental difficulties, and low grade fever. AR 127. These notes also
include what appears to be a finding of “fatigue, severe,” as well as a reference to depression. AR
128. Under “plan.” the notes indicate Brooks should “allow an additional 4-8 weeks for Plaquenil
to begin to work” and should return for a follow up appointment in eight weeks. The note does not
appear to contain any specific functional limitations or express statement that Brooks needed to be
out of work. In contrast, as noted above, Dr. Fant’s June 24, 2011 letter suggests support for her
claim that she is unable to work, although it, too, does not expressly state that Brooks needs to be
out of work.
The appeal was assigned to Carla Persley (“Persley”), Appeals Specialist. On July 12, 2011,
Persley sent a request to Crisostomo (Brooks’ supervisor), for a detailed job description for the
Retail Account Executive position held by Brooks. AR 156-57. Crisostomo responded on the
following day, July 13, 2011, providing a three-page job description and listing the following
physical requirements of the position:
*

Avg work day is 8 hrs:

*

Driving - 15%

*

Standing - 40% (in acct visits w/sales persons/customers)

*

Sitting - 35% (to access internal email, reporting & other tasks)

*

Lifting/Carrying - laptop, notebook (10 lbs) - 5% (carry in and out of
account visits)

AR 156-60.
13

Persley spoke with Brooks by phone on July 13, 2011. AR 28. Persley’s notes indicate she
returned a call from Brooks, advising Brooks of the status of the appeal as well as Brooks’ option
to file suit in the event the denial was upheld on appeal.15
On August 1, 2011, Persley sent a request for a review of Brooks’ claim to an External
Physician Advisor. AR 162-64. This request asks the physician to address a number of specific
questions concerning Brooks’ disability status. Id.
D. Dennis Payne, Jr., M.D., a board-certified specialist in internal medicine and
rheumatology, responded to this request. AR 165-67. In addition to reviewing the documents
submitted in support of Brooks appeal, Dr. Payne made a limited attempt to contact Brooks’ two
treating physicians (Drs. Fisher and Fant), leaving each a message to call back within twenty-four
hours or the decision would be made solely based on the written record. Id. There is no indication
either physician called back within the specified period or at any subsequent time.16

15

The referenced notation indicates that Persley returned a call from Brooks, and addressed
a variety of subjects including the appeal process. It also indicates Persley advised Brooks “the
appeal decision is final, next step is to, FILE SUIT if she chooses after this appeal decision is
rendered.” RA 28. Brooks argues that this notation suggests irregularities in the appeal process
because discussion of the post-appeal right to file suit suggests the decision on appeal was
predetermined, even though no final decision issued until October 4, 2011. Dkt. No. 26 at 7.
The court disagrees with Brooks’ interpretation of the evidence. Persley may simply have
been thorough, advising Brooks of her options in the event the appeal was denied. She may also
have been responding to a specific inquiry from Brooks regarding her options in the event the appeal
was denied. Either possibility is at least as likely as a predetermination of the appeal. Subsequent
actions by Sedgwick, acting through Persley, including obtaining two independent medical reviews
of the claim by specialists in the relevant fields, are, moreover, inconsistent with Brooks’ suggestion
that denial of the appeal was a foregone conclusion.
16

Brooks questions the reasonableness of Dr. Payne’s review based primarily on his failure
to give Brooks’ treating physicians more than twenty-four hours to return his calls before he would
make his recommendation on the records submitted. Dkt. No. 26 at 7-8 (noting Dr. Payne contacted
both physicians’ offices, leaving messages “he would submit his report without consultation” if he
did not hear back from them within twenty-four hours).
14

On August 9, 2011, Dr. Payne provided a report based on his review of Brooks’ medical
records. AR 164-67. This report concludes that, “[b]ased on the medical record data provided for
review, the employee is not disabled from her regular job from any rheumatological process for the
above noted time period.” AR 166. Dr. Payne explained the basis of his decision as follows:
I have carried out a complete and thorough review of the medical record data
provided in this case. There is mention of chronic pain with fatigue and multiple
nonspecific cognitive complaints in the setting of mild SICCA symptoms that are not
particularly destructive involving the eyes and the mouth. Her serological testing is
supportive of a possible immunological basis with the positive ANA and positive
SSA antibody. Her other testing is completely normal other than equivocal right
parotid enlargement on a CT scan. The examination findings are essentially
unremarkable with minimal findings that would support restrictions or limitations.
Summarizing, from a rheumatology viewpoint, there are no objective data provided
in this case that would support that the degree of Sjögren’s activity is present or any
other rheumatic process is present in this case that is producing any impairment in
function. Therefore, unrestricted work would be her expected capability.
AR 167.
At Sedgwick’s request, Dr. Dennis Payne subsequently reviewed additional documentation
consisting of Brooks’ job description (AR 156-60) and Brooks’ personal letter describing her
difficulties with daily living (AR 120-25). See AR 172. In his supplemental report, Dr. Payne stated
that his “findings [were] unchanged” by this additional information. AR 172-73 (report dated
August 26, 2011). Dr. Payne explained: “I do not find any evidence of any rheumatological process
or syndrome that would be restricting or limiting in her care. Therefore, she would be expected to
be capable of unrestricted work from a rheumatology perspective during the time period under
review.” AR 173.17

17

There is one erroneous assumption in the supplemental report. Specifically, Dr. Payne
refers to Brooks’ position as “sedentary” when all other evidence indicates the physical requirements
of her job are “moderate.” While Brooks is correct in noting this was a “flawed assumption” (Dkt.
No. 26 at 9-10), it does not appear significant given that Dr. Payne found Brooks was “capable of
unrestricted work from a rheumatology perspective during the time period under review.” AR 173
(emphasis added).
15

Sedgwick also arranged for Brooks’ medical records to be reviewed by Paul Giannandrea,
M.D., who is board-certified in psychiatry and neurology. AR 174-77 (report dated August 26,
2011). Dr. Giannandrea’s “Psychiatric Synopsis” indicates he reviewed all of Brooks’ medical
records, her job description, and her personal letter describing her difficulties. AR 176. Based on
this review, Dr. Giannandrea concluded “the employee is not disabled from her regular job from a
psychiatric perspective as of 05/12/11 through present.” Id. With respect to clinical findings, Dr.
Giannandrea stated:
The patient has fatigue, dryness of her eyes, weakness, and other symptoms that are
related to her medical problems and she also has some evidence of stress and
depression. However, there is little psychiatric symptomatology documented.
Disability from her regular job during the time period under review is not supported
from a psychiatric perspective.
Id.
Each of the three physicians involved in the review process included the following conflict
of interest attestation:. “I attest . . . that there is no conflict of interest with this review for referring
entity, benefit plan, enrollee/consumer, attending provider, facility, drug, device, or procedure. I
attest that my compensation is not dependent on the specific outcome of my review.” AR 17 (Dr.
Hinkamp); AR 173 (Dr. Payne); AR 177 (Dr. Giannandrea).
A draft letter denying the appeal was prepared on August 31, 2011, and sent for final review.
AR34. The final letter denying the appeal was sent to Brooks on October 4, 2011. AR 36; AR 18486. This denial letter summarizes the conclusions of Drs. Payne and Giannandrea and documents
the attempts to contact Brooks’ treating physicians, Drs. Fisher and Fant. It also notes that:
“Although some findings are referenced, none are documented to be so severe as to prevent you from
performing the duties of your job as Retail Account Executive, with or without reasonable
accommodation from May 12, 2011 through present.” AR 185. The letter concludes by advising
16

Brooks of her right under ERISA to bring a lawsuit against the Plan as she had exhausted her plan
remedies as to her STD claim. AR 185.
CONCLUSIONS OF LAW
A.

Standard of Review
Brooks does not appear to dispute that her claim would properly be reviewed under an abuse

of discretion standard of review if the final decision was made by the Plan Administrator or a
properly designated “Claims Administrator” or “Appeals Administrator.” See Dkt. No. 26 at 3
(Brooks’ quotation of DIP 32, 42-43).18 As the language Brooks quotes reveals: “The Plan
Administrator has delegated discretion and authority to decide appeals to the Appeals Administrator
. . . [which has] full and exclusive authority and discretion to grant and deny appeals under the
Program. The decision of the Appeals Administrator regarding any appeal will be final and
conclusive.” Id.
Brooks argues that this grant of discretion is inapplicable to her STD claim because the entity
which made both the claim and appeal decisions, Sedgwick, is not the properly designated Appeals
Administrator. Brooks bases this argument on language in the summary plan description which
advises participants to direct claims and appeals to the “AT&T Integrated Disability Service Center.”
Dkt. No. 26 at 4. She also, presumably, relies on the absence of any express identification of
Sedgwick in the Plan documents.
The court is not persuaded by this argument. First, while the Plan documents may not refer
expressly to Sedgwick, they clearly delegate the Plan Administrator’s discretion to a third-party

18

Brooks refers to this document as the “Summary Plan Description” or “SPD” and attaches
a copy to her memorandum. Except for the absence of the DIP page numbers, the SPD appears to
be identical to the document in the joint exhibit bearing DIP page numbers. The court, therefore,
refers to the document contained in the joint exhibit.
17

Claims and Appeals Administrator. See, e.g., Dkt. No. 24-4 at 44 (“The Plan Administrator, or in
matters delegated to third parties, the third party that has been so delegated will have sole discretion
to interpret the Program, including but not limited to, . . . determinations of coverage and eligibility
for benefits, and determination of all relevant factual matters.”).

It is also abundantly clear from

the record that Sedgwick, in fact, served as the designated Claims and Appeals Administrator, acting
through the AT&T Integrated Disability Service Center. See, e.g., Dkt. No. 24-2 at 56, 57, 58 (letters
from “AT&T Integrated Disability Service Center As Administered by Sedgwick CMS”). Brooks has
presented no evidence to the contrary. Neither has Brooks directed the court to any authority that
would suggest AT&T was required to name its third-party Claims and Appeals Administrator within
the SPD or other specific Plan document in order to delegate discretion to this third party.
The court, therefore, concludes that the denial of Brooks’ claim (and appeal) should be
reviewed under the abuse of discretion standard of review. Under this standard, the court is required
to uphold the administrator’s decision if it is reasonable, even if the court would have reached a
different conclusion had it considered the matter independently. See Ellis v. Metropolitan Life Ins.
Co., 126 F.3d 228, 232 (4th Cir. 1997). A decision is reasonable if it is “the result of a deliberate,
principled reasoning process and if it is supported by substantial evidence.” Id. at 232 (quoting
Brogan v. Holland, 105 F.3d 158, 161 (4th Cir. 1997)); see also DuPerry v. Live Ins. Co. of N. Am.,
632 F.3 860, 869 (4th Cir. 2011) (citing same standard).
In deciding whether the decision satisfies this “reasonableness” standard, the court considers
the following eight 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
18

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.
See Champion v. Black & Decker, 550 F.3d 335, 359 (4th Cir. 2008) (quoting Booth v. Wal-Mart
Stores, Inc. Assocs. Health and Welfare Plan, 201 F.3d 335, 342-43 (4th Cir. 2001)).
B.

The Process Was Deliberate, Reasoned, and Not Affected by Any Conflict of Interest
The evidence demonstrates that the Plan, through Sedgwick which served as both the

designated third-party Claims Administrator and Appeals Administrator, engaged in a deliberate and
reasoned process in reviewing Brooks’ initial claim and appeal. For example, Sedgwick sent
appropriate forms and instructions to Brooks to assist her in filing her claims. The instructions
emphasized the need for supporting medical documentation and included a specific request for a
detailed statement of any functional limitations.
Brooks’ claim was submitted with minimal documentary support. That support consisted
of the single-page Initial Physician Statement signed by her primary care physician, Dr. Fisher, on
May 19, 2011, and a report of a single visit to the same doctor on May 6, 2011. Neither the form nor
the report indicated a medical finding of any specific functional limitations. In addition, critical
inquiries on the form were left unanswered. Both did, however, refer to Brooks’ self-report of
“profound fatigue.”
This minimal documentation was reviewed by an in-house Physician Advisor, Dr. Hinkamp,
who concluded that the record was insufficient to support Brooks’ claim of disability.19 Dr.
Hinkamp set out his reasoning, which was subsequently shared with Brooks in the denial letter. The

19

Dr. Fisher’s notes of Brooks’ May 19, 2011 visit were not provided with the initial claim.
Thus, additional support found in this later note (including Brooks’ subjective report of “slow
mentation,” Dr. Fisher’s observation of a depressed mood,” and his assessment of “fatigue and
concentration difficulties”) was not available to Dr. Hinkamp when he made his recommendation.
19

letter disclosed that the evidence was insufficient to establish disability. It also disclosed that the
claims administrator had been unable to speak with (and consequently obtain additional information
from) Dr. Fisher. The court finds this process, which resulted in the initial denial, deliberate,
reasoned, and uninfected by any conflict of interest.20
The Plan, through Sedgwick, appropriately informed Brooks of her right to appeal and
provided forms and guidance as to how to perfect her appeal. Additional support Brooks offered
from Dr. Fisher consisted of notes from two additional office visits and a few lab reports. One of
the new office visit notes (for May 19, 2011) and one lab report (dated May 6, 2011) related to the
period for which disability benefits are sought. The May 6, 2011 lab report indicated certain thyroid
abnormalities, which, as noted above, do not appear to support a claim of disability. The May 19,
2011 doctor’s visit note indicated the primary purpose of Brooks’ visit was to obtain “short-term outof-work forms completed.” AR 142.21 Treatment provided on that date consists of a B12 shot and
a short, tapering course of Prednisone. There is a notation that Brooks “seem[ed] a bit depressed or
down mainly because she said she is so fatigued” and a diagnosis of “Sjogren’s syndrome
exacerbation with fatigue and concentration difficulties.” Id. The plan at that point was for Brooks
to be “[o]ut of work from 05/06/11 through 06/21/11.”
In addition to the medical records from Dr. Fisher, Brooks offered a personal letter detailing
her difficulties, a letter from rheumatologist Dr. Fant, and medical records or lab reports relating to
Dr. Fant’s care. The letter from Dr. Fant stated both that Brooks had a condition which could cause

20

Dr. Hinkamp signed an attestation that he was acting without conflict of interest. Brooks
has pointed to no evidence which would draw that attestation into doubt.
21

This doctor’s visit note corresponds with the date Dr. Fisher completed the Initial
Physician Statement that was submitted with Brooks’ initial claim.
20

disabling fatigue and that she was experiencing severe fatigue. It also requested that the reviewers
“give favorable consideration” to her appeal of the denial of STD benefits.
Sedgwick sent this documentation to two independent physicians with relevant specialties
(rheumatology and psychiatry) for review. Both physicians reviewed the available documentation
and found it insufficient to demonstrate that Brooks had functional limitations within the physician’s
area of specialization. Each provided a written rationale for his opinion which appears, on its face,
to be well reasoned and well supported.22 Each also signed an attestation that he had no conflict of
interest.
Brooks has not directed the court to any evidence which would suggest that (1) the records
should have been reviewed by a specialist in some other field; (2) either reviewer failed to fully
consider all information which Brooks provided; or (3) either reviewer had a conflict of interest.
Instead, she points to a few minor inconsistencies or errors that she suggests indicate some improper
motive or insufficiency in the review. Considered in context of the full record, however, the alleged
inconsistencies or errors are insignificant. They do not, in any event, suggest that the process itself
was less than deliberate and reasoned or was infected by improper motive.23

22

Dr. Payne reviewed Brooks’ record from the perspective of a board certified internist and
rheumatologist and concluded that Brooks would be “capable of unrestricted work.” AR 173. Dr.
Giannandrea reviewed Brooks’ record from the perspective of an expert in psychiatry and neurology.
AR 175-77. Dr. Giannandrea concluded that Brooks had “some evidence of stress and depression,
but none was delineated in a specific disorder and/or did not appear to be primary or independent
of her medical problems. Thus, the provided medical documentation does not support a disabling
psychiatric condition that would preclude her from her regular work during the time period under
review.” AR 177.
23

A number of the alleged inconsistencies or errors relate to Dr. Hinkamp’s review. That
review is not, however, relevant to the review conducted during the appeal process, which was the
basis for the Plan’s ultimate decision.
21

For example, Brooks suggests error because Drs. Payne and Giannandrea made only limited
attempts to contact the treating physicians for additional information, giving them only twenty-four
hours to respond to calls before a recommendation would be made. The more significant point is
that the reviewers each made such an attempt and neither received any response, including a request
for additional time from either of Brooks’ treating physicians. Brooks has offered nothing that
suggests more was required for the Appeals Administrator’s actions (or those of its independent
medical reviewers) to be reasonable.
For reasons explained above, the court finds the process was reasoned, principled, and not
affected by any conflict of interest at both the claim and, more critically, the appeal stage.
C.

Sufficiency of evidence to support decision

In her memorandum, Brooks relies on three specific medical records: Dr. Fant’s letter and
two lab reports. Dr. Fant’s letter provides some support for Brooks’ claim of disability, although it
describes no specific functional limitations.24 It was not, however, unreasonable for the Plan to look
beyond this letter to underlying medical records for specific findings and functional limitations. Two
physicians with expertise in the relevant fields reviewed the records for this purpose and found
insufficient support for Brooks’ claim. While Brooks’ treating physicians noted symptoms of
fatigue, concentration difficulties and depressed mood, diagnosed Sjorgren’s syndrome (which Dr.
Fant noted may cause debilitating fatigue), listed plans which adjusted medication and (at least Dr.
24

Dr. Fant’s letter includes the following statements: (1) he is treating Brooks for various
conditions including a “systemic autoimmune disorder, Sjorgrens syndrome” and “severe fatigue,”
(2) “systemic inflammation [associated with autoimmune disorders] nearly always results in fatigue
which, not uncommonly, can be debilitative”; (3) Brooks began taking Plaquenil for treatment of her
Sjorgren’s syndrome a month prior to her June 9, 2011 visit, but “[s]everal months are typically
required for this medication to take effect”; and he “request[s] that those who will be examining
[Brooks’] appeal for short term disability give favorable consideration to [her] request.” AR 126.
22

Fisher) indicated out-of-work dates, and prepared a form (Dr. Fisher) or letter (Dr. Fant) supportive
of disability, neither explained what functional limitations prevented Brooks from returning to work.
The referenced lab reports, likewise, fail to support Brooks’ position. While one supports
the diagnosis of Sjogren’s syndrome, it does not support a finding of disability because it relates to
an earlier time period when Brooks was able to perform her job. The lab report during the relevant
period relates to thyroid measures. There is, however, no evidence that Brooks’ thyroid condition
was disabling. Certainly neither of her treating physicians offered such an opinion.
While the Plan might have reached a different conclusion based on the evidence submitted,
the court cannot, on this record, find that it abused its discretion in concluding that Brooks did not
meet the Plan’s definition of disability.
CONCLUSION
For the reasons set forth above, the Plan’s motion for judgment is granted and Brooks’
motion for judgment is denied. Because the decision affirms the denial of benefits, and in light of
the relative resources of the parties, the court declines to award attorneys’ fees to either party. The
Clerk of Court is directed to enter judgment in Defendant’s favor.
IT IS SO ORDERED.
s/ Cameron McGowan Currie
CAMERON MCGOWAN CURRIE
Senior United States District Judge
Columbia, South Carolina
November 5, 2013

23