Keaton v. Sedwick Claims Management Services, Inc., et al

Filing 71

ORDER GRANTING 44 Charter's Motion for Summary Judgment; GRANTING 45 Sedgwick's Motion for Summary Judgment. Plaintiffs claims are hereby DISMISSED WITH PREJUDICE. Signed by Judge Xavier Rodriguez. (rg)

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF TEXAS
SAN ANTONIO DIVISION
WILLIAM KEATON,
Plaintiff,
v.
SEDGWICK CLAIMS MANAGEMENT
SERVICES, INC. AND CHARTER
COMMUNICATIONS, INC. (f/k/a TIME
WARNER CABLE, INC.),
Defendants.

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Civil Action No. SA-17-CV-223-XR

ORDER
On this date, the Court considered the status of the above captioned-cased. After careful
consideration, the Court hereby GRANTS Defendant Charter Communications, Inc.
(“Charter”)’s Motion for Summary Judgment (Docket no. 44) and GRANTS Defendant
Sedgwick Claims Management Services, Inc. (“Sedgwick”)’s Motion for Summary Judgment
(Docket no. 45).
BACKGROUND
On March 21, 2017, Plaintiff William Keaton filed his Complaint with this Court. Docket
no. 1. Plaintiff filed his First Amended Complaint on January 23, 2018. 1 Docket no. 55. Plaintiff
is a former employee of Charter and brings claims against it for denial of benefits under its
employee benefit plan (“the Plan”) for short-term disability (“STD”) and refusal to supply plan

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Plaintiff filed his Amended Complaint only to remedy technical errors in his cause of
action against Charter for violation of 29 U.S.C. § 1132(c)(1). See Docket no. 55.
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documents. Id. Plaintiff also brings claims against Sedgwick, the third-party administrator for the
STD component of the Plan, for denial of STD benefits. Id.
Plaintiff was employed by Time Warner Cable, Inc., with which Charter merged in 2016,
as a Major Account Executive and was a participant in the Plan. Id. at 2. Plaintiff states the Plan
pays STD benefits to claimants who are found to be “totally disabled,” and under the Plan, a
person is considered “totally disabled” after the Elimination Period if, “[y]ou are earning less
than 20% of your pre-disability Covered Compensation due to an injury or illness (including
Mental Illness, Substance Abuse and pregnancy); and [y]ou cannot perform the Essential Duties
of your own occupation.” Id. at 2–3.
Plaintiff alleges that he stopped working for Charter on April 30, 2015, “due to acute
chest pain, severe fatigue, and significantly lowered exercise tolerance he suffered as a result of
coronary artery disease, diabetes mellitus with neuropathy, hypertension, hyperlipidemia,
obstructive sleep apnea and adjustment disorder with depression and anxiety.” Id. at 3. On May
1, 2015, Plaintiff submitted a claim for benefits under the Plan to Charter, which then submitted
it to Sedgwick to determine if he qualified for STD benefits. Id. Plaintiff submitted a May 20,
2015, Attending Physician’s Statement (“APS”) completed by his cardiologist Dr. Rita
Friedrichs, who opined that Plaintiff was unable to return to work even in a restricted capacity.
Id.
Plaintiff alleges that Sedgwick never requested medical records that he authorized it to
obtain, failed to have his claim reviewed by a physician and/or request he undergo an
independent medical examination, and concluded on June 8, 2015, that he was not disabled
under the Plan based only on the APS. Id. Plaintiff appealed Sedgwick’s decision and alleges he

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requested a copy of the administrative record and all plan documents on June 30, 2015. Id. at 3–
4. Plaintiff states Defendants failed to produce the requested documents within the required thirty
days. Id. at 4. Plaintiff alleges he only received a portion of the administrative record after
making additional requests in October 2015. Id. Plaintiff submitted his appeal on February 11,
2016, and provided Sedgwick “with a letter supporting his disability authored by Dr. Friedrichs
and his medical records from Audie L. Murphy Veteran’s Administration Hospital in San
Antonio.” Id.
Plaintiff states that Dr. Friedrichs’s letter included that she examined him on several
occasions after his February 6, 2015, heart catheter implantation, and that during those visits,
Plaintiff was “still recovering from the implantation procedure, but his diabetes had become
uncontrollable, resulting in the disabling symptoms of profound fatigue and significantly lowered
concentration and energy levels.” Id. Dr. Friedrichs further opined that Plaintiff suffered from “a
possible adjustment disorder resulting in periods of acute anxiety and depression” and stated that
Plaintiff’s physical and cognitive symptoms prevented him from working beginning May 1,
2015, through the date of her letter. Id. at 4–5.
Sedgwick upheld its decision denying Plaintiff’s claim for STD benefits on April 8, 2016.
Id. at 5. Plaintiff states that two physicians from whom Sedgwick sought independent opinions
concluded that Plaintiff was “clinically stable” after the heart catheter implant procedure and his
medical records did not provide evidence to support his disabling symptoms. Id. Plaintiff alleges
that these findings were made “despite significant medical evidence to the contrary.” Id. Plaintiff
alleges he then attempted to seek Plan documents related to his claim, but Defendants never
acknowledged or produced the requested documents. Id.

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Plaintiff alleges he is entitled to STD under the Plan because he meets the definition of
“total disability.” Id. at 6. Plaintiff brings claims against Charter and Sedgwick for breach of the
Plan under 29 U.S.C. § 1132(a)(1)(B) for denying him STD benefits and failing to provide him
with a full and fair review of his claim. Id. Plaintiff also brings a claim against Charter for failure
to supply Plan documents under 29 U.S.C. § 1132(c)(1) after he requested specific documents.
Id. at 6–7.
Defendants state that under the STD program, a claimant is eligible to receive benefits if
he is “totally disabled,” which means he “cannot perform the Essential Duties of [his] own
occupation.” Docket no. 44 at 7. Defendants allege that Sedgwick, as claims administrator for the
STD program, has “sole authority to determine benefit claims under the terms of the Disability
Program.” Id. Defendants state that if a claimant exercises the right to appeal a denial of
coverage, that appeal is evaluated by “a person different from the person who made the initial
determination” who is not a subordinate of the initial claims handler, and “[n]o deference is
afforded to” the initial decision. Id. Claimants may present additional evidence, and the appellate
review “take[s] into account all new information, whether or not presented or available at the
initial determination.” Id. Defendants state that appellants are “provided, upon request and free
of charge, reasonable access to, and copies of, all documents, records, and other information
relevant to [their] claim for benefits.” Id.
Defendants state that Sedgwick reviewed Dr. Friedrichs’s APS, which estimated
Plaintiff’s duration of disability at thirty-one days. Id. at 8. Defendants allege that after reviewing
the APS, and following “two unsuccessful attempts to contact Dr. Friedrichs, Sedgwick’s initial
assessment was to deny [Plaintiff’s] claim.” Id. The claims adjuster found that “[t]here is no

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severity of condition” or “evidence of functional impairment,” and that Plaintiff’s “subjective”
complaints are not adequately supported by his doctor’s objective findings. Id. The adjuster
labeled Plaintiff’s employment position as “sedentary” and concluded that “[i]t is not known
why [Plaintiff] cannot perform his job duties at present.” Id. Sedgwick denied Plaintiff STD
benefits, noting that Dr. Friedrichs’s report “failed to provide objective medical evidence of
functional impairment or indicate any emergent or escalated care was required” during the
requested disability period. Id.
Defendants state that after Plaintiff appealed his denial of coverage, the file was reviewed
by Dr. Robert Bryg, a Board-certified cardiologist. Id. at 9. Dr. Bryg concluded in his report that
Plaintiff was not disabled from his occupation as of May 1, 2015, and noted clinical findings
evidencing “fatigue and poorly controlled diabetes,” but he observed that based on the medical
records provided, Plaintiff “had no further chest pain” following his stenting procedure. Id. Dr.
Bryg concluded that there was no evidence of disability. Id. Defendants state that a second report
by Dr. Anu Davis, a Board-certified endocrinologist, similarly found that Plaintiff suffered from
poorly-controlled diabetes and fatigue, but that there was “a lack of clinical records to support
disability” because “[t]here is no mention of [shortness of breath] in the clinical records due to
the claimant’s heart issues.” Id. Defendants allege that Sedgwick denied Plaintiff’s appeal after
reviewing all of the records provided by Plaintiff, which consisted of “medical records from
Timothy Dao, MD, Mithila Fadia, MD, Rita Friedrichs, MD, Son Pham, MD, Michael Phillips,
MD, Andrew Slusher, MD, Tanya Gambli, RN, Preciosa Jumamil, RN, and Myocardial
Perfusion Imaging dated February 06, 2015 through January 19, 2016.” Id. at 9–10. Sedgwick
also allegedly relied on the evaluations conducted by Drs. Bryg and Davis. Id. at 10. Defendants

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allege that Sedgwick determined that “the medical information in the file [did] not support
[Plaintiff]’s inability to perform [his] occupation.” Id. at 10.
Defendants state that Plaintiff sent Sedgwick three document requests related to his STD
claim on June 30, 2015, September 2, 2015, and September 24, 2015, and that Plaintiff sent
another request for Plan documents on May 12, 2016. Docket no. 44 at 10. Defendants allege
that Sedgwick complied with Plaintiff’s requests on July 8, 2015. Id.
On December 1, 2017, Charter moved for summary judgment, arguing that it did not
violate the Plan or ERISA by denying Plaintiff STD benefits and that it did not fail to properly
provide Plaintiff with copies of requested Plan documents. Docket no. 44. On the same date,
Sedgwick filed its motion for summary judgment, joining and incorporating Charter’s motion
and memorandum in support of same, arguing that it did not violate the Plan or ERISA by
denying Plaintiff STD benefits. Docket no. 45.
I.

Legal Standard
The court shall grant summary judgment if the movant shows that there is no genuine

dispute as to any material fact and the movant is entitled to judgment as a matter of law. FED. R.
CIV. P. 56(a). To establish that there is no genuine issue as to any material fact, the movant must
either submit evidence that negates the existence of some material element of the non-moving
party’s claim or defense, or, if the crucial issue is one for which the non-moving party will bear
the burden of proof at trial, merely point out that the evidence in the record is insufficient to
support an essential element of the non-movant’s claim or defense. Lavespere v. Niagra Machine
& Tool Works, Inc., 910 F.2d 167, 178 (5th Cir. 1990), cert. denied, 510 U.S. 859 (1993). Once

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the movant carries its initial burden, the burden shifts to the non-movant to show that summary
judgment is inappropriate. See Fields v. City of S. Hous., 922 F.2d 1183, 1187 (5th Cir. 1991).
In order for a court to conclude that there are no genuine issues of material fact, the court
must be satisfied that no reasonable trier of fact could have found for the non-movant, or, in
other words, that the evidence favoring the non-movant is insufficient to enable a reasonable jury
to return a verdict for the non-movant. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 250
n.4 (1986). In making this determination, the court should review all the evidence in the record,
giving credence to the evidence favoring the non-movant as well as the “evidence supporting the
moving party that is uncontradicted and unimpeached, at least to the extent that evidence comes
from disinterested witnesses.” Reeves v. Sanderson Plumbing Prods., Inc., 530 U.S. 133, 151
(2000).
II.

Application
Defendants argue they are entitled to summary judgment on both the denial of STD

benefits and the claim related to providing requested Plan documents. Plaintiff argues that
Defendants’ motion for summary judgment should be denied, and instead, the Court should enter
summary judgment in his favor on these claims. 2
I.

Denial of STD Benefits
Defendants argue that they are entitled to summary judgment because Sedgwick’s denial

of Plaintiff’s STD claim is subject to review under an abuse of discretion standard with respect to
both Defendants, and there is no evidence in the administrative record to indicate Sedgwick
abused its discretion. Plaintiff argues that, with respect to his claim against Charter, the Court
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Although Plaintiff did not formally and timely file a cross-motion for summary judgment,
the Court will consider the appropriateness of entering summary judgment in Plaintiff’s favor
when analyzing where material issues of genuine fact do or do not exist.
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should review the denial of STD benefits de novo because Charter did not have discretionary
authority to determine the payment of STD benefits—only Sedgwick had sole discretionary
authority under the Plan. Plaintiff argues the Court should enter summary judgment in his favor.
A. Plaintiff’s Claim Against Defendant Sedgwick
A participant or beneficiary of a benefits plan may bring a civil action in a district court
“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 statute, however, does not set out the appropriate standard of review. Fifth
Circuit law makes clear, however, that “when an administrator has discretionary authority with
respect to the decision at issue, the standard of review should be one of abuse of discretion.”
Baker v. Metro. Life Ins. Co., 364 F.3d 624, 629 (5th Cir. 2004) (quoting Vega v. Nat’l Life Ins.
Services, Inc., 188 F.3d 287, 295 (5th Cir. 1999) (en banc)). 3 A district court’s review is limited
to the administrative record, which consists of “relevant information made available to the
administrator prior to the complainant’s filing of a lawsuit and in a manner that gives the
administrator a fair opportunity to consider it.” Vega, 188 F.3d at 300. The Court may not review
evidence outside the administrative record to resolve an issue of fact. See id.
“The law requires only that substantial evidence support a Plan fiduciary’s decisions,
including those to deny or to terminate benefits, not that substantial evidence (or, for that matter,
even a preponderance) exists to support the employee’s claim of disability.” Ellis v. Liberty Life
Assurance Co. of Boston, 394 F.3d 262, 273 (5th Cir. 2004). Substantial evidence is “more than a
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The Court recognizes that the Fifth Circuit has recently held that a court should apply a
de novo standard of review even when a denial is based on a factual determination for plans that
do not validly delegate discretionary authority to a plan administrator. See Ariana M. v. Humana
Health Plan of Texas, Inc., 884 F.3d 246 (5th Cir. 2018). Because the present case does involve a
delegation of discretionary authority to Sedgwick, however, the Court applies an abuse of
discretion standard of review.
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scintilla, less than a preponderance, and is such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion.” Id. If the decision to deny benefits is supported by
substantial evidence and is not arbitrary and capricious, it must prevail. Id. The abuse of
discretion standard “sets a relatively high bar for the plaintiff to overcome.” Chapman v.
Prudential Life Ins. Co. of Am., 267 F. Supp. 2d 569, 578 (E.D. La. 2003). If a plaintiff shows
evidence that the plan administrator is a “self-interested insurer” that serves as both the insurer
and administrator of a plan “and stands to gain from a denial of the claim,” a district court may
apply a “sliding scale” that relaxes the abuse of discretion standard. Id. But a court will apply the
standard abuse of discretion standard when the plan administrator is not a self-interested insurer.
See id.; see also Vega, 188 F.3d at 295.
For the STD portion of the Plan, Sedgwick is “the claims fiduciary with sole authority to
determine benefit claims under the terms of the Disability Program.” Docket no. 44-1 at 51.
Defendants state that Sedgwick is not a “self-interested insurer” and no conflict of interest exists
because Sedgwick is independent from Charter, which funds the plan. See Docket no. 44-1 at 58.
Plaintiff does not dispute that Sedgwick is not a self-interested insurer. Accordingly, the Court
applies the abuse of discretion standard to Sedgwick’s denial of Plaintiff’s STD claim.
Under the Plan, Plaintiff was eligible to receive STD benefits if he was “totally disabled”
such that he “[could] not perform the Essential Duties of [his] own occupation.” Docket no. 44-1
at 49. An Essential Duty “means the important tasks, functions and operations generally required
by employers from those engaged in their usual occupation that cannot be reasonably omitted or
modified.” Id. at 55. In a Job Analysis Form prepared on October 17, 2014, a Major Account
Executive, which was Plaintiff’s position, is described as a “Field Sales Position.” Docket no.

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44-3 at 6–7. The position primarily requires sitting and standing, and the amount of lifting and
carrying is described as occasionally “[s]edentary,” which means up ten pounds for one to three
hours per shift. Id. The tasks that are described as “continuous work” (five or more hours) for
this position are “Inside Work” and “Depth Perception/Color Vision.” Id. Otherwise, the position
frequently involves sitting, standing, repetitive hand movements, computer viewing, and hearing.
Id.
After Plaintiff ceased working for Charter as a Major Account Executive on April 30,
2015, he submitted his claim for STD benefits on May 1, 2015. Docket no. 44-3 at 166–69.
Plaintiff submitted to Sedgwick an APS completed by his internist Dr. Friedrichs on May 20,
2015. Id. at 60–61. Dr. Friedrichs stated Plaintiff’s complaints as chest pain, low energy, and
limited exercise tolerance, and Dr. Friedrichs diagnosed Plaintiff with coronary artery disease,
diabetes, and chronic obstructive pulmonary disease. Id. Dr. Friedrichs reported Plaintiff would
be able to resume work after thirty-one days. Id.
Sedgwick initially determined it should deny Plaintiff’s STD claim, stating that the
“[m]edical information does not substantiate disability,” “[t]here is no severity of condition,
substantial change in condition or evidence of functional impairment,” the “[p]ain is subjective,”
and “[i]t is not known why [Plaintiff] cannot perform his job duties at present.” Id. at 149–50.
The adjuster recognized that the APS stated that Plaintiff had chest pain, diabetes, and chronic
obstructive pulmonary disease. Id. at 150. An attempt was reportedly made to call Dr. Friedrichs
twice and a message was left, “looking for medical evidence to support [the] claim,” but
Sedgwick was unable to reach Dr. Friedrichs. Id. A second review found that, after reviewing the

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APS, the APS did not “substantiate disability.” Id. at 147. This information was relayed to
Plaintiff in a June 8, 2015, letter, which stated in part:
The medical documentation provided by Dr. Rita Friedrichs failed to support your
claim for short term disability benefits. The documentation failed to provide
objective medial evidence of functional impairment or indicate any emergent or
escalated care was required during the requested period 05/01/2015 – Your
Return to Work. The documentation provided failed to substantiate the severity of
your current condition; therefore, your request for short term disability benefits is
denied from 05/01/2015 – Your Return to Work
Id. at 43. The letter also provided Plaintiff with information on his right to appeal the denial. Id.
Plaintiff appealed his denial of STD benefits on February 11, 2016. Docket no. 44-2 at
38. Plaintiff attached medical records related to a stenting procedure, progress notes from Dr.
Friedrichs, and a January 19, 2016, letter from Dr. Friedrichs. Sedgwick had two doctors review
Plaintiff’s appeal. First, Robert Bryg, M.D., a Board-certified cardiologist, issued a report that
Plaintiff was not disabled from his occupation as of May 1, 2015. Docket no. 44-2 at 25–34. In
his report, Dr. Bryg summarizes information from Plaintiff’s provided medical records. Dr. Bryg
states that there is no documented chest pain after February 2015, that Plaintiff “has a sedentary
occupation which does not require significant physical activity that would create complications
or further injury,” and that by February 21, 2015, it is expected Plaintiff “would be recovered
from the procedure and chest pain.” Id. at 27. Dr. Bryg states the “need to assess someone as
being unable to perform usual and customary work activities needs to be based upon clinical
examination or abnormalities as opposed to self-reported subjective complaints” and the “records
in this case do not include direct medical services provided to the claimant, and the records
included did not provide significant clinical findings to support the claimant’s condition as
disabling.” Id. Dr. Bryg concluded that Plaintiff should have recovered from his chest pain by

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February 21, 2015, and that there was no medical evidence to support a claim of disability as of
May 1, 2015. Id.
Second, Anu Davis, M.D., a Board-certified endocrinologist, issued a report similarly
concluding that Plaintiff was not disabled from his occupation as of May 1, 2015. Id. at 18–22.
Dr. Davis found that Plaintiff has a history of diabetes, hypertension, hyperlipidemia, obstructive
sleep apnea, and coronary artery disease, and that Plaintiff’s records “indicate poorly controlled
diabetes and complaints of fatigue, poor concentration, and low energy.” Id. at 20. Dr. Davis
concluded, however, there was “a lack of clinical records to support disability due to the
claimant’s heart conditions” and the records “fail to document new impairments or physical or
functional limitations [that] prevent the claimant from working his sedentary level job.” Id.
Sedgwick issued a letter on April 8, 2016, denying Plaintiff’s appeal, noting that it relied
on reports by Drs. Bryg and Davis, and that it reviewed Plaintiff’s medical records from
“Timothy Dao, MD, Mithila Fadia, MD, Rita Friendrichs, MD, Son Pham, MD, Michael
Phillips, MD, Andrew Slusher, MD, Tanya Gamblin, RN, Preciosa Jumamil, RN, and
Myocardial Perfusion Imaging dated February 06, 2015 through January 19, 2016.” Id. at 10.
Sedgwick stated that “the medical information in the file [did] not support [Plaintiff’s] inability
to perform [his] occupation.” Id.
The Court must analyze if Sedgwick’s decision is supported by the administrative record.
A decision is arbitrary only if “made without a rational connection between the known facts and
the decision or between the found facts and the evidence.” Meditrust Fin. Servs. Corp. v. Sterling
Chemicals, Inc., 168 F.3d 211, 215 (5th Cir. 1999) (quoting Bellaire Gen. Hosp. v. Blue Cross
Blue Shield of Michigan, 97 F.3d 822, 828–29 (5th Cir. 1996)).

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In Gooden v. Provident Life & Accident Insurance Co., the plaintiff employee, who
suffered from angina and coronary artery disease, sued the plan administrator for its denial of his
claim for long term disability benefits. Gooden v. Provident Life & Acc. Ins. Co., 250 F.3d 329
(5th Cir. 2001). With his application for benefits, the plaintiff submitted an APS from his
physician, medical records related to his treatment, and a letter from his physician dated after the
plaintiff learned he was terminated from employment. Id. at 331. The plaintiff’s physician
believed that the plaintiff was “disabled and could not return to his previous employment.” Id.
The plan administrator, however, denied the plaintiff’s claim, based on a review of the
physician’s records, the plaintiff’s hospital records, the results of a recent stress test that the
plaintiff underwent, and the administrator’s medical staff’s conclusion that the “objective
medical findings” did not support the plaintiff’s disability claim. Id. at 331–32. The Fifth Circuit
held that the administrator did not abuse its discretion in denying the plaintiff’s claim “because
its decision is supported by the administrative record,” which included the physician’s APS, the
recent stress test, the reviewer’s recommendation to deny the claim, and information regarding
the requirements of the plaintiff’s job. All of this evidence taken together indicated that the
plaintiff “was capable of fulfilling the duties of his job.” Id. at 334.
In Meditrust Financial Services Corp. v. Sterling Chemicals, Inc., the plaintiff was
denied a claim for coverage for medical treatment under her employment plan following a head
injury. Meditrust Fin. Servs. Corp. v. Sterling Chemicals, Inc., 168 F.3d 211 (5th Cir. 1999).
Although the plaintiff alleged instances of bad faith and challenged the procedures used during
the review process for medical coverage benefits, the Fifth Circuit held there was insufficient
evidence to find the denial of benefits arbitrary and capricious, because the medical records were

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reviewed six times and on each occasion the treatment requested was found not medically
necessary, the denial letters expressly contained the basis for the denial, and the reviews were
made “by a number of qualified physicians and based on all the hospital records.” 168 F.3d at
215.
Similar to Gooden and Meditrust, Sedgwick denied Plaintiff’s request for STD benefits
following a review by a medical professional, and the denial was upheld on Plaintiff’s appeal
after further review by two additional medical professionals. During these reviews, the record
indicates that those conducting the reviews based their decisions on the typical responsibilities of
someone in Plaintiff’s position and medical records that Plaintiff provided, and that Sedgwick
ultimately denied coverage based on a review of the medical professionals’ recommendations
and the medical records Plaintiff supplied.
Plaintiff argues that Sedgwick abused its discretion because it based its denial solely on
the fact that the APS failed to provide objective medical evidence of his disability, and that there
is no such requirement for “objective medical evidence” stated in any of the relevant Plan
documents. However, the fact that a plan administrator finds there is no objective medical
evidence proving that a claimant would be prevented from performing job duties does not
demonstrate that the administrator abused its discretion. See Keller v. AT & T Disability Income
Plan, 664 F. Supp. 2d 689, 702 (W.D. Tex. 2009), aff’d, 481 F. App’x 86 (5th Cir. 2010); see
also Vercher v. Alexander & Alexander, Inc., 379 F.3d 222, 230–31 (5th Cir. 2004) (finding that
an administrator’s insistence that a claimant provide objective evidence of an allegedly disabling
condition is not an abuse of discretion). Further, Plaintiff cannot show there was an abuse of
discretion just because his physician might disagree with the conclusion of those professionals

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conducting the reviews on Sedgwick’s behalf. See Sweatman v. Commercial Union Ins. Co., 39
F.3d 594, 603 (5th Cir. 1994) (finding no abuse of discretion where plaintiff argued the
administrator gave insufficient weight to her doctors’ opinions given the administrator reviewed
all submitted medical records, employed independent medical consultants to evaluate the records
and reach a conclusion, and reviewed the entire administrative record twice). Here, although
Plaintiff argues that those reviewing his claim gave insufficient weight to Dr. Friedrichs’s report,
the record indicates that the medical professionals and Sedgwick reviewed all records that
Plaintiff submitted to reach the conclusion, three times, to deny Plaintiff’s claim for STD
benefits.
Plaintiff argues that his position was improperly labeled as “sedentary,” and that it should
have actually been labeled as “light work.” But as Defendants argue, there is no indication that
Sedgwick’s decision to deny Plaintiff STD benefits turned solely on this distinction. Although
the reviewers acknowledged that Plaintiff’s position was labeled as “sedentary” by Sedgwick in
the Job Analysis Form, there is nothing in the administrative record to indicate that the reviewers
based their decision solely on this distinction. Rather, as discussed above, the administrative
record demonstrates that Sedgwick based its decision to deny Plaintiff STD benefits after
reviewing the medical records that Plaintiff submitted in the context of the essential duties of
Plaintiff’s position, then concluding that the medical records did not demonstrate that he was
unable to perform those duties.
Plaintiff also argues that Sedgwick failed to request and obtain additional medical records
that he did not submit for the initial review. But Plaintiff carries the burden of proving he is
entitled to the requested benefits. See Perdue v. Burger King Corp., 7 F.3d 1251, 1254 n.9 (5th

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Cir. 1993). Sedgwick did not abuse its discretion merely because it did not seek additional
records that Plaintiff did not submit. In any event, the administrative record indicates that the
reviewing medical professionals attempted to contact Plaintiff’s physician during their reviews,
but their calls were not returned.
Also, Plaintiff’s claim that Sedgwick failed to consider whether he was disabled due to
his adjustment disorder, anxiety, and depression fails to show that Sedgwick abused its
discretion. The administrative record indicates that the medical professionals reviewed the
records that Plaintiff submitted, and there is no indication that Sedgwick denied Plaintiff’s claim
because it ignored potentially disabling diagnoses that Plaintiff’s physician identified. Further,
Plaintiff was not diagnosed with depression, anxiety, and adjustment disorder until June 19,
2015, seven weeks after his employment ended due to an alleged disability, and in that diagnosis,
Dr. Friedrichs did not opine that Plaintiff was disabled from his position or could not perform the
responsibilities of that position. Dr. Friedrichs did write a statement on January 1, 2016, that
Plaintiff’s adjustment disorder “directly impacted his ability to concentrate at work and is
responsible for his poor productivity in recent months.” But the administrative record indicates
that the medical professionals were provided and reviewed these documents, along with all other
medical records that Plaintiff submitted, and Sedgwick denied Plaintiff’s claim based on a
review of all of this information. Plaintiff cannot demonstrate Sedgwick abused its discretion just
because a select set of medical records show his physician opined that symptoms of mental
illness affected his work productivity.
As discussed above, the plan administrator is entitled to deference, and there is nothing in
the record to suggest that there was an abuse of discretion after Sedgwick reviewed an extensive

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record and denied Plaintiff’s claim. Despite Plaintiff’s arguments, the administrative record
indicates that Sedgwick based its decision to deny Plaintiff’s claim for STD benefits on the
medical records Plaintiff provided, the requirements of Plaintiff’s position, and the
recommendations of the reviewing medical professionals, both in the initial review and upon
Plaintiff’s appeal. Plaintiff fails to show that Sedgwick’s decision was made without a rational
connection between the known facts and the decision to deny STD benefits. Accordingly, there is
no genuine dispute of material fact that Sedgwick did not abuse its discretion when it denied
Plaintiff’s claim for STD benefits.
B. Plaintiff’s Claim Against Defendant Charter
Plaintiff argues that the Court should review Charter’s denial of his claim for STD
benefits de novo because unlike Sedgwick, Charter did not have discretionary authority to
determine the payment of STD benefits, and that the Court should enter summary judgment in
his favor. Charter argues the Court should review the denial of STD benefits under an abuse of
discretion standard because Charter delegated sole discretionary authority under the Plan to
Sedgwick to determine STD benefits, leaving Charter with no authority to make STD benefit
determinations. Charter argues it is entitled to summary judgment because Sedgwick did not
abuse its discretion in denying Plaintiff’s STD claim.
Where a claims administrator has sole discretionary authority to determine benefit claims,
such a decision is reviewed for abuse of discretion, not under a de novo standard of review. See
Wildbur v. ARCO Chem. Co., 974 F.2d 631, 637 (5th Cir. 1992). In the present case, the
Disability Program Provisions states that for a STD claim, the “Claims Administrator is the
claims fiduciary with sole authority to determine benefit claims under the terms of the Disability

17

Program.” Docket no. 44-1 at 51. It has been established that Sedgwick is the Claims
Administrator for STD claims.
In Rusch v. United Health Group Inc., the plaintiff sought disability benefits under her
employer’s disability benefits plan and brought an action against her employer after her claim for
benefits was denied. Rusch v. United Health Grp. Inc., No. 2:12-CV-00128, 2013 WL 3753947
(S.D. Tex. July 15, 2013). The employer’s plan “delegated responsibility and authority for
administering claims to an unrelated third-party administrator” that had the “exclusive right and
discretion to administer the Plan’s benefits.” Id. at *6–7. Despite the fact that this plan listed the
employer as the “Plan Administrator,” the court applied an abuse of discretion for the claim
alleged against the plaintiff’s employer because the plan made it clear “that eligibility
determinations are made by an independent Claims Administrator.” Id. at *7.
Similarly, in Coronado v. SBC Communications, Inc., the plaintiff brought action against
her employer after her disability claim was denied. Coronado v. SBC Commc’ns, Inc., No. SA04-CA-0426-RF, 2005 WL 2137912, at *1 (W.D. Tex. Aug. 30, 2005), aff’d, 193 F. App’x 364
(5th Cir. 2006). Because the employer “delegated complete authority concerning the award of
benefits” to an independent third party administrator, the court applied an abuse of discretion
standard in reviewing the plaintiff’s claim against her employer. Id. at *2.
In this case, Plaintiff acknowledges that Sedgwick was the Administrator of the STD Plan
and had “sole authority to determine benefit claims under the Disability Program.” Docket no. 62
at 4. There is no dispute that Sedgwick, and not Charter, had sole authority to approve or deny
Plaintiff’s STD claim. Accordingly, Plaintiff’s claim against Charter for the denial of STD
benefits must be reviewed for abuse of discretion. As analyzed in depth above, the Court finds

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that there is no genuine dispute of material fact that Sedgwick did not abuse its discretion when it
denied Plaintiff’s claim for STD benefits, and thus, Charter is entitled to summary judgment on
Plaintiff’s claim against it for the denial of benefits.
II.

Failure to Provide Plan Documents
Charter argues it is entitled to summary judgment on Plaintiff’s claim that Charter

allegedly failed to provide requested Plan documents because (1) Charter is not subject to the
regulation underlying Plaintiff’s claim for damages, (2) the record shows that Sedgwick
responded to Plaintiff’s requests, and (3) Plaintiff cannot establish that Charter acted in bad faith
or that he suffered prejudice. Plaintiff argues in his Response that the Court should enter
summary judgment in his favor on this claim.
A. Applicability of Law to Plaintiff’s Claims
As to Charter’s first point on the applicability of the statute, the point is now moot.
Charter initially argued that the regulation Plaintiff cited in his Complaint as a basis for liability,
29 C.F.R. § 2560.503-1, imposes requirements on the “employee benefit plan,” not the plan
administrator, thereby imposing no liability on Charter as the Plan Administrator. After Charter
filed its motion for summary judgment, the Court granted Plaintiff’s Unopposed Motion for
Leave to File First Amended Complaint. Docket no. 55. In his First Amended Complaint,
Plaintiff removes the reference to 29 C.F.R. § 2560.503-1 and alleges that Charter failed to
timely provide him with requested Plan documents in violation of 29 U.S.C. § 1024(b)(4), which
results in statutory penalties under 29 U.S.C. § 1332(c)(1). Docket no. 56 at 6–7. Thus, Charter’s
argument about the applicability of 29 C.F.R. § 2560.503-1 is now moot.

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B. Charter’s Claim that Sedgwick Responded to Plaintiff’s Requests
Charter next argues that Sedgwick sent Plaintiff all documents relevant to his claim.
Plaintiff argues that his requests were not met because he did not timely receive Plan documents.
Under 29 U.S.C. § 1024(b)(4), plan administrators must, “upon written request of any participant
or beneficiary, furnish a copy of the latest updated summary [ ] plan description, and the latest
annual report, any terminal report, the bargaining agreement, trust agreement, contract, or other
instruments under which the plan is established or operated.” 29 U.S.C. § 1024(b)(4). If a plan
administrator fails to comply with this requirement within thirty days after the request is made,
courts have discretion to impose a penalty of up to $100 per day. 29 U.S.C. § 1132(c)(1)(B)
Plaintiff alleges that on June 30, 2015, September 2, 2015, and September 24, 2015, his
attorney sent letters to Sedgwick requesting “all plan documents and all documents, records, and
other information relevant to [Plaintiff’s] claim for short-term disability benefits.” Docket no. 62
at 13. Charter states that Sedgwick sent Plaintiff a letter on July 8, 2015, that enclosed “the
documents on file throughout the life of the claim.” Docket no. 44-3 at 29. Charter states that
Sedgwick sent a similar letter to Plaintiff’s attorney on October 1, 2015. Id. at 21. Plaintiff,
however, states that despite Sedgwick sending out these letters and described documents, these
documents “did not include any Plan documents.” Docket no. 62 at 23. Plaintiff argues that the
fact that he may have received a copy of records related to his claim does not absolve Charter of
liability for its alleged refusal to provide Plan documents that Plaintiff requested. Plaintiff states
that his attorney then sent Charter a written request for Plan documents on May 12, 2016, which
was received on May 16, 2016, but that Charter ignored his request. Id. at 13. Plaintiff states that
Sedgwick finally produced certain Plan documents on July 11, 2017, namely the Plan

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Information, the Highlights brochure, and the Disability Provisions, thirteen months after
Charter’s deadline to produce these documents expired. Id. at 13–14. Plaintiff further states that
neither Defendant has produced Plan documents entitled the Overall Plan and the Services
Agreement, both of which Plaintiff states Charter now asserts are documents that make up the
STD Plan. Id. at 14.
Charter’s evidence indicates that Sedgwick’s letters and relevant documents sent on July
8, 2015, and October 1, 2015, were a timely response to Plaintiff’s request for documents.
However, there is at least a genuine dispute of material fact that the documents sent on these
dates did not fully fulfill Plaintiff’s request for “all plan documents” given that some documents
that may fall under that request were not received until July 2017, and others were potentially
never received. Accordingly, Charter is not entitled to summary judgment based on the claim
that Sedgwick responded to and met Plaintiff’s request for Plan documents.
C. Charter’s Claim that Plaintiff Cannot Establish Bad Faith and Prejudice
Charter finally argues that Plaintiff cannot establish that it acted with bad faith in meeting
his request for Plan documents or that he suffered any prejudice. Plaintiff argues that the Court
need not find there was prejudice, or in the alternative, that he did suffer prejudice and Charter
acted with bad faith such that the Court should order Charter to pay a penalty.
The imposition of a statutory penalty under 29 U.S.C. §1132(c) is within the discretion of
the district court. Paris v. Profit Sharing Plan for Emp. of Howard B. Wolf Inc., 637 F.2d 357,
362 (5th Cir. 1981). To make this determination, courts consider: “(1) bad faith by the
administrator, (2) the length of delay, (3) the number of requests, (4) the documents withheld,
and (5) the existence of any prejudice to the plan participant.” Thomason v. Metro. Life Ins. Co.,

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Civ. Ac. No. 3:14-CV-0086-P, 2016 WL 791044, at *7–8 (N.D. Tex. Feb. 25, 2016) (citing
Romero v. SmithKline Beecham, 309 F.3d 113, 120 (3d Cir. 2002); Friz v. ADS Power Res., Inc.,
Civ. Ac. No. 3:00–CV–1116–D, 2001 WL 732197, at *4 (N.D. Tex. June 27, 2001)). Although a
plaintiff is not required to show he was prejudiced to be entitled to penalty damages under the
statute, the Fifth Circuit has suggested that a court may consider it in exercising its discretion.
Godwin v. Sun Life Assur. Co. of Canada, 980 F.2d 323, 327 (5th Cir. 1992).
Courts in the Fifth Circuit have denied requests for penalty damages if the plaintiff does
not allege bad faith by the defendant or show that he has been somehow prejudiced. See, e.g.,
Godwin, 980 F.2d at 327 (finding the district court’s decision to not award penalty damages
because plaintiff was not prejudiced was not an abuse of discretion); Shelby County Health Care
Corp. v. Genesis Furniture Indus., Inc., 100 F. Supp. 3d 577, 585 (N.D. Miss. 2015); Mouton v.
Mobil, No. CIV. A. H-00-1403, 2001 WL 963957, at *10–11 (S.D. Tex. June 18, 2001).
In Mouton, the plaintiff argued he was prejudiced by the defendant’s failure to provide
plan documents because he was “‘hampered’ in his ability to prepare for the lawsuit,”
experienced “frustration and aggravation,” and was “prevented from knowing the reason for
denial of benefits.” Moulton, 2001 WL 963957, at *10. The court, however, concluded he was
not prejudiced because the documents did not contain information that “would have materially
added to the Administrator’s explanation for the denial of benefits” and the documents were
provided to the plaintiff early in the lawsuit. Id. at *11. Thus, the court declined to award penalty
damages. Id.
Similarly, the Plan documents that Plaintiff claims were not sent to him when Sedgwick
initially responded to his requests would not have provided Plaintiff a more detailed explanation

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as to why his claim for STD benefits was denied. Also, Plaintiff admits that these three requests
made in 2015 “are irrelevant to his section 1132(c) claim against Charter.” Docket no. 62 at 28.
Plaintiff only argues that Charter’s failure to timely submit the documents that Plaintiff requested
on May 12, 2016, entitle him to penalty damages. But as Charter argues, this May 12, 2016,
request came long after Plaintiff’s initial claim for STD benefits and subsequent appeal were
submitted, evaluated, and denied. Although Plaintiff claims that he was prejudiced by Charter’s
delay to provide Plan documents, he only alleges that he suffered prejudice “in the form of
distress and frustration with his ability to obtain the plan documents.” Id. at 26. But as in
Moulton, despite claims of frustration and distress, Plaintiff fails to provide any evidence that the
delay in receiving certain Plan documents prevented him from knowing the reason for the denial
of STD benefits, or any other specific harm he suffered. This is made clear by the fact that the
denial letter identified Sedgwick’s role in the determination, defined and explained the
requirements for STD benefits, and specifically explained why Sedgwick denied Plaintiff’s
claim. Docket no. 44-3 at 42–44.
Further, Plaintiff fails to provide any evidence that Charter acted with bad faith in
providing the Plan documents. Plaintiff claims Charter acted in bad faith because its failure to
provide Plan documents in a more timely fashion showed a “reckless, if not deliberate
indifference to its responsibilities.” Docket no. 62 at 28. But Plaintiff fails to provide any actual
evidence of bad faith just because Sedgwick, rather than Charter, provided certain Plan
documents, or why another document was provided after the Court ordered such at a status
conference.

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As discussed above, the imposition of statutory penalties under 29 U.S.C. § 1332(c) is
within the discretion of the Court. Plaintiff has not shown that he was prejudiced by Charter’s
alleged failure to respond to the one request for Plan documents on May 12, 2016, nor that
Charter acted with bad faith. The Court exercises its discretion to decline to award penalty
damages under 29 U.S.C. § 1132(c). To the extent that Plaintiff attempts to move for summary
judgment on the imposition of penalty damages against Charter, Plaintiff’s motion is denied.
Charter’s motion for summary judgment on its alleged failure to provide Plan documents is
granted.
CONCLUSION
For the foregoing reasons, the Court hereby GRANTS Defendant Charter’s Motion for
Summary Judgment (Docket no. 44), GRANTS Defendant Sedgwick’s Motion for Summary
Judgment (Docket no. 45), and DENIES Plaintiff’s Motions for Summary Judgment (Docket
nos. 62, 63). Accordingly, Plaintiff’s claims are hereby DISMISSED WITH PREJUDICE. The
Clerk is directed to issue a Judgment in favor of Defendants, and that Plaintiff takes nothing on
his claims. Defendants may submit its Bill of Costs within 14 days in the form directed by the
Clerk should it desire to pursue these costs.
It is so ORDERED.
SIGNED this 30th day of April, 2018.

_________________________________
XAVIER RODRIGUEZ
UNITED STATES DISTRICT JUDGE

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