Mitchell v. The Guardian Life Insurance Company of America
Filing
16
OPINION. Signed by Judge James P. Jones on 7/23/12. (sc)
IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF VIRGINIA
ABINGDON DIVISION
RANDAL D. MITCHELL,
Plaintiff,
v.
THE GUARDIAN LIFE INSURANCE
COMPANY OF AMERICA,
Defendant.
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Case No. 1:11CV00090
OPINION
By: James P. Jones
United States District Judge
Carletta J. Faletti, Faletti Law Firm, Richlands, Virginia, for Plaintiff.
Bruce M. Steen, McGuireWoods LLP, Charlotte, North Carolina, for Defendant.
In this case, the plaintiff seeks a judgment that he is entitled to long-term
disability benefits pursuant to an ERISA plan sponsored by his employer. Because
I find that the plan administrator did not abuse its discretion in determining that the
plaintiff had a pre-existing condition rendering him ineligible for long-term
benefits under the plan, I will grant summary judgment in favor of the defendant.
I
In this case arising under § 502(a)(1)(B) of the Employee Retirement
Income Security Act of 1974 (“ERISA”), 29 U.S.C.A. § 1132(a)(1)(B) (West
2009), the plaintiff, Randal D. Mitchell, complains of the denial of his claim for
long-term disability benefits by the defendant, The Guardian Life Insurance
Company of America (“Guardian”), on the basis that Mitchell’s claim was barred
by the pre-existing condition provision of the benefits plan. This court has subjectmatter jurisdiction pursuant to 29 U.S.C.A. § 1132(e)(1) (West 2009) and venue is
uncontested. The parties have briefed and orally argued their positions and the
case is ripe for decision.
The facts of the case are substantially undisputed and are contained in the
administrative record. Mitchell was employed as a Master HVAC Installer for
Parrish Services, Inc. As a benefit of his employment, Mitchell participated in an
employee welfare benefit plan, Guardian Group Plan #444607 (the “Plan”), which
provided long-term disability benefits to eligible plan participants. The Plan was
maintained pursuant to and governed by ERISA. Mitchell began his employment
with Parrish Services on October 15, 2008. He became a participant under the
Plan on January 1, 2009.1 Mitchell stopped working on December 23, 2009, due
to his claimed disability.
The Plan states that “Guardian is the Claims Fiduciary with discretionary
authority to determine eligibility for benefits and to construe the terms of the plan
1
Guardian submitted the administrative record in this case, consisting of copies of
the Plan and the Summary Plan Description (“SPD”), as well as Guardian’s internal file
on Mitchell’s claim, including correspondence and medical records. Guardian filed these
documents as multiple exhibits to the Declaration of Richard Fisher, an Adjudication and
Procedural Specialist with Guardian, docketed at ECF 9. In citing the administrative
record, Exhibit 1 (the Plan) and Exhibit 2 (the SPD) will be referred to jointly as “Plan.”
Exhibit 3, the remainder of the record, will be referred to as “Mitchell.” Citations will
also include the ECF docket numbers and the relevant Bates-marked page numbers.
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with respect to claims.” (ECF 9-3, Plan 0177.) Guardian both administered the
Plan and had the sole authority to grant or deny benefits to applicants.
The Plan provides that if a participant works less than 12 consecutive
months after he becomes a participant in the Plan, he is not entitled to long-term
disability benefits if the alleged disability is due to a pre-existing condition. The
Plan defines a pre-existing condition as “a sickness or injury, including all related
conditions and complications, for which, in the look back period, a covered person:
(a) received advice or treatment from a doctor; (b) takes prescribed drugs; or (c)
received other medical care or treatment, including consultation with a doctor.”
(ECF 9-2, Plan 0084; ECF 9-3, Plan 0168.) The look-back period is defined as the
12 months prior to the date on which the participant becomes covered under the
Plan.
On October 13, 2008, just before starting work at Parrish Services, Mitchell
went to see Angela Harrison, a nurse practitioner, as a new patient. Harrison’s
notes indicate that he presented with low back pain and had tenderness in the
lumbar sacral spine.
Harrison assessed him with low back pain.
Mitchell
underwent an X ray of his spine on October 14, 2008, for his “low back pain
radiating dow[n] left leg.” (ECF 9-4, Mitchell 0162.) The findings were: “No
acute or focal bone changes are seen. Arthritic changes of facet joints at L5-S1
level is noted. Mild degenerative changes of L5-S1 disc is also noted. Alignment
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of the vertebrae are normal.” (Id.) Mitchell was treated with an injection and
Lidocaine patches for the pain.
Another X ray of Mitchell while he was working for Parrish Services in
August of 2009 showed “mild dextroscoliosis of the lumbar spine centered along
the level of L3-4 with complete loss of disc height on the left aspect of the
vertebral bodies.” (Id. at 0171.) Mitchell stopped working that December. An
MRI in February 2010 indicated degenerative changes at L3-4, L4-5, and L5-S1,
which caused tenderness in the lower lumbar region around L4 and L5.
After stopping work, Mitchell applied for and received short-term disability
benefits through Parrish Services’ Guardian Short Term Disability Plan.
On
March 16, 2010, Guardian invited Mitchell to apply for long-term disability
benefits. Guardian notified Mitchell that “a pre-existing investigation may be
necessary.” (ECF 9-5, Mitchell 0463) Mitchell applied for long-term disability
benefits on March 31, 2010. Because Mitchell had stopped working before the
expiration of 12 consecutive months after his coverage began on January 1, 2009,
the look-back period applicable to Mitchell’s application was the 12-month period
prior to that date.
By letter dated July 1, 2010, Guardian informed Mitchell that his claim for
long-term disability benefits had been denied “because the condition for which [he
was] claiming disability is a pre-existing condition.” (Id. at 0607.)
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Guardian
pointed to the 2008 medical records as establishing that during the look-back
period, Mitchell had received advice, treatment, and medication for low back pain,
which was his claimed disabling condition. Guardian notified Mitchell of his
internal appeal rights under the Plan, invited him to submit medical records or
other information necessary to support his appeal, and described his rights under
ERISA.
Mitchell administratively appealed the denial of his claim for long-term
disability benefits on August 4, 2011. He argued that his lower back pain was not
a pre-existing condition because the 2008 examination showed degenerative
changes to L5-S1 and indicated the other vertebrae were normal, whereas the 2009
diagnosis of the problems leading to his disability concerned the L3-L4 vertebrae.
On September 21, 2010, Guardian commissioned a multi-disciplinary
(neurosurgery and orthopedic) review of Mitchell’s claim. Michael J. Chmell,
M.D., a board-certified orthopedic surgeon, was engaged to perform an orthopedic
review of Mitchell’s claim. Eugene Collins, M.D., a board-certified neurosurgeon,
was commissioned to perform a neurological review of Mitchell’s claim.
Upon reviewing Mitchell’s file, Dr. Chmell concluded:
It is evident from the medical record based upon the x-ray report on
10/14/08, as well as Angela Harrison’s notes from 10/13/08 as well as
the letter from Phyllis Mitchell 10/27/08 that this claimant has been
evaluated and treated for a history of low back pain . . . during the
dates in question of 01/01/08 through 12/31/08.
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(Id. at 0555-56.) Dr. Chmell certified that he had no direct or indirect financial
incentive for a particular determination in this case.
Dr. Collins also review Mitchell’s file. He noted that Mitchell was seen on
October 13, 2008, for lower back pain, was x-rayed for that indication on October
14, 2008, and was treated for it with an injection and Lidocaine patches. Dr.
Collins opined that Mitchell’s 2008 lower back pain radiating down the leg to the
knee could have been caused by an L3 and/or L4 radiculopathy at that time. Dr.
Collins concluded:
There is evidence that the claimant received advice or treatment
concerning his low back and left leg pain within the period noted
above of 01/01/08 through 12/31/08. It should be noted that the
claimant saw his physician for low back pain on 10/13/08. The
claimant was sent for x-rays with the indication being “low back pain
radiating down the left leg.” The claimant was also treated for such.
(Id. at 0571-72.)
In addition, Dr. Collins states that Mitchell’s “records are
consistent that the claimant was treated for a preexisting condition from 01/01/08
through 12/31/08 specifically beginning in October 2008.” (Id. at 0575.) Dr.
Collins certified that he had no direct or indirect financial incentive for a particular
determination in this case.
Based upon this independent review, Guardian concluded that Mitchell’s
disabling lower back condition was a pre-existing condition and denied his
administrative appeal on November 8, 2010. Guardian notified Mitchell that he
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had exhausted his Plan remedies and had the right to bring a civil action under
ERISA challenging the final benefit decision. This case followed.
II
ERISA permits a participant or beneficiary to bring a civil action to recover
benefits due to him under the provisions of his employee benefit plan. 29 U.S.C.A.
§ 1132(a)(1)(B). Where a plan gives discretionary authority to an administrator or
fiduciary to determine eligibility for benefits or to construe the language of the
plan, courts will review the administrator’s decision for abuse of discretion.
Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). In this case, the
Plan states that “Guardian is the Claims Fiduciary with discretionary authority to
determine eligibility for benefits and to construe the terms of the plan with respect
to claims.” (ECF 9-3, Plan 0177.) The parties agree that the Plan vests discretion
in Guardian.
Under the abuse of discretion standard, the court will not disturb a plan
administrator’s reasonable decision, even if the court would have come to a
contrary conclusion independently. Williams v. Metro. Life Ins. Co., 609 F.3d 622,
629 (4th Cir. 2010). The court may not substitute its judgment for that of the plan
administrator. Id. An administrator’s decision is reasonable if it results from “a
‘deliberate, principled reasoning process’ and [is] supported by substantial
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evidence.” Id. at 630 (quoting Guthrie v. Nat’l Rural Elec. Coop. Ass’n LongTerm Disability Plan, 509 F.3d 644, 651 (4th Cir. 2007)).
The Fourth Circuit has set forth eight nonexclusive factors for courts to
consider when reviewing the reasonableness of a plan administrator’s decision:
(1) the language of the plan; (2) the purposes and goals of the plan; (3)
the adequacy of the materials considered to make the decision and the
degree to which they support it; (4) whether the fiduciary’s
interpretation was consistent with other provisions in the plan and
with earlier interpretations of the plan; (5) whether the
decisionmaking process was reasoned and principled; (6) whether the
decision was consistent with the procedural and substantive
requirements of ERISA; (7) any external standard relevant to the
exercise of discretion; and (8) the fiduciary’s motives and any conflict
of interest it may have.
Williams, 609 F.3d at 630 (citing Booth v. Wal-Mart Stores, Inc. Assocs. Health &
Welfare Plan, 201 F.3d 335, 342-43 (4th Cir. 2000)).
The Plan’s determination that Mitchell’s lower back pain was a pre-existing
condition is well supported and entitled to deference. The most significant factor
in this case is the language of the Plan. Because Mitchell had worked less than 12
months after he was first eligible under the Plan, Guardian was required to
determine whether his disabling condition was a pre-existing condition.
The
Plan’s definition of pre-existing condition is very broad, including “all related
conditions and complications, for which, in the look back period, a covered person:
(a) receives advice or treatment from a doctor; (b) takes prescribed drugs; or (c)
receives other medical care or treatment, including consultation with a doctor.”
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(ECF 9-2, Plan 0084 (emphasis added).)
Under this definition, degenerative
changes to the lower back, whether at L5-S1 or L3-L4, may be related conditions
and complications satisfying the pre-existing condition exclusion. See Hanley v.
Emps. of Agency Rent-a-Car Hospitalization Ass’n, Civ. A. No. HAR 94-531,
1994 WL 548776, at *3 (D. Md. Sept. 29, 1994) (finding that under plan’s broad
pre-existing condition definition, the exclusion in not limited “to conditions that
are ‘directly caused’ by a pre-existing ailment”).
In addition, Guardian’s conclusion that this was a pre-existing condition is
supported by substantial evidence (Booth factor 3). Mitchell sought treatment for
lower back pain in October 2008 and was treated with an injection and Lidocaine
patches. He again claimed lower back pain as a condition starting in August 2009.
Although in 2008 the condition seemed limited to L5-S1, in 2009 it became
evident that L3 and L4 were also degenerating and ultimately were the most
significant sources of pain. This conclusion is supported by the MRI in February
2010, which indicated degenerative changes at L3-4, L4-5, and L5-S1, causing
tenderness in the lower lumbar region around L4 and L5. Regardless, all of these
problems were part of the condition that caused him to stop working, i.e., his lower
back pain.
Both independent medical reviewers so concluded and their
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conclusions, in addition to the objective medical evidence, support Guardian’s
denial of benefits.2
To the extent applicable, the other Booth factors also support Guardian’s
determination of Mitchell’s claim. One of the purposes and goals of the Plan is to
provide benefits to those who are entitled to them under the terms of the Plan.
Ensuring that the terms of the Plan, including the exclusions, are properly
interpreted and applied in a uniform fashion furthers that goal. The decisionmaking process engaged in by the Plan was reasoned and deliberate. Mitchell was
informed of his obligations and rights under the Plan and was given the
opportunity to appeal and submit additional information as he saw necessary. At
the appeal level, Guardian engaged two independent medical consultants to review
the record and opine on the proper determination.
Further, Mitchell has not
alleged, and the record does not show, any violations of ERISA’s procedural or
substantive requirements.
Mitchell argues that Guardian has a conflict of interest in assessing his claim
for long-term disability benefits because it acted as both the administrator and
2
The fact that the independent medical reviewer’s conclusions that Mitchell’s
lower back pain was a pre-existing condition were different from that of Harrison, one of
Mitchell’s treatment providers, does not make the Plan’s denial of benefits an abuse of
discretion. See Booth, 201 F.3d at 345-46 (“[I]t was within the discretion of the
Administrative Committee – indeed it was the duty of that body – to resolve the conflicts,
and . . . ‘it is not an abuse of discretion for a plan fiduciary to deny . . . benefits where
conflicting medical reports were presented.’” (quoting Elliott v. Sara Lee Corp., 190 F.3d
601, 606 (4th Cir. 1999)).
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underwriter of the Plan. While it is undoubtedly true that Guardian does have a
structural conflict of interest because of its dual role of evaluating claims for
benefits and paying benefits, Williams, 609 F.3d at 632, there is no indication that
this conflict of interest caused Guardian to be inherently biased in making its
decision.3
Mitchell argues that the conflict of interest has so shaded Guardian’s review
of his case that it resulted in an abuse of discretion. To support this argument,
Mitchell references what he views as “procedural errors” occurring during
Guardian’s review of his claim. First, he notes that Guardian initially informed an
evaluating physician, Melvin Heiman, M.D., that Mitchell worked as a shipping
clerk and based upon this erroneous information, Dr. Heiman determined Mitchell
was not disabled. This error has nothing to do with Guardian’s conclusion that
Mitchell’s low back pain was an ineligible pre-existing condition. Dr. Heiman was
assessing Mitchell’s disability based upon his right knee problems. Although
Mitchell’s claim for benefits were initially based upon both back and knee
problems, it was ultimately concerned only with his back problems and thus Dr.
Heiman’s opinion on the disabling effect of his knee problems was irrelevant.
3
Mitchell contends that denying his long-term benefits saved Guardian $221,435
over the years (Compl. ¶ 35), and because of this large sum it can be assumed that
Guardian made special efforts to find a way to reject his claim. There is no evidence of
such special efforts; moreover, we do not know whether Mitchell’s claim was necessarily
large in comparison with all of the other disability claims that Guardian is obligated to
pay.
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Although Dr. Heiman’s opinion did have an effect on Guardian’s initial
decision to deny benefits, on appeal the reviewing physicians did not rely upon Dr.
Heiman’s opinion based on the erroneous information. Dr. Chmell noted that “Dr.
Heiman states that he does not think either knee would hold up to his job
requirements.” (ECF 9-5, Mitchell 0553.) Dr. Collins did not address or rely upon
Dr. Heiman’s opinion at all.
Mitchell also argues that Dr. Chmell’s emphatic opinion that Nurse
Practitioner Harrison’s assessments of Mitchell’s condition and ability to work
were less than reliable are further evidence of Guardian’s conflict of interest. Dr.
Chmell noted several issues with Harrison’s assessments. First, he noted that
Harrison gave Mitchell permission slips to be off from work that were not
supported by any objective data and, in his opinion, were arbitrary. (Id. at 0548,
0551, 0552.) Second, he noted that her letter to Guardian of July 28, 2010, in
which Harrison claimed that Mitchell’s back and knee pain in 2008 were distinct
issues which were resolved and not long-term problems, was unsupported by her
treatment notes. (Id. 0558.) He further contended that Harrison’s attempt to
retrospectively correct those treatment notes to conform to Mitchell’s disability
claim was unjustified. (Id.)
Dr. Chmell’s statements are not without support in the record. The fact that
Dr. Chmell questioned the conclusions of Mitchell’s treatment provider is not
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evidence of self-serving where the questions raised are the reasonable results of an
independent expert review of the record.4
III
Mitchell appears to be disabled (he has received a Social Security disability
award) and it is truly unfortunate for him that he left work nine days before his
anniversary in the Plan, which would have removed the pre-existing condition
exclusion. Nevertheless, for the reasons set forth, I must find that Guardian’s
determination that Mitchell’s lower back pain was a pre-existing condition
excluding him from long-term disability benefits is unassailable and that summary
judgment for Guardian is appropriate.
A separate Judgment will be entered
forthwith.
DATED: July 23, 2012
/s/ James P. Jones
United States District Judge
4
Mitchell also asserts that Guardian included six pages of another individual’s
claim file when it sent Mitchell his own claim file in response to his request for all the
information Guardian relied upon in reaching its final conclusion. Mitchell thus contends
that the denial of his benefits was based, in part, upon another claimant’s record. The six
pages in question are not in the present administrative record and Mitchell himself has
not submitted them or otherwise described their contents. There is thus no evidence
supporting Mitchell’s argument that Guardian’s determination was based on someone
else’s information. It is pellucid that this was a simple clerical error.
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