Opinion
CASE NO. 1:03CV912.
November 1, 2005
MEMORANDUM OF OPINION
On May 15, 2003, Suzan G. Brown, Plaintiff filed the above-captioned case seeking review of Defendant UNUM Life Insurance Company of America (hereinafter "UNUM") denial of her long-term disability benefits pursuant to § 1132(a)(1)(B) of the Employee Retirement Income Security Act. She also seeks attorney fees and costs pursuant to 29 U.S.C. § 1132(g)(1). On October 14, 2004, Plaintiff filed a brief on the administrative record. On November 11, 2004, Defendant filed its Motion for Confirmation of the Administrative Decision. Jurisdiction is appropriate pursuant to 28 U.S.C. § 1331.
UNUM was improperly identified in the complaint as Unum Provident Corporation.
FACTS
Plaintiff is a physical therapist and participant in Defendant's long-term disability policy ("Plan"). In May 1999, she injured herself while lifting patients at work. (Admin. R. at 00027.) On May 10, 1999, she was diagnosed with a lumbar sprain by Dr. Frank, her family physician. (Admin. R. at 0011-12.) He gave Plaintiff initial restrictions and limitations of limited standing, walking, bending, twisting, and overhead work. Id. Plaintiff immediately applied for and received worker's compensation. On March 29, 1999, Dr. Frank gave her an extensive list of restrictions and limitations which included a driving limitation of thirty minute intervals for a total of four hours per day. (Admin. R. at 00330.) On July 7, 1999, an MRI was taken of Plaintiff's back. (Admin. R. at 00505.)On April 13, 2000, Dr. Frank gave Plaintiff another set of restrictions and limitations that varied from the earlier list in that the driving limitation was changed to fifteen minute intervals for a total of two hours a day. (Admin. R. at 00318.)
On April 25, 2000, as Plaintiff's worker's compensation benefits were about to expire, she submitted her initial long-term benefit claim to Defendant. Under the Plan, a participant is disabled when:
UNUM determines that:
— you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and
— you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury.
After 24 months of payments, you are disabled when UNUM determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.
(Admin. R. at 00813.) On June 12, 2000, Defendant approved and began paying Plaintiff benefits because sufficient evidence was presented to demonstrate she was unable to perform her specific duties as a physical therapist. (Admin. R. 00127.)
In January 2001, Defendant sent Plaintiff to a vocational consultant for a transferable skills analysis. This analysis found that Plaintiff would be qualified to work in several sedentary occupations such as a Credit Counselor or Case Manager. The analysis further found such occupations to be within the limitations set forth by her doctor, and in her geographic area. (Admin. R. at 00226, 00321.) Plaintiff contended that despite her qualifications, Dr. Frank's new restrictions and limitations restricted her driving to fifteen minute driving intervals and all prospective jobs were outside that limitation.
Under the terms of the Plan, after twenty-four months of payments, Plaintiff had to show she was "unable to perform the duties of any gainful occupation for which [she was] reasonably fitted by [her] education, training or experience" to continue receiving benefits. (Admin. R. at 00813.) On October 15, 2001, two weeks before Plaintiff's twenty-fourth payment, she filed a Supplemental Statement to continue her long-term disability benefits. (Admin. R. at 00326.) Dr. Frank filed a Supplemental Physician's Statement concluding that even though Plaintiff had completed rehabilitation and physical therapy, there were still residual limitations that prevented her return to work. (Admin. R. at 00324.)
On January 18, 2002, Defendant denied Plaintiff's claim for continued long-term disability benefits finding she no longer met the definition of disability as defined in the Plan. (Admin. R. at 00705.) Defendant based its conclusion on its review of the record and treatment notes submitted by Dr. Frank. These records and notes indicated she was capable of performing four hours of sedentary work, two hours of light work, and one hour of medium work in an eight hour day. (Admin. R. at 00707.) Therefore, Defendant concluded it would be reasonable for Plaintiff to perform eight hours of light (completely sedentary) work per day. Id. According to Defendant's investigation and vocational consultants, Plaintiff would be able to perform several alternative sedentary occupations which would be appropriate notwithstanding the restrictions and limitations set forth by Plaintiff's physician. Id. Based on these determinations Plaintiff was denied further long-term disability benefits.
On February 4, 2002, Plaintiff filed her first appeal with Defendant. On May 8, 2002, Defendant's Dr. Brock conducted a medical review of Plaintiff's claim and concluded there was no "medical explanation" as to why Plaintiff could not return to work. (Admin. R at 450.) He concluded the record showed that the only diagnostic study available was the July 7, 1999, MRI which actually showed improvement in her lumbar spine region when compared to MRIs done in 1996. Id. He further concluded that
The [Plaintiff] appears to have only been seen by a [primary care physician] with no obvious neurologic orthopedic consultations. Treatment appears to have been limited to medications, physical therapy, manipulation, and stretching. Diagnoses varied depending upon the [Plaintiff's] statements and complaints rather than on physical and neurological findings and there do not appear to be medically established [injuries] other than for a possible initial sprain/strain of the lumbar region.
(Admin. R. at 00450.)
On July 15, 2002, Dr. Brock conducted another review of Plaintiff's file to clarify his May 8 review and reached similar conclusions. (Admin. R. at 00490.) He reiterated his prior conclusions that Plaintiff had at least eight hours of sedentary work capacity a day, that she should have recovered her original work capacities by July 1999, and that Dr. Frank's restrictions and limitations appeared excessive. Id.
On August 2, 2002, Dr. Brock wrote to Dr. Frank asking for additional medical information and clarification of his medical opinions. Defendant wrote:
Your extensive restrictions and limitations you listed in your 3-29-00, 10-15-01, 10-24-01 office notes appear to be based on [Plaintiff's] statements since there are no physical or neurological abnormalities documented within these notes. I was unable to determine the medical basis for concluding [Plaintiff] was only capable of working a total of 4 hours per day or why you believed she had either 4 hours of sedentary activity capacity, two hours of light activity capacity and one hour of medium activity.
(Admin. R. at 00604-05.) The purpose of this letter was to ensure Defendant had all available information before making its decision. Id. Dr. Frank responded by letter dated August, 18, 2002. (Admin. R. at 00743.) This letter included an independent functional capacity evaluation from February 21, 2000, and two MRI reports from a back injury Plaintiff sustained in 1996. Id.
On August 29, 2002, Defendant conducted another medical review of Plaintiff's file. Dr. Brock found the medical information provided by Dr. Frank did no more than reinforce his previous decisions. (Admin. R. at 00061.) He found that the MRIs from 1996, when compared to the MRI of July 7, 1999, showed an improvement from the 1996 disc herniation, not degeneration. Further, as far as the independent functional capacity report, he stated:
The presented information indicates that the evaluation was done at the local hospital where he practices, was done without apparent validity assessment, without an apparent attempt at observing consistency of non-testing and testing actions, without an appeared assessment of the [Plaintiff's] perception of pain and apparently in conjunction with Dr. Frank's apparent involvement in determining the evaluation conclusions of capacity.
(Admin. R. at 00661.) Dr. Brock concluded, "[b]esides testing not supporting a new or worsened lumbar pathology [Dr. Frank's] own notes and the [Plaintiff's] statements as previously reviewed do not support his conclusion." Id. On September 9, 2002, the Defendant denied Plaintiff's appeal based on Dr. Brock's medical reviews. (Admin. R. at 00525.)
On September 27, 2002, Plaintiff filed her final appeal with Defendant. In Plaintiff's letter, she indicated that she felt Defendant's decision was prejudicial and unfair. (Admin. R. at 00669.) Included with her appeal letter were forty-three exhibits she thought Defendant may not have had when making its previous decisions.
In December 2002, Defendant conducted another review of Plaintiff's claim and denied it. This review was conducted by Dr. Keller, Vice President and Medical Director of Defendant, and a board certified orthopedic surgeon. (Admin. R. at 00687.) In his review he noted that much of what Plaintiff submitted had been previously reviewed. (Admin. R. at 00681.) What had not been previously submitted consisted of mainly abstracts and articles discussing alternative treatments and testing. Dr. Keller found such treatments/tests as descriptive, but they had not been validated. Further, he found that Plaintiff's MRIs showed improvement over time and her examinations showed only muscle tension. Id. He stated that they "show[ed] no significant neurological findings or objective measures of limitations. Therefore, there [was] neither physical nor imaging evidence of significant lumbar [injury]." (Admin. R. at 00680.) He also found that Dr. Frank's notes were "brief but indicate a paucity of significant physical findings." Id. In conclusion, Dr. Keller stated that any restrictions and limitations would have applied to the sprain/strain diagnosed on May 10, 1999, which would have a usual recovery period of four to six weeks. He further concluded, "Given the prolonged and increasing nature of the [Plaintiff's] symptoms during the first 24 months of treatment, one would have anticipated specialty consultations and additional testing including cervical imaging studies, EMG/NCV, among others." Id.
On January 11, 2003, based on Dr. Keller's analysis, Defendant sent Plaintiff a letter stating:
[W]e do not have a medical basis to conclude that your condition results in restrictions or limitations that would preclude you from your regular occupation as physical therapist. Therefore, we do not have a basis to conclude that you are disabled by the terms of the policy, and we have no alternative but to uphold the denial decision.
(Admin. R. at 00696.)
STANDARD OF REVIEW
In Firestone Tire Rubber Co. v. Bruch, the United States Supreme Court held that an arbitrary and capricious or abuse of discretion standard of review applies where a plan gives the plan administrator "discretionary authority to determine eligibility for benefits or to construe the terms of the plan." 489 U.S. 101, 115 (1989). "The Court in Firestone . . . did not suggest that "discretionary authority" hinges on incantation of the word "discretion" or any other "magic word." Perez v. Aetna Life Ins. Co., 150 F.3d 550, 555 (6th Cir. 1998) (quotingJohnson v. Eaton Corp. 970 F.2d 1569, 1572 n. 2 (6th Cir. 1992)). "In order to vest the plan administrator with discretion, the grant of discretionary authority must be "clear" in order to trigger the arbitrary and capricious standard of review." Smith v. AETNA U.S. Healthcare, 312 F. Supp. 2d 942, 949 (S.D. OH 2004) (quotingHoover v. Provident Life Acc. Ins. Co., 290 F.3d 801, 807 (6th Cir. 2002)).
Defendant argues that the Certificate Section of the Plan contains express language that grants it discretion to determine eligibility for benefits and to construe the terms of the plan. That section states, "[w]hen making a benefit determination under the policy, UNUM has discretionary authority to determine your eligibility for benefits and to interpret the terms and provisions of the policy." (Admin. R. at 00821.) Plaintiff argues that this section is not part of the Plan and that there is no language within the Plan that constitutes a grant of clear discretionary authority to Defendant.
The Court finds no merit in Plaintiff's argument and agrees with Defendant that the Certificate Section contains language that clearly grants it discretion. The Court bases its finding on a plain reading of the Plan language and the Plan itself. First, because the Certificate Section of the Plan states it is a long-term disability policy, the only "benefit determination under the policy" Defendant can make is whether to grant or deny long-term disability benefits. Furthermore, the only "terms" or "provisions" Defendant can interpret under this policy are those relating to long-term disability benefits. Second, language found in the Benefits at a Glance section that outlines the long term disability plan states: "[f]or a full description of your coverage, continue reading your certificate of coverage section." (Admin. R. at 00826.) The only logical reading of that sentence is that the Certificate Section helps define the long-term disability policy. Given the clear language in these sections, the Court finds the Plan clearly vests discretion with Defendant to determine benefit eligibility and to construe terms of the plan. Therefore, the appropriate level of review for Defendant's denial of benefits is the arbitrary and capricious standard.
The Court finds the following language also grants Defendant discretion by requiring it to use its discretion and make a subjective benefit decision based on evidence presented to it. "You are disabled when UNUM determines that" (Admin. R. at 00813), "You will begin to receive payments when we approve your claim. . . ." (Admin. R. at 00811), and "so that a claim decision can be made in a timely manner" (Admin. R. at 00799).
ANALYSIS
The arbitrary and capricious standard "is the least demanding form of judicial review of administrative action. . . . When it is possible to offer a reasoned explanation, based on the evidence, for a particular outcome, that outcome is not arbitrary and capricious." Killian v. Healthsource Provident Adm'rs, Inc, 152 F.3d 514, 520 (6th Cir. 1998) (Quoting Perry v. United Food Commercial Workers Dist. Unions 405 442, 64 F.3d 238, 241 (6th Cir. 1995)). If an administrator's determination or interpretation has any "rational basis," a court reviewing that determination "should not disturb [it]." Hanser v. Ralston Purina Co., 821 F. Supp. 473, 477 (E.D. Mich. 1993) (citingMiller v. Metropolitan Life Ins. Co., 925 F.2d 979, 984 (6th Cir. 1991)). Therefore, this standard requires the decision "be upheld if it is the result of a deliberate principled reasoning process, and if it is supported by substantial evidence." Killian, 152 F.3d at 520 (Quoting Baker v. United Mine Workers of America Health Retirement Funds, 929 F.2d 1140, 1144 (6th Cir. 1991)).The question is whether Defendant's determination that Plaintiff was not disabled under the terms of the Plan and, therefore, did not qualify for continued long-term disability benefits, was well reasoned and rationally based on the Plan's provisions and the evidence before it. Under the terms of the Plan a participant is disabled when
UNUM determines that:
— you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and
— you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury.
After 24 months of payments, you are disabled when UNUM determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.
(Admin. R. at 00813.) After a careful review of the record, the Court finds that the Defendant's determination to discontinue Plaintiff's benefits was rationally based upon the medical information before it and was therefore, not arbitrary and capricious.
It was rational for Defendant to conclude, on the medical evidence presented to it, that the restrictions and limitations prescribed by Dr. Frank did not preclude Plaintiff from performing her regular occupation as a physical therapist. The restrictions and limitations were not accompanied by any medical evidence or reasoning as to how they were arrived at even after such evidence was requested by Defendant. The only evidence of disability found in the record appears to be based on Plaintiff's own self-diagnosis and the opinions of her doctor. The only diagnostic evidence presented was one MRI given after the May 1999 injury, and two MRIs that predated that injury. It was rational for Defendant to conclude Plaintiff was not disabled based on these because the newer MRI showed improvement in her lumbar region over the previous MRIs. It was also rational for Defendant to conclude Plaintiff was not disabled because she did not seek any other diagnostic testing or specialist treatment when she complained her symptoms were worsening.
Plaintiff requested attorney fees and costs pursuant to 29 U.S.C. § 1132(g)(1). Under this statute, the Court, in its discretion, may allow reasonable attorney fees and costs to either party. Because the Court finds in favor of the Defendant, the Court does not award attorney's fees or costs to Plaintiff.
CONCLUSION
Given the Court's determination that Defendant's decision not to continue long-term disability benefits was not arbitrary and capricious, Defendant's Motion to Confirm the Administrative decision is granted. Thus Plaintiff is not entitled to further long-term disability benefits.
IT IS SO ORDERED.