Opinion
Civil Action No: SA-04-CA-0385-XR.
May 19, 2005
ORDER
On this date the Court considered cross-motions for summary judgment. Plaintiff contends that he was wrongly denied disability benefits by Defendant SBC Disability Income Plan ("the Plan"). Plaintiff argues that it was an abuse of discretion to deny him benefits. The Plan argues that Plaintiff's medical records did not support a finding of total disability. After reviewing the record and the determination by the Plan, the Court finds that there was no abuse of discretion. Plaintiff's motion for summary judgment (docket no. 19) is DENIED and the Plan's motion for summary judgment (docket no. 23) is GRANTED.
The Plan is alternately referred to in the parties' filings as "SBC Disability Income Plan," "SBC Communications Inc. Disability Plan," and "Southwestern Bell Communications Inc. Disability Plan." To simplify matters, the Court refers to Defendant as "the Plan."
I. Factual and Procedural Background
Plaintiff worked for SBC (f/k/a Southwestern Bell) as a cable splicing technician for approximately 23 years before applying for disability. Plaintiff's occupation is described as "heavy duty," including climbing, crawling, bending, and lifting. On or about August 20, 2002, Plaintiff applied for short term disability ("STD") benefits, claiming that he could no longer perform his essential job functions because of back pain. Plaintiff last day of work was August 8, 2002. Under the Plan, Plaintiff's benefits automatically began eight days after the last day of work. Thus Plaintiff began receiving benefits back-dated to August 15, 2002. Plaintiff was eligible to receive STD benefits at full pay for 39 weeks and at half pay for 13 weeks as long as his application was approved under the Plan. Plaintiff was informed that he was responsible for providing medical records to support his claim of "Total Disability" by August 28, 2002.
Under the terms of the Plan, "`Total Disability' or "Totally Disabled' means, with regard to Short Term Disability, that because of Illness or Injury, an Employee is unable to perform all of the essential functions of his job or another available job assigned by the Participating Company with the same full — or part-time classification for which the Employee is qualified." SBC Disability Income Plan Art. II, ¶ 2.26.
Plaintiff submitted current medical records and supplemented his claim with records of his on-going treatment during the claims process. Plaintiff was eventually approved for STD benefits through October 13, 2002. On October 11, 2002, the Plan's Claims Manager received medical records and reports from Plaintiff's treating physicians, Harry Hernandez, D.O., and Holger Skerhut, M.D. The records and reports, including MRI scans, indicated that Plaintiff may have had a compression fracture in his spine, but that much of the physical examination conducted was normal. The Claims Manager approved the extension through October 13, 2002 and indicted that "[m]edical supports extension into maximum time frame." The Claims Manager also noted that the suspicion of a compression fracture needed to be verified prior to considering a return to work.
On October 17, 2002, the Claims Manager called Dr. Skerhut's office and was told that Dr. Skerhut was not evaluating Plaintiff for disability. Dr. Skerhut's office noted that Plaintiff's next appointment was not until November 14, at which time the bone scan and MRI previously administered would be discussed. Following this conversation, the Claims Manager determined that the available medical information did not support continuing benefits. Plaintiff was then called and informed of the decision to deny any further benefits.
Following this initial denial, Plaintiff continued to press his claim, appealing the denial decision. Plaintiff continued to supplement the record with medical documents. Plaintiff's appeal was presented before Clinical Appeals Specialist Karen Pink. Pink received a letter from Dr. Skerhut dated November 14, 2002, in which he noted that Plaintiff was improving and that the bone scan indicated either that Plaintiff had a compression fracture over seven years old or an oddly shaped vertebrae. Pink also received documentation from Dr. Hernandez, recommending no heavy lifting or strenuous exercise, and a report from Steven Schuleman, M.D. dated January 13, 2003, which indicated Plaintiff's MRIs were "unremarkable." Dr. Schuleman indicated an impression of myofascial pain syndrome. Eventually, Pink submitted Plaintiff's medical documentation to an independent physician, Richard A. Silver, M.D., for review. Dr. Silver prepared a report dated February 17, 2003 in which he concluded that Plaintiff's "subjective complaints of pain and discomfort are unsubstantiated." Dr. Silver noted that Plaintiff "had some discogenic disc disease and an old wedge compression fracture . . . more than two years old," but that this did not support a finding that would preclude him from returning to his job as a cable splicing technician. Plaintiff's appeal was denied by Pink on February 24, 2003.
The events following this denial are not entirely clear, but it appears that Dr. Hernandez sent in work restrictions for Plaintiff on March 20, 2003. Dr. Hernandez stated that Plaintiff could return to sedentary duty such as answering the telephone, but restricted him from lifting until after his evaluation by a rheumatologist scheduled for April 15, 2003. Human Resources declined the restriction of no lifting on April 8, 2003. Apparently, Plaintiff returned to active duty at some point, but went out on paid vacation leave without returning to work. On the final day of his vacation leave, Plaintiff filed a second claim for STD benefits. Plaintiff visited rheumatologist Joshua Stolow, M.D., who indicated a diagnosis of fibromyalgia and these documents were submitted to the Plan. Medical documents were also received from Dr. Hernandez indicating certain restrictions on Plaintiff's workday. On July 2, 2003, Dr. Hernandez stated in a letter that Plaintiff had requested to return to work without any restrictions and that this was being done without medical consent. Plaintiff's medical records were again submitted to an independent physician, M.Y. Walkup, D.O., for review. Though no report or specific findings of Dr. Walkup has been furnished to the Court, the Claims Record indicates that Dr. Walkup noted there was insufficient objective documentation of total disability. Plaintiff's claim was denied on July 15, 2003.
This second claim indicated the date of loss as August 7, 2002, the same date of loss as indicated in the first claim.
No party has informed the Court what the term "fibromyalgia" actually means. According to THE ARTHRITIS SOURCEBOOK, "fibromyalgia" is a type of rheumatism that is distinguished by chronic pain in the muscles, ligaments, tendons, or bursae around joints. EARL J. BREWER KATHY COCHRAN ANGEL, THE ARTHRITIS SOURCEBOOK (1998), available at www.webmd.com/content/article/6/1680_51250.htm.
Plaintiff filed the current federal action under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132, on May 4, 2004. Both Plaintiff and the Plan now move for summary judgment. Plaintiff argues he is entitled as a matter of law to STD benefits, as the Plan abused its discretion in denying benefits. The Plan argues that there is sufficient evidence in the record to hold that it did not abuse its discretion and that Plaintiff is not entitled to STD benefits or long term disability benefits.
II. Standard of Review
Summary judgment is proper "if the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to material fact and that the moving party is entitled to judgment as a matter of law." FED. R. CIV.P. 56(c). The moving party has the burden of showing that there is no genuine issue as to a material fact and that the moving party is entitled to judgment as a matter of law. Willis v. Roche Biomedical Lab., Inc., 61 F.3d 313, 315 (5th Cir. 1995). Once the movant carries its initial burden, the burden shifts to the nonmovant to show that summary judgment is inappropriate. Fields v. City of S. Houston, 922 F.2d 1183, 1187 (5th Cir. 1991). All justifiable inferences to be drawn from the underlying facts must be viewed in the light most favorable to the party opposing the motion. Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 587 (1986). In making this determination, the court will review the evidence in the record and disregard the evidence favorable to the moving party that the jury is not required to believe. Reeves v. Sanderson Plumbing Prods., Inc., 530 U.S. 133, 135 (2000). 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 nonmovant, or, in other words, that the evidence favoring the nonmovant is insufficient to enable a reasonable jury to return a verdict for the nonmovant. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 250 n. 4 (1986). If the record, viewed in this light, could not lead a rational trier of fact to find for the party opposing the motion, summary judgment is proper."[F]or factual determinations under ERISA plans, the abuse of discretion standard of review is the appropriate standard," even if the Plan does not expressly give the administrator discretionary authority. Vercher v. Alexander Alexander, Inc., 379 F.3d 222, 226 (5th Cir. 2004). "In applying the abuse of discretion standard, the Court analyzes whether the plan administrator acted arbitrarily or capriciously." Meditrust Fin. Servs. Corp. v. Sterling Chems., Inc., 168 F.3d 211, 214 (5th Cir. 1999) (quotation omitted). If the administrator's decision is supported by substantial evidence, the Court must affirm the decision. Id. at 215; Vega v. Nat'l Life Ins. Servs., Inc., 188 F.3d 287, 299 (5th Cir. 1999) ("[T]he administrator's decision [must] be based on evidence, even if disputable, that clearly supports the basis for its denial."). A decision is arbitrary only if "made without a rational connection between the known facts and the decision or between the found fact and the evidence." Meditrust, 168 F.3d at 215 (quotation omitted).
Plaintiff initially attempts to argue that a less deferential abuse of discretion standard should be applied to the Plan administrator's decision. Plaintiff's contention that because SBC funds the SBC Disability Income Plan there is an inherent conflict of interest is in error. Sedgwick Claims Management Services, Inc., is an independent administrator hired as a third party vendor. A conflict arises in this context only, however, where the party making the benefit determination also insures or funds the program. Vega v. Nat'l Life Ins. Servs., 188 F.3d 287, 295 (5th Cir. 1999). As there is no evidence supporting the contention of a conflict of interest, the typical abuse of discretion standard applies to the determination of Plaintiff's claim.
The Court is constrained to the evidence before the Plan administrator. Vega, 188 F.3d at 299 (citations omitted). The record must contain all information submitted to the administrator prior to the filing of the instant lawsuit which was provided in a manner that gave the administrator a fair opportunity to consider it. Id. at 300.
III. Analysis
Under the highly deferential abuse of discretion standard, it is clear that the Plan administrator did not abuse that discretion in denying Plaintiff's claim for STD benefits. Plaintiff argues that the administrator was incorrect in determining that the medical evidence did not substantiate his claim of total disability. Plaintiff points to evidence in the administrative record as of October 17, 2002 as evidencing disability. This included a diagnosis of a compression fracture in Plaintiff's spine, medical notations including numbness, tingling in arms and hands, weakness, pain, and chronic back spasms, and MRIs showing undetermined problems at T7 in the thoracic spine, disc dessication in the thoracic spine, degenerative disc disease in the lumbar spine, either a disc herniation or disc bulge at L5-S1, and degenerative changes in the right knee and hands.
The Court treats Plaintiff's second claim as an extension of the first claim. Under the Plan, a claimant that returns to work for less than 26 weeks and once again claims disability is eligible to collect STD benefits and this second claim is treated as an extension of the first claim. The second claim refers to August 7, 2003 as the date of loss; the same date of loss indicated in the original claim.
Though Plaintiff clearly has evidence that indicates some level of disability, there is strong evidence in the administrative record supporting the administrator's decision. As of October 17, 2002, in addition to the evidence pointed out by Plaintiff, there was also evidence in the record indicating that Plaintiff's subjective claim of total disability was not supported. The MRI scan of the cervical spine had been read as "essentially negative" by Barbara Sullivan, M.D. The MRI scan of the lumbar spine was read as having no significant abnormality in L1-2, L2-3, L3-4, and L4-5, and indicating degenerative disc disease with disc herniation in L5-S1. Dr. Skerhut's report of October 1, 2002 noted that Plaintiff had been given a diagnosis of compression fracture of T7, but that he had improved with physical therapy and was experiencing minimal pain at that point. Dr. Skerhut indicated that Plaintiff had "plain films," but that is was "difficult to know whether this at T7 is a compression fracture or just a [sic] oddly shaped vertebrae."
As of October 17, 2002, the administrator had evidence indicating a possible compression fracture in Plaintiff's spine, but no definitive determination, as well as evidence of degenerative disc disease. However, there was also evidence indicating Plaintiff's condition was improving, and that he may simply have had an oddly shaped vertebrae. It cannot be said that there was no rational connection between the facts and the determination. Although there had not been an independent examination conducted at this point, there was evidence in the record that clearly supports the decision.
As Plaintiff's claim made its way through the appeals process, the administrator received additional medical records purportedly in support of the disability claim. The appeals specialist, Karen Pink, collected this information and had it reviewed by Dr. Silver, an independent physician. Dr. Silver noted all the information presented to the administrator and determined that Plaintiff's subjective complaints of pain were not sufficient to support a determination of total disability. Plaintiff contends that Dr. Silver's opinion was wrong, and that he did not give sufficient weight to the objective evidence in support of Plaintiff's disability. Dr. Silver notes that the MRI of the cervical spine taken August 9, 2002 was "essentially negative." Plaintiff vehemently takes issue with Dr. Silver's findings, but his findings exactly track those of the doctors who performed both the cervical spine MRI and the lumbar spine MRI. Barbara Sullivan, M.D., noted that the MRI of the cervical spine dated August 9, 2002 was "essentially negative" and that the MRI of the lumbar spine indicated L5-S1 degenerative disc disease. Dr. Silver also noted the impressions of the MRI of the thoracic spine taken October 9, 2002, as well as clinical examinations of Plaintiff by Dr. Skerhut in November 2002 and Dr. Steve Schuleman in January 2003. In sum, Dr. Silver reviewed all the medical information that was before the administrator and came to the objective conclusion that, though there was some evidence of disability, Plaintiff was not disabled so that he could not perform the functions of his job. Dr. Silver determined that Plaintiff would not be precluded from returning to work. The administrator was permitted to rely on this determination. Black Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003) ("[C]ourts have no warrant to require administrators automatically to accord special weight to the opinions of a claimant's physician; nor may courts impose on plan administrators a discrete burden of explanation when they credit reliable evidence that conflicts with a treating physician's evaluation."); Sweatman v. Commercial Union Ins. Co., 39 F.3d 594, 601-02 (5th Cir. 1994) (upholding denial of benefits based on an independent review of the claimants' medical records); Donato v. Metropolitan Life Ins. Co., 19 F.3d 375, 380 (7th Cir. 1994) (holding that MetLife's denial of benefits was not an abuse of discretion when the "decision simply came down to a permissible choice between the position of UMAC, MetLife's independent medical consultant, and the position of [the claimant's physicians]."). There is no evidence that any of Plaintiff's evidence, including the opinions of his treating physicians, has been ignored. Nord, 538 U.S. at 834. The evidence before the administrator is sufficient to find that there was no abuse of discretion in denying Plaintiff's claim on appeal on February 24, 2003.
As of January 2, 2003, no additional information had been received by the administrator after the initial denial of October 17, 2002 except a set of documentation received October 31, 2002 that included the August and October MRIs and bone scan and October office notes of Dr. Hernandez. Dr. Skerhurt's letter dated November 14, 2002 was not received by the administrator until January 20, 2003.
Plaintiff mistakenly quotes Dr. Silver as stating that the MRI of the lumbar spine was "essentially negative." A review of Dr. Silver's report clearly shows that he noted the MRI of the cervical spine as essentially negative, which was the exact wording of the examining doctor, Dr. Barbara Sullivan, while noting the impression of L5-S1 degenerative disc disease in the MRI of the lumbar spine.
Dr. Schuleman observed that the MRIs "were really unremarkable in the cervical, thoracic and lumbar areas."
Plaintiff's final argument centers on the treatment of the supplementary documents submitted on May 8, 2003 and May 13, 2003. These documents included Dr. Stolow's diagnosis of fibromyalgia, return to work restrictions on activities such as sitting, standing, crawling, and kneeling, and a letter from Dr. Hernandez stating that Plaintiff wanted to return to work without any restrictions against medical advice. Plaintiff was sent a letter dated May 13, 2003 stating that his claim was final on February 21, 2003 and that these documents would not be considered. Though this may have been in error had no other action occurred, see Vega, 188 F.3d at 300-01, the administrator did examine these documents under Plaintiff's second disability claim. These documents were referenced to Dr. Walkup and it was again determined that the medical documentation did not support Plaintiff's claim that he could not return to work. Plaintiff's diagnosis of fibromyalgia was, in fact, noted in the July 15, 2003 letter denying Plaintiff's claim. Therefore Plaintiff's argument that documents submitted to the Plan after the February 2003 denial were not considered is without merit.
Plaintiff argues that Dr. Walkup's review cannot be credited because he is a Doctor of Osteopathy and not a rheumatologist like Dr. Stolow. Plaintiff cites to 29 C.F.R. § 2560.503-1(h)(iii) which requires that in an appeal of an adverse benefit determination based upon a medical judgment, the administrator is required to consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical treatment. This regulation is not so hyper-technical, however, that it requires a medical diagnosis by a rheumatologist to be reviewed by another rheumatologist. The review by Dr. Walkup was sufficient to base the denial of benefits upon. In any event, procedural violations of ERISA do not entitle the plan beneficiary to a substantive remedy of an award of benefits. See Duncan v. Assisted Living Concepts, Inc., No. 03-1931N, 2005 WL 331116, at *4 (N.D.Tex. Feb.10, 2002).
Thus, the decision to deny Plaintiff's claim was not an abuse of discretion.
IV. Conclusion
There was clear support in the record to support the administrator's decision to deny Plaintiff's claim for STD benefits. Though evidence in the administrative record supports the fact that Plaintiff's suffers from some level of disability, there is no evidence to support a finding that the denial of STD benefits under the Plan was an abuse of discretion. The analysis does not focus on the Plaintiff's, or the Court's, subjective beliefs. The focus is solely on whether the decision of the administrator was arbitrary and capricious, that is whether the was a rational connection between the known facts and the decision. The Court finds that there was such a rational connection. The medical documents, including the reports of Drs. Hernandez, Skerhut, Sullivan, Schuleman, and Stolow were noted and credited throughout the process. These reports were noted by Dr. Silver in his report. In fact, Dr. Silver apparently relied almost solely on the reports of Drs. Hernandez, Skerhut, Sullivan, and Schuleman, as Dr. Silver did not examine Plaintiff and did not independently examine the MRIs of Plaintiff's spine. The administrator was acting within its discretion to credit Dr. Silver's report over Plaintiff's complaints in denying Plaintiff's claim in February 2003. In addition, Dr. Stolow's diagnosis of fibromyalgia was credited in the July 2003 denial of Plaintiff's claim after Plaintiff had filed a separate claim. The Court finds that the decision to deny STD benefits to Plaintiff was not an abuse of discretion. Because entitlement to long term disability benefits is dependent upon entitlement to STD benefits, Plaintiff's claim for long term disability is disposed of by the adverse determination. Plaintiff's motion for summary judgment is DENIED (docket no. 19) and the Plan's motion for summary judgment is GRANTED (docket no. 23).
The Clerk of the Court is directed to enter judgment in favor of the Plan.