Opinion
Civil Action No. 00-2200, Section "N"
August 17, 2001
ORDER AND REASONS
Before the Court are defendants Guarantee Life Insurance Co.'s and Bollinger Shipyards Lockport, L.L.C.'s Motion for Summary Judgment. Plaintiff Olden Davis has not filed an opposition to the motion. For the following reasons, the defendants' motion is GRANTED.
BACKGROUND
In April 1997, plaintiff Olden Davis, an employee of Bollinger Shipyards Lockport, L.L.C. ("Bollinger"), filed a claim for total disability benefits under Bollinger's insurance plan, which is administered by Guarantee Life Insurance Company ("Guarantee"). Davis claimed he was no longer able to work due to neck, chest and knee injuries sustained in an automobile accident. See Def.'s Ex. 2 at 2. Guarantee initially determined that Davis was totally disabled and began paying benefits.
On December 1, 1997, Joseph L. Shine, Jr., P. T., performed a functional capacity evaluation ("FCE") on Davis and determined that he exhibited signs of "disability magnification" and was capable of performing work at a physical demand level between "Sedentary-Light" and "Medium." Def.'s Ex. 11 at 12. Davis' treating physician, Dr. Chris Cenac, examined Davis shortly after the FCE had been conducted. Like Shine, Cenac also found evidence of symptom magnification. See Def.'s Ex. 12. Ultimately, Cenac determined that Davis had reached maximum medical improvement; was capable of "lite/medium" employment; and was ready to return to work, albeit at a reduced physical demand level. Id. Based on the FCE results and Dr. Cenac's diagnosis, Guarantee found that Davis was no longer totally disabled but that he would qualify for partial disability benefits if he obtained partial disability employment. See Def.'s Ex. 14. Davis appealed Guarantee's determination.
On appeal, Davis argued that he "obtained another medical provider" and would provide Guarantee with "all new information." Def.'s Ex. 15. Guarantee denied Davis' appeal because he failed to provide the promised medical documentation. See Def.'s Ex. 16.
Davis filed a second appeal in August 1998, submitting four pages of notes from Dr. Pete H. Rhymes. These documents cover Davis' visits to Dr. Rhymes between April 20, 1998 and July 15, 1998. On June 8, 1998, Rhymes noted that he found "no evidence of objective abnormalities on examining" Davis and that Davis' inability to function is probably "more related to his symptom magnification which probably is more related to subjective fears rather than true objective findings." Def.'s Ex. 17 at 2. Rhymes concluded that he "would be happy to agree with the findings of Dr. Bunch in his FCE which was done in December 1997." Id. On July 15, 1998, Dr. Rhymes modified his opinion and decided that Davis "probably is not capable of performing in a sedentary intensive type occupation." Id. However, Rhymes did not cite any objective medical evidence in support of his conclusion, nor did he explain why he suddenly disagreed with the findings in the FCE. Finally, Rhymes qualified his conclusion by recommending that Davis "could attend some type of function in which he would do no significant amount of lifting, squatting, stooping, bending or kneeling or working in tight places." Id.
Dr. Bunch's FCE is the same examination on which Guarantee based its denial of benefits. Although the exam was actually performed by Joseph Shine, it was conducted pursuant to an evaluation system developed by Dr. Richard W. Bunch. As the Court has previously stated, the FCE results indicated that Davis was not totally disabled.
After reviewing Rhymes' notes together with the previously submitted evidence, Guarantee upheld its decision that Davis was not entitled to total disability benefits, explaining that it had not been provided "with any objective medical information to substantiate why there was a change in [Rhymes'] medical opinion from June 8, 1998, to July 15, 1998." Def.'s Ex. 18. Guarantee again advised Davis that he was eligible for partial disability benefits if he obtained partial disability employment.
Six months later, in April 1999, Davis filed a third appeal based on one additional note from Dr. Rhymes. Guarantee denied the appeal because the note provided no objective medical evidence of disability, and Guarantee entered its final decision that Davis was only eligible for partial disability benefits. Despite the fact that he exhausted his appeal rights with his third appeal, Davis filed a fourth appeal in November 1999. Again, Davis provided no objective medical evidence that he was totally disabled, and Guarantee affirmed its previous decision. Davis filed the instant suit on June 30, 2000.
LAW AND ANALYSIS
The Court has already determined that Davis insurance plan is governed by the Employment Retirement Income Security Act of 1974, 29 U.S.C. § 1001 ("ERISA"). See Rec. Doc. No. 13. In determining whether to pay or deny benefits, the administrator of an ERISA plan must determine (1) the facts underlying the claim for benefits and (2) whether those facts constitute a claim to be honored under the terms of the plan. See Schadler v. Anthem Life Ins. Co., 147 F.3d 388, 393 (5th Cir. 1998). Accordingly, to determine whether Guarantee was correct in denying Davis' claim, the Court must review Guarantee's findings of fact and its interpretation of the policy in light of those facts.
1. Findings of Fact
In reviewing an ERISA plan administrator's denial of benefits, the Court must first consider whether the administrator abused its discretion in determining the facts underlying the claim. Id. at 393. The Court should undertake this analysis "based on the evidence before the administrator, assuming both parties were given the opportunity to present facts to the administrator." Id. (quoting Wildbur v. ARCO Chem. Co., 974 F.2d 631, 639 (5th Cir. 1992)). Since Davis filed several appeals in connection with his disability claim, the Court must consider the facts presented to Guarantee in each instance.
of course, in considering a motion for summary judgment, the Court must view the facts and inferences from the evidence in the light most favorable to the non-moving party. See Crescent Towing Salvage Co., Inc. v. Motor Vessel Anax, 40 F.3d 741, 743 (5th Cir. 1994). 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 any material fact and that the moving party is entitled to judgment as a matter of law." FED. R. CIV. P. 56(c). A genuine issue of fact exists where the evidence is such that a reasonable jury could return a verdict for the non-moving party. See Anderson v. Liberty Lobby. Inc., 477 U.S. 242, 248 (1986).
a. Davis' Initial Claim and First Appeal
In connection with Davis' original claim, Guarantee reviewed Davis' claim form; Dr. Cenac's letters and medical records; the medical records of doctors William Kinnard, Dunstan Mascarenhas, Daniel Trahant and physical therapist Kenneth Barrileaux; two MRI reports; and the FCE. Guarantee specifically based its finding that Davis was able to perform light work on (1) Davis' FCE, which stated that he was capable of working at a physical demand level between "Sedentary-Light" and "Medium" and (2) the diagnosis of Davis' treating physician, Dr. Chris Cenac, who determined that Davis reached maximum medical improvement in January 1998, was capable of "lite/medium" employment, and was ready to return to the workforce. In light of this evidence and the absence of any evidence to the contrary, the Court does not find that Guarantee abused its discretion when it found that Davis was capable of working.
Davis did not supply Guarantee with any new information for his first appeal. Accordingly, for the reasons previously given, the Court does not find Guarantee abused its discretion in reaching its findings of fact on Davis' first appeal.
b. Davis' Second Appeal
Davis based his second appeal on Dr. Rhymes' opinion of July 15, 1998 that he could only lift twenty pounds and was probably not capable of performing sedentary work. However, only five weeks earlier, on June 8, 1998, Rhymes stated that he "would be happy to agree" with the findings set forth in the December 1997 FCE, which concluded that Davis was capable of something between sedentary-light or medium work. Def.'s Ex. 17 at 2. Guarantee rejected Rhymes' July 15, 1998 opinion because he did not provide any objective medical information to explain why he changed his diagnosis. In addition, despite his statement that Davis "probably is not capable of performing in a sedentary intensive type occupation," Rhymes still noted that Davis "could attend some type of function in which he would do no significant amount of lifting, squatting, stooping, bending or kneeling or working in tight places." Id. In light of the absence of evidence to support Rhymes' opinion and the ambiguity of his diagnosis, the Court does not find that Guarantee abused its discretion in affirming its original decision that Davis could perform light work.
c. Davis' Third Appeal
Davis filed a third appeal in April 1999 and submitted one additional note from Dr. Rhymes. This note stated that Davis "is pretty much the same, he doesn't have a great deal of difference." Def.'s Ex. 19 at 2. Once again, neither Rhymes nor Davis submitted any objective medical information in connection with the appeal; and again, Guarantee rejected Rhymes' conclusion and based its factual findings on the FCE results and Dr. Cenac's diagnosis. Choosing to follow one doctor as opposed to another is not an abuse of discretion, even when the doctor followed is the doctor chosen by the plan administrator. See Donato v. Metropolitan Life Ins. Co., 19 F.3d 375, 380 (7th Cir. 1994) (holding that administrator's denial of benefits was not arbitrary and capricious when its "decision simply came down to a permissible choice between the position of [the administrator's] independent medical consultant and the position of [the claimant's physicians].") (cited with approval inSweatman v. Commercial Union Insurance Co., 39 F.3d 594, 602 (5th Cir. 1994)). Because Dr. Rhymes' opinion was not based on objective medical evidence, Guarantee's refusal to modify its findings of fact was not an abuse of discretion.
d. Davis' Fourth Appeal
Davis filed his final appeal in November 1999. This time Davis submitted his medical records related to a hospital stay in June 1999 for an injury that occurred when he lifted heavy utensils while boiling crawfish. Def.'s Ex. 21. Nothing in this last submission addressed the issue of whether Davis could work. Accordingly, the Court does not find that Guarantee abused its discretion in affirming its previous findings of fact.
2. Policy Interpretation
In deciding whether the facts found by the administrator constitute a claim under the plan, the Court must first consider whether the administrator has discretionary authority. The Supreme Court has instructed that a denial of benefits is to be reviewed under a de novo standard "unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). "Where a plan does vest the administrator with such discretionary authority, courts review the decision under the more deferential abuse of discretion standard." Schadler, 147 F.3d at 394 (citations omitted).
In the instant case, the Court finds that Guarantee has discretionary authority to make coverage decisions. First, the policy required Davis to submit proof of disability to Guarantee. See Def.'s Ex. 1 at GL3001-LTD-8 94. Second, the policy required that Davis submit to a physician's examination "as often as it is reasonably required." Id. at GL3001-LTD-8 94. Because Guarantee requires proof of claims and because it can order physicians' examinations to help it evaluate claims whenever is reasonably necessary, the Court finds that Guarantee has discretion in determining benefits. Accordingly, the Court will review Guarantee's ultimate decision for an abuse of discretion as required by Schadler.
Under the abuse of discretion standard, the Court must first determine whether the administrator's interpretation is legally correct. See Schadler, 147 F.3d at 394, n. 5. "If the administrator's interpretation of the plan is legally correct, then the inquiry ends because no abuse of discretion could have occurred." Id. The Guarantee policy provides that:
TOTAL DISABILITY or TOTALLY DISABLED means that an Insured Employee, due to an Injury or Sickness, is unable:
1. during the Elimination Period and the Own Occupation Period, to perform each of the main duties of the Insured Employee's regular occupation; and
2. after the Own Occupation Period, to perform each of the main duties of any gainful occupation for which the Insured Employee's training, education or experience will reasonably allow.
Def.'s Ex. 1 GL3001-LTD-6. Guarantee consistently found that, according to the objective medical evidence, Davis was able to perform light work, i.e., some gainful occupation. At no time did Davis suggest that he lacked the training, education or experience to perform "any gainful occupation." Clearly, a covered individual who is able to perform some work is not totally disabled under the policy. Accordingly, the Court finds that Guarantee's conclusion that Davis is not totally disabled is legally correct, and therefore no abuse of discretion has occurred.
Although the Court has examined Guarantee's interpretation of the policy, the Court also notes that Davis did not dispute Guarantee's policy interpretation at any time during his appeal process. Davis focused his challenge on Guarantee's factual findings.