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concluding that the plan administrator did not abuse its discretion when it interpreted "regular occupation" because "[d]istrict courts have routinely construed the term . . . to mean `a position of the same general character as the insured's previous job, requiring similar skills and training, and involving comparable duties.'"
Summary of this case from Panther v. SynthesOpinion
CIVIL ACTION NO: 02-3386, SECTION: "R"(5)
March 23, 2004
ORDER AND REASONS
Defendants Avondale Industries, Inc. Employee Benefit Plan and Jefferson Pilot Financial Insurance Company move the Court for summary judgment on the issue of plaintiff Sandra Gerhold's eligibility for long-term disability benefits. Also before the Court is plaintiff Sandra Gerhold's cross-motion for summary judgment. For the following reasons, the Court GRANTS defendants' motion for summary judgment and DENIES plaintiff's cross-motion for summary judgment.
I. BACKGROUND
In January 1999, Avondale Industries, Inc. hired plaintiff Sandra Gerhold as a computer technician. Plaintiff's job description describes her as a system administrator of various UNIX-based operating systems in a network client/server environment. Gerhold is a long-time sufferer of Crohn's Disease, an inflammatory bowel disease that primarily affects the small intestine. Gerhold's Crohn's Disease progressed in severity, and she became unable to work. Gerhold's last day of employment with Avondale was October 12, 2001.
In January 2002, Gerhold filed a claim with Avondale and defendant Jefferson Pilot Insurance Company for long-term disability ("LTD") benefits. Gerhold submitted medical review information to Jefferson Pilot. After reviewing all of the materials submitted by Gerhold, Jefferson Pilot wrote to plaintiff's doctor, Dr. William Meyers, to obtain additional information. Dr. Meyers did not respond to this request. Jefferson Pilot tried again to contact Dr. Meyers. In the interim, Jefferson Pilot received a copy of Gerhold's job description from Avondale.
Plaintiff originally sued Guarantee Life Insurance Company because Guarantee issued the LTD policy to Avondale. Jefferson Pilot is, however, successor to Guarantee. For the sake of consistency, the Court will refer to Jefferson Pilot only.
In February 2002, Jefferson Pilot still had received no response from Dr. Meyers, and it determined Gerhold's claim based on the information that she originally submitted with her request. Jefferson Pilot denied Gerhold's claim on the grounds that she did not establish that her condition disabled her continuously during and after the 90-day elimination period as required by the company's LTD policy. The elimination period ran from October 13, 2001, the day after Gerhold's last day of work, to January 11, 2002. Jefferson Pilot's denial letter also informed Gerhold of her appeal rights. Jefferson Pilot alleges that the administrative record established that Gerhold's condition had improved and that she had ceased being disabled by December 2001.
In March 2002, Gerhold appealed the benefit specialist's determination and submitted further information to Jefferson Pilot in support of her appeal. Jefferson Pilot submitted Gerhold's file, including the materials submitted with the original claim and the appeal, to its in-house nurse for medical review. In March 2002, Jefferson Pilot denied plaintiff's appeal, finding that Gerhold's additional evidence did not
establish that her condition continuously and totally disabled her from October 12, 2001 through and beyond January 10, 2002.
In May 2002, Gerhold informed Jefferson Pilot that she would appeal the March 2002 decision. Gerhold again submitted additional medical information to support her appeal. In September 2002, Jefferson Pilot's Appeal Council considered Gerhold's evidence and again denied her appeal. Jefferson Pilot denied plaintiff's claim because it determined that the policy "insures a person's occupation, as it would be performed in the general economy and not his/her specific job duties at a particular employer." Defendant found that there was inadequate evidence to establish that Gerhold could not perform the meaningful duties of her occupation as a Unix administrator.
In November 2002, Gerhold sued Avondale Industries, Inc. Employee Benefit Plan and Jefferson Pilot in this Court under the Employee Retirement Income Security Act, 29 U.S.C. § 101, et seq. Plaintiff argues that defendants failed to award her the LTD benefits that she was entitled to under the plan. Plaintiff argues that Avondale, not Jefferson Pilot, is the plan administrator, and that Jefferson Pilot's eligibility determination should be reviewed de novo. In the alternative, plaintiff argues that even if the Court finds that Jefferson Pilot is the plan administrator, Jefferson Pilot's eligibility determination was arbitrary and capricious. Plaintiff also asserts claims for penalties and attorney's fees based upon defendant's allegedly arbitrary and capricious denial of benefits and its allegedly unlawful delay of payments.
Jefferson Pilot argues that it is the plan administrator and that its eligibility determination should be reviewed for an abuse of discretion. Moreover, defendant argues that it did not act arbitrarily or capriciously in denying Gerhold's claim for LTD benefits.
II. Discussion
A. Legal Standard
Summary judgment is appropriate when there are no genuine issues as to any material facts, and the moving party is entitled to judgment as a matter of law. See FED. R. CIV. P. 56(c); Celotex Corp. v. Catrett, 477 U.S. 317, 322-323 (1986). A court must be satisfied that no reasonable trier of fact could find for the nonmoving party or, in other words, "that the evidence favoring the nonmoving party is insufficient to enable a reasonable jury to return a verdict in her favor." Lavespere v. Niagara Mach. Tool Works, Inc., 910 F.2d 167, 178 (5th Cir. 1990) (citing Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 249 (1986)). The moving party bears the burden of establishing that there are no genuine issues of material fact.
If the dispositive issue is one on which the nonmoving party will bear the burden of proof at trial, the moving party may satisfy its burden by merely pointing out that the evidence in the record contains insufficient proof concerning an essential element of the nonmoving party's claim. See Celotex, 477 U.S. at 325; see also Lavespere, 910 F.2d at 178. The burden then shifts to the nonmoving party, who must, by submitting or referring to evidence, set out specific facts showing that a genuine issue exists. See Celotex, 477 U.S. at 324. The nonmovant may not rest upon the pleadings, but must identify specific facts that establish a genuine issue exists for trial. See Id. at 325; Little v. Liquid Air Corp., 37 F.3d 1069, 1075 (5th Cir. 1996).
B. The Plan
The Court must first determine what is the "plan" that applies to Gerhold's claim. Plaintiff argues that the Summary Plan Description controls her claim for LTD benefits. Defendant argues that LTD Policy number 000120011677 governs Gerhold's claim. Defendant is correct.
The summary plan description relied on by plaintiff is no more than its title suggests: a description in summary form of the plan. At the bottom of the cover page of the summary plan description, in bold, italicized letters, are the words: "The following is only a summary of the Plan. If there is any conflict between the summary and the Plan document, the Plan document controls." ( See Pl.'s Cross-Mot. Summ. J., Ex. A). The language is unambiguous. By indicating that a conflict could arise between it and the plan, the summary plan description acknowledges that it is not the plan.
Defendant submits LTD Insurance Policy number 000120011677 with its motion for summary judgment as the embodiment of the plan. Attached to the policy is the affidavit of Ruth Hagemann, manager of risk services at Jefferson Pilot, who attests that policy number 000120011677 is a true and correct copy of the LTD policy issued by Jefferson Pilot to Avondale. ( See Def.'s Mem. Opp. Pl.'s Cross-Mot. Summ. J., Ex. 1). The Court finds that defendant submits sufficient evidence to establish that LTD policy number 000120011677 governs whether Gerhold qualifies for LTD benefits.
C. ERISA Standard of Review
The parties do not dispute that ERISA governs the benefit plan here. Under ERISA, a plan administrator must make two findings to determine whether an employee is entitled to benefits under a plan. Schadler v. Anthem Life Ins. Co., 147 F.3d 388, 394 (5th Cir. 1998). The plan administrator must first determine the facts underlying the claim for benefits. Id. (citing Pierre v. Connecticut Gen. Life Ins. Co./Life Ins. Co. of N. Am., 932 F.2d 1552, 1557 (5th Cir. 1991)). The plan administrator must then "determine whether those facts constitute a claim to be honored under the terms of the plan." Id. (emphasis in original). If the plan administrator denies benefits to the participant, section 1132 of ERISA provides that the employee may bring suit in federal district court "to recover benefits due to him under the terms of the 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). With these basic principles in mind, the Court reviews Jefferson Pilot's factual and interpretative decisions.
1. Review: Findings of Fact
The Fifth Circuit has held that a plan administrator's determination of the facts underlying the claim should be reviewed by the district court for an abuse of discretion. Schadler, 147 F.3d at 394 (citing Pierre, 932 F.2d at 1562). The Court must therefore determine whether the plan administrator acted arbitrarily and capriciously in reaching its conclusion as to the facts. Johnson v. Sun Life Assurance Co., 2000 WL 33225469, No. Civ. A. 98-990-A, at *9 (M.D. La. 2000). An arbitrary decision "is one made without a rational connection between the known facts and the decision or between the found facts and the evidence." Id. at *9. A decision is not an "abuse of discretion if a reasonable person could have reached a similar decision, given the evidence before him." McCall v. Burlington Nor them/Santa Fe Co., 237 F.3d 506, 512 (5th Cir. 2000) (citing Cash v. Wal-Mart Group Health Plan, 107 F.3d 637, 641 (8th Cir. 1997)). Moreover, the court should review the administrator's fact findings regarding the eligibility of a claimant based on the evidence before the administrator. Schadler, 147 F.3d at 394 (citing Wildbur, 974 F.2d at 102). Thus, the Court is confined to the administrative record. For the following reasons, the Court finds that, based on the record before it, Jefferson Pilot did not abuse its discretion in determining the facts underlying Gerhold's claim.
a. Initial Determination
The LTD policy provides that
The Company will pay a Total Disability Monthly Benefit to an Insured Employee after the completion of the Elimination Period if such Insured employee: 1. is Totally Disabled; 2. requires the regular attendance of a Physician; and 3. submits proof of continued Total Disability, at the Insured Employee's expense, to the Company upon request.
( See Id., Ex. 1, at GL3001-LTD-12). The policy provides that the elimination period is "90 days of Disability due to the same or a related Sickness or Injury, which must be accumulated within a 180 day period." ( See Id., Ex. 1, at GL3001-LTD-SB, 3-7). In addition, the plan states 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 all of the material and substantial duties of the Insured Employee's regular occupation; and
2. after the Own Occupation Period, to engage in any employment or occupation:
(a) for which such Insured Employee is or becomes qualified by reason of education, training, or experience; and
(b) which provides substantially the same earning capacity as the Insured Employee's former earning capacity prior to the disability.
( See Id., Ex. 1, at GL3001-LTD-6) (emphasis added).
Gerhold submitted the following information with her initial claim:
1. Group Disability Claim Form, including the Employer's Report of Claim, the Long Term Disability Claim Employee's Statement, and the Long Term Disability Claim Physician's Statement;
2. Avondale Attending Physician's Supplementary Statements dated October 2, 2001; November 6, 2001; and December 3, 2001;
3. Avondale Request for Medical Information completed by Dr. William Meyers, dated October 10, 2001;
4. Progress Notes of Doctor William Meyers, Jr. dated October 4, 2001 (revised October 5, 2001); November 6, 2001; December 3, 2001; and December 26, 2001; and
5. Routine Chemistry and Hematology Reports, dated November 1, 2001.
(Def.'s Mem. Supp. Mot. Summ. J., Ex. 2, at 1-18). The medical information provided by Gerhold to Jefferson Pilot with her initial claim revealed that plaintiff suffers from Crohn's Disease. (Def.'s Mem. Supp. Mot. Summ. J., Ex. 2, at 1-18). The information showed that Gerhold suffers from severe Crohn's Disease, arthritis, and Erythem nodosum with symptoms that range from fatigue to severe abdominal cramping. ( See Id. at 11-12).
However, plaintiff's physician, Dr. William Meyers, noted that on November 6, 2001, Gerhold no longer had abdominal pain. (See id, at 14). On December 3, Dr. Meyers noted that Gerhold's appetite was good and that her bowel movements were normal. ( See Id. at 15). On that same day, he also noted the Gerhold's Crohn's Disease had improved. ( See Id.). On December 26, Dr. Meyers noted that Gerhold was eating well, had some diarrhea, fatigue, and ankle pain. ( See Id. at 16). He also assessed her Crohn's Disease as stable. ( See Id.). He noted that she did not want to go back to the same job. ( See Id.).
Although Jefferson Pilot asked Dr. Meyers for additional information, he did not respond. ( See Id. at 31-32). When it asked for additional information, Jefferson Pilot informed Dr. Meyers that his records indicated that Gerhold's Crohn's Disease was in remission. ( See Id. at 52). Jefferson Pilot specifically requested additional information on any limitations or restrictions that he placed on Gerhold and any information concerning Gerhold's condition after December 26, 2001. ( See Id.). Based on the information that it had before it, Jefferson Pilot determined that plaintiff had not demonstrated that her disability extended beyond January 11, 2002 — the end of the 90-day elimination period required by the policy. Jefferson Pilot Benefit Specialist Jan Brown informed Gerhold that
our determination has been based upon the information available to our office. We agree that you had a period of disability which may have prevented you from performing the material and substantial duties of your occupation during the month of October, however, we find that this period of disability did not extend beyond the 90 day Elimination Period required by this Policy. Therefore, your application for Long Term disability benefits has been denied.
( Id. at 48.) The Benefit Specialist's letter denying Gerhold's claims specifically identified several entries from Dr. Meyers' progress notes that influenced the specialist's decision:
10/4/01 Crohn's Disease with relapse over past month; started on Imuran, Pentasa, and given IV Remicaid;
11/6/01 BM's frequent, formed; no blood; no abdominal pain; Crohn's better;
12/3/01 Crohn's improved; remission now;
12/26/01 eating well; some diarrhea
( Id. at 47). Based on the information before the administrator, the Court finds that Jefferson Pilot did not abuse its discretion in making its initial, fact-finding that Gerhold was not disabled throughout the 90-day elimination period. Jefferson Pilot's conclusion that plaintiff submitted no objective medical evidence to indicate that she was disabled after January 11, 2002 was reasonable. Gerhold's medical reports reflect significant improvement in her condition between October 4, 2001 and December 26, 2001, when she last visited Dr. Meyers. Nor had any physician conclusively stated that Gerhold was totally disabled throughout the elimination period or assessed any limitations on her ability to work.
b. The First Appeal
Gerhold submitted her first appeal on March 1, 2002. In support of her first appeal, Gerhold submitted additional medical information to Jefferson Pilot's appeals specialist. The additional information included:
1. Dr. Meyers' Progress Notes for 12/26/01, 1/29/02, and 2/7/02;
2. Letter from Dr. Meyers dated 3/1/02; and
3. Report from Dr. Anastasio dated 3/4/02.
( Id. at 54-56, 58-63). The March 2002 letter from Dr. Meyers informed Jefferson Pilot that Gerhold's Crohn's symptoms continued only "to some degree at this time." ( See Id. at 58). In addition, Dr. Meyers indicated that her symptoms "have been aggravated in the past by stress and her previous job situation. Currently she is seeking new employment and I have encouraged this." ( See Id.). Dr. Meyers' letter informed defendant that plaintiff has had Crohn's disease for ten years and described her symptoms in detail. ( See Id. at 58).
On the other hand, a facsimile from Dr. Roger Anastasio, a psychiatrist consulted by Gerhold, reported that although plaintiff suffers from Crohn's Disease, as of March 2002, plaintiff appeared "well-developed" and "well-nourished." ( See id, at 62). Dr. Anastasio's report also indicated that Gerhold's attention span, intellectual functioning, insight, and judgment were adequate. ( See Id.). Dr. Anastasio's report additionally described plaintiff's symptoms and reported that " [r]emoval from perceived stressful work environment would likely have a beneficial affect [sic] upon patient's Crohn's disease." ( See Id. at 63).
On March 25, 2002, Jefferson Pilot's medical review panel found that Gerhold's symptoms were not severe enough to render her unable to perform the material and substantial duties of her occupation and that none of the additional evidence established that plaintiff was totally disabled through and beyond the 90-day elimination period. ( See Id. at 69). Jefferson Pilot informed plaintiff of its decision:
According to our records, you have been out of work since October 12, 2001, due to Crohn's disease. In order to receive benefits, you would have needed to provide proof during and beyond your 90-day elimination period. Your elimination period ended on January 10, 2002. However, the medical notes reflect that your symptoms were stable with "Crohn's stable" as of December 26, 2001. . . .
The evaluation [of Dr. Anastasio] indicated that you were oriented, hallucinations were denied, you were not suicidal, and attention span, intellectual functioning, insight and judgment were all adequate . . . In addition, the letter from Dr. Meyers stated that you were currently seeking new employment, and that he encouraged this. This also shows a lack of severity of impairment in your condition to warrant Total Disability beyond your elimination period.
( Id. at 73-74).
The Court finds that Jefferson Pilot's decision was reasonably based on the record before it. Dr. Meyers' December 2001 progress report indicated that plaintiff's Crohn's Disease was stable. ( See Id. at 16). As Jefferson Pilot concluded, plaintiff submitted no new evidence that indicated that her condition had materially worsened or that she was incapable of performing the meaningful duties of her occupation during and beyond the elimination period. ( See Id. at 69). Indeed, Jefferson Pilot's in-house nurse noted that both doctors' reports found that plaintiff's condition had been aggravated by the allegedly stressful environment at Avondale. ( See Id.). At this point in time, however, plaintiff was no longer working at Avondale, and plaintiff was therefore no longer in the environment that had conceivably worsened her situation. Also, Dr. Meyers reported that plaintiff actively sought new employment and was enrolled in classes at the community college, which further supported Jefferson Pilot's conclusion that plaintiff was not so impaired as to be disabled. ( See Id.). Based on the foregoing information, the Court cannot find that Jefferson Pilot abused its discretion in determining that Gerhold had not submitted proof of total disability beyond the elimination period.
The Court recognizes that Jefferson Pilot's in-house nurse conducted the review of Gerhold's evidence, instead of a licensed physician. Nevertheless, section 2560.503-1 of the Code of Federal Regulations provides that the appropriately name fiduciary "shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment." 29 C.F.R. § 2560.503-1(h)(3) (iii). The language of the C.F.R. does not in itself preclude an in-house nurse from reviewing Gerhold's evidence. Nor does plaintiff dispute the in-house nurse's qualifications.
c. The Second Appeal
In August 2002, Gerhold submitted additional information to support her second appeal. Gerhold sent the plan administrator the following information:
1. April 8, 2002 letter from Ms. Chiasson (Avondale) discussing plaintiff's job duties; 2. March 15, 2002 report from Dr. Herbert Mayer; 3. Unsigned and undated questionnaire from Dr. Smith/Dr. William Meyers; 4. Progress notes of Dr. William Meyers; 5. Surgical Pathology Report from Touro Infirmary, dated December 6, 1999; 6. Operative Report from Touro Infirmary dated December 3, 1999; 7. Ochsner Clinic noted by Dr. Smith dated April 9, 2002; 8. Ochsner Medical Institute Laboratory report dated April 9, 2002; 9. Questionnaire from Dr. Anastasio dated May 20, 2002; 10. Progress notes of Dr. Anastasio; 11. A description of plaintiff's job duties as a UNIX administrator; 12. General information about Crohn's Disease, apparently copied from the Internet; and 13. CD-Rom containing interviews with plaintiff and a couple who are identified as Gerhold's neighbors, as well as copies of the above documents.
( Id. at 98-227).
Avondale's job description of the Unix-based systems administrator noted that the administrator was "responsible for the installation, upgrading and daily maintenance of 500+ client workstations." ( Id. at 128). The description noted that the administrator's duties were to "[d]esign, develop and implement scripts and procedures which facilitate these functions" and to "direct and instruct lower lever employees" in the system's functions. ( See Id.). The April 2002 letter from Lana Chiasson at Avondale focused on the working conditions of UNIX administrators at Avondale, where she said they "work under very stressful and trying conditions." ( Id. at 98). She said that the department was currently in "transition" and that Unix operators had more work than they had had in the past and were always on "call to work notice." ( See Id.).
The May 2002 letter from Dr. Herbert Mayer informed Jefferson Pilot that he believed Gerhold to be totally disabled "[o]n the basis of the activity of her disease and on the basis of her presenting complaints and physical examination." ( Id. at 99). He refers to an April 2002 colonoscopy, but there is no evidence in the record of a report on such a colonoscopy. ( See Id.). Indeed, the only evidence in the record of a colonoscopy is of a 1999 colonoscopy. Dr. William Meyers scheduled a colonoscopy on April 11, 2002, but his progress reports note that Gerhold did not show up for this appointment. ( See Id. at 109). Dr. Herbert Mayer also stated that Gerhold was unemployable and needed to spend 100% of her time treating her advanced complicated Crohn's disease. ( See Id.). On the other hand, Dr. William Meyers' March 2002 report reflected that plaintiff's condition had improved and that he was uncertain as to when plaintiff could return to work. ( See Id. at 71). He also informed defendant that his best estimate for plaintiff's work-related limitations was that plaintiff suffered from moderate limitations of functional capacity and that she was capable of sedentary clerical or administrative work. ( See Id.). He noted that Gerhold tolerated job stress poorly and that she was "probably" disabled from her job. ( See Id. at 72).
Gerhold also submitted a medical questionnaire the authenticity of which the parties dispute. The questionnaire is addressed to Dr. Meyers, but contains a signature block for a Dr. James Smith. Neither person signed the questionnaire. The questionnaire itself contains conflicting information. The person who completed the questionnaire informed Jefferson Pilot that "he thinks" Gerhold has a marked limitation of physical activity, but that he has no idea how long Gerhold's symptoms may last. ( See Id. at 101). He said that only a low stress environment is acceptable for her. ( See Id.). Notwithstanding the above remarks, the person notes that he has placed no restrictions on Gerhold, nor does he know whether she is totally disabled from all occupations for "which [she] is reasonably qualified by education, experience or training to perform." ( See Id. at 102).
Gerhold also submitted more of Dr. Meyers' progress reports. The progress reports indicate that Gerhold cancelled her appointment with Dr. Meyers in February 2002. ( See Id. at 109). The report further indicates that Gerhold did not show up for her March 7 appointment or her April 11, 2002 colonoscopy. ( See Id.). The progress reports from March 14, 2002 reflect that Gerhold's Crohn's disease was variable and stable (although there is a question mark next to stable). ( See Id.). The documents from Touro concerning Gerhold's colonoscopy were written in 1999, and although they indicate that Gerhold's symptoms are consistent with Crohn's, they do not shed light on whether Gerhold was disabled during the elimination period. ( See Id. at 110-12).
In April 2002, Gerhold saw a new physician, Dr. James Smith. The progress reports of Dr. Smith indicate that Gerhold has "done fairly well" with Crohn's since 2001. ( See Id. at 113). In addition, the reports note that Dr. Smith scheduled a colonoscopy in June 2002, although there is no indication that he ever performed the procedure on Gerhold. ( See Id. at 117).
Gerhold also submitted a questionnaire completed by Dr. Anastasio. Although Dr. Anastasio indicated that Gerhold has "marked (life threatening) gastrointestinal problems related to Crohn's," he also noted that Gerhold has no marked limitation of physical activity. ( See Id. at 120). Dr. Anastasio called Gerhold a malingerer and noted that emotional factors contribute to the severity of her disease. ( See Id. at 120). Although Dr. Anastasio noted that Gerhold should avoid all perceived high stress situations and that he found her totally disabled at that time, he also stated that Gerhold can function in an "8hr, 5 day per week employment situation provided that stresses in the job would be low to moderate." ( See Id. at 122). He also stated the Gerhold's prognosis was "good" as long as she avoided "all perceived" high stress situations and environments. ( See Id. at 121). Gerhold also submitted information from the Internet on Crohn's disease and a CD-Rom that contained interviews with Gerhold and her neighbors.
Jefferson Pilot submitted all of the original and the additional information to Dr. Joseph Guarino, M.D. for further review, as required under 29 C.F.R. § 2650.503-1(h)(3)(iii). Jefferson Pilot specifically asked Dr. Guarino to compare Gerhold's medical records to the job description of a Unix administrator completed by her employer and to determine whether the evidence demonstrated that she could not perform the essential functions of her own occupation. ( See Id. at 233). After a review of the records, Dr. Guarino found that he was unable to conclude that plaintiff "is unable to perform the duties of her own occupation." ( See Id. at 237). He found that because her job is sedentary to light in character, there "are no [medical] conditions that would physically interfere with her performing this job." ( See Id.). Moreover, Dr. Guarino concluded that
[t]he premise that she is not physically disabled for a light to sedentary job on the basis of her Crohn's disease is supported by the Official Disability Guidelines, 2000, Work Data Loss Institute. It appears that she has the medical stability and functional capacity to work full time in her own occupation. It is also likely that she could perform similar work with a different employer where she may perceive that the stress level is not as high as she perceives in her current situation.
( See Id.).
The Plan Administrator Appeals Council denied plaintiff's second appeal on September 18, 2002. It reasoned that, based on the evidence in the record, Gerhold's Crohn's disease was not totally disabling at the end of the elimination period. The plan administrator informed her that Dr. Meyer's progress reports of December 2001 indicated that her Crohn's Disease had improved and was in remission. ( See Id. at 122). In addition, it found that the bleeding that she had experienced was in 1999 and that "as of April 2002 her blood work was in the normal range with no anemia." ( See Id.). It noted that she was attending community college part time and was considering a change in jobs. ( See Id.). In sum, it found that the evidence submitted by Gerhold did not support the conclusion that she was "totally disabled from performing the main duties of her occupation as a Unix administrator from 10/13/2001 throughout her 90 day elimination period or beyond." ( See Id.).
The Court finds Jefferson Pilot's conclusions reasonably supported by the administrative record. By August, plaintiff had produced no evidence that she had seen a doctor since May. Her own physician — Dr. Anastasio — described her as a "malingerer."( See Id. at 120). The record reasonably supports the finding that plaintiff's physical problems did not interfere with her performing the sedentary to light functions of her occupation, ( See Id. at 101-03, 105-09, 119-22), and that her difficulties related to situational stress in the work atmosphere that she perceived at Avondale.
2. Review: Policy Interpretation
In Firestone Tire Rubber Co. v. Bruch, the Supreme Court delineated the appropriate standard of review of a plan administrator's second determination — his interpretation of the terms of the plan and whether the claim falls within those terms. 489 U.S. 101 (1989). The Supreme Court held that "a denial of benefits challenged under § 1132(a)(1)(B) is to be reviewed under a de novo standard unless the benefit plan gives the plan administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Id. at 115 (emphasis added); Schadler, 147 F.3d at 394. When a plan vests discretionary authority in the administrator or a fiduciary, "courts review the decision under the more deferential abuse of discretion standard." Schadler, 147 F.3d at 394. Even under this deferential abuse of discretion standard, courts are not "`confined to the administrative record in determining whether . . . [the] plan administrator abused his discretion in making a benefit determination.'" Id. (citing Wildbur v. ARCO Chem. Co., 974 F.2d 631, 639 (5th Cir.), modified on other grounds, 979 F.2d 1013 (5th Cir. 1992)). The Fifth Circuit has noted that although it "has no desire to wade into the largely semantic" conflict that surrounds an exact definition of the abuse of discretion standard, "if a decision is supported by substantial evidence and is not erroneous as a matter of law, it is not arbitrary and capricious" or an abuse of discretion. Wildbur, 974 F.2d at 637 n. 12. The Court must therefore determine whether Jefferson Pilot's policy interpretation is a legally correct interpretation. See Id.
Although the parties dispute whether Jefferson Pilot is the plan administrator, the Court need not resolve this issue because it is clear that Jefferson Pilot is a fiduciary of the benefit plan because it exercises discretionary authority with respect to coverage determinations. Pursuant to ERISA, a plan "fiduciary" is an entity who "exercises any discretionary authority or discretionary control respecting the management of a plan or exercises any authority or control respecting the management or disposition of its assets," or one who "has any discretionary authority or discretionary responsibility in the administration of such plan." 29 U.S.C. § 1002(21)(A). Although "[a] third-party administrator who merely performs ministerial duties or processes claims is not a fiduciary," Reich v. Lancaster, 55 F.3d 1034, 1047 (5th Cir. 1995) (citing Kyle Rys. v. Pacific Admin. Serv. Inc., 990 F.2d 513, 516 (9th Cir. 1993)), "[t]he authority to grant, to deny, or to review denied claims can, however, make one a fiduciary." Id.
Here, the Court finds that the LTD policy vests Jefferson Pilot as fiduciary with discretionary authority to make coverage decisions. First, the policy requires an employee to submit written proof of loss to Jefferson Pilot. See Def.'s Ex. 1, at GL3001-LTD-8. The policy also requires that the claimant submit proof of continued disability and regular attendance of a physician to Jefferson Pilot. ( See Id.). Secondly, Jefferson Pilot may have the employee examined to determine if he is disabled. ( See Id.). The examination may be "as reasonably required" by Jefferson Pilot. ( Id.). Because Jefferson Pilot requires written proof of loss and because it can order the employee to be examined by a physician to help it evaluate a disability claim whenever it is reasonably necessary, the Court finds that Jefferson Pilot has discretion in determining benefits. See, e.g., See Davis v. Guarantee Life Ins. Co., No. 00-22, 2001 WL 946382, at * 4 (E.D. La. 2001) (finding that policy's requirement that employee submit proof of loss and submit to physician examinations when necessary gave plan administrator discretion to determine benefits); Coffman v. Guarantee Life Ins. Co., No. Civ. A. 99-3736, 2000 WL 798473, at *2 (E.D. La. 2000). There is thus no question that Jefferson Pilot has the authority to "grant, deny, or review denied claims," i.e., determine a participant's eligibility for benefits. See Reich, 55 F.3d at 1047. This is precisely what happened here. The Court therefore finds that Jefferson Pilot has "discretionary authority in the administration" of this plan. See 29 U.S.C. § 1002(21)(A).
In addition, this Court has already held that Guarantee Life Insurance Company, Jefferson Pilot's predecessor-in-interest, is a fiduciary with regard to this same plan because of its authority to determine eligibility for benefits. See Davis, 2001 WL 946382, at * 4; Coffman, 2000 WL 798473, at *2. Moreover, the Department of Labor's regulations require that LTD plans permit a claimant to appeal a denied claim "to an appropriate named fiduciary or to a person designated by such fiduciary." 29 C.F.R. § 2560.503-1(h)(1). When an insurance company like Jefferson Pilot performs this review function, it is the "appropriate named fiduciary." See Kerns v. Benefit Trust Life Ins. Co., 992 F.2d 214, 216 (8th Cir. 1993). The Court holds that Jefferson Pilot is therefore a fiduciary of this LTD benefits plan. The Court will accordingly review Jefferson Pilot's ultimate determination for abuse of discretion as required by Schadler.
Under the abuse of discretion standard, the Court must determine whether the fiduciary's interpretation of the plan is legally correct. See Id. at 394 n. 5. The Fifth Circuit has held that "[i]f the administrator's interpretation of the plan is legally correct, then the inquiry ends because no abuse of discretion could have occurred." Id.
As noted above, the LTD policy provides that the company will pay a total disability monthly benefit after the completion of the elimination period if the employee is totally disabled, requires the regular attendance of a physician, and submits proof to the company of continued total disability. ( See Def.'s Ex. 1, at GL3001-LTD-12). The elimination period is defined as "90 days of Disability due to the same or a related Sickness or Injury, which must be accumulated within a 180 day period." ( See Id.). The definition of "Total Disability" under the plan requires that the claimant be unable "to perform all of the material and substantial duties" of her regular occupation during the elimination and own occupation period. ( See Id. at GL3001-LTD-6). After the own occupation period, "total disability" requires the claimant to be unable to engage in any employment or occupation for which she "is or becomes qualified by reason of education, training, or experience" and that provides her with substantially the same earning capacity as her former occupation. ( See Id.).
The Court finds that Jefferson Pilot did not abuse its discretion in interpreting the terms of the policy and applying them to Gerhold's claim. Jefferson Pilot denied plaintiff's claim because she failed to submit sufficient evidence that she was totally disabled from performing the material duties of her occupation as a Unix administrator during her elimination period. Jefferson Pilot interpreted the plan as insuring Gerhold's occupation as a Unix administrator, not her job as a Unix administrator at Avondale. ( See Id. at 244). Jefferson Pilot specifically asked Dr. Guarino to compare Gerhold's medical records to the job description of a Unix administrator completed by her employer and to determine whether the evidence demonstrated that she could not perform the essential functions of her own occupation. ( See Id. at 233). This interpretation of "regular occupation" is legally correct. District courts have routinely construed the term "regular occupation" to mean "a position of the same general character as the insured's previous job, requiring similar skills and training, and involving comparable duties." Dahlin v. Metropolitan Life Ins. Co., 255 F. Supp.2d 987, 998 n. 4 (N.D. Iowa 2003) (finding that plan administrator did not abuse its discretion when it interpreted "regular occupation" to include the duties of plaintiff's occupation at any other employer); See Dionida v. Reliance Standard Life Ins. Co., 50 F. Supp.2d 934, 939 (N.D. Cal. 1999) (finding plan administrator's definition of "regular occupation," as noted above, reasonable).
The Court finds no abuse of discretion in Jefferson Pilot's application of its interpretation of the plan to Gerhold's case. Gerhold's evidence of her inability to work was limited to the stressful conditions at Avondale, where her department was described as undergoing a "transition" to a more demanding work environment. ( See Def.'s Ex. 2, at 98). There is no question that the administrative record suggests that the stress at Gerhold's job at Avondale could have exacerbated her Crohn's disease. But Dr. Guarino at Jefferson Pilot specifically addressed the duties of plaintiff's occupation in his review of the medical record, and relied on objective evidence to conclude that her duties were light to sedentary. Based on this information, he reasonably concluded that there was no evidence that she could not perform the duties of "her own occupation." ( See Id. at 237). Moreover, one of plaintiff's own physicians, Dr. Anastasio, noted that there is no reason that Gerhold could not work an eight-hour day, five days a week at a job with a less stressful environment. Even Dr. Meyers found that plaintiff was capable of sedentary clerical and administrative work. ( See Id. at 71). The evidence in the administrative record supports Jefferson Pilot's determination that Gerhold failed to show that she could not work as a Unix systems administrator.
Plaintiff argues that Jefferson Pilot's determination is an abuse of discretion because it should have accorded special deference to Dr. Meyers' opinion because he is plaintiff's treating physician. Contrary to plaintiff's argument, it is not a per se abuse of discretion if the fiduciary does not accord special weight to the opinion of the plaintiff's treating physician. See Black Decker Disability Plan v. Nord, — U.S. —, 123 S.Ct. 1965, 1967 (2003). Nor is it a per se abuse of discretion when Jefferson Pilot accorded greater weight to the opinion of Dr. Guarino than that of Dr. Meyers, even though Dr. Guarino was chosen by the fiduciary. 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 in Sweatman v. Commercial Union Ins. Co., 39 F.3d 594, 602 (5th Cir. 1994)). Nor may this Court impose on Jefferson Pilot "a discrete burden of explanation" as to why it may have afforded less weight to Dr. Meyers' opinions. See Black Decker, 123 S.Ct. at 1972. Here, the underlying findings of Gerhold's own doctors are not inconsistent with Dr. Guarino's determination. When Gerhold's doctors determined that she was "disabled, " they focused on her ability to perform her duties at Avondale and not on her ability to perform a job of the same general character, requiring similar skills and training as Unix administrators in general. This is amply demonstrated by Dr. Meyers' opinion that Gerhold could perform sedentary clerical and administrative work at another employer. ( See Def.'s Ex. 2, at 71). Accordingly, the Court finds that Jefferson Pilot's interpretation of the plan was legally correct, and that it did not abuse its discretion when it determined that Gerhold's claim did not meet the terms of the policy.
III. Attorney's Fees and Costs
Plaintiff also requests attorney's fees and costs based on Jefferson Pilot's arbitrary and capricious denial of her claim. 29 U.S.C. § 1132 (g)(1) allows a court to award reasonable attorney's fees to the prevailing party in an ERISA action. See 29 U.S.C. § 1332 (g)(1); Boggs v. Boggs, 82 F.3d 90, 94 n. 1 (5th Cir. 1996), rev'd on other grounds, 520 U.S. 833 (1997). Because the Court grants summary judgment in favor of defendant, the Court does not award attorney's fees or costs to plaintiff.
IV. Conclusion
For the foregoing reasons, the Court GRANTS defendant's motion for summary judgment and DENIES plaintiff's cross-motion for summary judgment.
New Orleans, Louisiana,