Opinion
Case No. 1:04-cv-216.
March 17, 2005
MEMORANDUM OPINION
This case is before the Court for review of an administrative record and claim for benefits arising under 29 U.S.C. § 1132(a)(1)(B) pursuant to the guidelines set forth in Wilkins v. Baptist Health Care Sys., Inc., 150 F.3d 609 (6th Cir. 1998). For the reasons that follow, the Court will affirm the denial of benefits and award judgment to defendant.
I. FACTS
Plaintiff was employed as a production associate at Donnelly Corporation ("Donnelly"). By virtue of his employment, he is a beneficiary of the employee welfare benefits plan ("Plan") including the group accident and health insurance policy ("Policy") established by Donnelly. Aetna is the Plan administrator. The Plan provides that plaintiff would be considered totally disabled and eligible to receive long term disability benefits upon evidence that:
During the period which ends right after the first 24 months benefits are payable in a period of total disability:
You are not able, solely because of injury or disease, to perform the material duties of your own occupation; except that if you start work at a reasonable occupation you will no longer be deemed totally disabled.
Thereafter during such period of total disability:
You are not able, solely because of injury or disease, to work at any reasonable occupation.
Record 785. The Plan further provides that, "a period of total disability will end after 24 monthly benefits are payable if it is determined that the disability is, at that time, caused to any extent by a mental condition." Record 787.
Plaintiff was admitted to the hospital twenty seven times from the summer of 1992 until the fall of 2003. Plaintiff was diagnosed with delayed gastric emptying and diabetic neuropathy. Plaintiff has also been diagnosed with depression, which has worsened over time.
Beginning December 5, 2002, plaintiff was hospitalized for four days, with complaints of vomiting and abdominal cramps. Upon discharge, the medical records indicated that: "[t]he patient would be discharged on a 2000 calorie ADA diet. He is to resume his normal medication regimen. Continue to monitor blood sugars carefully. Follow up with Dr. Hulst in one week." Record 243. There was no recommendation in the hospital records that plaintiff not return to work. However, plaintiff did not return to work thereafter. Plaintiff received short term disability benefits for a period of six months, ending on June 5, 2003. Aetna received plaintiff's initial claim for long term disability benefits on May 5, 2003. Aetna acknowledged receipt of plaintiff's claim and requested additional information from plaintiff's treating physicians in order to understand plaintiff's condition and how that prevented him from performing the material duties of his own occupation.
Based upon the initial evaluation of plaintiff's medical records, Aetna's claims representative noted that plaintiff had been diagnosed with diabetes, depression, gastroparesis and diabetic neuropathy. Record 28. Plaintiff had not been disabled from working for any significant length of time during that period and had not previously filed a claim for long term disability benefits. The claims representative also observed that plaintiff's job duties changed in or around November 2002 from a lab technician to a production associate, and that the physical demand for a production associate required only the ability to stand for an eight hour day and to lift up to ten pounds. Id.
On the Attending Physician's Statement in support of plaintiff's claim for disability benefits, plaintiff's own treating physician, Dr. Hulst, reported that plaintiff was unable to complete an eight hour day of work, yet he was capable of at least sedentary activity. Dr. Hulst classified plaintiff as moderately, as opposed to severely, disabled. Record 19. Dr. Hulst, however, did state that plaintiff was unable to maintain any job on a full-time basis. Record 1, 3, 18-19. Plaintiff's psychiatrist and vocational rehabilitation expert also stated that plaintiff could not return to Donnely to work. Record, 492-500.
Aetna denied plaintiff's claim for long term disability benefits on July 31, 2003. The denial letter noted that while plaintiff was diagnosed with the same conditions prior to leaving work in December, 2002, his inability to work after that date was not explained by any worsening or change in his medical condition. Aetna denied plaintiff's claim due to the lack of objective medical evidence documenting how plaintiff's condition had worsened in December 2002 such that he was precluded from performing the material duties of his occupation. Record 43-45.
Plaintiff appealed Aetna's decision, and plaintiff's claim was referred to Dr. Hopkins. Dr. Hopkins observed that the medical records contained no objective evidence supporting the diagnosis of diabetic neuropathy. The records indicated plaintiff's diabetic retinopathy and coronary artery disease were stable as of September 2002 and February 2003. Record 55, 495. Dr. Hopkins' review also noted that plaintiff's job duties changed in November 2002 and that plaintiff felt "harassed" by his boss and was experiencing stressors at home, including his son being in a coma. Dr. Hopkins referred to a report from plaintiff's psychiatrist that stated plaintiff felt overwhelmed and was thinking about applying for disability. Record 490.
Dr. Hopkins further noted that plaintiff's physical condition remained essentially unchanged even after plaintiff's last day of work. Eventually, Dr. Hopkins opined that plaintiff had been able to work prior to December 2002 and there was no objective medical evidence documenting a worsening in his medical conditions or any increase in physical limitations after December 2002. Furthermore, Dr. Hopkins found that while plaintiff could not have worked while hospitalized from December 5, 2002 until December 9, 2002, there was no evidence suggesting that he could not have resumed work after this time. Aetna advised plaintiff that the decision to deny him benefits was upheld.
II. ANALYSIS A. Standard of Review
This Court applies the "arbitrary and capricious" standard of review to an ERISA plan administrator's decision regarding benefits where, as here, "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, 109 S. Ct. 948, 103 L. Ed. 2d 80 (1989). The administrator's decision must be upheld if "it is the result of a deliberate, principled reasoning process and if it is supported by substantial evidence." Baker v. United Mine Workers of Am. Health and Retirement Funds, 929 F.2d 1140, 1144 (6th Cir. 1991). A plan administrator's determination is not arbitrary or capricious when a reasoned explanation, based on the evidence, supports that determination. Davis v. Ky. Finance Cos. Retirement Plan, 887 F.2d 689, 693 (6th Cir. 1989).
There is no dispute that the arbitrary and capricious standard of review applies in this case.
B. Defendant did not act arbitrarily and capriciously in denying plaintiff long-term disability benefits.
Plaintiff cites opinions from Dr.'s Hulst and Biegelman as well as a vocational rehabilitation expert, Roy Welton, in support of his claim that he is entitled to benefits. Plaintiff claims that defendant ignored medical evidence that documents plaintiff's disability. Plaintiff also analogized this case, at oral argument, to one of a person who is running a race and is only able to take one last step before he finally collapses. Plaintiff argues that this applies to his case because he has been suffering from various ailments for years and finally reached the point in December 2002, where he could finally no longer continue working. Defendant argues that its decision must be upheld because there is evidence to support its decision and there is a reasonable explanation for its decision. See Abbott v. Pipefitters Local Union No. 522, 94 F.3d 236, 240 (6th Cir. 1996) (upholding administrator's decision where there was a reasonable explanation for the decision).
Plaintiff argues that there is nothing to contradict the opinions of his examining physicians, who determined plaintiff was disabled as of December 5, 2002, except the opinion of Dr. Hopkins, who did not examine him. However, the Supreme Court has held that ERISA does not require a plan administrator to accord special deference to the opinion of treating physicians. Black Decker Disability Plan v. Nord, 538 U.S. 822, 830, 123 S. Ct. 1965, 1970, 155 L. Ed. 2d 1034 (2003). The Court also stated that plan administrators may not arbitrarily refuse to credit a claimant's reliable evidence, including the opinion of a treating physician. Id. at 834. Nonetheless, a court may not impose on a plan administrator "a discrete burden of explanation when they credit evidence that conflicts with a treating physician's evaluation." Id.
In Eriksen v. Met. Life Ins. Co., 39 F. Supp. 2d 864, 870 (E.D. Mich. 1999), the court held that an administrator's decision to deny benefits was not arbitrary and capricious where there was no objective evidence to support the disability recommendation of plaintiff's treating physician. The plan at issue in Eriksen required plaintiff to establish that he could not perform "any type of work." Id. The court noted that the defendant's decision to deny plaintiff benefits was rational under the plan provisions where the medical evidence submitted by plaintiff showed that he could perform "light duty" work. Id.
Plaintiff has been suffering from several ailments and illnesses for more than a decade. Plaintiff's treating physicians stated that plaintiff was disabled as of December 5, 2002. Aetna afforded more weight to the opinion of the reviewing physician, Dr. Hopkins who found that there was no objective medical evidence documenting a worsening in plaintiff's condition. However, Aetna did not have to accord any special deference to the opinions of plaintiff's treating physicians. Black Decker, 538 U.S. at 830, 123 S. Ct. 1970. Furthermore, while plaintiff's argument that he finally reached a breaking point on December 5, 2002 could be compelling under some circumstances, such a claim is unsupported by the facts of this case. The Court notes that this case is similar to Eriksen, 39 F. Supp. 2d 864, as the Plan in this case requires plaintiff to establish that he cannot "work at any reasonable occupation." Here, the medical evidence also establishes that plaintiff can at least perform "sedentary" work. Record 19. As was the case in Eriksen, there is no objective medical evidence in the record documenting a change in plaintiff's condition as of December 5, 2002. Eriksen at 864.
Even Dr. Hopkins noted that plaintiff's gastroparesis "may be impairing for periods of time," but there is nothing to suggest that plaintiff could not continue to work with it as he had been doing for many years. Record 56.
The Court has carefully examined the record in search of objective medical evidence documenting a change in plaintiff's condition as of December 5, 2002. The Court is aware of and not unsympathetic to plaintiff's medical conditions. However, after reviewing the entire record, there does not appear to be objective medical evidence that would lead the Court to the conclusion that defendant acted arbitrarily and capriciously. Under Black Decker, 538 U.S. 822, Aetna was not required to give any special deference to plaintiff's treating physicians. No significant evidence was overlooked or not appreciated. Therefore, because defendant is able to offer a reasoned explanation that is based on the evidence in the record in this case, the Court finds that the defendant did not act arbitrarily and capriciously. Accordingly, the Court will AFFIRM Aetna's decision denying plaintiff's claim for benefits and enter judgment in favor of Aetna.
An Order consistent with this Memorandum Opinion shall follow.