Summary
In Simpson v. Ameritech Corp., Inc., 2000 U.S. Dist. Lexis 14607 (E.D. Mich. 2000), the plaintiff quit work based upon problems with carpal tunnel syndrome.
Summary of this case from Barone v. Unum Life Insurance Company of AmericaOpinion
Case No. 00-CV-73391
August 9, 2000
OPINION AND ORDER GRANTING IN PART DEFENDANTS' MOTION FOR SUMMARY JUDGMENT, AND: GRANTING DEFENDANTS' MOTION FOR JUDGMENT ON THE MERITS
Background
Plaintiff Yvonne Simpson filed a complaint in federal court on February 4, 2000 alleging she was employed by Ameritech Corporation and/or its predecessors from 1977 until sometime in 1997. Plaintiff alleges she began experiencing pain and tingling in her right hand in August 1996 as a result of her routine use of a computer at work. Plaintiff continues by alleging that she was thereafter diagnosed and treated for carpal tunnel syndrome, with surgery performed on June 23, 1997. Plaintiff alleges she has also been treated for Menieres Disease, a condition of the ear causing dizziness and hearing loss. Plaintiff further alleges she has been treated for "depression, anxiety, dizziness, migranes, asthma, bladder difficulties, and tinnitus", and has been prescribed Paxil, Zoloft, and other anti-depressant medications. Plaintiff alleges she was admitted to the Providence Hospital's intensive care unit in 1995 for a severe panic attack, and was admitted to Harbor Oaks Hospital on January 31, 1998 with major psychological disorders and other physical maladies. Plaintiff alleges that she has been unable to engage in gainful employment since June 28, 1997.
The record reveals plaintiff received sickness and accident disability benefits ("SADB") through her Ameritech employment prior to July 9, 1998, but was denied Long Term Disability ("LTD") benefits on August 14, 1998. An internal appeal was denied on January 13, 1999. By letter of April 8, 1999, the Ameritech Employees' Benefit Committee ("Committee) allegedly provided copies of the SADB and LTD Plans to plaintiff, but denied any further obligation to provide plaintiff with medical records, stating their decision would be reconsidered only if plaintiff submitted new objective medical evidence to support her disability claims. Plaintiff alleges she filed another appeal for LTD benefits on April 27, 1999. Plaintiff alleges the defendants have since refused to provide her with requested medical records, as well as her complete LTD and SADB files, thus preventing her from meaningfully evaluating her claim.
More specifically, plaintiff alleges that the denial of her claim for LTD benefits was arbitrary and capricious, coupled with a deliberate refusal to produce the evidence on which the denial was based. Plaintiff alleges she is entitled to de novo review of her claims for benefits, disclosure of her medical records, LTD and SADB benefits, and an award of attorney fees. Counts I-III of plaintiff's complaint contain only factual allegations, and do not state claims for relief. Count IV alleges plaintiff is entitled to receive LTD and SADB benefits. Count V alleges the defendants are liable under 29 U.S.C. 1132(a)(1)(B) of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1101 et seq., for failing to pay LTD and SADB benefits. Count VI alleges liability under 29 U.S.C. 1132(a)(1)(B) of the ERISA based on an alleged violation of Section 5 of the applicable LTD Plan in failing to provide plaintiff with: (1) copies of the disability policies and a summary plan description; (2) a specific reason for the denial of benefits; (3) a description of the additional information plaintiff needs to perfect her claims; (4) the name of the person or persons to whom an appeal should be directed, and; (5) 90 days notice of her right to appeal. Count VII alleges the defendants are estopped from denying benefits because plaintiff has provided all required information. Count VIII alleges breach of fiduciary duties to properly exercise "full discretionary authority" under the Plan documents. Count IX alleges breach of contract. Count X simply alleges "DAMAGES".
Defendants' Motions for Summary Judgment and Entry of Judgment On the Merits I. Estoppel and Breach of Contract Claims
Defendants move for summary judgment of plaintiff's claims of estoppel and breach of contract as alleged in Counts VII and IX as being pre-empted by ERISA. Plaintiff's state law claims of estoppel and breach of contract are premised upon, and directly relate to, plaintiff's alleged right to receive benefits under Ameritec's SADB and LTD Plans, Plans that are unquestionably governed by the ERISA. Plaintiff's general claim under Count IV that she is entitled to receive LTD and SADB benefits is also directly related to the Plans, and is pre-empted by ERISA. See Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 52-54 (1987);Cromwell v. Equicor-Equitable HCA Corp., 944 F.2d 1272, 1275 (6th Cir. 1991). Accordingly, plaintiff's estoppel claim, breach of contract claim, and general claim to Plan benefits should be dismissed as pre-empted by federal ERISA law. Celotex Corp. v. Catrett, 477 U.S. 317, 327 (1986); Winningham v. North Am. Resources Corp., 42 F.3d 981, 984 (6th Cir. 1994).
II. ERISA Claims Seeking SADB Benefits
Defendants have proffered unchallenged evidence that plaintiff received the full 52 weeks of SADB benefits she was entitled to under the subject Plan. At the June 22, 2000 hearing, plaintiff's counsel conceded that plaintiff has received all of the SADB benefits to which she was entitled under the Plan. There being no evidentiary dispute, defendants are entitled to summary judgment of plaintiff's claims to SADB benefits, as alleged in Counts IV, V, and VIII, as a matter of law. See Celotex, 477 U.S. at 323; Winningham, 42 F.3d at 984.
III. ERISA Claim Alleging Breach of Fiduciary Duty
Count VIII alleges the defendants breached their fiduciary duties owing under ERISA to properly exercise "full discretionary authority" under the Plan documents. A claim of breach of fiduciary under 29 U.S.C. § 1132(a)(3) is not available to a plan participant who, as here, is entitled to challenge a denial of benefits under 29 U.S.C. § 1132(a)(1)(B) . See Wilkins v. Baptist Healthcare System, Inc., 150 F.3d 609, 615 (6th Cir. 1998) (holding that "[t]he Supreme Court clearly limited the applicability of § 1132(a)(3) to beneficiaries who may not avail themselves of § 1132's other remedies. Varity [Corp. v. Howe, 516 U.S. 489, 512 (1996)]."). Defendants are entitled to summary judgment of plaintiff's ERISA breach of fiduciary duty claim as alleged in Count VIII as a matter of law. Wilkins, 150 F.3d at 615; Winningham, 42 F.3d at 984.
1132. Civil enforcement
(a) Persons empowered to bring a civil action
A civil action may be brought —
(1) by a participant or beneficiary —
. . .
(B) to recover benefits due to him under the terms of his 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;
. . .
(3) by a participant, beneficiary, or fiduciary (A) to enjoin any act or practice which violates any provision of this subchapter or the terms of the plan, or (B) to obtain other appropriate equitable relief (i) to redress such violations or (ii) to enforce any provisions of this subchapter or the terms of the plan. . . .
IV. Remaining ERISA Claims A. Scope of Review
Plaintiff's remaining claims for relief under Counts V and VI allege the defendants are liable under 29 U.S.C. 1132(a)(1)(B) for failing to pay LTD benefits, and for alleged violations of Section 5 of the LTD Plan. The LTD Plan at issue grants the Committee, and any subcommittee or Committee delegate, "full discretionary authority to interpret the terms of the Plan and to determine eligibility for and entitlement to Plan benefits in accordance with Plan terms." Ameritech Long Term Disability Plan (as amended and restated effective June 1, 1996), ¶ 5.2(f), at 7, attached as Defendants' Exhibit A. The Committee also "serve(s) as the final review committee, under the Plan and ERISA, for the review of all appeals by individuals whose initial claims for benefits have been denied, in whole or in part," Id., ¶ 5.2(e), at 7. In that the LTD Plan grants the Committee express discretionary authority to determine a participants eligibility for benefits, and to construe the terms of the Plan, this court reviews the challenged decision to deny plaintiff LTD benefits for an abuse of discretion. See Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 113 (1989); Wilkins v. Baptist Healthcare System, Inc., 150 F.3d 609, 619 (6th Cir. 1998); Perry v. Simplicity Engineering, 900 F.2d 963, 965 (8th Cir. 1990).
While plaintiff does not challenge the express discretionary authority granted to the Committee and its delegates under the LTD Plan, plaintiff nonetheless argues that the court should perform a de novo review because of an inherent conflict caused by the fact that the defendant Ameritech Corporation, Inc. is both plaintiff's employer and the Plan administrator. In Eley v. Boeing Co., 945 F.2d 276 (9th Cir. 1991), relied upon by plaintiff, the Eley Court affirmed the dismissal of an employee's claim for medical benefits under an abuse of discretion standard, citing inter alia Bruch, 459 U.S. at 115. The Eley Court explained that any potential conflict of interest caused by the employer's dual role should be reviewed under the arbitrary and capricious standard, that is whether a potential conflict faced by an employer/plan administrator resulted in an arbitrary and capricious decision, or whether the decision was "consistent with the plain language of the plan." Eley, 945 F.2d at 279. Eley applied an arbitrary and capricious standard, not de novo review. A court may consider a potential conflict of interest as one factor in deciding whether a denial of benefits was arbitrary and capricious. See Parker v. Metropolitan Life Ins. Co., 99 F.3d 181, 185 (6th Cir. 1996), cert. denied, 118 S.Ct. 871 (1998); Brown v. National City Corp., 166 F.3d 1213, 1998 WL 787084 (6th Cir. Oct. 29, 1998). Plaintiff's argument for de novo review is without merit. Id; Bruch, 489 U.S. at 113; Wilkins, 150 F.3d at 619; Perry, 900 F.2d at 965.
Rather, a decision to deny ERISA benefits, including a denial following an administrative appeal, must be "reviewed by the district court under an arbitrary and capricious standard, taking into account the entire record before the administrator at the time of the determination," Daniel v. Eaton Corp., 839 F.2d 263, 267 (6th Cir. 1988). The court's review is limited to "the facts known to the plan administrator at the time he made the decision." Yeager v. Reliance Standard Life Ins. Co., 88 F.3d 376, 381 (6th Cir. 1996). The decision is not arbitrary or capricious if it "is rational in light of the plan's provisions." Id. "Under the arbitrary and capricious standard of review, an administrator's decision will be overturned only upon a showing of internal inconsistency, bad faith or some other ground for calling such determinations in to question."Livingston v. Central States, Southeast and Southwest Areas Health end Welfare Fund, 900 F. Supp. 108, 115 (E.D. Mich. 1995) (citing Davis v. Kentucky Finance Co. Retirement Plan, 887 F.2d 689, 695 (6th Cir. 1989),cert. denied, 495 U.S. 905 (1990)).
B. Administrative Record
The parties agree that the entire administrative record below has been submitted to the court as defendants' Exhibit B. Under the applicable LTD Plan:
"Disability" or "Disabled" . . . shall mean an illness or injury, other than accidental injury arising out of and in the course of employment by the Company [Ameritech Corporation], or a Participating Company, supported by objective medical documentation, that prevents the Eligible Employee from engaging in any occupation or employment (with reasonable accommodation as determined by the Company or its delegate), for which the Eligible Employee is qualified, or may reasonably become qualified, based on training, education or experience. An employee shall continue to be considered disabled if prevented by reason of such illness or injury, supported by objective medical documentation, from working at a job which pays wages which, when combined with benefits payable from the Plan, equal less than 75% of the Eligible Employee's Base Pay at the time the Disability occurred.
Defendants' Exhibit A. Appendix A, at 12 (emphasis added). If an "Eligible Employee is Disabled" beyond the period when SADB benefits are payable, the LTD Plan "shall provide" benefits as provided by the Plan.Id. ¶ 32, at 3.
By letter of August 14, 1998, plaintiff Simpson was notified that her claim for LTD benefits had been denied, Defendants' Exhibit B, at 62-63. After setting forth the definition of "Disability" as set forth above, the letter continued:
We have reviewed medical records that your attorney has provided from a stay at Harbor Oaks Hospital. We have provided a copy of the Independent Medical exam performed by psychiatrist Michael Freedman and testing of John F. O'Leary Ph.D. to your treating physician, Dr. Lingnurkar. We asked that he respond as to whether he agreed or disagreed with the conclusions of these reports. If he disagreed, he was to supply objective findings as well as office notes and test results from February 1, 1998 to present. We gave Dr. Lingnurkar one month to respond, and when we were called by his office and told that he was out of town, we gave him an additional month to review and respond if he was in disagreement with the results of these reports. Dr. Lingnurkar has not supplied any objection nor any medical information to support that he disagrees with the conclusion that you are not psychiatrically disabled from employment. Review of this information by our medical staff also concluded that there is no clinical basis to support a psychiatric disability.
Records were obtained and reviewed regarding your physical condition, as well. We obtained updated information from Dr. Barker. This information was reviewed in addition to information provided by Dr. Panush, an Independent Medical Exam by Dr. Gowda, an Independent Medical Exam by Dr. Austin as well as Dr. Barker's response to the findings of Dr. Austin's report.
Dr. Austin and Dr. Barker disagree as to whether the appropriate diagnosis for your condition is reflex sympathetic dystrophy. Review of all the information in your file revealed that you appear to have residual pain in your right hand after a carpal tunnel syndrome release procedure. The data does not satisfactorily support a diagnosis of reflex sympathetic dystrophy at this time. The objective data does not support that you have active carpal tunnel syndrome at this time either. Dr. Barker feels that you should not be able to do any type of work with your right arm. He also feels that since carpal tunnel syndrome tends to be bilateral, you would be at risk at developing carnal tunnel syndrome on the left side if you were to do repetitive work with your left hand. Therefore, he has restricted you from doing any work with your left hand.
Review of Dr. Austin's report reveals that although you state that she [sic] cannot use your right hand/arm, you were observed on numerous occasions using your right arm without difficulty. There is no objective evidence in our file that shows you have any impairment involving your left arm or left hand.
A review by our consultative physician of all the medical information listed above in our claim file supported the following conclusions: The objective data in the claim file supports that you retain a level of functioning despite your impairment which should enable you to perform left handed duty, with minimal use of the right hand. You can be employed with full and unqualified use of the left hand. Regular breaks (every hour) for stretching should be implemented, An ergonomically correct work station would also be prudent.
Given this level of functioning, we were able to identity jobs which you should be able to perform based on your training, education and experience. Jobs were considered viable if they allowed you to earn at least 50% of your predisabililty earnings.
When contacted, prospective employers for each of the following positions felt that, given your experience and skill level, you would be an appropriate candidate for these positions. These positions are located within 40 miles of your home and can be performed with one hand, while only using both hands minimally. You should be able to stretch your hands once an hour. All the employers contacted stated that they address ergonomic issues. The following positions would allow you to earn at least $8.50 per hour, thus being viable positions.
These jobs are receptionist DOT#237.367-038, clerk dispatcher DOT#215.362-014, taxicab dispatcher DOT#239.167-014, auto rental clerk DOT#249.167-014.
Since you have the ability to engage in occupations or employment for which you are qualified, based on training, education or experience, you do not meet the definition of Long Term Disability. Therefore, this claim for Long Term Disability Benefits has been denied.
Should you wish to appeal this decision, you may do so by submitting a written request for reconsideration, including any medical records or written statements which you or your health care provider feel support the presence of a totally disabling medical condition, within 60 days of receipt of this letter. Requests and supporting evidence should be submitted to:
Ameritech Secretary — Employee Benefit Committee 225 W. Randolph HQ26A Chicago, IL 60606
If you have any questions, please call the Ameritech Disability Service Center at 1-888-212-3300 between 8 a.m. and 5 p.m., Central time. Monday through Friday.Id.
The record indicates Dr. Freedman performed a personal psychiatric evaluation of plaintiff on January 30, 1998. Id. at 24-32. After setting forth his observations in some detail, Dr. Freedman concluded in his February 9, 1998 report:
Based upon today's evaluation, there is nothing to indicate Ms. Simpson is psychiatrically disabled from employment, regardless of any underlying symptoms and/or complaints she might have. Her thought processes were intact. Her memory, recall, concentration and thought organization were within normal limits. Ms. Simpson appears to have some underlying resentment toward her previous supervisor, Gloria Eggers. I cannot rule out the possibility that Ms. Simpson has channeled her feelings of resentment in a passive-aggressive manner into a work avoidance situation.
I would defer comment on any physical problems she might or might not have to a physician whose expertise were in the appropriate area. Some psychological testing might provide further information as to Ms. Simpson's possible tendency to exaggerate or over-state complaints. The testing might also give further information about her underlying pre-existing personality structure,Id. at 32. Following up on the possible need for objective psychological testing, Dr. O'Leary had plaintiff perform the Minnesota Multiphasic Personality Inventory-2. Id. at 18. After setting forth plaintiff's various test scores, Dr. O'Leary concluded:
The pattern of psychological distress presented at this time is not consistent with any type of psychological disability impairing her ability to work. Rather, there was very consistent evidence of symptom exaggeration and probable malingering associated with her claim of psychiatric disability. As a result, I do not believe that she is disabled from returning to work. This examination does not focus on any physical symptoms she may or may not have which could affect her ability to work.Id. at 18. In an April 15, 1998 addendum to his initial report, Dr. Freedman commented that "Dr. O'Leary's findings are consistent with my opinion that Ms. Simpson was not psychiatrically disabled from employment." Id. at 25.
Pursuant to a physical examination of plaintiff on January 26, 1998, Dr. D. Bradford Barker gave his impressions of plaintiff's maladies in a January 30, 1998 letter:
1. Severe right carpal tunnel syndrome.
2. Mild left carpal tunnel syndrome.
3. Severe myofascial strain injury to right neck.
4. Mild myofascial strain injury to the right deltoid.
5. Severe headaches.
6. Anxiety and depression.
The above diagnoses are work related. Her headaches, anxiety and depression were aggravated by her work and that these have been reduced when she hasn't worked. The carpal tunnel syndrome is clearly work related because of repetitive work with the keyboard. Because of the severe pain and discomfort in her right hand she has developed reflex tightening in her neck muscles on the right side and in her right upper trapezius and she has severe headache problems. The bone scan shows abnormalities in her right wrist.
She also has a musculoskeletal problem involving temporomandibular joint syndrome but I am uncertain as to whether this is work related or not.
Mrs. Simpson is unable to work and she should remain off of work through June 30, 1998.
EMG and Nerve Conduction testing are planned at a future date.Id. at 39. Pursuant to a February 20, 1998 EMG requested by Dr. Barker:
IMPRESSION: Nerve conduction testing in the right upper extremity was within normal limits. Testing of the left median sensory nerve was within normal limits.
EMG testing in the right upper extremity and related paraspinals showed no evidence of acute or chronic denervation. Muscular effort in the right intrinsic hand muscles was poor due to pain.
DIAGNOSIS: Normal study.
Id. at 34. Consistent with these objective testing results, Dr. Barker reported in an April 1, 1998 letter that: "The study was in normal limits. There was no evidence of carpal tunnel syndrome in the nerve conduction testing studies." Id. at 40, Dr. Barker continued, however, that he was under the impression that plaintiff suffered from: "1. Right reflex sympathetic dystrophy. 2. Myofascial strain injury to right neck. 3. Anxiety and depression. 4. History of severe right carpal tunnel syndrome. 5. Severe headaches," Id. at 40. Dr. Barker continued:
The right reflex sympathetic dystrophy was much more severe on 2-20-98 than it was when I first saw her on January 26, 1998. At this time, I would consider her to be totally and permanently disabled from any type of work. Given the multitude of problems that she has I cannot realistically see her returning to any type of gainful employment.Id. Dr. Barker gave the same diagnoses in an April 3, 1998 letter. Id. at 16.
At Ameritech's request, Dr. Donald Austin examined plaintiff on May 26, 1998. After relating plaintiff's medical history and his own observations, Dr. Austin concluded:
[O]n the basis of my clinical, physical and neurological examination, I find no definite clinical criteria for diagnosing [plaintiff] as a reflex sympathetic dystrophy. The patient brought with her a number of medical records which she left with me. This included a report from Dr. Barker dated April 1, 1998. He indicates that on January 30, 1998 he performed [EMG] of both hands and found the study to be within normal limits with no evidence of carpal tunnel syndrome. There was a report of a bone flow and scan performed on October 20, 1997 which showed ill defined areas of increased activity about the right wrist felt to be related to degenerative disease. There was another report from Dr. Barker dated January 30, 1998 in which he indicated that nerve conduction studies by Dr. Samuel Milton on August 26, 1996 showed significantly prolonged right median distal latencies compatible with carpal tunnel syndrome and had surgery performed on June 23, 1997. She had a stellate ganglion block performed on March 23, 1998 and March 25. I also received medical records which you had forwarded to me as well. The only additional thing in those records was a medical report dated January 20, 1998 by Dr. Mune Gowda, a hand surgeon, who says, "At this time, although I see no absolute medical contradiction of her ability to perform her normal employment duties, based on her surgical history, I believe some additional prophylactic restrictions would be appropriate; to avoid constant typing or keyboarding for more that one hour at a time and not to exceed more than four hours in a day. After approximately one month of these restrictions, I would think that she could gradually increase her activities as her capabilities increase. It would also be beneficial to evaluate her work station and make sure that it is ergonomically adjusted to minimize the stress placed upon her wrists by constant keyboard work". I agree this would be a reasonable plan for getting Mr. Simpson back to work particularly now that her EMG studies have returned to normal. Again, I do not feel that she has a diagnosis of reflex sympathetic dystrophy.Id. at 14-15.
Dr. Austin's report was forwarded to Dr. Barker for review. In a July 1, 1998 letter, Dr. Barker stated his disagreement with Dr. Austin and Dr. Gowda, Id. at 9-10.
To summarize the patient [plaintiff] did have well documented carpal tunnel syndrome based upon abnormal nerve conduction studies prior to surgery. Since she had the surgery the nerve conduction testing has returned to normal but it should be understood that this is not necessarily going to remove all of her symptoms. In addition injuries to the median nerve can lead to reflex sympathetic dystrophy with a variety of signs and symptoms.
CONCLUSION: Mrs. Yvonne Simpson continues to suffer from carpal tunnel syndrome and from a mild form of reflex sympathetic dystrophy unresponsive to stellate ganglion blocks.
Mrs. Simpson continues to remain disabled from doing any type of work with her right arm. In addition, since carpal tunnel syndrome tends to be bilateral she would be at high risk at developing carnal tunnel syndrome on the left side if she were to do repetitive work with her left hand.Id. at 11.
C. Review
Upon reviewing the entire administrative record underlying the August 14, 1998 decision to deny plaintiff's claim for LTD benefits, the court concludes that the decision is rational in light of the LTD Plan's provision defining an eligible disability as an illness "supported by objective medical documentation" that prevents an employee from engaging in any occupation or employment" for which the employee is or will become qualified "based on training, education or experience." Yeager, 88 F.3d at 381; Eley, 945 F.2d at 279. Nothing in the record supported plaintiff's claim that she suffered from a mental illness that might prevent her from resuming employment. Plaintiff concedes that her treating physician Dr. Lingnurkar did not submit evidence to support her claim of a disabling mental illness. The reports of Dr. O'Leary and Ph.D. Freedman permitted the Committee to rationally conclude that plaintiff did not suffer from a psychiatric disability. Yeager, 88 F.3d at 381; Eley, 945 F.2d at 279.
Likewise, the record evidence permitted the Committee to rationally conclude that plaintiff no longer suffered from carpal syndrome in her right hand, any illness in her left hand, or reflex sympathetic dystrophy, at least to the extent such might prevent plaintiff from engaging in any employment for which she was qualified, or would become qualified, based on her training, education or experience. It was undisputed in the record that plaintiff was not suffering from a physical disability in her left hand; even Dr. Barker conceded that plaintiff "Would be at high risk at developing carpal tunnel syndrome on the left side." Defendants' Exhibit B, at 11 (emphasis added). The LTD Plan does not include a risk of disability as a compensable "disability" entitling a participant to receive LTD benefits.
As the Committee communicated to plaintiff in the August 14, 1998 decision, the evidence demonstrates Dr. Barker and Dr. Austin disagreed whether plaintiff currently suffered from carpal tunnel syndrome in her right hand, and whether plaintiff suffered from what Dr. Darker characterized as "a mild form of reflex sympathetic dystrophy." Defendants' Exhibit B, at 11. As to any objective sign of reflex sympathetic dystrophy, Dr. Barker could only rely upon his own examination of plaintiff that revealed "1+ edema in the right hand which is a symptom seen in sympathetic dystrophy." The court notes that Dr. Barker does not state that 1+ edema is seen only in cases of sympathetic dystrophy. Dr. Austin's and Dr. Gowda's evaluations refute Dr. Barker's impressions of sympathetic dystrophy. It was not irrational for the Committee to conclude that plaintiff did not suffer from sympathetic dystrophy. Consistent with Dr. Austin's and Dr. Gowda's recommendations, the Committee adopted the rational conclusion that plaintiff "retain[ed] a level of functioning despite [her] impairment which should enable [her] to perform left handed duty, with minimal use of the right hand" in available positions such as receptionist, clerk dispatcher, taxicab dispatcher, or auto rental clerk. Id. at 62-63.
Plaintiff has filed to demonstrate that the August 14, 1998 decision to deny her eligibility for LTD benefits was irrational in light of the LTD Plan's express provisions, was internally inconsistent, or was the result of bad faith or a conflict of interest. The challenged decision was not arbitrary or capricious, nor the result of an abuse of discretion. See Daniel, 839 F.2d at 267; Yeager, 88 F.3d at 381; Livingston, 900 F. Supp. at 115; Parker, 99 F.3d at 185; Brown, 1998 WL 787084; Eley, 945 F.2d at 279. Plaintiff's claims that she was denied copies of the applicable policies and plan summaries, a specific reason for the denial of her benefits, a description of information needed to support her contention that she was disabled, the name of the entity to which an appeal could be directed, or 90 days notice of a right to appeal are not supported by the record.
D. Post-Decision Relief
Plaintiff argues that, at minimum, the court should remand to the Committee to allow her to present more evidence of her disability in that she was denied a meaningful review when defendant denied her requests for copies of the administrative record after a final decision had been rendered. Consistent with the initial August 14, 1998 decision informing plaintiff that she could appeal the Committee's decision within 60 days by filing a request for reconsideration with the Committee at its Illinois address along with supporting medical evidence (see Defendant's Exhibit B, at 63), plaintiff in fact filed a timely appeal, which was denied on January 13, 1999. See Defendant's Exhibit B, at 1. The Committee reiterated its conclusion that it "found no objective evidence of a severe medical or psychiatric illness to substantiate your claim that you remain totally disabled beyond 7/9/98." Id.
Plaintiff's instant claims are based on the Committee's post-January 13, 1999 denials of her March 10, 1999 and April 27, 1999 requests for evidentiary materials on which the Committee based its final decision. C.F.R. § 2560.5031(g)(1) provides:
(g) Review procedure,
(1) Every plan shall establish and maintain a procedure by which a claimant or his duly authorized representative has a reasonable opportunity to appeal a denied claim to an appropriate named fiduciary or to a person designated by such fiduciary, and under which a full and fair review of the claim and its denial may be obtained. Every such procedure shall include but not be limited to provisions that a claimant or his duly authorized representative may:
(i) Request a review upon written application to the plan;
(ii) Review pertinent documents; and
(iii) Submit issues and comments in writing.
(emphasis added). Another federal regulation sets forth the notices that must be included with an initial claim denial:
(f) Content of notice. A plan administrator or, if paragraph (c) of this section is applicable, the insurance company, insurance service, or other similar organization, shall provide to every claimant who is denied a claim for benefits written notice setting forth in a manner calculated to be understood by the claimant:
(1) The specific reason or reasons for the denial;
(2) Specific reference to pertinent plan provisions on which the denial is based;
(3) A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary; and
(4) Appropriate information as to the steps to be taken if the participant or beneficiary wishes to submit his or her claim for review.29 C.F.R. § 2560.503-1(f).
The August 14, 1998 decision complied with 29 C.F.R. § 2560.503-1(f) by providing plaintiff with: (1) specific reasons for denying her request for LTD benefits; (2) specific reference to the LTD Plan provision defining a compensable "disability"; (3) a description of the materials needed to perfect her claim, being "any medical records or written statements which you or your health care provider feel support the presence of a totally disabling medical condition", and; (4) the steps to be taken for her to submit an appeal. The issue raised by plaintiff under C.F.R. § 2560.5031(g)(1)(ii), however, is whether the LTD Plan contained an appellate review procedure that provided her with a meaningful opportunity to review pertinent documents to pursue an appeal.
The LTD Plan does not contain an express provision in its appellate procedure stating that a claimant may review all pertinent documents underlying the Committee's decision. The LTD Plan does provide:
(e) The Committee shall serve as the final review committee, under the Plan and ERISA, for the review of all appeals by individuals whose initial claims for benefits have been denied, in whole or in part. Any individual whose claim for benefits has been denied, in whole or in part, may (and must for the purpose of seeking any further review of a decision or determining any entitlement to a benefit under the Plan), within 60 days after receipt of notice of denial, submit a written request for review of the decision denying the claim.
(emphasis added). Plaintiff has not come forward with evidence that, in submitting her written request for appellate review within 60 days of the August 14, 1998 decision, she also asked to review the pertinent records underlying the decision, or was denied such a request by the Committee.
Consistent with 29 C.F.R. § 2560.503-1(f), plaintiff was provided with adequate notice of her right to appeal; this regulation governing notice of an initial appeal did not require the Committee to inform plaintiff that she had a right to review all pertinent records in pursuing an appeal. The Committee's post-appeal March 10, 1999 and April 27, 1999 refusals to provide plaintiff with the administrative record below does not implicate C.F.R. § 2560.5031(g)(1)(ii) because these requests were not made during plaintiff's initial appeal, but months after plaintiff's appeal was denied and a final decision was rendered. To find under the instant circumstances that the Committee violated C.F.R. § 2560.5031(g)(1)(ii) by denying plaintiff a "meaningful review" on appeal, the court would have to assume that the Committee denied or would have denied plaintiff's request to review pertinent documents had plaintiff made the request within 60 days after the August 14, 1998 decision. That, however, is not the premise of plaintiff's claims.
In Halpin v. W.W. Grainger, Inc., 962 F.2d 685 (7th Cir. 1992), the Seventh Circuit, interpreting ERISA and C.F.R. § 2560.5031, framed the issue of "meaningful review" broadly:
The purpose of the statute and regulations must be our guide: was the beneficiary supplied with a statement of reasons that, under the circumstances of the case, permitted a clear understanding of the administrators position to permit effective [administrative appellate] review.Id. at 690. Under the circumstances of the case at bar, this Court answers that question in the affirmative. Plaintiff was specifically informed in the initial August 14, 1998 denial of benefits that the Committee relied upon: (1) Harbor Oaks Hospital medical records provided by plaintiff; (2) IMEs performed by Drs. Freedman end O'Leary which were provided to plaintiff's treating physician Dr. Lingnurkar; (3) the absence of any objections by Dr. Lingnurkar as to Dr. Freedman's and Dr. O'Leary's conclusion that there was no clinical basis for finding a psychiatric disability; (4) information provided by plaintiff's treating physician Dr Barker; (5) information provided by one Dr. Panush, (6) an IME performed by Dr. Gowda; (7) an IME performed by Dr. Austin, and; (8) Dr. Barker's response to Dr. Austin's IME report, disagreeing with Dr. Austin. See Defendant's Exhibit B, at 61-62. Plaintiff was further informed that:
The objective data in the claim file supports that you retain a level of functioning despite your impairment which should enable you to perform left handed duty, with minimal use of the right hand. You can be employed with full and unqualified use of the left hand. Regular breaks (every hour) for stretching should be implemented. An ergonomically correct work station would also be prudent.
Given this level of functioning, we were able to identify jobs which you should be able to perform based on your training, education and experience. . . . When contacted, prospective employers for each of the following positions felt that, given your experience and skill level, you would be an appropriate candidate for these positions. These positions are located within 40 miles of your home and can be performed with one hand, while only using both hands minimally. . . . These jobs are receptionist DOT#237.367-038, clerk dispatcher DOT#215.362-014, taxicab dispatcher DOT#239.167-014, auto rental clerk DOT#249.167-014.
Defendant's Exhibit B, at 61-62. Plaintiff was also told that, in filing an appeal, she should "includ[e] any medical records or written statements which you or your health care provider feel support the presence of a totally disabling medical condition," Id. at 62. From all of this information, the Committee provided plaintiff with enough information to promote "a clear understanding of the administrators position to permit effective [administrative appellate] review." Halpin, 962 F.2d at 690.. There is no evidence to support a claim that plaintiff asked for the administrative record when she pursued her appeal to a final conclusion.
The Halpin plaintiff was faced with dissimilar circumstances in that the trial court found he was not given "adequate disclosure of reasons for the initial denial." Halpin, 962 F,2d at 695.
Even assuming that the Committee violated C.F.R. § 2580.5031(g)(1)(ii) when they denied plaintiff's request for pertinent documents after her administrative appeal had been exhausted in January 1999, substantial compliance with the regulation is sufficient to prove that an ERISA Plan claimant was provided with meaningful appellate review. See Halpin, 982 F.2d at 693-694. The Committee provided plaintiff with a procedure by which she had a reasonable opportunity to appeal the August 14, 1998 decision, and a reasonable opportunity to ask for pertinent documents and to submit further objective evidence of her claimed disabilities. The LTD Plan substantially complied with C.F.R. § 2560.5O31(g)(1)(ii), Plaintiff's claim that she was denied full and meaningful appellate review is not well taken.
Conclusion
For the reasons set forth above, the defendants are entitled to summary judgment as to plaintiff Yvonne Simpson's claims of estoppel and breach of contract as alleged in Counts VII and IX, claims for SADB as alleged in Counts IV, V, and VIII, and breach of fiduciary duty as alleged in Count VIII. Defendants are entitled to judgment as a matter of law with respect to plaintiff's claims for LTD benefits under Counts V and VI. Plaintiff's claims for relief are hereby DISMISSED with prejudice in their entirety.
SO ORDERED.