Opinion
Case No. 1:00-CV-76
June 22, 2001
MEMORANDUM OPINION
Plaintiff Alan Needham brings this action under the federal Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq., for benefits allegedly owed under a group life insurance policy administered by defendant Connecticut General Life Insurance Company ("CIGNA" or "the administrator"). Plaintiff's claim for benefits presents a federal question under 29 U.S.C. § 1132 (a)(1)(B) of ERISA.
Plaintiff refers to the administrator as "Cigna," while defendants refer to "Connecticut General Life." In the administrative record now before the Court, the administrator refers to itself as "CIGNA." That usage shall be continued here.
The parties were instructed to file simultaneous briefs in lieu of trial in accordance with the procedures set out in Wilkins v. Baptist Healthcare Systems, Inc., 150 F.3d 609 (6th Cir. 1998).
Each party filed briefs, as well as subsequent responses. The matter was taken under advisement after a hearing before the Court.
I. BACKGROUND
Plaintiff is a former employee of ATT. In his last position held at the company, plaintiff was a Technical Support Specialist, a managerial position. As an employee, he was a participant in the company's Sickness and Accident Disability Plan ("SD Plan") as well as its Long-Term Disability Plan ("LTD Plan" or "plan"). Both plans were sponsored by ATT and administered by CIGNA.
In November 1995, plaintiff suffered a major episode of depression. Plaintiff thereafter sought benefits under the SD Plan, which were approved by CIGNA. As his SD benefits were about to expire, plaintiff filed a claim for benefits under the LTD Plan on August 12, 1996. As grounds, he stated that he suffered from "depression and anxiety" and was "[u]nable to cope with others in stressful situations." Administrative Record ("AR") 18. CIGNA approved his claim and commenced paying benefits for the period beginning on November 13, 1996.
On May 14, 1997, CIGNA notified plaintiff that it was "in the process of an evaluation to determine [plaintiff's] continuing eligibility" for LTD benefits. AR 78. The plan provided that a claimant seeking disability benefits had to meet certain requirements:
You must have been disabled for 52 weeks in which you received sickness disability benefits.
During the first year of receiving LTD benefits, you must be unable to perform all of the duties of your job because of a nonoccupational illness or injury.
After that:
You must be unable to do any job for which you are qualified, or may reasonably become qualified by training, education, or experience, or
You must be unable to work at any salaried job other than one that pays less than half your annual base pay at the time he became disabled, and
At all times during your disability, you must be under a physician's care and following the recommended course of treatment to receive benefits. The Plan Administrator will determine the extent of your disability based on medical evidence. The Plan Administrator reserves the right to have a physician of its choice examine you.
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If you are able to return to work for an employer other than the Company, in a job that pays more than 50 percent of your previous rate of pay, you are no longer covered by the Plan.
AR 511-12 (emphasis in original).
As part of its investigation, the plan administrator sought medical information regarding plaintiff's depression from both plaintiff and his treating physician or physicians. In a "Clinical Summary" dated April 28, 1997, Dr. Daniel DeWitt, Psy.D., indicated that he treated plaintiff during a total of 28 outpatient psychotherapy visits between October 3, 1995, and November 14, 1996. AR 76. He diagnosed plaintiff with Major Depressive Disorder, Single Episode, Moderate Severity (DMS-IV code 296.22), and Alcohol Dependence, Early Full Remission (DMS-IV code 303.93). Id. Dr. DeWitt noted that plaintiff took anti-depressant medication prescribed by his primary physician in addition to the psychotherapy sessions. AR 77. Dr. DeWitt opined that plaintiff "was unable to return to work because the threat of losing his job and financial security was likely to trigger additional depression and anxiety." Id.
"DMS-IV" stands for the American Psychiatric Association's widely — referenced publication, DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed. 1994).
Several months later in June 1997, Dr. DeWitt completed and returned to CIGNA an evaluation form describing plaintiff's condition. He reiterated his original diagnosis of DMS-IV 296.22 and 303.93. AR 285. He noted that during his sessions, plaintiff: (1) was coherent and spontaneous; (2) had an improved mood at the time of the last session in November 1996; (3) did not suffer from any hallucinations or delusions; (4) had improved thinking and decision-making functions; (5) had normal concentration and memory; and (6) had an above-average intelligence. AR 285-86.
Plaintiff's judgment was deemed to be within societal norms. AR 286. Dr. DeWitt further reported that plaintiff's daily activities included basic upkeep of home and yard, working on his car, and participating in a car club. AR 287. Plaintiff was, however, "guarded with relationships and became upset if there was conflict or tension." Id. Dr. DeWitt indicated that plaintiff could not perform a job which required influencing people and performing under stress. He concluded that plaintiff's prognosis was "Good." Id.
Also attached was an "Evaluation of Psychiatric Impairment" form filled out by Dr. DeWitt. He indicated that as a percentage of impairment, plaintiff was in the "0% — 5%" range on all of the listed criteria: (1) intelligence; (2) thinking; (3) perception; (4) judgment; (5) affect; and (6) behavior. AR 288. Plaintiff's ability in activities of daily living was found to be "Self — Sufficient." Id. When asked to indicate the DMS code which classified plaintiff, Dr. DeWitt wrote 296.26," meaning Major Depressive Disorder, Single Episode, In Full Remission. DMS-IV at 370 (emphasis added).
Upon reviewing the information provided by Dr. DeWitt, CIGNA concluded that plaintiff had failed to provide sufficient medical evidence to support total disability under the plan. It closed his claim effective July 13, 1997. AR 99.
Based on subsequent submissions by plaintiff, CIGNA decided to contact several of plaintiff's physicians for further evidence. Dr. Joseph Wolschleger provided information relating to a normal colonoscopy. In addition, CIGNA performed a Transferable Skills Study to determine whether plaintiff could engage in viable work.
The study identified four occupations appropriate for plaintiff-Technical Support Specialist; Order Department Supervisor; Department Manager; and Credit Analyst. AR 112-20. Based on Dr. DeWitt's June 1997, submission, CIGNA did not take into account any psychiatric deficits in performing the study. However, the analyst did note that "[t]he appropriateness of these occupations depends upon the amount of `stress' of each job with each employer. The same issue applies to the amount of influencing one must do on the job which also differs from employer to employer." AR 111.
Upon review of the submitted medical information and its own Transferrable Skills Study, CIGNA declined plaintiff's claim by letter dated November 18, 1997. AR 121-23. Plaintiff appealed the decision. Additional medical information was provided to CIGNA. Dr. Robert Scuilli sent office notes and test results from June 13, 1997 to October 29, 1997 relating to impotence and a cellulitis/abscesses on plaintiff's neck. Dr. DeWitt also submitted a written narrative statement and office notes for the period of October 2, 1997 through December 11, 1997. AR 294-303.
These sessions with Dr. DeWitt focused primarily on plaintiff's relationship with an unstable woman and the multiple crises that resulted. Primary symptoms included sexual dysfunction and associated anxiety. Dr. DeWitt also noted that it was "apparent that [plaintiff] ha[d] not fully recovered from his earlier depression. Although he stabilized on medications, he did not recover in areas of productive work, satisfying leisure activities, and a healthy support network." AR 294.
CIGNA again declined plaintiff's claim on January 8, 1998. AR 134-35. It found Dr. Scuilli's notes provided no information in support of a physical disability. While Dr. DeWitt's narrative and notes documented several mental/emotional problems, CIGNA stated that it found nothing "`that showed that you would be incapable of performing any occupation." AR 135.
Several months later in August 1998, plaintiff again appealed the denial of benefits. He provided CIGNA with additional information, including: (1) office notes dated October 2, 1997 to February 9, 1998 by Dr. DeWitt; (2) office notes dated June 13, 1997 to February 24, 1998 by Dr. Scuilli; and (3) a copy of his partially favorable decision from the Social Security Administration dated June 26, 1998. Upon review, CIGNA concluded that the notes of Drs. DeWitt and Scuilli did not provide any additional support for plaintiff's claim. Furthermore, the Social Security Administration had found that plaintiff was disabled as defined by the Social Security Act beginning on November 7, 1995, but had improved to the point that he was no longer disabled as of October 7, 1997. AR 150. Although the occupations identified by the administration paid less than fifty percent of plaintiff's last position with ATT, CIGNA determined that all of the four occupations it had identified paid in excess of that amount. AR 189. Accordingly, CIGNA concluded that plaintiff was not entitled to benefits.
Plaintiff appealed a third time. He submitted the deposition testimony of Dr. DeWitt taken ex parte by plaintiff's counsel. While most of Dr. DeWitt's testimony dealt with plaintiff's mental health and functional capacities as of February 8, 1999 (the date of the deposition), he did make several observations related to plaintiff's past condition:
A He was, you know, fairly — he was in fairly good shape in November of `96, you know, he was stabilized on the medicine. They had come to an agreement about a disability retirement, you know, at that point, and he was relieved of most of his symptoms, and I did not see him again until October of `97.
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Q Do you view the impairment he has now, the diagnosis associated with it, to be tied into whatever developed in 1995 when he first came to see you?
A Right, he has never fully recovered from that initial treatment in 1995. The most uncomfortable symptoms of anxiety and depression were relieved, for example, at different points, like in November of '96, but he never did return to his former level of work performance and ability to handle job stress, and he remained vulnerable to recurrence of some symptomatology as occurred in October of `97, and that incidence was precipitated by stresses in dating relationships, and they, were performance-related stresses.
Q Your testimony that you just gave about his level of impairment and the inability to perform his past work, did that apply to all periods of time since you first started treating him, including the period from November of `96 through October of `97, that he was not, even at that time, capable of returning to his former work?
A Well, I didn't see him during that period. We had talked about how it would be desirable for his continued improvement of mood and self confidence, you know, that, ideally, some type of productive work would assist with that. But I — during that year when I didn't see him, I don't know.
AR 346-48.
Plaintiff also submitted a psychological/vocational evaluation by psychologist Dr. James Lozer, Ed.D. Dr. Lozer interviewed plaintiff on April 19, 1999 for approximately two hours and administered the Minnesota Multiphasic Personality Inventory-2 (MMPI-2"). AR 387. He reviewed the transcript of Dr. DeWitt's ex parte deposition. (However, because a page of his report is missing from the administrative record provided to the Court, it is unclear what additional medical information — if any — Dr. Lozer also reviewed. See AR 387-88.) Dr. Lozer found that plaintiff's responses to the MMPI-2 produced a valid profile that indicates severe psychopathology. He is an individual who is extremely anxious and depressed and has a very low self-esteem. AR 390. Based on Dr. DeWitt's testimony, he concluded that plaintiff "is not able to engage in any type of full-time gainful employment due to his anxiety, depression, and low self-esteem." AR 392.
CIGNA submitted plaintiff's entire administrative file — including the deposition of Dr. DeWitt and report of Dr. Lozer — to Dr. Edward Kern, M.D., a staff psychiatrist, to provide an overview of the medical evidence and Transferable Skills Study.
Based on Dr. Kern's report and the updated administrative record, CIGNA again affirmed its denial:
The medical documentation in Mr. Needham's file shows that he was not under the care of Dr. DeWitt for the period of November 14, 1996 through October 2, 1997. A psychiatric impairment form completed by Dr. DeWitt dated June 9, 1997 indicated that his depression was in full remission and there wasn't any signs or symptoms of a disturbance were present [sic]. Dr. DeWitt also rated Mr. Needham as having no impairments of intelligence, thinking, perception, judgement, affect, behavior, or impairments of activities of daily living. Mr. Needham's only limitation may be in influencing others and performing under stress. No explanation of stress was provided to clarify functionality with others in a work environment.
The deposition taken from Dr. DeWitt was an attempt to clarify past treatment and functioning. This deposition however was not a reflection of this patient's medical condition at the time we reevaluated his ongoing eligibility for Long Term Disability. Also this deposition is not considered clinical data reflective of Mr. Needham's medical status in November 1997. This only reflects his current medical condition and the opinion of Dr. DeWitt at the time of his deposition. Mr. Needham was not under the doctor's care for the period of November 1996 through October 1997. The clinical [data] available at the time of our reevaluation shows Mr. Needham's depression was fully resolved and in remission. This data regarding his medical condition at the time his treatment was provided provide [sic] is a more accurate assessment of his medical status during the period in question.
Also, the Psychological/Vocational assessment by Dr. Lozer would not be applicable to the period in time in contention when Mr. Needham's medical condition was in full remission and would have been capable of obtaining another job in a field that was identified in our Transferable Skills Analysis.
In summary, the medical evidence provided does not substantiate or document total disability since November 1996 through October 1997 and current. There is insufficient medical information to establish a period of continuous and total disability and therefore, we are reaffirming our previous denials of this Long Term Disability Claim.
In no way are we stating that your client is not limited by his depression, rather the medical evidence provided does not support that his limitations were so severe at the time of the closure of his claim that . . . he would be unable to perform the essential duties of any occupation as outlined in our Transferable Skills Analysis. Therefore, we have no other alternative but to uphold our previous decision to deny Long Term Disability for Mr. Needham.
AR 230. It is this final determination by the administrator that the Court now reviews.
II. ANALYSIS
The Plan provides that CIGNA has the sole discretion "to determine conclusively . . . any and all questions arising from administration of the Plan and interpretation of all Plan provisions, determination of all questions relating to ongoing participation of eligible employees and eligibility for benefits, [and] determination of all relevant facts." AR 518. This reservation of discretion limits the Court's review of the administrator's interpretation and application of plan provisions and fact-finding determinations to whether these were "arbitrary and capricious." See Rowan v. Unum Life Ins. Co. Am., 119 F.3d 433, 436 (6th Cir. 1997); Yeager v. Reliance Standard Life Ins. Co., 88 F.3d 376, 381 (6th Cir. 1996). See also Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989) (explaining that judicial review is de novo "unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan"). The Court is further limited in its review to the evidence presented or otherwise known to the plan administrator at the time it made its final determination. See Yeager, 88 F.3d at 381.
Under the "arbitrary and capricious" standard of review, the Court is to uphold the administrator's determination if it is "rational in light of the plan's provisions." Id. (internal quotations and citation omitted). In other words, "[w]hen it is possible to offer a reasoned explanation, based on the evidence, for a particular outcome, that outcome is not arbitrary or capricious." Davis v. Kentucky Fin. Cos. Retirement Plan, 887 F.2d 689, 693 (6th Cir. 1989) (internal quotations and citation omitted), cert. denied, 495 U.S. 905 (1990). Courts have found this to be "the least demanding form of judicial review of administrative action." Williams v. International Paper Co., 227 F.3d 706, 712 (6th Cir. 2000). However, a plaintiff may show that the administrator failed to use its judgment by, for example, coming forward with "material, probative circumstantial evidence that [leaves] the court with serious doubts as to whether the result reached was the product of an arbitrary decision or the plan administrator's whim." Buttram v. Central States, S.E. S.W. Areas Hlth., 76 F.3d 896, 900 (8th Cir. 1996) .
As noted above, CIGNA determined that "since November 1996 through October 1997 and current," plaintiff was no longer totally disabled as defined under the plan. It based this determination on several sources of information, including the information provided by Dr. DeWitt in June 1997; its Technical Skills Study; and the overview of the administrative record by Dr. Kern.
Plaintiff argues, however, that instead of relying on Dr. Kern's report, CIGNA should have in the first instance, and this Court should now on review, focus on "the unmistakably clear statements" regarding plaintiff's disability made by Dr. DeWitt in his February 1999 deposition. In support counsel cites Branham v. Gardner, 383 F.2d 614 (6th Cir. 1967). In that case the Sixth Circuit found that under the "Treating Physician Rule,"
The evidence of physicians who have been treating a patient over a long period of time . . . is substantial evidence as compared to the evidence of physicians who have examined [a patient] on only one occasion and whose reports are inconclusive, fragmentary, uncertain, and not contradictions of unqualified evidence that the patient is totally and permanently disabled.Id. at 634. See also 20 C.F.R. § 404.1527 (d)(2) (requiring that greater weight be given to treating physicians opinions in social security disability cases than the opinions of other doctors). However, while prevalent in the social security context, this rule has not been universally adopted in the ERISA context. While the Sixth Circuit has not addressed whether this standard applies in ERISA cases, several other circuits have expressly declined to apply the rule in such cases, including the Fourth, Fifth, Eighth, and Eleventh Circuits. See, e.g., Marsteller v. Life Ins. Co. N. Am., 24 F. Supp.2d 593, 596-98 (W.D.Va. 1998) (discussing case law); Campbell v. Fortis Benefits Ins. Co., No. 98-496, 2000 WL 1567943 (M.D.Tenn. Sept. 29, 2000) (same). Given that the Sixth Circuit has not found that application of the rule is proper in the ERISA context, and given the persuasive reasons for not incorporating the rule in the ERISA context, including the potential for conflicts of interest when a treating physician stands to profit if benefits are not to be terminated, the Treating Physician Rule appears to be inapplicable in this context.
Notwithstanding this, however, the record clearly shows that the information of plaintiff's mental health provided to CIGNA by Dr. DeWitt was decidedly mixed. As noted in the clinical summary dated April 28, 1997, Dr. DeWitt's original diagnosis was that plaintiff suffered from a Major Depressive Disorder, Single Episode, Moderate Severity, as well as Alcohol Dependence, Early Full Remission. AR 76. By June 1997, however, Dr. DeWitt indicated that plaintiff suffered from little or no impairment in all the listed categories. Significantly, he further concluded that plaintiff's single episode of major depression was in full remission.
Plaintiff does not assert here that any of his documented physical ailments are severe enough to support a finding of total disability under the plan.
There is nothing in the record by Dr. DeWitt or any other treating physician that reconciles the June 1997 evaluation that plaintiff's depression was in full remission and the generally positive findings as to impairments with his subsequent deposition testimony that plaintiff had not returned to his past level of work performance since his initial episode of depression. In fact, when asked whether plaintiff was capable of returning to work during the period of November 1996 through October 1997, Dr. DeWitt responded that he did not know. AR 348. Given this ambivalent testimony, it was not unreasonable for CIGNA to focus on Dr. DeWitt's June 1997 evaluation in weighing the medical evidence and conclude that at some point between November 1996 and October 1997, plaintiff had recovered from his depression and suffered little to no significant impairments that would qualify him for benefits under the plan.
Similarly, it was not unreasonable for CIGNA to place greater emphasis on its own Technical Skills Study rather than Dr. Lozer's subsequent vocational evaluation. The administrator's study was clearly based on Dr. DeWitt's June 1997 evaluation which suggested plaintiff suffered from "no [psychiatric] deficits." AR 111. The psychological/vocational evaluation by Dr. Lozer was not based on Dr. DeWitt's earlier evaluation of plaintiff, but rather on his deposition testimony in February 1999. See AR 391-92. To the extent that CIGNA could reasonably give greater weight to the June 1997 evaluation by Dr. DeWitt rather than the subsequent testimony, the administrator did not act arbitrarily and capriciously by relying upon that earlier evaluation to perform its vocational analysis.
It is certainly plausible, based on the medical evidence in the record, that plaintiff may have suffered a relapse of depression which may have inhibited him from gainful employment in an occupation paying at least fifty percent of his past wages at ATT. Yet, CIGNA has interpreted the plan to require continuous disability. AR 230. The plan provides that "LTD benefits . . . continue until the earliest" of three events: recovery, death, or the end of the maximum duration of benefits period based on the claimant's age. AR 512. Thus, once CIGNA found that plaintiff had recovered from his depression, it reasonably concluded that he was no longer eligible for benefits and could have returned to gainful employment. If he had (or attempted to) returned to work, then became disabled again, the plan would have again provided coverage. See id. Plaintiff has not suggested CIGNA's requirement of continuous disability was an "arbitrary and capricious" interpretation or application of the plan's provisions, and, upon review, the Court does not find this to be the case.
Although plaintiff has not claimed here that the Social Security Administration's findings of partial disability provide prima facie evidence of total disability under the plan, the Court notes several significant differences between the administration's and CIGNA's respective reviews that lessen the former's import to the latter. First, the regulations governing eligibility for social security disability benefits provide that when a claimant has established he cannot perform "past relevant work," the burden shifts to the administration to show that other jobs that the claimant can perform are available in the national economy. See 20 C.F.R. § 404.1520. The parties have pointed to no analogous burden-shifting provision in the plan.
Additionally, several relevant and material records were excluded from one or the other reviews. For example, Dr. DeWitt's June 1997 evaluation forms are not listed as exhibits submitted to the Social Security Administration. See AR 160. Nor does it appear that CIGNA was provided with a transcript of plaintiff's testimony before the administration, which was identified as a significant basis for decision. See, e.g., AR 146.
III. CONCLUSION
For the reasons provided above, the Court finds that CIGNA's denial of benefits under ATT's Long-Term Disability Plan was not "arbitrary and capricious," and, accordingly, plaintiff's claim for benefits shall be DENIED. A judgment order consistent with this memorandum opinion shall issue forthwith.JUDGMENT ORDER
In accordance with the Court's memorandum opinion of even date, the Court finds that the denial of long-term benefits to plaintiff was not "arbitrary and capricious." Accordingly,
IT IS HEREBY ORDERED that plaintiff's claim for benefits is DENIED.