Summary
In Wadyal v. Metropolitan Life Insurance Co., 2003 WL 22846229 (N.D.Cal. Nov. 24, 2003) a case cited by Hartford for further support, the insured did not seek disability for depression until after a decision on the final appeal had been issued.
Summary of this case from Plummer v. Hartford Life Insurance Co.Opinion
No. C 02-05815 WHA
November 24, 2003
JUDGMENT
For the reasons stated in the November 24 summary-judgment order, judgment is hereby entered against plaintiff on behalf of defendant.
IT IS SO ORDERED.
ORDER GRANTING DEFENDANT'S MOTION FOR SUMMARY JUDGMENT AND DENYING PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT INTRODUCTION
In this action under the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1132, challenging defendant's denial of plaintiff's claim for disability benefits, both parties move for summary judgment. This order GRANTS defendant's motion and DENIES plaintiff's.STATEMENT
Plaintiff is a forty-three-year-old woman who worked as a research assistant for Genentech, Inc., from August 18, 1997, through December 15, 1998. As a regular, full-time employee, plaintiff was a participant in the group long-term disability benefit plan that Genentech maintained for its employees. Defendant Metropolitan Life Insurance Company issued the group insurance policy that funded the benefit.
Under the terms of the plan, "disability" or "disabled" means that (Sullivan Exh. 1 at 41):
due to an Injury or Sickness, you require the regular care and attendance of a Doctor and:
(1) you are unable to perform each of the material duties of your regular job; and
(2) after the first 60 months of benefit payments, you must also be unable to perform each of the material duties of any gainful work or service for which you are reasonably qualified taking into consideration your training, education, experience and past earnings; or
(3) you, while unable to perform all of the material duties of your regular job on a full-time basis, are:
a. performing at least one of the material duties of your regular job or any other gainful work or service on a part-time or full-time basis; and
b. earning currently at least 20% less per month than your Indexed Basic Monthly Earnings due to that same Injury or Sickness.
Plaintiff submitted a claim, dated June 1, 1999, for long-term disability benefits. Plaintiff indicated on the claim form that she was involved in an accident on October 30, 1998, while working with a rabbit specimen. Plaintiff described the accident as follows: "Working with whole body unit (rabbit). Lifting, twisting, reaching, pulling, looking down on specimen, taking pictures, making types from the frozen rabbit, pressing down with palm of the hand. My lower back pain the [right] leg gave up on me." She identified December 16, 1998, as the date on which she was first disabled.
The attending physician statement, dated May 27, 1999, was completed by Dr. Dilbagh Chattha. Dr. Chattha identified the date of plaintiff's first visit as February 2, 1999. His statement indicated that plaintiff subjectively suffered from neck pain, arm pain, back pain, and pain in her right leg. Dr. Chattha diagnosed plaintiff with cervical and lumbar sprains with radiculopathy. He concluded that plaintiff was totally disabled and estimated that she would be able to resume work activities for her occupation on July 15, 1999.
"Radiculopathy is compression of the nerve root caused by a displaced intervertebral disc or narrowing of the spinal canal." Lawson v. Massanari, 231 F. Supp.2d 986, 990 n. 4 (D. Or. 2001) (citing Dorland's Illustrated Medical Dictionary 1404, 1564, 1576 (28th ed. 1994)).
Upon receiving plaintiff's claim, defendant determined that additional information was needed. Defendant therefore contacted Dr. Chattha on June 29, 1999, and requested that he submit his office notes regarding plaintiff, as well as any test or lab results. Defendant received on July 7, 1999, the requested material from Dr. Chattha, as well as a copy of plaintiff's short-term disability claim file from a disability claims-management company called VPA, Inc.
After reviewing all of these materials, defendant determined that plaintiff's medical records did not support her alleged disability from cervical or lumbar strain. By letter dated August 20, 1999, defendant denied plaintiff's claim for long-term disability benefits. Defendant informed plaintiff in the letter that if she wanted further review, she should send a written request within sixty days.
In October 1999, in response to a request by plaintiff, defendant provided an attending-physician-statement form and physical-capacities-evaluation form to Dr. Chattha for him to complete during plaintiff's visit scheduled for October 15. The completed forms were submitted to defendant on December 1, 1999.
In March 2000, plaintiff and defendant spoke by phone. Plaintiff expressed that she wanted to appeal the denial. She made a similar requests by telephone on several previous occasions. As before, defendant informed plaintiff that, as stated in the denial letter, a written request for an appeal was require under the terms of the plan. Although the sixty-day deadline for an appeal had passed, defendant decided to give plaintiff another chance to request an appeal in writing.
Defendant received additional material regarding plaintiff's alleged condition from Dr. Chattha, as well as several disability slips from Dr. Ritu Singh, a chiropractor. Upon reconsideration, defendant determined that there remained insufficient medical evidence to substantiate plaintiff's disability claim. On April 4, 2000, defendant denied plaintiff's appeal.
On April 20, 2000, plaintiff requested that defendant provide a mental/behavioral functional assessment form to Dr. Waldorf Kahlon, a psychiatrist. Defendant received the completed form from Dr. Kahlon, which diagnosed plaintiff with major depression. On April 26, 2000, defendant informed plaintiff that the new material did not alter its decision. Defendant noted that plaintiff's claim was for cervical and lumbar sprains with radiculopathy and stated that this was the first time it received medical information to support a diagnosis of major depression. Defendant determined that the records did not indicate that plaintiff had been rendered unable to perform her occupational duties. In its April 26 denial letter, defendant also informed plaintiff that a full and fair review had already been completed in accordance with the terms of the plan and that plaintiff had exhausted her administrative reviews.
On May 26, 2000, Dr. Chattha requested that defendant reevaluate plaintiff's case on the basis of the depression diagnosis, now stating that she had suffered from depression since 1998. Defendant advised plaintiff that its conclusion remain unchanged because there was no documentation that plaintiff was unable to work in 1998 on account of depression.
Although defendant had informed plaintiff that no more reviews were available, defendant later received additional unsolicited reports from Dr. Chattha. Defendant reiterated in a letter dated October 23, 2001, that the review was complete. Plaintiff commenced the instant action on December 13, 2002. Both parties now move for summary judgment.
ANALYSIS
1 STANDARD OF REVIEW.
A district court generally reviews an administrator's decision to deny benefits de novo, unless the plan language unambiguously vests the fiduciary or administrator with discretionary authority to determine eligibility for benefits or construe the plan's terms. Ingram v. Martin Marietta Long Term Disability Income Plan for Salaried Employees, 244 F.3d 1109, 1112 (9th Cir. 2001). The plan here at issue explicitly grants such authority (Sullivan Exh. 1 at MET 58): "In carrying out their respective responsibilities under the Plan, the Plan administrator and other Plan fiduciaries shall have discretionary authority to interpret the terms of the plan and to determine eligibility for and entitlement to Plan benefits in accordance with the terms of the Plan."
Plaintiff argues that there is evidence of a conflict of interest and that de novo is therefore the applicable standard of review. For the de novo standard of review to apply, plaintiff must submit "material, probative evidence, beyond the mere fact of the apparent conflict, tending to show that the fiduciary's self-interest caused a breach of the administrator's fiduciary obligations to the beneficiary." Atwood v. Newmont Gold Co., 45 F.3d 1317, 1323 (9th Cir. 1995). Were such a showing made here, the burden would then shift to defendants to show that the conflict did not influence the decision. Ibid. Plaintiff has not carried her burden of showing that defendant's self-interest caused such a breach. Indeed, all five of plaintiff's arguments on this point fail.
First, plaintiff states that defendant failed to conduct a full and fair review of plaintiff's claim as required by 29 U.S.C. § 1133(2) because defendant did not obtain medical records from Mariner Medical Clinic and Dr. Bunke or inform plaintiff that it did not have these records. Although the Mariner Medical Clinic and Dr. Bunke were identified as treating physicians in plaintiff's claim form, no attending physician statements by them were submitted. plaintiff's claim form was accompanied only by an attending-physician-statement from Dr. Chattha, and it was the records of Dr. Chattha that defendant then requested. Moreover, in its initial denial letter, defendant invited plaintiff to submit any additional information that would bear on the determination. Plaintiff points to no authority requiring defendant to gather all of plaintiff's medical records in order to fulfill its obligations of full and fair review.
Second, plaintiff contends that de novo review is warranted on the ground that defendant improperly rejected the opinion of plaintiff's treating neurologist, Dr. Chattha. To say that plaintiff "rejected" Dr. Chattha's opinion is an overstatement: defendant referred to the medical records at issue and used much of the information therein to support its conclusion. In any event, defendant was not obligated to adopt the treating physician's opinion. Black Decker Disability Plan v. Nord, ___ U.S. ___, ___, 123 S.Ct. 1965, 1969 (2003). Third, plaintiff points to defendant's refusal to consider new evidence regarding plaintiff's claim until she submitted a formal written request for an appeal. This "formalistic, adversarial approach," plaintiff argues, is at odds with defendant's fiduciary duty and thus evidences a conflict of interest. Defendant, however, was properly following plan procedures. The record also shows that defendant informed plaintiff this requirement on several occasions. Moreover, defendant ultimately permitted the appeal to proceed in spite of plaintiff's failure to submit a written request within sixty days of the initial denial letter.
Fourth, plaintiff argues that defendant's rationale for denying plaintiff's claim contained requirements that did not exist in the plan. For example, plaintiff faults defendant for not giving plaintiff's subjective complaints more weight, noting that the plan does not require that subjective findings equal objective findings in order to evidence disability. This argument ignores the fact that defendant had discretion to interpret and apply plan provisions. What matters is whether defendant made a rational eligibility determination in a manner consistent with the plan provisions. Defendant was not precluded from considering relevant factors just because such factors were not specifically mentioned in the plan.
Fifth, plaintiff claims that defendant mischaracterized Dr. Chattha's conclusions regarding her ability to return to work. Whether or not this is so, the "inconsistencies" that are relevant in the conflict-of-interest analysis are those within the reasoning employed by the administrator or fiduciary, not inconsistencies between the administrator's ultimate eligibility determination and record evidence concerning an alleged disability. See Lang v. Long-Term Disability Plan of Sponsor Applied Remote Tech., 125 F.3d 794, 799 (9th Cir. 1997).
As the foregoing arguments lack merit, plaintiff has not sustained her burden of producing evidence showing that a conflict of interest influenced defendant's decision. Nor has plaintiff made a sufficient threshold showing to persuade the Court to allow discovery with respect to this issue. The standard of review is abuse of discretion.
2. REVIEW FOR ABUSE OF DISCRETION.
The question of whether the administrator abused its discretion in denying disability benefits is a question of law. In such a case, a motion for summary judgment functions as a "conduit to bring the legal question before the district court." Bendixen v. Standard Ins. Co., 185 F.3d 939, 942 (9th Cir. 1999). Accordingly, "the usual tests of summary judgment, such as whether a genuine dispute of material fact exists, do not apply." Ibid. When reviewing an administrator's decision for abuse of discretion, the district court must consider only the evidence that was before the plan administrator when the decision was made. McKenzie v. Gen. Tel. Co., 41 F.3d 1310, 1316 (9th Cir. 1994). The administrator's decision must be upheld unless it denies claims without explanation, construes plan provisions in a way that conflicts with the plain language of the plan, or relies on clearly erroneous findings of fact. Taft v. Equitable Life Assurance Soc'y, 9 F.3d 1469, 1472-73 (9th Cir. 1993). This order holds that defendant did not abuse its discretion in denying plaintiff's claim.
Defendant denied plaintiff's claim for lack of objective medical evidence supporting plaintiff's diagnoses and claim for disability. Significantly, despite plaintiff's alleged symptoms, the EMG nerve conduction velocity tests of her left upper and right lower extremities did not evidence any radiculopathy. As stated in a report by Dr. Chattha (Sullivan Exh. 1 at 242) (emphasis added):
When I saw this patient for the first time on February 2, 1999, . . . . I told the patient that she would need and [sic] EMG nerve conduction velocity of the right lower and left upper extremity to rule out radiculopathy. . . . The patient has been subsequently seen in my office and the patient had an EMG nerve conduction velocity done on the left upper and right lower extremity that were normal. There was no evidence of radiculopathy or neuropathy. . . . The patient has had radicular symptoms, but her EMG nerve conduction velocity does not show any evidence of radiculopathy.
Similarly, her MRI scans were normal (ibid.):
I had a chance to review some of the patient's old records that she brought with her. The patient had an MRI scan done on the thoracic spine that was normal. I do not see an MRI of the lumbar spine report, but it was recorded in the patient's record that it was normal.
Thus, the available objective tests failed to substantiate plaintiff's subjective complaints. To require objective substantiation in this case was not unreasonable, even though the plan did not set forth a requirement of objective proof. See Martin v. Continental Cas. Co., 96 F. Supp.2d 983, 991-94 (N.D. Cal. 2000) (Jenkins, J.). Significantly, plaintiff's condition was not one for which no objective testing was available.
Furthermore, defendant notes that although plaintiff claims that she was rendered totally disabled as of December 16, 1998, from a workplace incident that occurred on October 30, 1998, plaintiff did not visit Dr. Chattha until February 2, 1999. Defendant observed that this too undermines the seriousness of plaintiff's claimed disability. This order agrees. The record further reflects that plaintiff's doctor expected a rather quick recovery: Dr. Chattha's report, dated May 27, 1999, predicted that with physical therapy and rest, plaintiff would be able to return to work less than two months later, on July 15, 1999. Dr. Chattha also said (Sullivan Exh. 1 at 237): "I have told the patient that with aggressive physical therapy and with rest her symptoms should go away, but it is definitely taking much more time, and of course, we know her subjective complaint is slightly more than the objective findings at this time."
The job-description information in the record shows that the physical requirements associated with plaintiff's research-assistant position were limited. Nonetheless, according to Dr. Chattha, plaintiff had a moderate limitation with respect to sitting and a severe limitation with respect to reaching overhead. According to a description provided by her employer, plaintiff's job entailed six hours of sitting per day and "occasional" reaching above the shoulder. Thus, there can be no question Dr. Chattha's assessment of plaintiff's physical limitations supports her claim. This assessment, however, need not itself be dispositive. Dr. Chattha's explained that this assessment was "because of . . . pain" ( id. at 271). Yet, as even Dr. Chattha acknowledged, testing failed to verify that plaintiff's symptoms were as severe as she claimed they were. Under the circumstances, defendant was not obligated to conclude from the physical-limitations assessment that plaintiff was necessarily disabled.
Plaintiff's eleventh-hour focus on depression is a case of "too little, too late." The request for a medical/behavioral functional assessment form came only after a decision on plaintiff's appeal had issued. Moreover, neither Dr. Kahlon's nor Dr. Chattha's records showed that depression rendered plaintiff unable to perform her occupational duties at the time her claimed disability commenced. To be sure, the records received by defendant from Dr. Chattha on July 7, 1999, stated that plaintiff was found to be "slightly depressed" and noted a previous diagnosis "that the patient probably had some depression." It cannot be said that defendant abused its discretion by failing to award plaintiff disability benefits based on depression in the face of this evidence. Furthermore, defendant was under no obligation either to gather all of plaintiff's records on its own or to continue reviewing plaintiff's submissions once plaintiff's appeal had been denied.
In sum, defendant did not abuse its discretion when it denied plaintiff's claim for long-term disability benefits. plaintiff's arguments to the contrary are without merit.
CONCLUSION
For the foregoing reasons, defendant's motion for summary judgment is GRANTED, and plaintiff's motion for summary judgment is DENIED. The clerk shall CLOSE the file.
IT IS SO ORDERED.