Opinion
Civil Action No. 3:01CV-109-S
July 16, 2002
MEMORANDUM OPINION
This matter is before the court on cross-motions for summary judgment in this action challenging the denial of disability benefits to the plaintiff, Brenda Broussard, under an employee benefit plan.
Broussard we employed by Brinly-Hardy Company as an assembly line worker. She began experiencing pain in her knees some time in 1998. She was advised by her treating physician, Dr. Frank Bonnarens, to cease working on January 24, 2000 due to a meniscus tear in the left knee, requiring arthroscopic surgery. The surgery was performed on January 25, 2000. Broussard underwent physical therapy from January 31, 2000 through March 23, 2000 when she was found to have met all short-term and long-term goals established at her initial evaluation, and was released to return to work without restrictions. The physical therapy discharge notes included the following:
Reason for Discharge: Patient has reached maximal improvement in physical therapy and met goals established at initial evaluation. The patient is independent with their [sic] home program and will continue independent self treatment . . . Pt. states that she is a lot better since initiation of therapy and that she is able to do most everything without trouble.
On April 17, 2000, Broussard was seen by Dr. Bonnarens. His notes from that appointment stated, in pertinent part:
She returns today saying that her knee is still causing problems. She feels much better after her surgery, but she is still having aching pain particularly with changes in weather. Her job requires a lot of standing and she doesn't feel she is ready to go back to work . . . Continue out of work. She will return here in two months' time for re-evaluation.
On May 1, 2000, Broussard fell, injuring her left knee. She returned to Dr. Bonnarens a number of times after May 1, 2000 for re-evaluation. On July 26, 2000, Dr. Bonnarens noted that Broussard "has been unable to attend physical therapy [prescribed for the May 1st injury] for financial reasons, and says that she feels like she would be incapable of returning to work in any meaningful capacity. Based on what we see on exam, I would agree . . . We are going to keep her out of work and see her return here in six months' time for re-evaluation, sooner if she feels strong enough to return to work."
On August 3, 2000, Broussard filed for disability benefits under a group long-term disability benefits plan purchased by Brinly-Hardy from the defendant, Continental Casualty Company. As an active, full-time employee, as defined by the policy, she was a covered employee on January 24, 2000.
The policy defines "total disability" to mean that
during the Elimination Period and the Insured Employee Occupation Period shown in Statement 4 of the Application, the Insured Employee, because of Injury or Sickness, is:
(1) continuously unable to perform the substantial and material duties of her regular occupation;
(2) under the regular care of a licensed physician other than herself, and (3) not gainfully employed in any occupation for which he is or becomes qualified by education, training or experience.
The elimination period for this group policy was 180 days and the employee occupation period for Class II employees, including Broussard, was 12 months. The policy provided for payment of total disability benefits for illness or injury continuing after the elimination period.
Broussard's application for benefits was denied. By letter dated October 4, 2000, Broussard was advised by the claims administrator of the reasons for the denial:
The policy contract states that in order to become eligible to be considered for benefits you must be continuously disabled for a period of 180 days. Our records indicate that your last day worked was 1/24/00 and you are claiming disability from 1/25/00. The elimination period is from 1/25/00 through 7/22/00. Following 180 days you must continue to meet the policy contract's definition of total disability . . .
In order for us to determine if you are totally disabled from a medical condition your doctors must be able to provide medical evidence of a physically disabling impairment that would prevent you from performing the substantial and material duties of your occupation . . .
We have throughly reviewed the medical records received from Dr. Bonnarens and Preston Physical Therapy. The physical therapy discharge summary dated 3/23/2000 returned you to work without restrictions . . .
Broussard appealed the denial of benefits, and on November 14, 2000, Broussard was informed by letter that the decision was reviewed and it was determined that the original decision would not be altered:
Based on the records reviewed the claimant indicates throughout that she does not think that she is capable or ready to return to work. The medical findings do not support a condition that would preclude her inability [sic] to perform the duties of her occupation as a Packer Assembler. The physical therapist discharge summary dated 3/23/00 indicated that she had reached maximum medical improvement, met the goals established and the medical findings showed overall improvement. She was released to return to work without restrictions at that point. She returned to the Dr. on 4/17/00 and advised the Dr. she did not feel ready to return to work. There was no medical evidence provided to support why she did not return to work when released in March other than Ms. Broussard advising her physician that she did not feel she was ready to return to work.
The appeal was then forwarded to the Appeals Committee for a second review. A second review was performed and, in a comprehensive letter dated December 19, 2000, the Appeal Committee concluded that "no medical evidence was submitted supporting her claimed level of impairment due to a physical condition(s) that would preclude her from working after her completion of physical therapy on 3/23/00. As the medical information received does [sic] support that she remained disabled in accordance with the provisions of the policy, the decision to deny her claim was proper and correct based upon the medical records submitted."
The letter omits the word "not." A mistake which is critical to the meaning of the sentence, but which is clearly a typographical error. The Appeals Committee found that the medical information did not support a finding of disability.
On January 22, 2001, Broussard filed this action in the Jefferson County, Kentucky, Circuit Court challenging the denial of benefits by Continental Casualty. Continental Casualty removed the action to this court under our federal question jurisdiction, on the ground that the claims are governed by the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq. ("ERISA").
A party moving for summary judgment has the burden of showing that there are no genuine issues of fact and that the movant is entitled to summary judgment as a matter of law. Adickes v. S.H. Kress Co., 398 U.S. 144, 151-60, 90 S.Ct. 1598, 16 L.Ed.2d 142 (1970); Felix v. Young, 536 F.2d 1126, 1134 (6th Cir. 1976). There are no genuine issues of material fact in dispute, and the parties have filed-cross motions for summary judgment, citing to the administrative record.
The parties agree that Brinly-Hardy's disability benefits plan is an "employee welfare benefit plan," as that term is defined by ERISA, 29 U.S.C. § 1002(1); Williams v. WCI Steel Company, Inc., 170 F.3d 598 (6th Cir. 1999). Claims concerning the denial of benefits under an employee benefit plan have been found to "relate to" that plan. Therefore, such claims come under the exclusive coverage of ERISA's civil enforcement scheme. McMahan v. New England Mutual Life Insurance Co., 888 F.2d 426 (6th Cir. 1989).
The Brinly-Hardy plan afforded the administrator discretionary authority to determine eligibility for benefits. See, Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). The plan stated that benefits would be paid after Continental Casualty received "due written proof of loss." This proof requirement allowed the administrator to determine the adequacy of the evidence submitted by Broussard to support her claim of total disability. Perez v. Aetna Life Insurance Co., 150 F.3d 550 (6th Cir. 1998); Yeager v. Reliance Standard Life Insurance Co., 88 F.3d 376 (6th Cir. 1996).
Where the administrator of the plan has discretionary authority in evaluating eligibility for benefits, we review the denial of benefits under an arbitrary and capricious standard, and base our determination upon a review of the administrative record. Wilkins v. Baptist Healthcare System, Inc., 150 F.3d 609 (6th Cir. 1998). Under the arbitrary and capricious standard of review, a determination by the administrator to deny benefits which is based upon a reasoned explanation for the outcome and rational in light of the plan provisions must be upheld. Williams v. International Paper Co., 227 F.3d 706, 712 (6th Cir. 2000); Perry v. United Food Commercial Workers District Union, 405 442, 64 F.3d 238 (6th Cir. 1995).
The reason for denial of benefits to Broussard was stated consistently and clearly in each explanatory letter at each level of administrative review. The basis remained the same throughout.
Broussard was discharged from physical therapy on March 23, 2000. She was released to return to work without restrictions. The discharge summary indicated that she had reached maximum improvement and had met all goals during her months of post-surgical rehabilitation. On physical evaluation, she was found to have full active range of motion and 5/5 MMT upon discharge. Broussard herself indicated that she was able to do most of her usual work. Earlier in March she had stated that she was able to do most things for herself. It was reasonable for Continental Casualty to conclude that this diagnostic and self-evaluative evidence established that she was not disabled on March 23, 2000, as that term was defined by the plan.
When Broussard saw Dr. Bonnarens a few weeks later on April 17, 2000, she indicated that she did not feel ready to return to work. The doctor's note related Broussard's reluctance to return to work, and her statements that she had aching pain particularly with weather changes and that her job required a lot of standing. His notes did not indicate the results of any physical examination performed by him, nor any suggestion that he disagreed with the physical therapist's clinical evaluation of her condition. He simply concluded "Continue out of work. She will return here in two months' time for re-evaluation." The content of this doctor's note does not contain any medical evidence which contradicts the physical therapy discharge report. The only contradiction can be found in Broussard's own self-assessment that she was not ready to return to work because she had to stand for long periods of time. It was within the discretion of the administrator to deny benefits upon the medical evidence submitted.
Broussard's focus on her May injury, and reliance on the July 26, 2000 doctor's note by Bonnarens concerning her condition at that time is misplaced. The medical evidence reasonably showed that as of March 23, 2000, Broussard was not continually disabled during the 180-day elimination period, thus rendering her ineligible for benefits on her claim of disability beginning January 25, 2000. Her fall in May of 2000 and subsequent convalescence has no bearing on the question of her physical condition on March 23, 2000.
The decision to deny benefits to Broussard was not arbitrary and capricious. Therefore, the motion of Continental Casualty for summary judgment will be granted, and Broussard's motion for judgment will be denied. A separate order will be entered herein this date in accordance with this opinion.