Opinion
CIVIL ACTION NO. 07-11803-GAO.
April 16, 2009
OPINION AND ORDER
I. Background
The plaintiff, Carol Ciarlone, has brought this action under Section 502 of the Employment Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1132(a)(1)(B), to recover long term disability benefits she claims are owed to her under a Group Long Term Disability Policy (the "Policy") issued by defendant The Lincoln National Life Insurance Company ("Lincoln") to her former employer, Best Chevrolet, Inc.
The plaintiff worked full-time as an office clerk until having a right total mastectomy on April 13, 2005, after which she developed right-sided chest wall pain. In October 2005 she submitted a claim for long-term disability ("LTD") benefits under the policy, which was approved in November. Lincoln continued to pay her benefits until January 11, 2007, when it discontinued her benefits on the ground that she was no longer totally disabled under the terms and conditions of the policy. Lincoln National maintained its denial after two successive appeals by the plaintiff. This lawsuit followed. The parties have cross-moved for summary judgment. For the reasons discussed below, I conclude that the defendant's denial of benefits was not arbitrary or capricious, and therefore the defendant is entitled to summary judgment.
II. Standard of Review
The parties agree that the Policy constitutes an ERISA employee benefit plan as defined by 29 U.S.C. §§ 1102 and 1103, established for the benefit of the employees of Best Chevrolet, Inc. They also agree that the Policy gives Lincoln discretionary authority to determine eligibility for benefits, and therefore the arbitrary and capricious standard of review applies. See Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989) ("a denial of benefits challenged under [29 U.S.C.] § 1132(a)(1)(B) is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or construe the terms of the plan."). Under that standard, a decision to deny benefits is upheld if it was "reasoned and supported by substantial evidence." Gannon v. Metro. Life. Ins. Co., 360 F.3d 211, 213 (1st Cir. 2004). "Evidence is substantial if it is reasonably sufficient to support a conclusion." Id.
Although the plaintiff argued in her brief in support of her motion that review should be de novo because of the conflict of interests that exists where, as here, a plan administrator both evaluates claims for benefits and pays benefits claims, see Metro. Life Ins. Co. v. Glenn, ___ U.S. ___, 128 S.Ct. 2343, 2348 (2008), the plaintiff conceded at oral argument that the arbitrary and capricious standard of review applies. Even absent that concession, the standard of review would remain deferential, and the conflict is simply "one factor among many that a reviewing judge must take into account." Id. at 2350.
This Court's review is based only on the record that was before the plan administrator. See Leahy v. Raytheon Co., 315 F.3d 11, 18 (1st Cir. 2002). Summary judgment is the proper vehicle by which to evaluate the reasonableness of the administrative determination in light of that record, but "the non-moving party is not entitled to the usual inferences in its favor." Orndorf v. Paul Revere Life Ins. Co., 404 F.3d 510, 517 (1st Cir. 2005).
III. The Decision to Deny Benefits was not Arbitrary or Capricious
A review of the administrative record compels the conclusion that Lincoln's decision to terminate LTD benefits was not arbitrary or capricious. The record fails to support the plaintiff's contention that she was totally disabled as defined by the Policy, whether because of pain, pain medication, or some combination of the two. The record simply lacks temporally relevant evidence of pain, prescribed medication for pain, and the impact of either on her capacity to perform sedentary work. The only evidence in the record that does relate to the pertinent time period (starting in January 2007) is wholly conclusory and fails to substantiate the plaintiff's claim. As a result, Lincoln's decision to terminate her benefits on the record before it was a reasonable one.
A. The Policy
The Policy provides that it will pay a monthly benefit to an insured who:
1. is Totally Disabled;
2. is under the regular care of a Physician; and
3. at his or her own expense, submits proof of continued Total Disability and Physician's care to the Company upon request.
(AR 018.)
The Policy defines "Total Disability" or "Totally Disabled":
1. During the Elimination Period and Own Occupation Period, it means that due to an Injury or Sickness the Insured Employee is unable to perform each of the main duties of his or her regular occupation.
2. After the Own Occupation Period, it means that due to an Injury or Sickness the Insured Employee is unable to perform each of the main duties of any Gainful Occupation.
(Id.) The "Own Occupation Period" is the "period beginning at the end of the Elimination Period and ending 24 months later. . . ." (Id. at 003.) The "Elimination Period" is "180 days of Disability due to the same or a related Sickness or Injury, which must be accumulated within a 360 day period." (Id.) In the plaintiff's case, the "Elimination Period" was from April 13, 2005 to October 10, 2005, and benefits began to accrue on October 11, 2005. The plaintiff was therefore still in the "Own Occupation Period" when benefits were terminated on January 11, 2007.
The Policy defines "Regular Occupation" and "Own Occupation" as:
[T]he occupation, trade or profession:
1. in which the Insured Employee was employed with the Employer prior to Disability; and
2. which was his or her primary source of earned income prior to Disability.
It includes any work in the same occupation for pay or profit; whether such work is with the Employer, with some other firm or on a self-employed basis. It includes the main duties of that occupation as performed in the national workforce; not as performed for a certain firm or at a certain work site.
(Id. at 008.) The plaintiff's occupation, as defined above, was "office clerk," (id. at 303), and accordingly the question facing Lincoln was whether the plaintiff could perform each of the main duties of her regular occupation as an office clerk. The amended complaint lists her responsibilities as answering telephones, bookkeeping, and "[o]ther various office responsibilities." (Am. Compl. ¶ 31.) The plaintiff's Statement of Undisputed Facts, contained in the Plaintiff's Motion for Summary Judgment, states only that "[h]er duties consisted of various office tasks." (Pl.'s Mot. for Summ. J. 1.)
B. The Administrative Record
The plaintiff argues that Lincoln's determination that she is unable to perform the sedentary duties of her occupation as an office clerk because of (1) right side chest wall pain resulting from her mastectomy, and (2) the effects of pain medication she is prescribed. These contentions are not borne out by the administrative record such that Lincoln's decision to terminate benefits could be considered arbitrary or capricious. (Nor would the evidence in the record support the plaintiff's view even under a de novo standard.)
The medical records in the administrative record are of limited help to the plaintiff because they mostly predate the period in question (from January 11, 2007 to the present) and because the conclusory nature of the more recent records limits their significance.
The record contains: (1) post-surgical care records from South Shore Hospital dated between the time of her surgery on April 14, 2005 and September 6, 2005; (2) records from the plaintiff's treatment with Dr. Gordon Juric at the South Shore Hospital Pain Clinic (the "Pain Clinic"), consisting of office visits in January 2006, April 2006, and August 2006; and (3) "Work Capacity Forms" filled out by, and a handwritten letter from, Dr. Philip Nedelman, her primary care physician.
The post-surgical hospital records are remote in time and shed no light on the plaintiff's ability to work after January 2007. In fact, some statements contained in these records would contradict her claim even if these records were of temporal relevance. For example, the notes from a May 2, 2005 visit state that "[s]he has been doing a little bit better with her pain management since her Dilaudid was increased to 4 mg every 6 hours," and that "[s]he has no difficulty driving or functioning at home." (AR at 263.)
The records relating to the plaintiff's treatment with Dr. Juric also fail to support the plaintiff's claim. An October 19, 2005, letter from Dr. Juric addressed "To Whom it May Concern" states that he had treated the plaintiff since May 2005 for right chest wall pain, that she "has had a prolonged course of pain and dysfunction likely secondary to radiation injury," and that she "still requires multiple medications to control her pain" and "is currently disabled from work because of her condition." (Id. at 251.) This letter pre-dates even the initial payment of LTD benefits by Lincoln beginning in November 2005. (See id. at 235.) Office treatment notes from January 9, 2006 state that the plaintiff "continues to complain of right-sided chest wall pain," and "has found that Dilaudid still works well for her," and "allows her to function most adequately with the least amount of side effects." (Id. at 200.) The Pain Clinic records for this date reflect that the plaintiff assessed her pain as a 3 on a scale of 0 to 10. (Id. at 199.)
The next visit to Dr. Juric was on April 10, 2006, and office notes state that the plaintiff was taking 22 mg of Dilaudid and 300 mg of Zonegran per day and "has actually come to a reasonable balance between her pain level on these medications." (Id. at 196.) At this visit, the records reflect that the plaintiff assessed her pain as a 6 on a scale of 0 to 10. (Id. at 195.)
On July 6, 2006, Dr. Juric submitted a "Work Capacity Form" which stated that the plaintiff was "[n]ot capable of full time work secondary to pain/medication side effects." (Id. at 171.) As far as is reflected in the record, the plaintiff last saw Dr. Juric on August 25, 2006. His notes from that visit state that:
She has been maintained on oral Dilaudid for the last year and a half. She has come into a balance between this and Zonegran for the relief of her pain. We see her approximately every 6 months as followup. She seems to be doing fairly well now. . . . She seems to be in a reasonable balance of her 11 Dilaudid tablets of 2 mg per day and her Zonegran 300 mg twice a day.
(Id. at 141.)
The October 2005 letter expressing Dr. Juric's opinion that she was "currently disabled from work because of her condition," (id. at 251), and the May 2006 Work Capacity Form stating that she was not capable of full time work "secondary to pain/medication side effects," (id. at 171), each substantially predate the January 2007 termination of benefits. The treatment records are similarly remote. The office notes from August 2006 are the most recent treatment notes contained in the record. They do not support a conclusion that the plaintiff was then disabled from sedentary office work. The comments that she was, in August 2006, "doing fairly well" and "in a reasonable balance" with her medications do not seem to support the proposition that she was then disabled from employment as an office clerk.
The record includes submissions by Dr. Nedelman within the relevant time period after January 2007, but they do not support the plaintiff's claim with anything more than the conclusory statement that she is totally disabled and cannot work. Dr. Nedelman submitted several Work Capacity Forms (including one dated January 24, 2007 and submitted in support of the plaintiff's first administrative appeal) that state that the plaintiff was unable to work at any occupation and is permanently disabled, but he did not submit any treatment notes, test results, or progress notes to support or substantiate his expressed conclusion. (See id. at 175, 126.) He submitted a handwritten note dated March 26, 2007 in support of the plaintiff's first administrative appeal which stated:
Plaintiff's counsel stated at oral argument, in response to a question from the bench, that no treatment notes from Dr. Nedelman were provided. Defense counsel indicated that some records from Dr. Nedelman were received by Lincoln, but were largely unreadable and do not appear to make any reference to pain or medication. (See AR 146, 151-52.) This characterization of the documents appears to be accurate, and the plaintiff has not suggested otherwise.
My patient Carol Ciarlone . . . is totally disabled and unable to work at any occupation. She has a history of breast cancer which was initially treated with radiation but later she had a mastectomy. She suffers with post surgical chest wall pain since her mastectomy in 2005. She is followed by Dr. Gordon Juric at the South Shore Hospital pain clinic. She recently had an increase in her pain medication.
(Id. at 119.) No medical records or test results were submitted with the note to support the observations. As a matter of fact, there are no apparently relevant treatment notes at all from Dr. Nedelman, and the quoted note rather suggests, consistent with the rest of the record, that it was Dr. Juric, not Dr. Nedelman, who was the physician actually treating the plaintiff for pain and prescribing her medication. As already noted, no treatment records from Dr. Juric — or anyone else — for the period beginning January 2007 were submitted to Lincoln. The only materials that the plaintiff submitted after Lincoln's termination of benefits were Dr. Nedelman's conclusory Work Capacity Form and his handwritten note, neither of which was supported by treatment records.
In sum, the record does not contain any medical evidence showing treatment for pain or prescription of medication for pain during the relevant time period beginning in January 2007. Lincoln could reasonably have refused to approve continued disability payments where the sole support offered by the plaintiff was the unsupported and summary conclusion offered by Dr. Nedelman that pain and/or the side effects from pain medication restricted and limited the plaintiff's ability to perform the duties of an office clerk.
IV. The Claims Review Process
The plaintiff lists several perceived flaws in Lincoln's claims review process which she contends rendered Lincoln's decision arbitrary and capricious. The plaintiff's underlying complaint, it seems, is that Lincoln itself did not do more to gather evidence in support of her claim. For example, she faults Lincoln for not making more attempts to obtain further information from Dr. Juric and for never specifically asking for her pain medication prescriptions. "A claimant seeking disability benefits bears the burden of providing evidence that [she] is disabled within the plan's definition." Morales-Alejandro v. Med. Card Sys., Inc., 486 F.3d 693, 701 (1st Cir. 2007). The plaintiff had the opportunity to submit more information during the claims review process, but did not.
The plaintiff also criticizes Lincoln because it did not conduct a physical examination of her during the claims process and for not taking into account, at least to the plaintiff's satisfaction, that she was granted Social Security Disability Insurance ("SSDI"). It is not necessary for a plan administrator to have its own physician examine a claimant, and a denial of benefits may instead be based on the review of the medical records submitted by the claimant. Orndorf, 404 F.3d at 526. And although the claims file noted that the plaintiff had been awarded SSDI in July 2006, (AR 71), the Social Security Administration's determination that she was entitled to SSDI is not binding on an insurer. Gannon, 360 F.3d at 215. "[I]t can be relevant to an insurer's determination whether that claimant is eligible for disability benefits," id., but the plaintiff never submitted a copy of the Social Security Administration's determination that would have explained the basis for the award. Lincoln was not required to assume the plaintiff's responsibility for fact-gathering. Moreover, like most of the evidence in the record, the basis for the award of SSDI benefits in July 2006 would not necessarily have been probative of the plaintiff's ability to work beginning in January 2007, which is the period in question.
In the end, none of the plaintiff's criticisms of the claims review process substantially undercuts the conclusion that Lincoln's decision to discontinue the plaintiff's LTD benefits in January 2007 was reasonably supported by the evidence in the administrative record and was not arbitrary or capricious.
IV. Conclusion
For the foregoing reasons, the Motion for Summary Judgment of Defendant The Lincoln National Life Insurance Company (dkt. no. 31) is GRANTED and the Plaintiff's Motion for Summary Judgment (dkt. no. 33) is DENIED. Judgment shall enter for the defendant.
It is SO ORDERED.