Summary
denying LTD benefits because the plaintiff did not show through the operative period that she was under the regular care of a doctor, or that she was "limited from performing the material and substantial duties of her job" as required by her policy
Summary of this case from Nagy v. Hartford Life & Accident Ins. Co.Opinion
Civil Action No. 2:03-cv-0104-WCO.
September 23, 2004
ORDER
The captioned case was removed to this court from the Superior Court of Barrow County, Georgia, pursuant to 28 U.S.C. § 1441 [1-1]. The plaintiff then filed a motion to remand [4-1], which this court denied [19-1]. The defendant has now filed a motion for summary judgment [21-1], to which the plaintiff has responded [24-1].
I. Background
The plaintiff is a former employee of Athens Regional Medical Center (ARMC). While employed by ARMC, the plaintiff was a participant in ARMC's employee benefits plan and was covered by a group insurance policy. The plaintiff was employed by ARMC as a Utilization Management Registered Nurse until September 11, 2001, her last day of work with ARMC. On January 3, 2002, the plaintiff submitted a claim to the defendant, UNUM Life Insurance Company of America (UNUM), for long-term disability benefits, reporting that she was disabled due to fibromyalgia. The alleged onset of the fibromyalgia was during December 2000 or January 2001.
A. Hospital Authority of Clarke County
In 1990, the Hospital Authority of Clarke County reorganized and established Athens Regional Health Services (ARHS), a nonprofit holding company. In 1994, the Hospital Authority established the ARMC as a nonprofit corporation. In 1995, the Hospital Authority and ARMC established a lease by which the Hospital Authority leased its assets and transferred the operations and liabilities of the hospital to ARMC, which is responsible for the daily operation of the hospital. ARMC employees are paid by ARMC on separate payrolls from the Hospital Authority. ARMC also established and maintained insurance, retirement, and pension plans for its employees; the Hospital Authority neither established nor maintained these plans.
B. Long Term Disability Plan
On January 1, 1996, UNUM issued a group insurance policy to ARHS as the group policyholder. This policy funded long-term disability benefits under the Athens Regional Health Services Disability Insurance Plan (LTD plan), which was sponsored and maintained by ARHS for eligible employees of ARHS and its subsidiaries, including ARMC.
The plaintiff alleges in her Brief in Opposition to the Defendant's Motion for Summary Judgment that ARMC is not necessarily a subsidiary of ARHS for purposes of the LTD plan. The defendant has provided evidence, however, that ARMC and ARHS share the same IRS employer identification number and that the plaintiff submitted her applications for disability benefits under the LTD plan at issue.
To receive benefits, claimants under the LTD plan must be continuously disabled throughout an elimination period of ninety days. (Summary Plan Description at 3, 10, 27, Ex. 3 to Deft.'s Mo. For Summ. J.). To provide substantial proof of a disability, beneficiaries must show: 1) that they are under the regular care of a doctor; 2) the appropriate documentation of monthly earnings; 3) the date the disability began; 4) the cause of the disability; 5) the extent of the disability, including restrictions and limitations that would prevent the beneficiaries from performing their regular occupations; and 6) the name and address of any hospital or institution where treatment was received, including all attending doctors. Id. at 5.
Under the LTD plan, UNUM will stop sending payments and the claim will end if, during the first twenty-four months of payments, a beneficiary is able to work in her regular occupation on a part-time basis but chooses not to, or after twenty-four months of payments, she is able to work in any occupation on a parttime basis but chooses not to. (Id.)
C. Plaintiff's Medical History
The plaintiff submitted an Attending Physician Statement from Dr. William MacNew, Jr. dated December 11, 2001. Dr. MacNew is a family practitioner, and he reported that he first examined the plaintiff on April 10, 2001 for her fibromyalgia and last examined her on December 10, 2001. He reported that her symptoms first appeared on December 1, 2000, and that her restrictions and limitations began on April 10, 2001. Dr. MacNew believed that the plaintiff had fibromyalgia; there were no objective laboratory findings but her subjective symptoms were fatigue, malaise, and widespread joint pain. Dr. MacNew did not specify the plaintiff's limitations and restrictions with regard to her ability to work, but the plaintiff contends that he provided sufficient information to show that she could not perform her job with ARMC or any other work. (Pla.'s Resp. to Deft.'s Statement of Material Facts ¶ 40). UNUM requested copies of the plaintiff's medical records from providers identified by the plaintiff from January 1, 2001, to the present, which are summarized below.
The plaintiff visited Dr. Stephen Lucas, an allergist, from January 4, 1999 through February 15, 2002. Dr. Frederick Breme, a psychologist, gave the plaintiff therapy for depression from January 11, 1999 through September 2, 1999. UNUM also obtained medical records from Dr. Jeffrey Thomas, a hematologist. Dr. Thomas wrote a letter on May 25, 2000, stating that he examined the plaintiff for heterozygosity for Factor V Leiden and her complaints of easy bruising in the lower extremities. The Factor V Leiden heterozygosity is characterized by a poor anticoagulant response to certain proteins and put the plaintiff at a slightly increased risk for forming blood clots in her veins. Dr. Thomas informed the plaintiff that despite this increased risk, the risk was not high enough to place her on prophylactic medicine and that she should not have problems with easy bruising. The plaintiff complained of swelling in her leg, but the ultrasound of her leg was negative. Dr. Thomas surmised the plaintiff's easy bruising may be caused by a clinical syndrome known as "auteoerythrocyte sensitization," which is a diagnosis of exclusion that is of no clinical significance for treatment.
The plaintiff also visited Dr. Medders, an orthopedist, whose August 28, 2000 record revealed that the plaintiff had complained of neck and back pain sporadically for ten years but it had gotten worse recently. Multiple x-rays were taken of the cervical and lumbar spine. These revealed degenerative disc disease, which Dr. Medders told the plaintiff was best treated conservatively through continuing on the medication she was taking at the time and by beginning an exercise regime.
Treatment records from Dr. MacNew indicate that the plaintiff saw him from December 27, 2000 through November 16, 2001. On February 18, 2001, the plaintiff complained of pain in her right elbow, and Dr. MacNew diagnosed lateral epicondylitis, more commonly known as tennis elbow.
UNUM obtained records from Dr. McCord Smith, a neurologist. Dr. Smith examined the plaintiff on January 16, 2001 for complaints of numbness and tingling in the extremities. Dr. Smith assessed her as having obesity, vision problems, mild bladder incontinence, sleep disturbance, anxiety, depression, mild hypercholesterolemia, hyperthyroidism that was under treatment, and high cholesterol. On February 23, 2001, Dr. Smith obtained a series of tests on the plaintiff, all of which were normal except for elevated cholesterol. Because the plaintiff was anxious about the possibility of multiple sclerosis, Dr. Smith obtained an MR scan of the brain which was "essentially negative." The plaintiff reported "a miraculous improvement" in the paresthesias in her extremities. Paresthesias is the abnormal skin sensations usually associated with nerve damage. She also reported to Dr. Smith that her sleep disturbance, anxiety, and depression were improving and that she was pleased with her current health status.
On March 6, 2001, the plaintiff complained of pain in her right knee in a visit to Dr. MacNew. On April 24, 2001, Dr. MacNew noted that he completed a Family and Medical Leave Act (FMLA) form for the plaintiff.
On May 29, 2001, the plaintiff returned to Dr. Smith, who noted that the burning sensation, or paresthesias, of her extremities was relieved and that she was sleeping better with less depression and anxiety and had lost eight pounds. Dr. Smith did note that the plaintiff dislocated her right knee and required a temporary brace.
On June 11, 2001, the plaintiff complained to Dr. MacNew of pain in her right arm and back. On July 16, 2001, the plaintiff complained of right arm pain. Dr. MacNew noted on that date that she exhibited symptoms of depression and that she had tennis elbow. At her August 30, 2001 visit to Dr. MacNew, the plaintiff complained of left shoulder pain. UNUM obtained records from Dr. Daniel Moye, an orthopedist, whom the plaintiff saw from August 16, 2001 through October 11, 2001. On August 16, 2001, Dr. Moye obtained an MRI of the plaintiff's right elbow after her complaints and diagnosed her with "lateral recalcitrant epicondylitis," or "tennis elbow."
On September 12, 2001, the plaintiff told Dr. MacNew that she wanted to take a leave of absence from September 12, 2001 through October 12, 2001, and that she would apply for disability benefits. On September 18, 2001, the plaintiff complained to Dr. Moye about both elbows and again on October 11, 2001, at which point Dr. Moye told the plaintiff there was not much he could do for her. The first mention of fibromyalgia in Dr. MacNew's notes is on that same date, October 11, 2001.
On November 13, 2001, the plaintiff returned to Dr. Smith. Her burning paresthesias of the extremities was improved and she was sleeping better with less anxiety and depression. He noted that she had not lost weight since her last visit in May and that she was having knee problems, for which she had seen another doctor, and he urged the plaintiff to start an exercise regime at the new local swimming pool.
UNUM obtained records from Dr. Cynthia Lawrence-Elliott, a rheumatologist, for the period of December 19, 2001 through March 18, 2002. On January 11, 2002, the plaintiff complained to Dr. Elliott of depression and of general myofascial pain, a neuro-muscular condition sometimes associated with fibromyalgia. Dr. Elliott noted that the plaintiff was able to walk without a cane or other assistance and that her musculoskeletal system was normal, although she had some pain and tenderness and swelling in her hands and knees. Dr. Elliott diagnosed the plaintiff with osteoarthritis, fibromyalgia syndrome ("FMS"), and hyperglycemia. On January 22, 2002, the plaintiff underwent an MRI of her knees, revealing osteoarthritis of the knee. On January 28, 2002, the plaintiff complained to Dr. Elliott of fibromyalgia and fatigue. Dr. Elliott noted that the plaintiff had pain and tenderness and swelling in her hands and that she had fibromyalgia and hyperglycemia.
At Dr. Elliott's request, Dr. Breme performed a psychological assessment of the plaintiff on January 25, 2002. Dr. Breme reported that the plaintiff did not present in "an obviously depressed manner" but that she was "significantly depressed." He administered the Minnesota Multiphasic Personality Inventory — 2 (MMPI-2), used to help diagnose psychiatric disorders, and noted that, with the plaintiff's pattern of scores, one would expect her to be functioning at "a lower level than normal" but would not expect a significant level of depression or anxiety. Dr. Breme noted that the plaintiff "prefers medical explanations for her problems and lacks insight into how psychological factors play a role in her symptoms." Dr. Breme interpreted the results of the Oswestry Pain Questionnaire to show that the plaintiff felt moderate pain relief from pain medication. He also noted that the plaintiff's ability and desire to work at her job is "much less than before." Dr. Breme concluded that the plaintiff was suffering from depression and required treatment. Additionally, Dr. Breme noted that the plaintiff was walking with a cane, that she could lift light to moderately heavy objects if they were conveniently positioned, and that she could not sit for more than an hour at a time or stand for more than thirty minutes because of the pain she experienced.
On March 18, 2002, the plaintiff complained to Dr. Elliott of joint pain, depression, and fatigue. The doctor noted that she had pain and tenderness and swelling in her knees and had tender points and trigger points. Dr. Elliott assessed the plaintiff with osteoarthritis in her knees, fibromyalgia, recurrent fatigue, and depression.
D. Denial of Benefits
On January 11, 2002, a UNUM representative telephoned the plaintiff to discuss her claim for disability benefits. The plaintiff's ailments included: inability to use her right arm, a need for assistance to get up and down, inability to write or carry her briefcase, and the occasional inability to dress herself without assistance. It took the plaintiff more than three hours to get up, cleaned, groomed, and dressed. She reported to the UNUM representative that her usual activities at that time included writing letters for her church and addressing envelopes by hand, looking up Bible verses, performing light housework, reading, cooking, playing the piano, and doing arts and crafts. The plaintiff had taken two leaves of absence before her date of disability, and she was limited to working only five hours a day from April 30 to July 1, 2001.
1. Initial Review
On March 28, 2002, Bradford Stuman, a registered nurse, reviewed the plaintiff's medical records and noted that her medical file did not support restrictions and limitations based on a general medical diagnosis.
On April 5, 2002, Dr. Laird Caruthers, a family practitioner, reviewed the plaintiff's medical records to determine whether they supported a work capacity impairment. Dr. Caruthers determined that the plaintiff was obese and suffered from arthritis in her knees, positive tender points, and depression. He summarized the assessments of the plaintiff's doctors and concluded:
There are no physicians in this file noting any restrictions and limitations. There is no medical documentation in this file to support a work capacity impairment especially a sedentary work capacity impairment. It might be prudent, however, to have the notes of the claimant's psychologist, Dr. Breme, reviewed by our in-house psychologist to evaluate the severity of the claimant's depression.
(Admin. File at 133).
Thereafter, Dr. Les Kertay, a psychologist, reviewed the bulk of the file, paying special attention to the psychiatric medication, the psychotherapy, and the diagnoses of the plaintiff's neurologist, Dr. Smith, and her psychologist, Dr. Breme. Dr. Kertay noted that the plaintiff was diagnosed with and treated for "a moderate Major Depressive Disorder" with rapid and good results in 1999. No information in the file shed light on the plaintiff's psychiatric condition from September 1999 to September 12, 2001, the date of disability. The next information in the file regarding the plaintiff's psychiatric condition was Dr. Breme's January 2002 assessment of the plaintiff. Dr. Kertay noted that Dr. Breme's assessment of a recurrent and severe depressive condition did not seem to be supported by the symptoms he described and that the evidence does not show that the plaintiff was severely impaired based on a psychiatric condition. (Admin. File at 141).
After these reviews, UNUM determined that the plaintiff was not entitled to benefits and so notified the plaintiff of its determination by a letter dated April 19, 2002. The letter stated in part:
While your medical records support the diagnosis and treatment for fibromyalgia, your treating physician, Dr. William MacNew, provided no restrictions and limitations to your physical activities. Medical records provide insufficient evidence to support your inability to perform the material and substantial duties of your regular occupation of Utilization Management Registered Nurse. In a telephone conversation on January 11, 2002, you reported daily activities to be at least if not greater than sedentary in nature. Based on this compiled information, we are unable to issue benefits.
(Admin. File at 149-50).
2. First Appeal
On May 7, 2002, the plaintiff appealed UNUM's decision. In support of the appeal, the plaintiff submitted a Daily Living Questionnaire that she had completed on October 30, 2001. The questionnaire noted that her regular chores included laundry, dusting, cooking or heating simple meals, loading the dishwasher, grocery shopping with or without assistance, and changing the sheets with assistance. The plaintiff also noted that she regularly attended church, wrote cards for her church, played piano, attended choir practice, and painted ceramics. She noted that she took a leave of absence from October 23, 2000 through November 3, 2000 and another from April 10 to April 29, 2001. The plaintiff stated that she did not have problems remembering things, concentrating, completing tasks, or following instructions.
UNUM received a FMLA Certificate of Physician from Dr. MacNew, dated October 11, 2001, which diagnosed the plaintiff with fibromyalgia. With regard to her impairments, Dr. MacNew stated that the plaintiff had a Class IV "moderate limitation of functional capacity; capable to clerical/administrative (sedentary) activity." He also stated that the plaintiff was totally disabled from her job as well as any other work and had been since September 11, 2001.
On May 21, 2002, the plaintiff's file was reviewed by Latisha Hailes, a registered nurse and senior clinical consultant for UNUM. Ms. Hailes determined that the information provided by the plaintiff and her doctors did not "reflect clinical data to support a loss of functional capacity to prevent continuance in her prior status from either psychiatric or gen-med condition." (Admin. File at 211). Although there were symptoms of depression, there was no record of psychotherapy or aggressive medical management, which Ms. Hailes alleges would have been in place if her psychiatric state were preventing her from functioning as usual. Furthermore, Ms. Hailes noted that the plaintiff probably suffered from osteoarthritis, but its severity did not appear to prevent her from functioning in her previous capacity with ARMC.
Dr. Thomas Pendergrass, a clinical psychologist, reviewed the plaintiff's records on May 23, 2002. Dr. Pendergrass noted that in her questionnaire, the plaintiff documented symptoms of depression but that her functional impairments were caused by pain and fatigue. He found this consistent with Dr. Breme's prior analysis that psychological factors were contributory, rather than primary, in the plaintiff's perception of her status. Dr. Pendergrass also agreed with Dr. Kertay's assessment that Dr. Breme's January 2002 evaluation of the plaintiff contained several inconsistencies. He also referred to Dr. Smith's office note of November 13, 2001, which noted that the plaintiff's sleep had improved and that her anxiety and depression were alleviated because of her medications, compared to Dr. Smith's initial January 16, 2001 evaluation. Dr. Pendergrass ultimately agreed with Dr. Kertay's findings.
Dr. Wei Kuo, a board-certified physician in occupational medicine, reviewed UNUM's file on the plaintiff on May 23, 2002. Dr. Kuo reviewed "the bulk of the legible records that seem to be specifically relevant to the primary complaints." (Admin. File at 221). Dr. Kuo agreed with Dr. Caruthers' conclusion about the plaintiff's overall medical condition, noting that the plaintiff's laboratory results were normal except for her elevated cholesterol levels. He highlighted Dr. MacNew's impairment rating of Class IV, giving her moderate limitation but finding her capable of sedentary clerical and administrative activity. Dr. Kuo examined the plaintiff's self-described daily activities, noting that most required at least a sedentary physical capacity. He wrote:
There are no objective measurements of her functional capacity such as a formal functional capacity evaluation in the documentation. Therefore, based on her self-described activities of daily living, I would expect her to perform at least in the sedentary category and some of the household chores such as laundry and loading the dishwasher could involve lifting over 10 pounds.
(Admin. File at 221). Dr. Kuo specifically found that the information provided about the plaintiff's fibromyalgia and other conditions did not support restrictions and limitations to prevent her from functioning in her previously sedentary capacity. (Id. at 220-21).
While the plaintiff maintains that she could not perform all the material requirements of her regular job and did not have the capacity to work at a sedentary level, UNUM believed that the plaintiff had the capacity to function at a sedentary level. As such, UNUM referred her claim to a vocational rehabilitation consultant to determine whether she would be limited from performing the material and substantial duties of her regular occupation. On June 14, 2002, Elaine Caye, a certified disability management specialist, performed an occupational analysis of the job of Utilization Management Nurse in accordance with the Dictionary of Occupational Titles (DOT). She reviewed Dr. Kuo's report, the plaintiff's statement, the employer's statement, and the job description submitted by the employer. She found that the job most closely resembled that of a Utilization-Review Coordinator, which the DOT classified as a sedentary job. Ms. Caye then concluded that the plaintiff's restrictions and limitations, based on the medical information in the file, were consistent with sedentary work, so the plaintiff thus would not be precluded from performing the duties of her occupation. The plaintiff maintains that Ms. Caye and the others evaluating her claim erred because they were referring to generic sedentary work, not to the plaintiff's specific job. (Pla.'s Resp. to Deft.'s Statement of Material Facts ¶ 81).
UNUM notified the plaintiff by a June 24, 2002 letter that it was upholding its initial denial of her claim. The letter referred to the applicable provisions of the LTD, the reviewing family practitioner's report, the reports by the two reviewing psychologists, the report by the occupational medicine practitioner, and the vocational consultant's review.
3. Second Appeal
The plaintiff provided further records in July 2002 to support her second appeal. These included a range of motion study from July 18, 2002, and an MRI of the plaintiff's knee dated January 25, 2002. On August 14, 2002, Dr. Caruthers reviewed the information in the file. He noted some limitation in the plaintiff's range of motion in her neck, back, shoulders, and knees, and a moderate restriction in dexterity and grip strength in her right hand. Despite further review, Dr. Caruthers did not find evidence of a sedentary work capacity impairment. (Admin. File at 441). On August 20, 2002, Dr. Pendergrass, the clinical psychologist, reviewed the additional information. Upon receiving the test data from the MMPI-2 protocol and the Oswestry Pain Questionnaire, Dr. Pendergrass provided a report, stating that there was plausible support that the plaintiff had functional limitations due to a psychiatric disorder. While Dr. Pendergrass did not make clear to what extent the disorder was affecting the plaintiff's life, the treatment the plaintiff was receiving suggested at least a "moderate" disorder. Despite this finding, UNUM upheld its prior determination denying benefits, and notified the plaintiff of this decision by letter on November 8, 2002.
II. Motions for Summary Judgment
Summary judgment shall be granted when "the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law." Fed.R.Civ.P. 56(c). Only those claims for which there is no need for a factual determination and for which there is a clear legal basis are properly disposed of through summary judgment. See Celotex Corp. v. Catrett, 477 U.S. 317 (1986).
It is well-settled that a court evaluating a summary judgment motion must view the evidence in the light most favorable to the non-movant. See, e.g., Samples v. City of Atlanta, 846 F.2d 1328, 1330 (11th Cir. 1988). To survive a motion for summary judgment, the non-moving party need only present evidence from which the trier of fact might return a verdict in his favor.Id. at 1330. Consideration of a summary judgment motion does not lessen the burden on the non-moving party; the non-moving party still bears the burden of coming forth with sufficient evidence. See Earley v. Champion Int'l Corp., 907 F.2d 1077, 1080 (11th Cir. 1990). "If the non-movant in a summary judgment action fails to adduce evidence which would be sufficient, when viewed in a light most favorable to the non-movant, to support a jury finding for the non-movant, summary judgment may be granted." Herzog v. Castle Rock Entertainment, 193 F.3d 1241, (11th Cir. 1999) (internal citation omitted).
III. Analysis
A. ERISA Preemption
ERISA supercedes state law on employee benefit plans covered by ERISA in its preemption section, 29 U.S.C. § 1144. To determine whether ERISA preempts the plaintiff's state law claims, the court must first determine whether the case involves an employee benefit plan that would be ordinarily governed by ERISA. Smith v. Jefferson Pilot Life Ins. Co., 14 F.3d 562, 567-68 (11th Cir. 1994). If it does, the court must then decide whether the plaintiff's state law claims relate to the plan in such a way that they are preempted by ERISA. Id. Generally, a state law relates to ERISA if "it has a connection with or reference to such a plan." Egelhoff v. Egelhoff, 532 U.S. 141, 147 (2001), citing Shaw v. Delta Air Lines, Inc., 463 U.S. 85, 97 (1983).
1. Government Exception to ERISA
A hospital authority, under Georgia law, is not a county, municipal corporation, or political subdivision of the state when it acts as an employer. See Richmond County Hospital Auth., 112 Ga. App. 209 (1965); see also Thomas v. Hospital Auth. of Clarke County, 264 Ga. 40, 41 (1994). Although the facts are unclear whether ARMC employees are part of the Hospital Authority, it does not make a difference to this claim. Therefore, the plaintiff's LTD program does not fall under a government exemption to ERISA.
2. State Law Claims Preempted by ERISA
An ERISA plan, by definition, involves (1) "a plan, fund, or program, (2) established or maintained" (3) by an employer, an employee organization, or both, (4) "to provide medical, surgical, hospital care, sickness, accident, disability, death, unemployment or vacation benefits . . . (5) to participants or their beneficiaries" through the purchase of insurance or otherwise.Donovan v. Dillingham, 688 F.2d 1367, 1371 (11th Cir. 1982). A party's state law claim relates to ERISA law for the purpose of preemption if the issue is "intertwined with" payment of benefits. Farlow v. Union Cent. Life Ins. Co., 874 F.2d 791, 793-94 (11th Cir. 1989); see also Garren v. John Hancock Mut. Life Ins. Co., 114 F.3d 186, 187-88 (11th Cir. 1997). State breach of contract and tort claims for denial of benefits are generally preempted by ERISA. See Garren, 114 F.3d at 187;Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 45-48 (1987);Trustees of Laborers Local Union No. 800 Health Welfare Trust Fund v. Pump House, Inc., 821 F.2d 566 (11th Cir. 1987).
B. Standard of Review under ERISA
A court reviews the denial of benefits under ERISA de novo unless the plan gives the administrator discretionary authority to determine eligibility for benefits or to construe the terms of the plan. Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). If the administrator has discretionary authority, the standard of review is "arbitrary and capricious." Brown v. Blue Cross Blue Shield, 898F2d 1556, 1562-63 (11th Cir. 1990). "A decision to deny benefits is arbitrary and capricious if no reasonable basis exists for the decision." Levinson v. Reliance Standard Life Ins. Co., 245 F.3d 1321, 1326-27 (11th Cir. 2001),citing Shannon v. Jack Eckerd Corp., 113 F.3d 208, 210 (11th Cir. 1997). Thus, a claim administrator's decision under the arbitrary and capricious standard is upheld if a reasonable basis exists for the denial of benefits based on the facts known to the administrator at the time the decision was made, even if the evidence could support a different decision. Barron v. K-Mart Corp., 938 F. Supp. 847, 851-52 (S.D. Ga. 1996), citing Jett v. Blue Cross Blue Shield, 890 F.2d 1137, 1139-40 (11th Cir. 1989), Chilton v. Savannah Foods Indus., 814 F.2d 620 (11th Cir. 1987).
When there is a conflict of interest for the administrator in reviewing the legal interpretations, the standard is "heightened" arbitrary and capricious. Carnaghi v. Phoenix Am. Life Ins. Co., 238 F. Supp. 2d 1373, 1376 (N.D. Ga. 2002) (Forrester, J.),citing Jones v. Champion Int'l Corporation, Civ. Action No. 00-CV-1186-JOF; see also Adams v. Thiokol Corp., 231 F.3d 837, 842 (11th Cir. 2000). A conflict of interest exists when an insurance company that makes the claims decisions is also the party responsible for paying the claims. Brown v. Blue Cross Blue Shield of Ala., Inc., 898 F.2d 1556, 1561-62 (11th Cir. 1990). When the standard of review is heightened arbitrary and capricious, the plan administrator must show that the interpretation of the plan was not tainted by self-interest.Id., citing Florence Nightingale Nursing Serv., Inc. v. Blue Cross/Blue Shield of Ala., 41 F.3d 1476, 1481 (11th Cir. 1995). A wrong but reasonable interpretation is considered arbitrary and capricious if it "advances the conflicting interest of the fiduciary at the expense of the affected beneficiary or beneficiaries unless the fiduciary justifies the interpretation on the ground of its benefit to the class of all participants and fiduciaries." Id., citing Brown, 898 F.2d at 1566-67.
C. Application of Standard to Facts
The Summary Plan Description gives UNUM the explicit discretionary authority to interpret the terms of the LTD plan and to determine eligibility for benefits under the LTD plan. This language triggers review under the arbitrary and capricious standard, and a heightened standard is applied here because of UNUM's conflict of interest. Daniels v. Hartford Life Acc. Ins. Co., 898 F. Supp. 909, 912 (N.D. Ga. 1995) (O'Kelley, J).
In reviewing the plan administrator's factual determinations, the court may use only those materials available to the administrator when the final decision was rendered. Carnaghi, 238 F. Supp. 2d at 1377, citing Jett v. Blue Cross Blue Shield, 890 F.2d 1137 (11th Cir. 1989). The court does not conduct a de novo review of the factual determinations in the case and is limited to reviewing it under the heightened arbitrary and capricious standard of review. Only those administrators' decisions that are objectively unreasonable or otherwise improper may be reversed. Id. at 1378.
Much of the evidence in the administrative file suggests that the plaintiff is no longer ambulatory and is in significant pain. It also indicates that the plaintiff was suffering from a moderate psychiatric disorder in early 2002. On September 12, 2001, the Date of Disability, however, the evidence suggests that the plaintiff was ambulatory and able to perform the substantial duties of her position. Upon review of the administrative record it is clear that UNUM's denial of the plaintiff's claim is based on a number of factors, including the plaintiff's own assessment of her activities that indicate she was capable of performing sedentary work at least part-time. While her treating physicians stated that she "cannot work," many of the plaintiff's self-described daily activities include at least sedentary work. Although the plaintiff claims in her questionnaires that it took her longer to complete her work, there is no indication that she was unable to work at all because of her disability.
The plaintiff has not presented evidence that for the elimination period, September 11, 2001 through December 10, 2001, she was limited from performing the material and substantial duties of her job or that she was under the regular care of a doctor. As for the plaintiff's depression, she was not under the care of a psychologist or psychiatrist during this time period, and although she was taking medication for the disease, she did not receive any psychotherapy from September 3, 1999 through January 24, 2002, and saw a psychiatrist only in January of 2002 on the recommendation of her neurologist. Because the same disease or illness must cause the plaintiff to be on leave for disability throughout the elimination period, she did not fulfill the requirements to receive benefits under the LTD plan. The denial of benefits is not arbitrary and capricious if the plaintiff fails to submit objective evidence of a disability. Daniels, 898 F. Supp. at 912; see also Donato v. Metropolitan Life Ins. Co., 19 F.3d 375, 380 (7th Cir. 1994). While medical examiners may not ignore evidence provided by the plaintiff from her treating physicians, they are permitted to determine that the medical evidence provided is insufficient. See Carnaghi, 238 F. Supp. 2d at 1378.
The plaintiff contends that her claim was denied because the defendant erroneously based its decisions on a generic "sedentary" occupation rather than the plaintiff's specific job. The plaintiff maintains that the LTD plan requires UNUM to refer to the specific qualifications of her job, but the language of the plan does not specify this. The LTD plan gives UNUM the ability to determine whether a participant is disabled, giving benefits to those limited from performing the material and substantial duties of one's regular occupation due to sickness and injury. For benefits after twenty-four months, a participant can receive benefits only if she cannot perform the duties of any gainful occupation for which she is reasonably qualified by education, training, or experience. (Summary Plan Description at 10, Ex. 3 to Deft.'s Mo. for Summ. J.). "Material and substantial duties" are defined as duties that "are normally required for performance of your regular occupation; and cannot be reasonably omitted or modified." Id. at 28. "Regular occupation" means the occupation the beneficiary was routinely performing at the onset of the disability. Id. at 29.
Although the defendant's decision was in favor of the fiduciary, there is no indication that it was arbitrary and capricious. The defendant has an interest in not paying inappropriate claims. The denial of benefits can be reasonable if "the fiduciary justifies the interpretation on the ground of its benefit to the class of all participants and beneficiaries."Brown, 898 F.2d at 1567. The defendant argues that UNUM evaluates claims under employee benefits plans "fairly, without regard to the manner in which the plan is funded." (Aff. of Kari Luedtke). It tries to pay claims "consistently and in accordance with the applicable benefit provisions, so that those claims which are payable under the plan are paid, and those which are not payable are not paid." (Id.) The defendant argues that paying claims that are not legitimately covered does not benefit the participants of the plan as a group, because this type of payment could result in increased premiums or reduced benefits to the detriment of all participants and beneficiaries. (Id.).
IV. Conclusion
Because the court finds that the defendant reasonably concluded that there was insufficient evidence that the plaintiff was disabled as of September 12, 2001 throughout the ninety-day elimination period, the defendant's motion for summary judgment is hereby GRANTED [21-1].
IT IS SO ORDERED.