Summary
In Knapp we found no support for the plaintiff's argument that the document review process used by Prudential in making its benefit determination was arbitrary and capricious.
Summary of this case from Scott v. Prudential Insurance Company of AmericaOpinion
File No. 4:02-CV-130
April 4, 2003
OPINION
Plaintiff Alice Knapp challenges Defendant Prudential Insurance Company's administrative decision denying her application for long-term disability benefits. This matter is before the Court on cross-motions for decision on the administrative record. For the reasons that follow, the administrative decision will be affirmed.
I.
Plaintiff worked until April 19, 2000, as a production control clerk for Uniroyal Technology Corporation ("Uniroyal"). Uniroyal has a Long Term Disability Coverage Plan ("the Plan") for all salaried employees. (AR at 1). The Plan is insured and administered by Defendant Prudential Insurance Company ("Prudential").
Citations to the Administrative Record will be designated as "AR at ___."
Plaintiff, who was born in 1946, went on sick leave beginning April 20, 2000, complaining of chronic pain. She collected short term disability benefits for approximately 3 months, then applied for long-term disability benefits under the Plan in November 2000. She stated in her application that she was first treated for her condition in March 1999, and had been hospitalized for her condition in April 2000. (AR at 207). She listed a disability onset date of April 20, 2000. Plaintiff's Attending Physician's Statement, filled out by Dr. Zaman, described her illness as fibromyalgia syndrome, osteoporosis, transient ischemic attack ("TIA"), small vessel cerebrovascular disease, and coronary artery disease. (AR at 402-03). According to Dr. Zaman, Plaintiff was unable to perform any work duties. (AR at 403).
Prudential denied Plaintiffs application for long-term disability benefits on March 26, 2001, based on its determination that the medical evidence did not establish any impairment that prevented Plaintiff from performing the substantial duties of her occupation. (AR at 154-56). According to Prudential, all objective tests relating to TIA and small vessel cerebrovascular disease were "essentially normal," and the neurologist gave only a "questionable" diagnosis as to this condition; there was no objective medical evidence to support a cognitive impairment or a coronary impairment; Plaintiff did not demonstrate the 11 out of 18 tender points needed for a diagnosis of fibromyalgia; and there was no evidence that Plaintiffs osteoporosis had worsened. (AR at 155). Plaintiff appealed the denial. Prudential upheld its decision by letter dated April 27, 2001. (AR at 133-35).
On October 19, 2001, Plaintiff requested a second appeal of the denial and submitted additional medical information from Dr. Zaman and Dr. Sirisuth, a rheumatologist. Prudential forwarded Plaintiffs file to David L. Kneapler, M.D., for review. Dr. Kneapler determined that Dr. Zaman's assessment of Plaintiffs long-term disability was not supported by Dr. Zaman's records. Dr. Kneapler also noted that the physical findings did not support fibromyalgia because there were only 4 tender points, not many, as required under the medical description of the disease. Dr. Kneapler advised that he was unable to verify Plaintiff's multiple subjective complaints by any objective findings. He was unable to find a physical basis for her complaints, and suspected that the physical complaints could well be attributed to her chronic emotional problems. (AR 454-58). Based upon Dr. Kneapler's report, Prudential upheld its denial of Plaintiff's claim for benefits by letter dated December 18, 2001. (AR at 106-08).
On January 25, 2002, Plaintiff was granted Social Security Disability benefits. The Social Security administrative law judge determined that she suffered from chronic myofascial pain syndrome, dextroscoliosis, chronic obstructive pulmonary disease ("COPD"), hypertension and cognitive disorder. (AR 176-80).
Plaintiff appealed Prudential's denial of long-term benefits to the Appeals Committee on February 6, 2002, relying in large part on the intervening award of Social Security Disability benefits. On June 6, 2002, after reviewing the medical evidence submitted to the Social Security Administration, Prudential upheld its decision to disallow long-term disability benefits. Prudential advised that there was still no medical evidence of a physical or mental impairment which would have prevented Ms. Knapp from performing the duties of her sedentary occupation. (AR at 89-91). Plaintiff subsequently filed this action.
II.
The Uniroyal Long Term Disability Coverage Plan is an employee welfare benefit plan that is governed by the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001-1461. In an action challenging the denial of ERISA benefits under 29 U.S.C. § 1132 (a)(1)(B), a plan administrator's decision is reviewed "under a de novo standard unless the benefit plan gives the administrator or fiduciary 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 plan contains a clear grant of discretion to the administrator to determine benefits or interpret the plan, the plan administrator's decision to deny benefits is reviewed under the highly deferential arbitrary and capricious standard of review. Shelby County Health Care Corp. v. Southern Council of Indus. Workers Health and Welfare Trust Fund, 203 F.3d 926, 933 (6th Cir. 2000). Where the plan provides that determination of total disability will be "on the basis of medical evidence satisfactory to the [administrator]," the decision is entitled to review under the arbitrary and capricious standard. Miller v. Metropolitan Life Ins. Co., 925 F.2d 979, 983-84 (6th Cir. 1991). The arbitrary and capricious standard is the least demanding form of judicial review of administrative action. Williams v. International Paper Co., 227 F.3d 706, 712 (6th a particular outcome, that outcome is not arbitrary or capricious. Killian v. Healthsource Provident Administrators, Inc., 152 F.3d 514, 520 (6th Cir. 1998) (quoting Perry v. United Food Commercial Workers Dist. Unions, 405 442, 64 F.3d 238, 242 (6th Cir. 1995)).
The Uniroyal Plan provides that a participant is disabled "when Prudential determines that: • you are unable to perform the material and substantial duties of your regular occupation due to your sickness or injury." (AR at 41) (emphasis in original).
Plaintiff does not dispute that this language gives sufficient discretionary authority to Prudential to trigger application of the arbitrary and capricious standard of review. Plaintiff argues, however, that a heightened standard of review is required because of Prudential's conflict of interest.
Where, as here, the same entity both funds and administers a plan, it has an actual conflict of interest because it incurs a direct expense as a result of the allowance of benefits and benefits directly from the denial or discontinuation of benefits. Killian v. Healthsource Provident Administrators, 152 F.3d 514, 521 (6th Cir. 1998). A conflict of interest does not alter the standard of review, id., but a reviewing court is required to take the conflict into account as a factor in determining whether the decision was motivated by self-interest or was otherwise arbitrary and capricious. Peruzzi v. Summa Medical Plan, 137 F.3d 431, 433 (6th Cir. 1998). See also Darland v. Fortis Benefits Ins. Co., 317 F.3d 516. 527 (6th Cir. 2003). ("Notwithstanding this deferential standard of review, courts must be aware of a possible conflict of interest and consider it as a factor in determining whether the decision to deny benefits was arbitrary and capricious.").
III.
To be eligible for long-term disability benefits under the Plan, the disability must begin while the individual is covered under the Plan and the participant must be continuously disabled through a 90-day elimination period. (AR at 41-42).
Plaintiff contends that Prudential acted arbitrarily and capriciously in denying Plaintiff's claim for long-term disability benefits because it merely conducted a document review of Plaintiffs claim, because it improperly discounted the disability diagnosis of Plaintiff's treating physician, and because it ignored the Social Security Administration's disability determination.
Plaintiff contends that because Prudential had a conflict of interest it was required to do more than rely on Dr. Kneapler's examination of the medical records on file before denying Plaintiffs application for long-term disability benefits. Plaintiff contends that Prudential should have taken further steps in its review process such as interviewing Plaintiff about her medical conditions, having a vocational expert determine whether Plaintiff had transferable skills, asking Plaintiffs physicians whether there was any objective evidence to support their conclusions, and sending Plaintiff to specialists for an independent medical examination.
The Plan language does not support Plaintiffs argument that Prudential's review procedure was insufficient. The Plan clearly provides that it is the claimant's burden to provide evidence of disability to Prudential. (AR at 52). As stated in the Plan: "Your proof of claim, provided at your expense, must show: . . . (4) Appropriate documentation of the disabling disorder." (AR at 52). Although the Plan also provides that Prudential "may require you to be examined by doctors, other medical practitioners or vocational experts of our choice" at Prudential's expense, (AR at 41), this language gives Prudential the right, but not the obligation to conduct its own medical examination.
Neither does Plaintiff cite any case law in support of her assertion that the review procedure used in this case was arbitrary and capricious. In fact, Plaintiff candidly admits that independent examinations of claimants are not required. (Pl.'s Supp. Br. at 11). Courts routinely affirm administrative decisions in ERISA cases that are made solely on the basis of document review. See, e.g., Kocsis v. Standard Ins. Co., 142 F. Supp.2d 241, 254-55 (D. Conn. 2001) ("Because the Plan does not require an independent examination, it is not per se unreasonable for Standard to deny the plaintiff benefits without requesting an independent medical examination, in light of Standard's file review by two independent medical examiners."); Robinson v. Phoenix Home Life Mut. Ins. Co., 7 F. Supp.2d 623, 632 (D. Md. 1998) (holding insurer's claim review not defective for failure to order independent medical examination ("IME") because IME in 1996 would have been only marginally relevant to plaintiffs medical condition in 1994). This Court finds no support for Plaintiffs argument that the process used by Prudential in making its benefit determination was arbitrary and capricious.
Plaintiff also contends that Prudential acted arbitrarily and capriciously by disregarding overwhelming evidence of her disability, and in particular the diagnosis offered by Dr. Zaman, her treating physician.
The treating physician rule is a standard that was developed in the Social Security context requiring the administrative law judge to give deference to the opinions of a claimant's treating physician when determining the claimant's eligibility for benefits. Darland v. Fortis Benefits Ins. Co., 317 F.3d 516, 531 (6th Cir. 2003). The Sixth Circuit has recently held that the "treating physician" rule applies in ERISA cases and requires courts to defer to the opinions of a claimant's treating physicians unless there is substantial evidence contradicting them. Id. at 532. The Sixth Circuit acknowledged that the treating physician's opinion does not "trump" all other evidence, but held that the treating physician's opinion is entitled to deference particularly when, as in Darland, there is an absence of substantial evidence to the contrary. Id. at 533.
Dr. Zaman's primary basis for finding Plaintiff disabled was his assertion that she has fibromyalgia. Dr. Sirisuth, the rheumatologist who examined Plaintiff on May 10, 2000, at Dr. Zaman's request, noted that Plaintiff had tender points palpable over the base of her occiput bilaterally, and also over both sacroiliac notches areas and might have chronic pain syndrome compatible with regional myofascial pain syndrome. (AR at 321). He noted that he discussed fibromyalgia with Plaintiff. (AR at 321).
Prudential found that although Plaintiff had demonstrated a few tender points, her rheumatologist did not identify the 11 out of 18 points that were needed for a diagnosis of fibromyalgia, and he did not make a definitive finding of fibromyalgia. (AR at 155).
On May 31, 2001, Dr. Sirisuth saw Plaintiff for a reevaluation and to see whether she had chronic fibromyalgia syndrome. (AR at 314). Dr. Sirisuth advised that Plaintiff had multiple tender points, including the base of occiput, upper and mid-trapezius bilaterally, and over both sacroiliac notches. (AR at 315).
My impression is that this patient has chronic pain syndrome. A classic definition of fibromyalgia is chronic widespread pain in four quadrants of the body with at least eight reproducible tender points. However, some patients do not have "classic findings," and they just have chronic widespread pain associated with fatigue and unrestful sleep. In this patient I also believe that her problem is compounded by her thoracic kyphoscohosis and depression.
(AR at 315).
Plaintiff also provided Prudential a copy of Dr. Sirisuth's August 13, 2001, letter advising that Plaintiff has fibromyalgia syndrome based on chronic widespread pain, fatigue, sleep disturbances, and multiple tender points. (AR at 313). Plaintiff contends she also supplied Prudential with a copy of a diagram attached to that letter which, according to Plaintiff, shows 11 tender points. Because the letter does not reference any attachments, it is questionable whether the diagram was submitted to Prudential. More significantly, the Court has reviewed Plaintiff's Exhibit 1, and finds that the drawing shows no more than 8 tender points.
Dr. Kneapler, who reviewed Plaintiff's file for Prudential, determined that the medical records failed to confirm fibromyalgia because the May 10, 2000, exam showed at most only 4 tender points. (AR at 455). Because Plaintiffs condition was to be evaluated as of the date she left work, it appears that Dr. Kneapler's reliance on the May 10, 2000, exam rather than the later assessments of her tender points is not arbitrary or capricious.
Moreover, even if Prudential should have considered Dr. Sirisuth's May 31, 2001, letter as a clarification of Plaintiffs condition in May 2000 rather than as evidence of new symptoms, and even if Prudential should have accepted a diagnosis of fibromyalgia, that diagnosis would not require Prudential to accept Dr. Zaman's determination that the fibromyalgia rendered Plaintiff totally disabled from her employment.
On November 20, 2000, Dr. Zaman stated in his Attending Physician's Statement that Plaintiff was unable to perform any work duties because of her fibromyalgia. (AR at 402). He stated that she had impaired thought process and severe pain with restricted movement to hands, legs and feet (joints). (AR at 402-03). On March 27, 2001, Dr. Zaman filled out a Medical Assessment of Ability to do Work Related Activities listing Plaintiffs deficits that have been in effect since April 1, 2000. (AR 384-87). He indicated on that form that Plaintiff had difficulty with simple grasping. (AR at 386). His only supportive medical finding is "fibromyalgia."
Dr. Sirisuth's findings do not support Dr. Zaman's statement that Plaintiffs fibromyalgia prevented her from performing any work duties. In fact, Dr. Sirisuth advised Dr. Zaman that he discussed chronic fibromyalgia with Plaintiff and advised her that is it not crippling, that she would benefit from regular low impact aerobic exercise, and that she should start walking 20-30 minutes at least five days a week. (AR at 321).
The physical examinations also fail to support Dr. Zaman's findings regarding Plaintiff's problems with strength and grasping. On August 4, 1999, Dr. Ward noted that Plaintiff's strength, tone and reflexes were normal, and her fine and gross motor movements were normal. (AR at 346). On April 29, 2000, Dr. Ward stated that Plaintiff denied any numbness, weakness, tingling or coordination problems. (AR at 326). On May 10, 2000, Dr. Sirisuth found that Plaintiff had a normal range of motion in all joints and that her muscle strength was grade 5/5 in all four extremities including both grips. (AR at 321). On January 12, 2001, Dr. Kountanis, a neurologist with the State Disability Determination Service, confirmed that Plaintiff had no atrophy or weakness to manual muscle testing, no spasm, her fine and gross motor coordination was intact, and her deep tendon reflexes were equal and symmetric in her upper and lower limbs. (AR at 307). On June 5, 2001, Dr. Sirisuth again found that Plaintiff had a normal range of motion in all joints and her grip strength was within normal limits. (AR at 315).
Dr. Zaman's Attending Physician's Statement states that Plaintiff suffers from TIA, small vessel cerebrovascular disease, and coronary artery disease, (AR at 402-03). Dr. Zaman's October 4, 2001, letter also advises that Plaintiff "has a history of stroke problems and stroke damage which has been shown by old MRI's, she has small vessel cerebrovascular disease, coronary artery disease by history." (AR at 382). These assertions also lack firm medical support. In June 1999, Plaintiff was admitted to the hospital on June 6, 1999 with chest pain. Dr. Zaman indicated that tests ruled out a myocardial infarction, but he thought she may have had a stroke and referred her to Dr. Ward, a neurologist. (AR at 443). Dr. Ward originally diagnosed TIA and small vessel cerebrovascular disease on July 21, 1999. (AR at 363 365). Plaintiff was hospitalized in March 2000 for chest pain and hypertension. Her EKGs and cardiac enzymes were normal. (AR at 417). In April 2000, Plaintiff saw Dr. Ward, complaining of chronic right ear pain, numbness in her left arm, stiffness in her neck, headache pain, and disorientation. Testing revealed no abnormality of the ear. Dr. Ward noted that her mental status, cranial nerves, motor examination, reflexes, sensory examination, gait testing, cerebellar examination, and HEENT were all normal. (AR at 333). He also noted that Plaintiff had had a normal carotid ultrasound, a normal holter monitor and a normal transthoracic echocardiogram. (AR at 333). He observed that a new MRI of the brain and an intracranial MRA were also found to be essentially normal. Based upon these tests and Plaintiffs report that she had had no further signs or symptoms of stroke, he changed his prior diagnoses of TIAs and small vessel cerebrovascular disease to questionable diagnoses. (AR 327 333).
Prudential did not discount evidence that Plaintiff has scohosis and osteoporosis. On August 4, 1999, Dr. Ward indicated that the bone densitometry test showed that Plaintiff had distinct evidence of osteoporosis. (AR at 349). The Cedarwood Osteoporosis Center recommended treatment with calcium, vitamin D, weight bearing exercises and healthy lifestyle. (AR at 350). Dr. Kountanis determined on January 15, 2001, that Plaintiff has a moderate scohosis that contributes to her low back pain. (AR at 307). Dr. Sirisuth also noted on June 5, 2001, that Plaintiff had kyphoscohosis of thoracic spine with convexity to the right. (AR at 315). He also noted, however, that forward flexion of lumbar spine was within normal limits and straight leg raising test was negative bilaterally. (AR at 315). Nothing in the medical file, other than Dr. Zaman's unsupported conclusions, suggests that either the scohosis or the osteoporosis were disabling.
In a letter dated October 4, 2001, Dr. Zaman indicated that he had informed Plaintiff that "she is totally disabled because of her blood pressure not able to keep level because of the fibromyalgia." (AR at 382). In fact, none of the specialists indicated a correlation between Plaintiffs high blood pressure and her fibromyalgia. Dr. Sirisuth noted that Plaintiff's blood pressure was elevated on May 10, 2000, but he noted further that she had not been taking her blood pressure medication regularly. (AR at 320). Dr. Ward similarly indicated on June 29, 1999, that Plaintiff had been hypertensive but stopped her blood pressure medication on her own the week before. (AR at 370).
Dr. Zaman's diagnosis of disability was based in part on his assertion that Plaintiffs thought process was impaired. (AR at 402-03). He also reported in his October 4, 2001, letter that Plaintiff "has a loss of strength and is unable to deal with daily functions because of the pain, loss of strength and thought process." (AR at 382). On January 12, 2001, Dr. Kountanis noted that Plaintiff had a "not quite normal" affect that may reflect potential psychiatric disease compatible with anxiety or panic attacks. (AR at 307). Dr. Sirisuth described her as depressed in June 2001. (AR at 314-15). There is nothing in the medical records, however, to establish extent of Plaintiffs psychological problems or to show that they preclude her from working.
In Yeager v. Reliance Standard Life Ins. Co., 88 F.3d 376 (6th Cir. 1996), the disabling condition on which the plaintiff based her claim for disability benefits was fibromyalgia, but no doctor ever actually definitively diagnosed plaintiff as having this condition. Id. at 381-82. Although no doctor doubted the veracity of the plaintiffs subjective complaints of fatigue and joint pain, the Sixth Circuit held that in the absence of any definite anatomic explanation of plaintiffs symptoms, it could not find that the administrator's decision to deny benefits was arbitrary and capricious. Id. See also Michele v. N.C.R. Corp., No. 94-3518, 54 F.3d 776 (Table), 1995 WL 296331 (6th Cir. May 15, 1995) (unpublished) ("It is not arbitrary or capricious to deny a difficult-to-prove claim that has not objectively been shown to exist. . . . A physician's statement that a patient feels he is disabled is not enough, nor is a physician's conclusion, without supporting objective medical evidence, that a patient probably has CFS.").
Upon review of the file this Court finds that Prudential did not act unreasonably in discrediting Dr. Zaman's diagnosis. Dr. Zaman is the only doctor who opined that Plaintiff was totally disabled. Dr. Zaman's diagnoses, however, are based on little more than Plaintiff's subjective complaints. They are not supported by physical tests and they overstate the findings of Plaintiffs other treating physicians, the specialists who examined and tested her. In fact, in many instances Dr. Zaman's opinions are directly contrary to the findings of the treating specialists. Prudential accordingly had a substantial basis for not crediting Dr. Zaman's conclusions.
Finally, Plaintiff argues that although the Social Security Administration's award of disability benefits is not binding on Prudential, Prudential's failure to follow it demonstrates the arbitrariness of Prudential's final decision. Plaintiff notes that unlike Block v. Pitney Bowes, Inc., 952 F.2d 1450 (D.C. Cir. 1992), cited by Defendant, this is nota case where the Social Security award rested on medical reports never submitted to the Plan. Plaintiffs entire Social Security file was produced to the Plan, yet the Plan arrived at a decision contrary to that of the Social Security Administration.
It is not clear from a review of the Social Security decision what medical records were available to the administrative law judge ("ALJ"). The ALJ made one reference to Dr. Zaman and an oblique reference to Plaintiffs consultation with Dr. Kountanis. (AR at 176-80). However, based upon his references to Plaintiff's uncontrolled hypertension, TIA, and small vessel cerebrovascular disease, it appears to this Court that Dr. Ward's medical records either were not submitted to the ALJ or were not considered by him. Because the ALJ did not consider the underlying medical tests that discounted Dr. Zaman's opinions, Prudential was not unreasonable in declining to adopt the findings of the Social Security Administration.
Based upon the evidence presented, Prudential could reasonably conclude that Plaintiff was able to return to her employment. Factoring in Prudential's role as both administrator of the Plan and payor under the Plan, this Court is satisfied that Prudential's denial of long-term disability benefits to Plaintiff was neither arbitrary nor capricious. There is nothing in the record to suggest that Prudential put its own financial interest above its fiduciary duty to Plaintiff. The administrative record contains sufficient evidence upon which a reasonable mind could base a rational decision that Plaintiff was not disabled. Accordingly, Prudential's denial of long-term disability benefits will be affirmed.
An order and judgment consistent with this opinion will be entered.