Opinion
Civil Action No. 3:97CV-435-S
July 26, 1999
MEMORANDUM OPINION
This matter is before the court on motion of the defendants, Providian Corporation, et al. (hereinafter collectively "Providian"), for judgment in this ERISA action brought by Wonda Maynard ("Maynard"), challenging the denial of her claim for disability benefits under a long-term disability plan.
Maynard was employed by Providian, and she subscribed to a disability plan available to Providian employees. On October 4, 1995, Maynard went on medical disability leave from her position as Senior Training and Relief Administrator. She was initially approved for and received disability benefits while on leave. She did not return to work, and subsequently applied for permanent disability benefits. Her claim for benefits was reviewed on six occasions. The plan administrator's final decision was rendered on September 29, 1997. In this action, Maynard contends that the September 29, 1997 decision of the plan administrator to deny her benefits was arbitrary and capricious.
There appears to be no dispute that the terms of Providian's Long-Term Disability Plan ("the plan ") granted discretionary authority to the plan administrator and named fiduciaries to review and determine benefit claims. The parties agree that under such a plan, the proper standard of review of a denial of benefits is the "arbitrary and capricious" standard. See, Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989); Bartling v. Fruehauf Corp., 29 F.3d 1062, 1071 (6th Cir. 1994).
In December of 1995, Dr. Lynn Simon reported to Aetna that Maynard had certain persistent neurological symptoms and joint pain. She was having speech, vision, and motor function problems and was suffering from fatigue. On December 20, 1995, she was examined at the Mayo Clinic and diagnosed with fibromyalgia syndrome. On February 5, 1996, Dr. Joseph Duffy at the Mayo Clinic reported:
Ms. Wonda Maynard was seen for rheumatology consultation on December 21, 1995. Ms. Maynard reported a history of approximately five episodes of severe musculoskeletal pain sometimes accompanied by muscle spasms . . . My diagnosis was severe fibromyalgia. The good news is that she had recovered from similar episodes previously and I thought it likely that she will again. Recommendations were as follows: 1) Amitriptyline 10 mg at bedtime with an increase of the dose at three-day intervals as necessary to achieve satisfactory sleep without morning hangover, 2) attend the fibromyalgia class, and 3)remain active, and consider a program of physical therapy at home.
It was noted by Dr. Daniel E. Maddox, also of the Mayo Clinic, that "[t]he laboratory studies were negative, as detailed on the attached laboratory sheets, respecting connective tissue disease and other inflammatory states . . . Other important studies which gave negative or normal results included x-ray films of the chest and hands."
Maynard was seen by Dr. Warren Bilkey following her visit to the Mayo Clinic. He sent reports to Aetna on January 12, January 26, and February 16, 1996 regarding her progress. He noted in each report that she was improving somewhat. On January 12th he reported that "[a]t this point Ms. Maynard is slowly improving from a recent flareup of pain . . . During the interview, no undue pain behaviors were noted. She presents a normal affect and is in no clinical distress." On January 26th, he reported that "[o]verall pain is diminished . . . There has been improvement in biomechanics with this home exercise program. There is less tenderness to palpation." On February 2nd Dr. Bilkey indicated his impression that Maynard was exhibiting Chronic Pain Syndrome. He noted
While the patient reports modest improvement in symptoms, examination findings that in my view specifically refer to the nature of her symptoms are actually worse. This means prognosis for substantial benefit from the therapy alone is quite poor. There are no distinctly treatable problems that apply to her limb symptoms . . . I am recommending Ms. Maynard be seen by the Frazier Rehab Center Pain Management Program for evaluation and for admission to their full-time program.
On February 19, 1996, Maynard had a functional capacity evaluation performed by the Rehab Clinic. This evaluation was required by Aetna to determine whether she was able to return to work. The notes indicate that Maynard did not exert maximum effort on the tests, refused to perform others, exhibited inappropriate illness behavior and symptom magnification throughout the test, and the Clinic determined that "secondary gain seems to be playing in PT's behavior," and that "[s]he does not appear to desire to function at any higher level than what was demonstrated during her FCE." On March 4, 1996, Aetna denied Maynard further disability benefits on the basis of the lack of evidence of any organic impairment and the results of the functional capacity evaluation.
Maynard appealed Aetna's decision. On June 7, 1996, Dr. Bilkey responded to questions from Aetna regarding Maynard's condition and prognosis. In the request for information, Aetna stated that "This patient has a medium job classification that requires 100% traveling." In stating that Maynard had been diagnosed with fibromyalgia and that no further treatment was anticipated, he concluded
In my opinion, there is no specific medical reason why Ms. Maynard cannot work. She is most appropriately limited at a light-duty work setting with a maximum lift at 20 pounds to be done occasionally, and the avoidance of repetitive neck and upper limb motions and the avoidance of repetitive bending and stooping. There is no specific medical contraindication to doing heavier work. It will simply make her hurt more. There also is no specific contraindication to travel, including driving, but I believe her endurance with travel will be very, very limited. In my opinion, these restriction recommendations are permanent.
On June 21, 1996, Aetna completed its review of the medical records and the letter of Dr. Bilkey, and determined to maintain the denial of benefits.
On August 9, 1996, Maynard appealed the denial of benefits, submitting another letter from Dr. Bilkey dated June 28, 1996 in which he stated
On June 7, 1996, I responded to questions from the insurer regarding Ms. Maynard's activity restriction recommendation. The insurer took one sentence from this without context and denied benefits. I want to make the following correction. In my opinion, Ms. Maynard's recommended activity restrictions preclude her from being able to work her job as training and relief administrator. In my opinion, this exceeds the recommended activity restrictions for Ms. Maynard. In my letter, I stated that there was no medical contraindication to work. By this I meant that the diagnosis of fibromyalgia generally does not preclude employment. In this specific case, the fibromyalgia diagnosis precludes Ms. Maynard from doing her job.
Aetna's medical director reviewed the file and the June 28th letter from Dr. Bilkey and determined that it was appropriate to maintain the denial of benefits. The decision was based upon "the fact that Dr. Bilkey gave very clear return to work guidelines in the 6/7/96 letter." Letter from Aetna to Providian, September 18, 1996. Aetna looked at the return to work restrictions suggested by Dr. Bilkey and reached the conclusion that she was able to return to her position as training and relief administrator. Aetna reviewed and considered Dr. Bilkey's follow-up letter, but reached a different conclusion concerning whether those limitations precluded her from performing the duties of her job. The opening paragraph of Dr. Bilkey's June 7th letter indicates that he understood and intended to be responsive to the questions posed to him:
This letter is in answer to your recent letter requesting information on Wonda Maynard. You have asked whether she is capable of returning to work, what her clinical diagnosis and associated restrictions and limitations are, and how they prevent her from working. You request a current course of treatment, including date of last office visit. You have requested a statement of prognosis for return to work, and a statement regarding driving limitations.
Aetna found that the June 7th letter was responsive, and indicated that she was able to return to her job.
By letter dated October 15, 1996, the plan administrator agreed with Aetna's termination of Maynard's disability benefits. The plan administrator indicated that his review consisted of reviewing the "complete documentation of the claim." In maintaining the denial of benefits, the plan administrator stated
In his June 28, 1996 report, Dr. Bilkey does not change these very specific and very clear guidelines on Ms. Maynard's capacity to work. He simply offers his opinion based on his knowledge of Ms. Maynard's job requirements. Aetna's determination as Claims Administrator is based on the medical provided by Dr. Bilkey and the definition of work requirements provided by Providian. Based on the work requirements for the position held by Ms. Maynard at the initial date of her absence from work and Dr. Bilkey's very specific and very clear guidelines on Ms. Maynard's capacity to work, Aetna has determined that Ms. Maynard's restrictions do not preclude her from performing her job. Based on this documentation and the terms of the Long-Term Disability Plan, I agree with Aetna's termination of Long-Term Disability benefits for Ms. Maynard.
On June 20, 1997, Maynard filed this action in Jefferson Circuit Court and the case was removed to this court. On July 22, 1996, Maynard received a Social Security disability award. In light of this award, the parties agreed to another review of the claim. The plan administrator submitted the disability claim file and the Social Security disability award to an independent reviewer, Dr. April D. Campbell at the Ann Arbor Medical Center, for review and opinion. By letter dated August 15, 1997, Dr. Campbell recited the history of Maynard's illness, noting the various doctors' findings and impressions, including the findings of Dr. Miller whose neuropsychological evaluation formed the basis for the Social Security disability award. Her conclusions include the following findings:
Based upon review of the records, I would agree that she does appear to have a diagnosis of fibromyalgia. At no time in the review of the records, was there any documentation of any organic impairment. It would appear that many of her symptoms are functional in origin. She does also appear to be depressed and is apparently being treated for depression. However, based on the job description available to me, her job as that of a relief administration and training instructor, is certainly well within her functional abilities. The job itself is classified as light duty and it is my professional opinion that the claimant could perform the substantial material acts necessary to pursue her prior job. Patients who suffer from fibromyalgia are best served by remaining active and physically fit. She apparently has been well instructed in how to perform a home exercise and stretching program, and I believe that if she is allowed to periodically perform some of these stretches and exercises during the course of her work day, that this would be very helpful to her. I therefore must conclude, from the records available to me, that there is no evidence of any permanent, either partial or total, disability and I reiterate that I do believe that she can perform the substantial material acts necessary to the pursuance of her regular job as a trainer and relief administrator.
The conclusion of the independent reviewer was consistent with the earlier decisions denying disability benefits. On September 29, 1997, the plan administrator determined that the denial of benefits should be affirmed. He indicated in his letter that he had reviewed the findings of Dr. Campbell, quoting the paragraph recited hereinabove, and that he had considered the Social Security disability award in reaching his decision. He concluded that "Ms. Maynard is able to perform the substantial and material acts necessary to pursue her own job as a trainer and relief administrator in the usual or customary way and is therefore not disabled under the terms of the Plan ."
In challenging the plan administrator's final determination of her claim, Maynard raises two grounds for her contention that the decision is arbitrary and capricious. First, she contends that the Social Security disability award and the June 28, 1996 letter of Dr. Bilkey were not adequately considered, and should have convinced the plan administrator to find Maynard disabled. Second, she urges that Dr. Campbell's decision was erroneously based upon job requirements of 40% travel and light duty, instead of 100% travel and medium duty.
Under the arbitrary and capricious standard of review which we must employ in this case, the conclusion of the Plan administrator must be upheld "[w]hen it is possible to offer a reasoned explanation, based on the evidence, for a particular outcome." Davis v. Kentucky Finance Company Retirement Plan, 887 F.2d 689, 693 (6th Cir. 1989).
The Social Security disability award was considered both by the independent reviewer and the Plan administrator. Such an award is not entitled to undue weight, and we do not find the two results to be problematic, in light of the detailed and well founded September 29, 1997 decision. As noted in Freeman v. Sickness and Accident Disability Plan of AT T Technologies, Inc., 823 F. Supp. 404, 415-16 (S.D.Miss. 1993), where the court quoted the same standard applied by the Sixth Circuit,
The Seventh Circuit had no problem with the conflicting conclusions of the plan's decision maker and the Social Security Administration with regard to the plaintiff's claim of disability, noting that this discrepancy did not suggest arbitrariness which was important for judicial review. Instead, said the Seventh Circuit, "[w]hen it is possible to offer a reasoned explanation, based on the evidence, for a particular outcome, that outcome is not arbitrary or capricious. [citation omitted] . . . In the case sub judice, the court finds that the plan administrator reached a well reasoned conclusion based upon the evidence before it at the time plaintiff's claim was being considered. That the Social Security Administration reached another conclusion, under another standard does not mean that the decision of the plan administrator here was incorrect or ill-considered under the standard which here applies.See also, Paramore v. Delta Airlines, Inc., 129 F.3d 1446, 1452, fn. 5 (11th Cir. 1997):
We find unpersuasive Paramore's assertion that the district court should have given greater weight to the Social Security Administration's determination that Paramore was totally disabled. Although a court may consider this information in reviewing a plan administrator's decision regarding eligibility for benefits under an ERISA-governed plan, see Kirwan v. Marriott Corp., 10 F.3d 784, 790 n. 32 (11th Cir. 1994), an award of benefits by the Social Security Administration is not dispositive of the issue before us, particularly given the measure of deference that we afford a plan administrator's decision.
With respect to the contention that the plan administrator and independent reviewer failed to consider the June 28th letter of Dr. Bilkey, it appears from Dr. Campbell's report and the plan administrator's final decision that the letter was indeed considered, but his conclusion regarding the ability to perform her job was rejected. What Dr. Bilkey couched in his June 28th letter as a "correction" of his June 7, 1996 statement did not encompass a change in the restrictions or limitations he had identified in his prior letter. Rather, he added to his earlier recitation, recites symptoms from which she has suffered, and further draws the conclusion that she is unable to perform her job as training and relief administrator because, in his opinion, it exceeds the recommended activity restrictions for her. Dr. Campbell found his return to work guidelines to be clear, and so concluded in her report. The plan administrator's decision is well supported by evidence in the record. We do not find his decision to be arbitrary and capricious, especially in light of the fact that Dr. Bilkey does not offer any explanation regarding specific job requirements which he concluded in his June 28th letter exceeded the restrictions recommended by him. Without such an explication for his conclusion, it was reasonable for the plan administrator to rely upon the specific (the restrictions and limitations delineated in the June 7th letter) over the general conclusion (that her job exceeded the suggested restrictions), and apply that return to work protocol to determine whether Maynard was disabled under the terms of the plan.
With respect to the work requirements for her position, it appears that Providian determined that, at the time she became ill and absent from work, her position required light duty with 40% travel, rather than medium duty with 100% travel. The review by Dr. Campbell and the final decision of the plan administrator were based upon this light/40% characterization. Maynard contends that the 100% travel designation came from a November, 1990 job posting for the position and should have been applied in the plan administrator's evaluation. The plan administrator provided to the independent reviewer, and applied himself, the light/40% characterization taken from a March 3, 1995 self-evaluation written by Maynard, in which she discusses her recent job performance. Maynard has not shown any basis for her assertion that the plan administrator acted arbitrarily and capriciously in utilizing the 7-month-old description authored by Maynard herself, rather than a 5-year-old job posting, in determining the requirements of her job. Entitlement to disability benefits is not based upon inability to perform the requirements found in a job posting, but rather an inability to return to the job one was performing. While such a job description may be persuasive evidence of the requirements of a position in some instances, in this case it was not unreasonable for the plan administrator to find a very recent self-evaluation to be more persuasive than a generic 5-year-old job posting.
Based upon the foregoing, the court concludes that the decision of the plan administrator to deny disability benefits was not arbitrary and capricious, and judgment must be entered in favor of the defendants, Providian Corporation and Aetna Life Insurance Company. A separate order will be entered this date in accordance with this opinion.