Opinion
No. 1:02-cv-102
August 11, 2003
MEMORANDUM
Plaintiff Frankie Moore ("Moore") brings this action for disability benefits against the defendant, The Canada Life Assurance Co. ("Canada Life"), pursuant to the Employee Retirement Income Security Act, 29 U.S.C. § 1001-1461 ("ERISA"). Specifically, the plaintiff challenges the denial of benefits under 29 U.S.C. § 1132(a)(1)(B). This matter is presently before the Court on the defendant's motion for judgment on the administrative record [Court File No. 15]. The plaintiff opposes this motion and also moves for judgment on the administrative record [Court File No. 17]. For reasons expressed below, both motions [Court File Nos. 15 and 17] will be DENIED and the case will be REMANDED to the plan administrator.
I. BACKGROUND
Following the suggested guidelines established in Wilkins v. Baptist Healthcare Systems, Inc., 150 F.3d 609 (6th Cir. 1998), the Court will consider the administrative record in resolving the parties' dispute. The record establishes the following relevant facts. Additional facts will be discussed in the analysis where appropriate.
Moore was a Murata Technician at R.L. Stowe Mills, Inc., and was insured under her employer's Group Life and Health Plan ("Plan"). Canada Life is apparently both the insurer and plan administrator. On February 16, 2001, Moore was involved in an automobile accident after which she suffered vertigo and neck and shoulder pain. Moore filed a claim for short term income replacement under the Plan on March 1, 2001, due to a "disability." The Plan provides a definition of disability:
Although not argued by the plaintiff, this Court recognizes that a conflict of interest exists where an insurer not only determines eligibility for benefits, but also pays those benefits. Killian v. Healthsource Provident Adm'rs, 152 F.3d 514, 521 (6th Cir. 1998) (citations omitted). While still applying the arbitrary and capricious standard of review, the Court weighs the conflict of interest as a "factor in determining whether there is an abuse of discretion." Id.
"Disabled" and "disability" mean the person is not able to perform with reasonable continuity the substantial and material duties of his own occupation in the usual or customary way due to injury, disease, illness, pregnancy or mental disorder.
On March 6, 2001, Moore submitted to Canada Life its standard claim form and attending physician's statement. Moore's physician, Dr. Kent Grotefendt, indicated a primary diagnosis of cervical strain and right shoulder pain and that Moore was "unable to use r[ight] arm/shoulder/neck." (A.R. 00044-00045). On March 20, 2001, on a form entitled "Continuance of Short Term Disability Claim Attending Physician's Statement," Dr. Grotefendt again diagnosed cervical strain and shoulder pain as well as vertigo or severe dizziness. The doctor remarked, "Patient improving but still [indecipherable] severe vertigo limiting function, difficulty working, etc." (A.R. 00046-00047).
Canada Life requested additional medical information, and on May 17, 2001, Canada Life denied Moore's claim on the grounds that "there was no objective medical evidence that supports [Moore's] inability to work." (A.R. 00053). One of the documents reviewed, however, was a March 6, 2001 CT Scan of the Cervical Spine, on which the technologist opined: "C4-5 and C5-6 Cervical Spondylolysis. This may be sources of neck pain." (A.R. 00121). Canada Life characterized this CT Scan as "normal." (A.R. 00053).
Spondylolysis is defined as a "dissolution of a vertebra." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1684 (29th ed. 2000).
Moore appealed the denial of benefits. In a letter dated July 20, 2001, the earlier decision to deny benefits was upheld because, upon the Medical Review Board's reassessment of Moore's claim, Canada Life again determined that "the medical evidence fail[ed] to support [Moore's] inability to perform the duties of [her] job." (A.R. 00059). The record shows that the Medical Review Board was comprised of John P. Shallcross, Psy.D., an employee of Canada Life, and Mitchell S. Nudelman, M.D., J.D., F.C.L.M., Chief Medical Officer at Disability Solutions Plus, Inc. (A.R. 00138-00140). Both doctors issued medical opinions based on Moore's medical records. On June 12, 2001, Shallcross opined that the documentation did not support a determination that Moore had a mental health condition that would preclude all work capacity. (A.R. 00138-00139). On July 20, 2001, Nudelman concluded there was insufficient objective medical evidence "that would be consistent or proportional to the subjective complaints of the claimant." (A.R. 00140). Nudelman did not name specifically the medical records he reviewed.
The Court gleaned this information from the record; however, the Medical Review Board may consist of more members. "Disability Solutions Plus, Inc." is on the letterhead of Nudelman's opinion letter to Canada Life. The record does not explain the relationship between this entity and Canada Life.
Some time after the appeal, Moore apparently communicated with Canada Life about the status of her claim. By letter dated October 5, 2001, Canada Life reiterated its denial of Moore's claim because "there is no medical evidence which supports disability benefits. . . ." (A.R. 00064). The letter also stated that "the only documentation we have received [since the May 17, 2001 denial of benefits] was a copy of an MRI test result, a CT scan of the brain, a CT scan of your neck, and office notes dated 6/21 and 26." (A.R. 00064). However, the record appears to contain additional medical records.
Moore then filed suit in the Circuit Court for Hamilton County, Tennessee. Canada Life properly removed the suit to this Court. The Court later dismissed Moore's state law claims due to ERISA preemption.
II. ANALYSIS
A. Standard of Review
Courts generally review a denial of benefits, challenged pursuant to § 1132(a)(1)(B), under a de novo standard. Firestone Tire Rubber Co. v. Brunch, 489 U.S. 101, 115 (1989). However, where an employee benefit plan gives the plan administrator the discretionary authority to determine eligibility for benefits or to construe the terms of the plan, the Court applies "the highly deferential arbitrary and capricious standard of review." Yeager v. Reliance Standard Life Ins. Co., 88 F.3d 376, 380 (6th Cir. 1996).
The parties dispute the appropriate standard of review. Canada Life argues that the plan language grants it, as the plan administrator, the discretionary authority to determine eligibility and benefits under the plan. Moore asserts that the plan language is ambiguous. The Court concludes that the plan language grants discretionary authority to Canada Life.
In general, a plan administrator has the discretionary authority to construe plan language and to make benefit determinations where the plan requires the claimant to submit "proof" of disability. See Perez v. Aetna Life Ins. Co., 150 F.3d 550, 556 (6th Cir. 1998). The plan at issue in Perez provided: "Written proof of total disability must be furnished. . . . [The plan administrator] shall have the right to require as part of the proof of claim satisfactory evidence. . . ." Perez, 150 F.3d at 555. The Perez court found this language to be a grant of discretionary authority to the plan administrator and reasoned that "under the only reasonable interpretation of the [plan] language, [the plan administrator] retains the authority to determine whether the submitted proof of disability is satisfactory." Id. at 557.
In the instant case, the plan provides in relevant part: "When we receive satisfactory proof of claim, benefits payable under this policy . . . will be paid as they are incurred." (A.R. 00019). The plan further states: "Indemnities . . . will be paid as they accrue upon receipt of due written proof of such loss." (A.R. 00039).
This language is sufficiently similar to the plan language in Perez for the Court to conclude that Canada Life has retained the authority to determine eligibility under the plan. Accordingly, the Court will apply the arbitrary and capricious standard of review.
The decisions of a plan administrator "are not arbitrary and capricious if they are rational in light of the plan's provisions." See Yeager, 88 F.3d at 381 (citations and quotations omitted). The decision of the plan administrator must be upheld "if it is the result of a deliberate, principled reasoning process and if it is supported by substantial evidence." Baker v. United Mine Workers Health Ret. Funds, 929 F.2d 1140, 1144 (6th Cir. 1991).
B. Denial of Benefits
Canada Life denied Moore short term disability benefits because the disability she claimed was not based on objective medical proof. Moore "concedes that, absent the findings of the June 29, 2001 MRI, there was probably insufficient objective evidence of disability." [Court File No. 17, at 2]. Yet Moore argues that "the MRI's results indicated a serious, disabling condition which was clearly compatible with Mrs. Moore's symptoms." Id. The diagnosis noted on the MRI results shows that Moore suffered from "Cerebellar Tonsillar Ectopia bordering on Chiari I Malformation." (A.R. 00119-00120). Chiari's malformation is defined as "a congenital anomaly in which the cerebellum and medulla oblongata, which is elongated and flattened, protrude into the spinal canal through the foramen magnum." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1050 (29th ed. 2000). Chiari's malformation is classified into three types based on severity with Type I being the least severe. See id. Moore draws the Court's attention to a website describing the causes, symptoms, and treatment of Chiari's malformation; however, the Court cannot consider evidence outside the administrative record. See Wilkins, 150 F.3d at 619; Yeager, 88 F.3d at 381.
The cerebellum is the part of the brain that is located behind the brain stem and is concerned in the coordination of movements. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 324 (29th ed. 2000).
The medulla oblongata is the truncated cone of nerve tissue between the pons and the spinal cord that contains important collections of nerve cells that deal with vital functions, such as respiration, circulation, and special senses. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1072 (29th ed. 2000).
The foramen magnum is a large opening in the bone that connects the vertebral canal and the cranial cavity. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 697 (29th ed. 2000).
Moore claims that Chiari I Malformation is a "disability per se;" however, she does not cite to any authority supporting the existence of a "disability per se" under ERISA denial of benefits jurisprudence, nor is the Court aware of support for that proposition.
Canada Life denied Moore's claim three times because it claims there was no objective medical evidence to support her subjective complaints of pain and vertigo. However, in reviewing Moore's claim, Canada Life had in its possession not only the March 6, 2001 CT Scan of Moore's cervical spine, indicating the existence of spondylolysis, a possible source of Moore's neck pain, but also the June 29, 2001 MRI results noting a possible diagnosis of Chiari I Malformation. Even if the CT Scan in and of itself was not sufficient evidence of disability, it appears to the Court that these two documents together comprise the "objective medical evidence" that Canada Life sought from Moore. Therefore, the Court must conclude that the plan administrator's denial of benefits was arbitrary and capricious where, as here, the record contains at least two medical records that appear to support Moore's claim of disability.
If Canada Life's short term disability examiners and Medical Review Board had determined that it needed additional evidence of spondylolosis or Chiari I malformation, or that these diseases could not possibly cause Moore's symptoms of head and neck pain and vertigo, or that the CT scan and MRI did not constitute "satisfactory proof" of disability, such conclusions should have been explained in Canada Life's denial to Moore. Because the cervical CT scan was dismissed as "normal" and the significance, if any, of the MRI was never mentioned, the Court concludes that Canada Life did not engage in a "deliberate, principled reasoning process." Moreover, Canada Life appears to have failed to consider the MRI results.
The administrative record lacks even more information that is necessary to Canada Life's decision-making process. The record lacks any evidence of the "substantial and material duties" of Moore's occupation or of Moore's ability to perform those duties. The record contains no evidence that Canada Life's disability examiners or Medical Review Board knew the actual duties of a Murata Technician or considered those duties in their review of Moore's claim. Furthermore, the Court finds it strange that Canada Life did not ask Moore to submit to an examination or interview by a physician or vocational expert of its choice in order to confirm or deny Dr. Grotefendt's opinion that Moore was unable to work. This is especially so where a provision in the Plan requires a claimant to submit to an examination by Canada Life's medical evaluators at Canada Life's discretion. (A.R. 00040).
III. CONCLUSION
Based on the incomplete administrative record and Canada Life's failure to consider evidence, the Court must find that the denial of benefits is unwarranted. Therefore, Canada Life's motion [Court File No. 15] will be DENIED. However, the evidence contained in the administrative record does not clearly establish that Moore was disabled under the meaning of the Plan. Plaintiff's motion [Court File No. 17] also will be DENIED. This action will be REMANDED to Canada Life for further development of the record and reconsideration consistent with this Court's opinion.
An order will enter.
ORDER
In accordance with the accompanying memorandum, the defendant's motion for judgment on the administrative record [Court File No. 15] is DENIED. Plaintiff's motion for judgment on the administrative record [Court File No. 17] is DENIED.
This case is REMANDED to the plan administrator for reconsideration of the denial of benefits to the plaintiff. The plan administrator shall fully develop the administrative record, consider the evidence in its entirety, and thoroughly explain its reasoning for the action it takes on the plaintiff's claim.
The Court retains jurisdiction of this matter.