Opinion
Case No. 03-73530.
July 21, 2004
ORDER AFFIRMING THE ADMINISTRATOR'S TERMINATION OF BENEFITS [12][10]
This matter involves a dispute over Defendant The Prudential Insurance Company of America's ("Prudential") termination of Plaintiff's long term disability benefits, which she received under a benefit plan governed by the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. §§ 1001, et seq. Plaintiff sued Defendant under ERISA's Section 1132(a)(1)(B), which allows persons to bring a civil action to recover benefits due to them under the terms of their plan and to enjoin any act which violates the terms of the plan. For the reasons stated below, the Court AFFIRMS the plan administrator's termination of benefits.
The parties waived oral arguments, and the Court decided this matter on the briefs.
I. Facts
A. Background
Plaintiff Patricia D. Newport was a Nurse's Aide at the Shiawassee County Medical Care Facility in Corunna, Michigan. (Adm. R. 94.) She participated in the Shiawassee County Medical Group Insurance Contract #G-24629 (the "Policy"). Id. at 0006-0060. The Policy defines disability as follows:
Total Disability exists when Prudential determines that all of these conditions are met:
(1) Due to sickness or accidental injury, both of these are true:
(a) You are not able to perform, for wage or profit, the material and substantial duties of your occupation.
(b) After the Initial Duration of a period of Total Disability, you are not able to perform, for wage or profit, the material and substantial duties of any job for which you are reasonably fitted by your education, training, or experience. The initial duration is equal to the first 24 months of benefits.
(2) You are not working at any job for wage or profit.
(3) You are under the regular care of a Doctor.
(Adm. R. 00043.)
Plaintiff left work on May 11, 1999, complaining of pain in her left shoulder. Id. at 67, 94. She consulted Dr. Mokbel K. Chedid, M.D., and reported that she had a one-year history of shoulder pain and tingling in her left arm. Id. at 237. Dr. Chedid concluded that she had cervical disc disease at C6-C7 with radiculopathy, canal stenosis and cord compression. Id. at 238. Plaintiff elected to have an anterior cervical diskectomy at C6-C7 with interbody fusion. Dr. Chedid performed the surgery on May 29, 1999. Id. at 244.
Plaintiff applied for Long Term Disability benefits on May 12, 1999. Id. at 93-97. Prudential awarded Plaintiff benefits effective November 9, 1999 for an initial period of twenty-four months. Id. at 98-134. On July 23, 2001, after completion of the "initial duration period" as defined by the Policy, Prudential informed Plaintiff that she did not meet the requirements for total disability as that term was defined in the Policy. Id. at 148. Prudential decided that Plaintiff was able to perform the duties of a job for which she might reasonably be fitted, based upon her education, training or experience and Plaintiff's medical records. Id. Prudential terminated Plaintiff's benefits effective November 8, 2001. Id.
B. Medical Records
On June 12, 1999, Plaintiff told Dr. Chedid that she was feeling well and "was doing great." Id. at 243. She reported that the pain in her arms had subsided and her strength had returned. Id. Her x-rays revealed good alignment and positioning of the bone graft and instrumentation. Id. Subsequently, at a July 20, 1999 follow-up, Dr. Chedid reported that the Plaintiff exhibited excellent strength in her arms as well as a good bilateral grip. Id. at 244.
On August 27, 1999, Plaintiff began complaining of increased lower back pain including radiation into her extremities. Id. at 188. Dr. Chedid obtained imaging studies which revealed lumbar spondylolisthesis and an L5/S1 disc herniation. Id. Dr. Chedid recommended surgery, and he performed a multilevel decompression and L5/S1 fusion on September 30, 1999. Id. Dr. Chedid issued restrictions for two weeks post-surgery including restrictions on lifting over ten pounds and prolonged sitting or bending. Id. On December 10, 1999, Plaintiff was reportedly doing very well. Her strength and reflexes were intact and she walked normally. Id. On April 14, 2000, Dr. Chedid completed a work status form predicting Plaintiff's return to work after a period of physical therapy. Id. at 252.
On May 5, 2000, Plaintiff again reported lower back pain. Id. at 254. Dr. Chedid noted that she was not taking much pain medication. Id. He prescribed another medication and wanted to see additional x-rays. Id. He also extended her sick leave "to make sure that all of these things are controlled before she goes back to work." Id.
On August 4, 2000, Plaintiff saw Dr. Chedid again for a follow-up. She reported that she was active and was doing fine until a week before the appointment, when some pain returned to her lower back. Id. at 258. Dr. Chedid prescribed new medication to help with muscle spasms. Id. He also decided that if she returned to work, she should avoid repetitive bending and prolonged sitting and not lift more than 10 or 15 pounds. Id.
Plaintiff saw Dr. Chedid again on November 3, 2000. Id. at 260. Dr. Chedid reported that Plaintiff was doing very well, that she was experiencing some pain but that "she is much better" and is able to live with the pain. Id. He also extended the same work restrictions that he had previously issued. Id.
During Plaintiff's disability period, Prudential arranged for an independent vocation counselor to determine if any jobs fell within Plaintiff's medical restrictions for which Plaintiff was reasonably fitted based upon her education, training, or experience. Id. at 148-49. The report identified several sedentary or light duty occupations suitable for Plaintiff including 12,000 positions in the State of Michigan. Id. at 188. Among the suitable occupations were Blood Donor Unit Assistant, Hospital Rental Clerk, Parking Lot Attendant and Gate Guard. Id. at 149. Prudential's letter to Plaintiff dated July 23, 2001 indicates that Prudential's decision to terminate Plaintiff's benefits as of November 9, 2001 was based on that report and the work restrictions issued by Dr. Chedid. Id.
Plaintiff appealed the termination on May 6, 2002. Id. at 159. As part of its review of Plaintiff's appeal, Prudential looked at additional medical documentation provided by Plaintiff including a Functional Capacity Evaluation ("FCE") performed at Plaintiff's request. Id. at 232. According to the FCE, Plaintiff has restrictions on lifting, carrying, or pulling over ten pounds, repetitive lifting, prolonged walking, bending, or forceful gripping. Id. at 268-78. Based on these findings and a reconsideration of the medical documentation in the file, Prudential maintained its determination that Plaintiff was capable of performing some jobs and therefore upheld its decision to terminate her benefits. Id. at 183.
On January 6, 2003, Plaintiff appealed a second time. Id. at 194. In support of her appeal, she submitted a copy of the decision letter from the Social Security Administration approving her for Social Security Disability Benefits. Id. at 186-193. Prudential denied her appeal, explaining that the Social Security Administration's standards of disability differ from Prudential's, and the Social Security decision actually stated that Plaintiff was not disabled as of November 9, 2001, the determinative date for Prudential. On March 3, 2003, Plaintiff submitted a third appeal. She attached letters from Dr. Chedid and Dr. Gurden. Id. at 230.
The Social Security Administration determined that she was disabled as of January 21, 2002.
In his letter dated February 19, 2002, Dr. Chedid summarized the FCE and concluded, "based on that, I do not think that this lady will really be able to perform any gainful employment on a full-time basis and this is supported by the functional capacity testing which is very clear to us." Id. at 266.
Dr. Barbara Gurden, a family practice physician, wrote a letter dated April 17, 2003, which stated in full:
After reviewing the patients [sic] past medical history and reviewing a 2002 functional assessment, I agree with Social Security Administration findings that the patient is indeed disabled. Her impairments include no lifting over 10-15 pounds, repetitive rotation and extension of bending or prolonged sitting. If you have any questions, do not hesitate to give my office a call.Id. at 297.
Prudential reviewed the available medical documentation with a medical consultant, whose specialty was physical and medical rehabilitation, and then denied her appeal. Id. at 232. Prudential concluded that there were several inconsistencies between the FCE and the additional medical evidence. Id. Prudential also concluded that the medical documentation provided by Plaintiff lacked support for its findings and did not support Plaintiff's impairment from sedentary occupations. Id.
On September 15, 2003, Plaintiff filed this action against Prudential, alleging that Prudential terminated her benefits in violation of 29 U.S.C. § 1132(A)(1)(b).
II. Standard for Challenge of Denial of ERISA Benefits
A court reviews a denial of benefits challenged under 29 U.S.C. § 1132(A)(1)(b) de novo, unless the plan gives the plan administrator or fiduciary discretionary authority to determine benefit eligibility or construe the terms of the plan. Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101 (1989). Where the plan grants its administrator discretion to pay or deny claims, the Court will review the administrator's decision under an arbitrary and capricious standard and will reverse the decision only if it is clearly wrong or downright unreasonable. Anderson v. Great West Life Assurance Co., 942 F.2d 392, 395 (6th Cir. 1991). The parties do not dispute that the decision denying Plaintiff benefits is to be reviewed under an arbitrary and capricious standard because the SADB Plan expressly grants Prudential discretionary authority to determine eligibility for Plan benefits. ("Total Disability exists when Prudential determines that all of these conditions are met. . . ." Adm. Rec. 43.) The Sixth Circuit has observed that the arbitrary and capricious standard is deferential, and "[w]hen applying his deferential standard, [the Court] must decide whether the plan administrator's decision was `rational in light of the plan's provisions.'" Smith v. Ameritech, 129 F.3d 857, 863 (6th Cir. 1997) (quoting Daniel v. Eaton Corp., 839 F.2d 263, 267 (6th Cir. 1988)). The Smith Court further explained that: "[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." Smith, 129 F.3d 863 (internal quotes and citations omitted). Furthermore, when conducting its review, the court considers "only the facts known to the plan administrator at the time [it] made [its] decision." Id.
Because this is an ERISA denial of benefits action, summary judgment is not the appropriate mechanism to review this dispute:
1. As to the merits of the action, the district court should conduct a de novo [or arbitrary and capricious, as appropriate] review based solely upon the administrative record, and render findings of fact and conclusions of law accordingly. The district court may consider the parties' arguments concerning the proper analysis of the evidentiary materials contained in the administrative record, but may not admit or consider any evidence not presented to the administrator.
2. The district court may consider evidence outside of the administrative record only if that evidence is offered in support of a procedural challenge to the administrator's decision, such as an alleged lack of due process afforded by the administrator or alleged bias on its part. This also means that any prehearing discovery at the district court level should be limited to such procedural challenges.
3. For the reasons set forth above, the summary judgment procedures set forth in Rule 56 are inapposite to ERISA actions and thus should not be utilized in their disposition.Wilkins v. Baptist Healthcare System, Inc., 150 F.3d 609, 619 (6th Cir. 1998). Therefore, even though Defendant styled its motion as one for summary judgment, the Court does not apply the summary judgment standard. Instead, the Court reviews the administrator's decision for arbitrariness or capriciousness.
Wilkins involved a denial of ERISA benefits where the standard of review was de novo, and there is some doubt as to whether the procedure outlined above applies to an arbitrary and capricious review. As the Wilkins court pointed out, however, there is no harm in applying the summary judgment analysis instead of the one outlined above when the court concurs with the ruling of the administrator. Even if this Court analyzed these motions as cross-motions for summary judgment, the Court would affirm the administrator's decision because Plaintiff has failed to raise a genuine issue as to whether it was arbitrary or capricious for Defendant to terminate Plaintiff's benefits. Therefore, whether or not this Court uses a summary judgment standard or not is not determinative of the outcome.
III. Analysis
The critical dispute in this case is the import of Plaintiff's treating physicians' reports. Defendant contends that its decision was not arbitrary or capricious because it carefully considered all of Plaintiff's medical evidence, including the reports of her treating physicians, in reviewing Plaintiff's case. Plaintiff maintains that Prudential did not give enough weight to the treating physicians' opinions that Plaintiff should not work.
In The Black Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003), the Supreme Court rejected the application of the Treating Physicians Rule in the ERISA context: "courts have no warrant to require administrators automatically to accord special weight to the opinions of a claimant's physician; nor may courts impose on plan administrators a discrete burden of explanation when they credit reliable evidence that conflicts with a treating physician's evaluation." The Court reasoned that treating physicians' opinions are not necessarily more reliable than opinions rendered by experts hired by benefit plans. Id. at 832. Moreover, even though the Social Security program uses the Treating Physician rule, ERISA plans are critically different from Social Security and do not necessarily need to employ the same presumptions. Id. at 832-33. Therefore, Defendant was not obligated to give Plaintiff's treating physicians, Drs. Chedid and Gurden, any more weight than its own experts.
After reviewing the same evidence considered by Defendant, and reviewing the analysis Defendant employed in denying Plaintiff benefits, this Court cannot conclude that Defendant acted arbitrarily and capriciously when it terminated Plaintiff's benefits. Dr. Chedid's opinion that Plaintiff could not work in the February 19, 2002 letter contradicts his work restrictions in which he restricted Plaintiff only in ways consistent with sedentary work. Moreover, he did not apply the definition of "disabled" as defined by the Policy. Dr. Gurden likewise did not apply the Policy's standard for "disabled." She simply supported the Social Security Administration's determination. ERISA plan administrators are not bound by Social Security Administration findings of disability because the Social Security Administration must use the treating physician rule while ERISA plan administrators do not. See Hurse v. Hartford Life and Accident Ins. Co., No. 02-5496, 2003 WL 22233532 (6th Cir. Sept. 26, 2003).
Rather than disregarding Dr. Chedid's opinion entirely, Defendant submitted Dr. Chedid's opinion of Plaintiff's work restrictions to its vocational rehabilitation counselor. Using the restrictions issued by Dr. Chedid, the counselor determined sedentary jobs were suitable for Plaintiff considering her physical restrictions. Moreover, even taking into account the restrictions recited in the FCE, Plaintiff could perform sedentary work. In sum, considering Plaintiff's own physician's reports, the FCE, and the vocational rehabilitation report, this Court concludes that Defendant offered a reasoned explanation, based on evidence, for terminating Plaintiff's benefits.
Plaintiff argues that the vocational rehabilitation report conflicts with the FCE because it recommends jobs that require functions Plaintiff is incapable of performing. Plaintiff does not explain exactly what functions those jobs require that Plaintiff is unable to perform. Plaintiff also argues that common sense and equity require this Court to give Plaintiff's treating physicians' opinions significant weight. This Court and Defendant did consider the medical findings of Dr. Chedid, with the exception of his determination that there were not any jobs suitable for Plaintiff, an issue clearly not within his expertise. Finally, Plaintiff argues that Defendant ultimately based its decision to deny benefits on a medical consultant of Defendant's choosing, which presents a conflict of interest. The Supreme Court, in Black Decker, acknowledged that bias might exist but also acknowledged the possibility that treating physicians would be equally biased towards plaintiffs. 538 U.S. at 832. Therefore, the Court is not persuaded that Prudential's experts should be disregarded.
IV. Conclusion
Being fully advised in the premises, having read the pleadings, and for the reasons set forth above, the Court hereby orders as follows:
The plan administrator's termination of Plaintiff's benefits is AFFIRMED, and this case is DISMISSED.