Opinion
Civil Action No. 04-1188 Section "L" (4).
March 18, 2005
ORDER REASONS
Pending before the Court are the Parties' cross motions for summary judgment. The motions came before the Court with oral argument on March 2, 2004, at 9:00 a.m. For the following reasons, the Defendants' Motion for Summary Judgment is GRANTED and the Plaintiffs' Motion for Summary Judgment is DENIED.
I. BACKGROUND
The Plaintiff brings this action under the Employee Retirement Income Security Act of 1974, 29 USC § 001, et. seq. ("ERISA") and pursuant to 28 USC § 1331. Plaintiff Eugene White was employed as a maintenance mechanic and later as a maintenance supervisor for approximately 27 years by Cyprus Amex Minerals Company ("Cyprus"), during which time Cyprus was acquired by Phelps Dodge Corporation, the alleged successor in interest to Cyprus. Defendant Cyprus Amax Minerals Company Benefits Committee (the "Benefits Committee") was the Plan Administrator for Cyprus' Long-Term Disability Plan for Salaried Employees (the "Plan").
The Plaintiff claims that on or about July 7, 1999, while at work, he felt a sharp pain in his back and was told to go home by his supervisor. The Plaintiff has been unable to return to work since that date. The next day, the Plaintiff went to a doctor for treatment and an MRI revealed that Plaintiff had three herniated lumbar discs. The Plaintiff admits that he has suffered chronic lower back pain for years and claims that he is now totally disabled due to the herniated discs and related pain. The Plaintiff also claims that his disability is heightened by the partial replacement of his right knee in February 2003 and of his left knee in January 2004. According to the Plaintiff, he is unable to engage in any gainful occupation for which he is reasonably fitted by education, training, and experience.
The Plaintiff was paid short-term disability benefits as well as long-term disability benefits for a period of thirty months, through January 6, 2002, at which time the Defendants terminated the benefits. The Plan provided that [f]or the first thirty months of disability:
Total Disability means, with respect to any Participant who is disabled because of a sickness, injury or pregnancy, the incapability of performing the essential functions of the Participant's position with the Company, with or without reasonable accommodation . . . (ADMIN — 0007).
After the Plaintiff exhausted all of his administrative remedies under the disability plan, he received a letter from Defendant Phelps Dodge dated April 28, 2003 indicating that the Benefits Committee had rejected Plaintiff's claim for benefits. The Plaintiff believes that the Defendants failed to fully and fairly review his claim for benefits and that they abused their discretion in determining that he is not totally disabled within the meaning of the Plan. The Plaintiff seeks recovery of unpaid benefits from January 6, 2002 and a continuation of his benefits in accordance with the Plain until he is no longer totally disabled, if ever.
The Defendants deny owing Plaintiff any disability benefits. After thirty months of disability, the Plan's definition of "Total Disability" becomes more restrictive by including the previous definition of "Total Disability" and adding:
provided that, for any period beginning 30 months or more after the Participant's Total Disability commenced, the Participant is also incapable if engaging in any gainful occupation for which he is reasonably fitted by education, training, or experience. (ADMIN — 0007).
The Defendants claim that after January 6, 2002, Plaintiff no longer qualified as totally disabled under the Plan because he could perform sedentary jobs which existed in sufficient number to allow the Plaintiff's reentry into the work force. The Benefits Committee and Phelps Dodge further deny that Phelps Dodge has any responsibility in the decision to provide disability benefits through January 6, 2002. According to the Defendants, they all acted reasonably and justly in evaluating and ultimately terminating Plaintiff's disability benefits.
II. CROSS MOTIONS FOR SUMMARY JUDGMENT
1) Summary Judgment
A. Applicable Law
The parties agreed to submit this case for consideration on cross motions for summary judgment. Summary judgment will be granted only if the pleadings, depositions, answers to interrogatories, and admissions, together with affidavits show that there is no genuine issue as to any material fact and that the defendant is entitled to a judgment as a matter of law. Fed.R.Civ.P. 56. When considering a motion for summary judgment, the Court must "review the facts drawing all inferences most favorable to the party opposing the motion." General Universal Systems, Inc. v. Lee, 379 F,3d 131, 137 (5th Cir. 2004). If the party moving for summary judgment demonstrates the absence of a genuine issue of material fact "the nonmovant must go beyond the pleadings and designate specific facts showing that there is a genuine issue for trial." Willis v. Roche Biomedical Laboratories, Inc., 61 F.3d 313, 315 (5th Cir. 1995).
2) Review of ERISA Claims
Federal Courts have exclusive jurisdiction to review determinations made by employee benefit plans, including disability benefit plans. 29 U.S.C. § 1132(a)(1)(B). Usually, ERISA cases fall into one or both of the following categories: 1) cases that contest the Plan Administrator's determination of the facts underlying the claim for benefits; and 2) cases that contest the Plan Administrator's determination of whether those facts constitute a claim to be honored under the terms of the plan. Ramos v. BellSouth Long Term Disability Plan, et al., 2001 WL 1352319 (E.D. La. 2001), citing, Wilbur v. ARCO Chemical Co., 974 F.2d 631, 637 (5th Cir. 1992). The appropriate standard of review depends upon which category or categories the case falls into. "A factual determination usually consists of an administrator's finding that a claimant's condition meets a definition in the policy." Chapman v. The Prudential Life Ins. Co. of America, 267 F.Supp.2d 569, 576 (E.D. La. 2003). In the instant matter, the Plaintiff does not challenge the Plan Administrator's interpretation of the Plan. Rather, the Plaintiff argues that the Plan Administrator did not have a sufficient factual basis for concluding that the Plaintiff is not totally disabled. Therefore, this case is one contesting the Plan Administrator's determination of the facts underlying the claims for benefits.
It is well settled in the Fifth Circuit that the factual determinations made by the Defendants during the course of the Plaintiff's benefit proceeding are reviewed for an abuse of discretion. Estate of Bratton v. Nat'l Union Fire Ins. Co. of Pittsburg, PA, et al., 215 F.3d 516, 522 (5th Cir. 2000). A determination that a person is disabled is a factual determination. See Sweatman v. Commercial Ins. Co., 39 F.3d 594, 598 (5th Cir. 1994). Under the abuse of discretion standard, the Court must determine if the Defendants acted arbitrarily or capriciously. Sweatman, 39 F.3d at 601. A decision is arbitrary when made "`without a rational connection between the known facts and the decision or between the found facts and the evidence.'" Lain v. Unum Life Ins. Co. of Am., 279 F.3d 337, 342 (5th Cir. 2002) (quoting Bellaire Gen. Hosp. v. Blue Cross Blue Shield of Mich., 97 F.3d 822, 828 (5th Cir. 1996)). Ultimately, if the Plan Administrator's decision "is supported by substantial evidence and is not arbitrary or capricious, it must prevail." Ellis v. Liberty Life Assurance Co. of Boston, 2004 WL 2635692, *6 (5th Cir. 2005). Furthermore, "If an administrator has made a decision denying benefits when the record does not support such a denial, the court may, upon finding an abuse of discretion on the administrator's part, award the amount due on the claim and the attorney's fees." Id.
Even if this case did fall into the category of plan interpretation, the abuse of discretion standard would still apply because the Plan explicitly gives the Plan Administrator discretionary authority to construe the terms of the plan. (ADMIN-0015); see Firestone Tire and Rubber Co. et al. v. Bruch, et al., 489 U.S. 101, 115 (1989); see also Ramos, 2001 WL 1352319 at *3.
B. The Parties' Arguments
In support of his position that the Defendants abused their discretion in finding that the Plaintiff was not disabled under the plan, the Plaintiff sets forth two main arguments. First, the Plaintiff argues that it was unreasonable for the Defendants to find that the Plaintiff was capable of performing sedentary work while he has three lumbar herniated discs and two operated knees. The Plaintiff points out that the Defendants' determination is disputed by the Plaintiff's long-time treating physician, Dr. Ralph Gessner, the only doctor who physically examined the Plaintiff. (Plaintiff's Exhibit Q). Second, the Plaintiff claims that the Plan Administrator abused its discretion in finding that there are sedentary jobs which would allow the Plaintiff to reenter the workforce. Specifically, the Plaintiff argues that, in the "Transferable Skills Assessment and Any Occupation Review", the Defendants' vocational case manager reaches an unsubstantiated conclusion that the Plaintiff could work as a dispatcher in maintenance service or as a service clerk. (ADMIN-0199 — ADMIN-0203). The Plaintiff further argues that the unreasonableness of the case manager's conclusion is evident in the contradictory decision of the Social Security administrative law judge who found the Plaintiff to be eligible for Social Security benefits. In that decision, the judge noted that a vocational expert determined that "there are no jobs existing in the national economy that such a person as [the Plaintiff] could perform on a regular, full time basis." (ADMIN-0352). Due to the alleged arbitrariness of the Defendants' actions, the Plaintiff also argues that an award of attorney's fees is appropriate in the instant matter.
Plaintiff's Exhibit Q includes several examination notes and letters of Dr. Gessner, found in the administrative record at ADMIN-0218; ADMIN-0059; ADMIN-0058; ADMIN-0056; ADMIN-0054; ADMIN-0052; ADMIN-0051; ADMIN-0196; and ADMIN-0233.
The Defendants respond that substantial evidence exists to support the Plan Administrator's denial of the Plaintiff's claim, proving that the decision to terminate benefits was neither arbitrary nor capricious. According to the Defendants, it was not an abuse of discretion for the Plan Administrator to rely upon the professional opinions of both a board-certified physician and a vocational consultant who each reviewed the Plaintiff's records before reaching their conclusions. Furthermore, the Defendant argues that, in ERISA case law, there is nothing that suggests that Plan Administrators must accord special deference to the opinions of treating physicians. The Defendants also point to cases that show that it is not an abuse of discretion for a Plan Administrator to rely upon the conclusions of a physician who had not physically examined the Plaintiff. Lastly, the Defendants claim that the Plaintiff's functional capacity evaluation shows that he is capable of performing sedentary work.
C. Analysis
1. Sedentary Work
Due to the fact that this is a case concerning the denial of benefits under an ERISA plan, the Court's resolution of the summary judgment motions can only be based, with few exceptions, on the evidence contained in the administrative record (referred to as "ADMIN"). There is substantial evidence in the administrative record before the Court to conclude that the Plan Administrator's determination that the Plaintiff was not totally disabled under the Plan was neither arbitrary nor capricious. The Plan Administrator considered the opinions of consulting physicians (ADMIN-0075; ADMIN-0184;), the results of a functional capacity evaluation (ADMIN-0178-ADMIN-0183), a vocational rehabilitation study (ADMIN-0199 — ADMIN-0203), as well as an independent review (ADMIN-0244 — ADMIN-0247). All of these reports and opinions concluded that the Plaintiff is capable of sedentary work, and therefore, not totally disabled. Therefore, the Plan Administrator's decision to terminate the Plaintiff's benefits was based on evidence in the administrative record and was not an abuse of discretion.
For example, the district court may consider other evidence related to how an administrator has interpreted terms of the plan in other instances and evidence, including expert opinion, that assists the court in understanding the medical terminology or practice related to a claim. Estate of Bratton v. Nat'l Union Fire Ins. Co. of Pittsburg, PA, et al., 215 F.3d 516, 521 (5th Cir. 2000) (citing Vega v. Nat'l Life Ins. Services, 188 F.3d 287, 299 (5th Cir. 1999)).
The Plaintiff argues that his treating physician, Dr. Gessner, the only physician to physically examine the Plaintiff, repeatedly concluded that the Plaintiff was totally disabled and not capable of sedentary work. (ADMIN-0291). Firstly, the Fifth Circuit has concluded that it is not an abuse of discretion for a Plan Administrator to rely upon the conclusions of physicians who have reviewed a claimant's medical records without physically examining the claimant. Gooden v. Provident Life Accident Ins. Co., 250 F.3d 329, 335 (5th Cir. 2001); see also Champan, 267 F.Supp.2d at 579. Secondly, while Dr. Gessner's opinion that the Plaintiff could not perform even sedentary work is clearly expressed in the administrative record, the Defendants "need not give more weight to the opinion of a claimant's treating physician than it gives to the opinions of other physicians or other evidence in the record." Ramos, 2001 WL 1352319 at *4; see also Chapman, 267 F.Supp.2d at 579, citing Black Decker Disability Plan v. Nord, 538 U.S. 822 (2003). Therefore, it is of no consequence that Dr. Gessner's conclusion directly contradicts the opinions on which the Plan Administrator relied. Rather, an administrator's denial of benefits must be "based on evidence, even if disputable, that clearly supports the basis for its denial." Vega, 188 F.3d at 299. In this case, the Plan Administrator's decision to give lesser weight to Dr. Gessner's opinion is supported by evidence in the record. Specifically, one consultant physician points out that Dr. Gessner made his initial determination about the Plaintiff's disability status before the functional capacity evaluation had been conducted and without reporting any objective abnormalities to support the decision. (ADMIN-0173, referring to ADMIN-0175). Therefore, the Plan Administrator has support in the administrative record for its doubt regarding the accuracy Dr. Gessner's opinion.
Dr. Gessner does reaffirm his opinion that the Plaintiff is totally disabled after the functional capacity evaluation as well. (ADMIN-0291). However, this fact still does not change the current state of the law which maintains that the Plan Administrator is not required to give greater weight to the opinion of the claimant's treating physician.
While the Court should defer to the Plan Administrator's supported decisions, the Court "owes no deference to the administrator's unsupported suspicions." Vega, 188 F.3d at 302. The Plaintiff argues that the Defendants rely on the mere assumptions of Dr. Waldram, a physician consultant in orthopedics. Dr. Waldram questioned the true extent of the Plaintiff's disability in the light of the Plaintiff's non-pursuit of aggressive treatment, noting, "Under the circumstance, if [treatment is not] being pursued at this time, one would wonder the level of pain that the patient is experiencing. It would seem reasonable that the patient could be involved in sedentary occupation." (ADMIN-0184). While Dr. Waldram did review the Plaintiff's medical records, he did not physically examine the Plaintiff nor did he look at the Plaintiff's MRI. (ADMIN-0184). Therefore, it does appear as though Dr. Waldram's opinion is based primarily on his suspicion that the Plaintiff must be capable of sedentary work because he has not pursued certain types of treatment. This might be a significant issue had Dr. Waldram's opinion been the only information in the administrative record supporting the denial of the Plaintiff's claim for disability benefits. See Vega, 188 F.3d at 301-2. However, as discussed above, the Defendants relied upon the opinions of other consultants and physicians as well.
The Defendants' decision to deny benefits is also supported by the conclusions presented in the functional capacity evaluation, which showed that, even though Mr. White magnified his symptoms, he was capable of "sedentary to light work on a full time basis". (ADMIN-0178). Specifically, the Functional Capacity Evaluation concludes that the Plaintiff is capable of sitting, standing, and walking, "occasionally and self-paced". (ADMIN-0181). The definition of sedentary work states in pertinent part that "[j]obs are sedentary if walking and standing are required only occasionally." The evaluation, performed by an occupational therapist, was conducted over two days and the report gives a full description of the tests performed and the therapist's clinical observations. (ADMIN-0178 — ADMIN-0181). Therefore, in depending upon the conclusions stated in the functional capacity evaluation, the Plan Administrator was relying upon a report backed by substantial evidence. Accordingly, it was not an abuse of discretion for the Plan Administrator to conclude, based on the functional capacity evaluation, the Plaintiff's medical records, and the opinions of consulting physicians, that the Plaintiff is capable of sedentary work and is, consequently, not totally disabled.
2. Availability of Sedentary Jobs
The Plaintiff argues that the Plan Administrator abused its discretion in finding that there are sedentary jobs which would allow the Plaintiff to reenter the workforce. The Defendants obtained a Transferrable Skills Assessment and Any Occupation Review, which was performed and compiled by a vocational case manager. (ADMIM-0199). The review identified "maintenance service dispatcher" and "service clerk" as alternative sedentary occupations that are available to the Plaintiff in the Louisiana area. (ADMIN-00201 — ADMIN-0203). Once again, the Plaintiff's dispute is with the Plan Administrator's factual determination that there are sedentary jobs available to the Plaintiff, rather than with the Plan Administrator's interpretation of the Plan. According to the Plaintiff, the vocational case manager's conclusion was unsubstantiated.
In support of his argument, the Plaintiff makes reference to his proceedings before the Social Security Administration at which the Administrative Law Judge found the Plaintiff to be disabled as defined in the Social Security Act, 20 CFR §§ 404.1520(f) and 416.920(f). (ADMIN-0352 — ADMIN-0353). In that decision, the Administrative Law Judge explained that, because the Plaintiff could not return to his previous job, it was the Social Security Administration's burden "to show that a significant number of jobs exist in the national economy that [the Plaintiff] is capable of performing, given his residual functional capacity, his age, educational level, and vocational background." (ADMIN-0352). The Administrative Law Judge further noted that, at the hearing, when asked to assume a person of the Plaintiff's characteristics, the vocational expert responded that "there are no jobs existing in the national economy that such a person as [the Plaintiff] could perform on a regular, full time basis." (ADMIN-0352).
It is important to recognize that other Circuits as well as several District Courts in this Circuit have held that it is not necessarily an abuse of discretion for an ERISA administrator to make a disability determination that conflicts with the benefit determination made by the Social Security Administration. Milson v. St. Luke's Episcopal Hospital, 71 F.Supp.2d 634, 639 (S.D. Tex. 1999); Freeman v. Sickness Accident Disability Plan of ATT Technologies, Inc., 823 F.Supp. 404, 416 (S.D. Miss. 1993); Anderson v. Operative Plasterers' and Cement Masons' Int'l Assoc. Local No. 12 Pension and Welfare Plans, 991 F.2d 356, 358 (7th Cir. 1993); Madden v. ITT Long Term Disability Plan for Salaried Employees, 914 F.2d 1279, 1286 (9th Cir. 1990). In the instant case, the Administrative Law Judge concluded that the Plaintiff is disabled for the purposes of Social Security partially because the vocational expert was unable to present any evidence that there were jobs existing in the national economy for which the Plaintiff would be qualified. The situation is different in the Plaintiff's ERISA case. The occupational review conducted for the purposes of the ERISA determination explicitly states that the vocational case manager's review was "performed using a variety of tools and resources including careful review of the medical and vocational documentation in the claimant's file as well as LifeStep, U.S. Department of Labor publications and relevant wage/salary survey data." (ADMIN-0201). Furthermore, the review states that the alternate occupations identified by the vocational case manager "exist in the [Plaintiff's] labor market in sufficient numbers to allow reentry into the workforce given the [Plaitniff's] residual functional capacity and transferrable skills" and that the occupations "also meet or reasonably approach the wage consideration[.]" (ADMIN-0203). Unlike the Administrative Law Judge, the Plan Administrator was presented with evidence of the existence of jobs in Louisiana for which the Plaintiff is qualified. The occupational review did not make unsupported statements, but rather presented to the Plan Administrator the factual basis for the case manager's determination that there were sedentary jobs available to the Plaintiff. There is clearly a rational connection between the facts considered by the vocational case manager and the Plan Administrator's decision that there are sedentary jobs available to the Plaintiff. See Lain, 279 F.3d at 342 (requiring "a rational connection between the known facts and the decision").
"LifeStep is a transferable skills analysis tool that consists of job matching software that helps in identifying functionally appropriate alternative occupations for which the claimant has the education, training, and experience to perform." (ADMIN-0201).
The Plaintiff's objection to the vocational case manager's conclusion could also be characterized as an issue of plan interpretation. The Plaintiff claims that the occupational review offered no meaningful information about the number of available alternative positions in the Plaintiff's specific local area of Braithwaite, Louisiana, though the Defendants' denial of benefits was "based upon the purported existence of Service Clerk positions." (Plaintiff's Motion for Summary Judgment at 14). As support for the position that this was an abuse of the Defendants' discretion, the Plaintiff refers the Court to Ramos v. BellSouth Long Term Disability Plain, et al., 2001 WL 1352319 (E.D. La. 2001). The Defendants correctly point out that Ramos is easily distinguishable from the instant case. In Ramos, the benefits plan at issue specifically required the plan administrator to search for jobs for which the claimant is qualified and that are located within a thirty-five (35) mile radius of the claimants home in order to determine whether the claimant is disabled. Id. at *5. To the contrary, pursuant to the Plan in the instant case, the Plaintiff is entitled to benefits if, among other things, he "is incapable of engaging in any gainful occupation for which he is reasonably fitted by education, training, or experience." (ADMIN — 0007). There is no requirement in the Plan for "any gainful occupation" to be located in a specific area.
Language similar to that found in the instant Plan was at issue in Duhon v. Texaco, Inc., 15 F.3d 1302 (5th Cir. 1994). In Duhon, the Fifth Circuit found that the plan administrator did not have to ensure the availability of an alternate job for the claimant under a benefits plan that only required a finding that the claimant could perform "any job for which he is, or may become, qualified by education, training, or experience." Id. at 1309. the Duhon court found that "[i]t was not an abuse of discretion for the plan administrator to conclude that a sixty five year old man with a high school diploma and plenty of experience in the work-a-day world, although unable to squat, stoop, bend, or lift more than twenty-five pounds, would be able to perform the functions of some identifiable job." Id. at 1308. In support of its conclusion in Duhon, the Fifth Circuit cited Block v. Pitney Bowes Inc., 952 F.2d 1450, 1455 (D.C. Cir. 1992), in which the District of Columbia Circuit found that a benefits plan using the language "reasonably fitted by education, experience, capability, or training" did not contain any provision requiring the administrator to ensure the availability of an alternative job. The same is true for the Plan at issue in the instant case. The instant Plan does not call for the Plan Administrator to identify jobs within a certain are, nor does it require the Plan Administrator to identify specific jobs at all. At the time in question, the Plaintiff was forty-eight (48) years old with a high-school degree and twenty-six (26) years of maintenance experience. As in Duhon and Block, it would not have been an abuse of discretion for the Plan Administrator in this case to conclude that the Plaintiff was capable "of engaging in any gainful occupation for which he is reasonably fitted by education, training, or experience" as called for by the Plan, without performing a study to actually identify those positions. However, in this case, the Plan Administrator chose to go beyond what was required by the Plan and actually identify sedentary jobs in Louisiana for which the Plaintiff is qualified. Certainly, there was no abuse of discretion in the Plan Administrator determining, after an occupational assessment identifying sedentary jobs available in Louisiana, that the Plaintiff was not totally disabled under the terms of the Plan.
III. CONCLUSION
For the aforementioned reasons:
(1) The Plaintiff's Motion for Summary Judgment is DENIED.
(2) The Defendants' Motion for Summary Judgment is GRANTED.