Opinion
Case No. 3:02-CV-122
October 21, 2002
MEMORANDUM AND ORDER
This matter is before the Court on Plaintiff's, Beverly Yohe's ("Yohe"), motion for summary judgment pursuant to Rule 56 of the Federal Rules of Civil Procedure. The Plaintiff is seeking additional short-term disability benefits. The Defendant, Employee Benefits Administrative Committee in its capacity as Plan Administrator for Square D Company ("Square D"), filed its own motion for summary judgment requesting that the Court enter summary judgment in their favor, and award Defendant its costs, including attorneys' fees reasonably incurred in obtaining summary judgment.
I. BACKGROUND
Square D has a Disability Plan ("the Plan") which is a sub-plan of its Employee Welfare Benefit Plan. Square D is the Plan sponsor and Square D Employee Benefits Administrative Committee is the Plan Administrator. The UNUM Life Insurance Company of America ("UNUM") is the Claims Administrator for the Plan.
Under the Plan, eligible employees are entitled to short-term disability benefits. The Plan states that in order to be eligible for short-term disability benefits, eligible employees must be: 1) unable to perform their job responsibilities because of accident or sickness as determined by the claims' administrator; and 2) under the regular care of a doctor.
Yohe was hired by Square D on December 12, 1991. On or about March, 2001, Square D received a claim for short-term disability benefits from Yohe, in which Yohe claimed severe headaches. After reviewing the medical evidence UNUM initially approved Yohe's claim for short-term disability benefits. Yohe received short-term disability benefits for the period of March 7, 2001, through June 6, 2001.
On July 31, 2001, UNUM notified Yohe that her claim for further short-term disability benefits for the period of June 7, 2001 to July 31, 2001, was denied due to the lack of medical support. Yohe filed an appeal to UNUM on August 9, 2001, requesting reconsideration of UNUM's denial of her short-term disability benefits. On August 23, 2001, UNUM notified Yohe that it had forwarded her August 9, 2001 letter to the Committee pursuant to the Plan's appeal procedures.
On October 18, 2001, the Committee responded to Yohe's appeal. The Committee granted Yohe additional short-term disability benefits for the week of July 12, 2001, to July 19, 2001, based on information from Dr. Schneider, one of Yohe's physicians, which indicated that during that period of time Yohe had experienced some temporary discomfort after a medical procedure. The Committee upheld the remainder of UNUM's denial of Yohe's claim for additional short-term disability benefits. The Committee determined that Yohe was not entitled to further short-term disability benefits under the Plan.
II. SUMMARY JUDGMENT STANDARD
Summary judgment is to be granted "forthwith" when, after an adequate period for discovery one party is unable to show a genuine issue as to a material fact on which that party will bear the burden of proof at trial, so long as judgment against that party is appropriate as a matter of law. Department of Commerce v. U.S. House of Representatives, 525 U.S. 316, 327 (1999); Celotex Corp. V. Catrett, 477 U.S. 317, 322 (1986). When there are no genuine issues of material fact, contract interpretation is particularly well- suited for summary judgment. Anstett v. Eagle-Picher Industries, 203 F.3d 501 (7th Cir. 2000).
III. STANDARD OF REVIEW
In Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101 (1989) the Supreme Court set out the applicable standard of review for a decision made by a plan administrator in an ERISA case. A de novo standard of review is not applied in cases where a benefit plan gives the administrator or fiduciary discretionary authority to construe the terms of the plan. Id. at 115. In situations where the administrator is given discretionary authority courts apply an arbitrary or capricious standard in reviewing the administrator's decision. Russo v. Health, Welfare Pension Fund, 984 F.2d 762, 765-766 (7th Cir. 1993); Exbom v. Central States, Southeast and Southwest Areas Health and Welfare Fund, 900 F.2d 1138 (7th Cir. 1990).
IV. DISCUSSION
The issue before this Court is whether the Committee's decision denying Yohe's claim for additional short-term disability benefits was arbitrary and capricious. Under this standard the Seventh Circuit has held that cases involving the challenge of a denial of benefits under ERISA, where it is undisputed that the plan expressly gives the administrator discretion to construe the terms of the plan, may only be reversed by the court if the denial of benefits was arbitrary and capricious. See, Chojnacki v. Georgia Pacific Corp., 108 F.3d 810, 814 (7th Cir. 1997). According to Perlman v. Swiss Bank Comprehensive Disability Protection Plan, 195 F.3d 975, 982 (7th Cir. 1999), a court's review of a plan administrator's decision is strictly limited to the evidence in the administrative record. There must be sufficient evidence to support the plan administrator's decision, otherwise it may be deemed arbitrary and capricious.
A. Background of ERISA
In 1974, Congress enacted the Employee Retirement Income Security Act or ERISA in response to wide disuniformity among various state laws as they applied to employee benefit plans. 29 U.S.C. § 1144 (West 1998). The purpose of the Act was to afford employers with a uniform set of administrative procedures rather than trying to comply with a different set of procedures for creating health plans in each state. Fort Halifax Packing Co. Inc., v. Coyne 482 U.S. 1 (1987). With this point in mind, Federal Courts are quick to establish that ERISA's concern is with the administration of the benefits plan and not the actual design or contents of the plan. The actual terms and conditions of the plan are left to the discretion of the various employers who create the plan. Hickey v. A.E. Staley Mfg., 995 F.2d 1385, 1388 (7th Cir. 1993). ("Decisions of this Circuit have recognized that plan providers have great latitude in determining whom to include in a plan and the scope of the plan."); See Also; Nazay v. Miller, 949 F.2d 1323, 1329 (3rd Cir. 1990).
In enacting ERISA, congress felt that a body of federal common law should be developed in order to establish uniformity in applying various concepts of law to areas not addressed specifically by the benefits plan. See; Franchise Tax Bd. v. Construction Laborers Vacation Trust, 463 U.S. 1, 24 n. 26 (1983) (quoting 120 Cong.Rec. 29942 (1974) (remarks of Senator Javits)); see also Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 110 (1989); Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 56 (1987). However, various legal principals recognized under federal common law may not be employed by a Court where there exists specific language in a plan to the contrary. Cutting v. Jerome Foods, Inc. 993 F.2d 1293, 1297 (7th Cir.) cert denied, 510 U.S. 916 (1993). Trustmark Life Ins. Co. v. University of Chicago Hosp., 207 F.3d 876, 884 (7th Cir. 2000).
The principles of contract interpretation require this Court to interpret the terms of this ERISA plan in an ordinary and popular sense as would a person of average intelligence and experience. Swaback v. American Info. Techs. Corp., 103 F.3d 535, 540-541 (7th Cir. 1996). "Extrinsic evidence should not be used where the contract is unambiguous." Id. at 541; GCIU Employer Retirement Fund v. Chicago Tribune Co., 66 F.3d 862, 865 (7th Cir. 1995) (citing Bidlack v. Wheelabrator Corp., 993 F.2d 603, 608 (7th Cir.), cert. denied, 510 U.S. 909, 114 S.Ct. 291, 126 L.Ed.2d 240 (1993)).
B. The Committee's Decision Based on the Administrative Record
The Committee denied Yohe's request for additional short-term disability benefits based on the evidence contained in the administrative record. On June 6, 2001, Dr. Gordon examined Yohe, and concluded that as of that time, she was able to return to work. Dr. Schneider, Yohe's other physician, deemed that Yohe was to be excused from work from May 25, 2001 through June 29, 2001. However, Yohe did not have any appointments with Dr. Schneider during that time and the only doctor who saw her was Dr. Gordon, who had released her to return to work. Then on July 6, 2001, Dr. Schneider saw Yohe and noted that she had been headache-free for two weeks. Yohe contended that her treatment continued until August, 2001, and that the Committee did not take into account such medical evidence. However, there needed to be evidence that she was unable to perform her job responsibilities due to her headaches as well as evidence that she was under the regular care of a doctor. Evidence of treatment or continuing pain related to her headaches would not be sufficient to establish a right to additional short-term disability benefits under the terms of the Plan.
Also in her appeal, Yohe asserted that a third party physician, Dr. Hatch, had advised her to stay off of work until he saw her again on August 8, 2001; however no documentation was provided by Dr. Hatch to support that assertion. Furthermore, Yohe was not examined regularly by Dr. Hatch during this time and when Dr. Hatch did examined Yohe on August 8, 2001, he opined that she was not restricted in her ability to work.
There is sufficient medical evidence to support the Committee's decision that Yohe was not disabled as defined by the Plan. Yohe was deemed able to return to work by Dr. Gordon as of June 6, 2001, with the exception of the time period of July 12, 2001, through July 19, 2001, for which Yohe did receive short-term disability benefits. No evidence was presented of any other physician contradicting Dr. Gordon's action of releasing Yohe to return to work as of June 6, 2001.
There have been indications and evidence supporting that Yohe continued to suffer from headache related problems at certain times, however, that is not the issue. The issue is not whether Yohe is still being treated or still having problems with her headaches. Rather, the issue is whether there is substantial evidence to support that she is unable to perform her job responsibilities and that she is under the regular care of a doctor because of her problems with her headaches. Without proof that Yohe is unable to perform the responsibilities of her job due to her headache problems and that she is under the regular care of a doctor, which are requirements under the Plan for receiving short-term disability benefits, Yohe is not entitled to such benefits. The Committee reviewed all of the relevant medical records and correspondence during the process of the appeal that were contained in the administrative record. The evidence contained in the administrative record established that Yohe was able to return to her job responsibilities as of June 6, 2001, and was not disabled as defined by the Plan's language. Such evidence is sufficient to support that the plan administrator's decision to deny additional short-term disability benefits was not arbitrary and capricious.
C. Independent Medical Evaluation
Yohe further contended that the decision of the plan administrator was arbitrary and capricious because Square D did not afford her an independent medical evaluation. The Seventh Circuit held that while ERISA demands a "reasonable inquiry" into a claimant's medical condition, ERISA does not require a "full-blown investigation." O'Reilly v. Hartford Life and Accident Insurance Co., 272 F.3d 955, 961 (7th Cir. 2001). ERISA requires the plan administrator to have enough evidence to make a decision. Id. In Yohe's case, the Committee reviewed the medical records and correspondence from both of her physicians at the time, Dr. Gordon and Dr. Schneider.
In her appeal, Yohe did not dispute either Dr. Gordon's or Dr. Schneider's opinions regarding her ability to return to work and the fact that she had been headache-free for two weeks. Further, Yohe had the opportunity and did not submit any additional medical evidence when she filed her appeal. The Committee reviewed evidence of Yohe's medical condition from both Dr. Gordon and Dr. Schneider. Evidence from Yohe's two treating physicians was sufficient for the Committee to make a decision regarding the determination of her eligibility for short-term disability benefits without the need for an independent medical evaluation.
The Committee considered the evidence contained in the administrative record, applied such to the Plan's definition of disability, and determined that Yohe did not meet the Plan's definition, and therefore was ineligible for additional short-term disability benefits.
V. CONCLUSION
For the foregoing reasons, the Plaintiff's motion for summary judgment pursuant to Rule 56 of the Federal Rules of Civil Procedure is now DENIED. The Defendant's motion for summary judgment in its favor as to Plaintiff's claims pursuant to Rule 56 of the Federal Rules of Civil Procedure is now GRANTED. Request by Defendant for costs including attorneys' fees are DENIED with leave to renew after the case is closed.
IT IS SO ORDERED.