Opinion
Case No. C 04-02943 JF, [Docket Nos. 17, 23].
July 29, 2005
Plaintiff Gretchen Heinrich ("Heinrich") and Defendants The Prudential Insurance Company of America and Knight-Ridder, Inc. Long Term Disability Plan (collectively "Defendants") dispute whether Heinrich properly was denied long-term disability benefits. The parties have filed cross-motions for summary judgment. The Court has read the moving and responding papers and has considered the oral arguments of counsel presented on July 15, 2005. For the reasons set forth below, Heinrich's motion for summary judgment will be granted, Defendants' motion for summary judgment will be denied, and the case will be remanded to Defendants for determination of benefits in accordance with the findings and conclusions set forth herein.
I. BACKGROUND
Heinrich, a former employee of Knight-Ridder, Inc. ("Knight-Ridder"), was a participant in the Knight-Ridder, Inc. Long Term Disability Plan ("Plan"). The Plan offers long-term disability benefits to employees through an insurance policy issued by The Prudential Insurance Company of America ("Prudential"). Prudential also functions as the claims administrator. This action, brought pursuant to the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001 et seq., arises out of Heinrich's allegation that Prudential improperly denied her claim for long-term disability benefits.
Heinrich was employed by Knight-Ridder as an office systems manager responsible for general maintenance of the computer network system. See Silver Decl., Ex. 4. Heinrich's last day of work was August 7, 2002. She stopped working due to stress, depression, and the effects of fibromyalgia. The American College of Rheumatology describes fibromyalgia as "a common condition that is associated with widespread aching, stiffness and fatigue, and originates in muscles and soft tissue." Silver Decl., Ex. 23. According to the Arthritis Foundation, other symptoms include sleep disorders, irritable bowel syndrome, chronic headaches, and cognitive or memory impairment. See Silver Decl., Ex. 20. Heinrich had been diagnosed with fibromyalgia in 2000.
On February 23, 2003, Heinrich filed a claim for long-term disability benefits under the Plan. See Silver Decl., Ex. 2. The Plan provides that "[y]ou are disabled when Prudential determines that . . . you are unable to perform the material and substantial duties of your regular occupation due to your sickness or injury. " Silver Decl., Ex. A2 at 12. "Material and substantial duties" are defined as duties that "are normally required for the performance of your regular occupation" and "cannot be reasonably omitted or modified." Id. "Regular occupation" is defined as "the occupation you are routinely performing when your disability begins" and is based on how the occupation "is normally performed instead of how the work tasks are performed for a specific employer or at a specific location." Id. The Plan requires that the claimant be "continuously disabled" for an "elimination period" of 180 days before she is eligible to receive benefits. Id. at 13.
As part of her claim, Heinrich submitted, among other things, a medical report from her primary care physician, Dr. Rakesh Chaudhary, M.D. ("Chaudhary"), dated February 28, 2003. In this report, Chaudhary made a primary diagnosis of fibromyalgia and a secondary diagnosis of depression. See Silver Decl., Ex. 8. Chaudhary noted that Heinrich was experiencing "lots of pain from fibromyalgia with severe sleep disturbance" and characterized Heinrich's functional abilities as "sedentary." Id. In a follow-up report dated March 10, 2003, Chaudhary added that Heinrich "cannot concentrate on work tasks due to severe sleep disturbance [and] depression." Silver Decl., Ex. 9. On May 1, 2003, Prudential Claim Manager Susan Williams ("Williams") prepared a "SOAP Note" summarizing Heinrich's medical history as reported by her treating physicians and analyzing her claim for benefits. See Silver Decl., Ex. 11. The "SOAP Note" described Heinrich's condition from August 9, 2002, to January 16, 2003, including her disturbed sleep patterns, and listed the prescription medications she was taking. See id. On May 6, 2003, Williams prepared another "SOAP Note," in which she concluded that the medical information in Heinrich's file "does not support continuous disability through [the elimination period] of 8/8/02 through 2/4/03 for depression or [fibromyalgia] flare." Id. Prudential denied Heinrich's claim on May 13, 2003. See Silver Decl., Ex. 12. The denial letter stated that "the current medical documentation in file [sic] does not support that the severity of your conditions rendered you unable to perform the material and substantial duties of your regular occupation throughout the elimination period" and that Heinrich "should have been able to perform the duties of [her] regular occupation with reasonable self-accommodations or modifications during the elimination period." Id. It addressed both Heinrich's fibromyalgia and her psychiatric conditions, concluding that there was insufficient evidence to support Heinrich's claim for disability as a result of either condition.
Heinrich appealed the denial of her claim on November 3, 2003. See Hanna Decl., Ex. A at PRU0339-63. As part of her appeal, Heinrich submitted several additional reports regarding her conditions. Jeff Beeman ("Beeman"), a self-titled "vocational expert," interviewed Heinrich on September 10, 2003. See Silver Decl., Ex. 6. Based on that interview, Heinrich's medical record, and various occupational references, Beeman concluded that
Ms. Heinrich's physical, mental and cognitive problems, including fatigue, weakness, insomnia, depression, severe pain, inability to do physical labor, and difficulty with concentration, presents [sic] an individual unable to perform the material and substantial duties of her regular occupation. Ms. Heinrich is simply not able to sustain on a full time basis work activities at any exertional level with any reasonable continuity. Based on the totality of medical records reviewed, Ms. Heinrich is not employable in her own occupation or in any occupation, at any skill or exertional level at this time.Id. at 10. Beeman characterized Heinrich's job as "high stress and physically demanding," requiring "high level sophisticated skills and physical demands along with high aptitudes." Id. at 9. In response, Prudential Claim Manager Thomas Virgilio ("Virgilio") prepared a "SOAP Note" dated December 3, 2003, in which he concluded that Beeman's characterization of Heinrich's job was accurate but distinguished what Heinrich actually did from how the occupation normally is performed, noting that the latter is the relevant inquiry under the Plan. See Silver Decl., Ex. 26. By Virgilio's analysis, Heinrich's occupation necessitated only "light work" in the areas of lifting, carrying, pushing, and pulling, and her actual physical activities in "mov[ing] equipment, crawl[ing] under desks, etc. . . . would not be considered material and substantial." Id.
Heinrich also was examined by Dr. Oscar Abeliuk, M.D. ("Abeliuk"), a neurologist, who conducted a neurological consultation on September 11, 2003. See Silver Decl., Ex. 13. Abeliuk diagnosed Heinrich with (1) chronic fibromyalgia syndrome according to the criteria established by the American College of Rheumatology, (2) "chronic pain syndrome, sleep disturbance and chronic spinal pain," and (3) a "history of significant depression and anxiety as well as other psychological difficulties." Id. at 9. Abeliuk concluded that Heinrich had "significant residual functional capacity problems . . . as documented not only on a subjective basis but also on her clinical evaluation," noting that, "although at one point in the past she was able to work despite her fibromyalgia, she has noted significant worsening," which is "true in many patients with fibromyalgia, despite treatment." Id. at 10. He also stated that "[a]ll of these significant residual functional capacity difficulties . . . secondary to her fibromyalgia are clear-cut impairments for her to return to [her] job." Id.
On September 17, 2003, Dr. L. Neena Madireddi, M.D. ("Madireddi"), a specialist in physical medicine and rehabilitation, examined Heinrich and noted "multiple fibromyalgia tender spots" and "active trigger points" throughout the body. Silver Decl., Ex. 15 at 5-6. Madireddi also tested Heinrich's range of motion and evaluated her tenderness, sensitivity, and reflexes at various points on the body. Based on the physical examination and a review of Heinrich's medical record, Madireddi described her "impression" of fibromyalgia, lumbar strain, carpal tunnel syndrome, migraine headaches, and "history of attention deficit activity disorder." Id. at 7. Madireddi concluded that "Ms. Heinrich can not [sic] return to her prior line of work as an office system manager," that "she cannot concentrate on the tasks at hand [and] will be constantly bothered by such severe pain that she cannot work in a typical work day," and that "she is incapable of even a low stress job." Id.
On October 14, 2003, Dr. Alfred Scopp, Ph.D ("Scopp"), a licensed psychologist, prepared a neuropsychological report on Heinrich based on four examinations of her verbal and cognitive abilities. See Silver Decl., Ex. 17. Scopp conducted a number of neuropsychological tests to evaluate Heinrich's verbal skills, recall ability, speech and language functioning, and motor functioning, as well as to test whether Heinrich was malingering. The tests revealed impairment in memory and recall ability. Scopp stated that "there is clear evidence of major verbal impairment on the Verbal Memory Scale of the Memory Assessment Scale. . . . [H]er Verbal Memory is . . . at the 6th percentile." Id. at 8. Thus, Scopp concluded that "it would be impossible for her to assimilate and remember new technical information required of her job. . . . She would also have difficulty understanding her own notes of things to do, remember, understand and respond to e-mail requests from other employees, of which she receives many per day." Id. at 9.
Finally, in a letter dated October 20, 2003, Chaudhary reiterated that the "manifestations [of Heinrich's fibromyalgia] . . . make it impossible for her to function in her usual job. She is unable to concentrate on complex tasks . . . [and] her severe sleep disturbance precludes her ability to stay on a work schedule of any type." Silver Decl., Ex. 18.
In processing Heinrich's appeal, Prudential arranged for Dr. Douglas Martin, M.D. ("Martin"), who is board certified in occupational and environmental medicine, and Dr. Carroll Brodsky, M.D. ("Brodsky"), who is board certified in psychiatry, to evaluate Heinrich's claim. See Silver Decl., Exs. 28, 29, 39. Based upon a review of Heinrich's record, Martin concluded that "the medical documentation presented does not support an ongoing claim for long-term disability as a result of fibromyalgia." Silver Decl., Ex. 28 at 8. He explained that
[t]here is very little if any objective information contained within the medical report presented that shows any effect with respect to function from the standpoint of range of motion, strength, or cardiovascular problems. Rather, what I see throughout the medical records presented are claims of subjective difficulties such as pain, anxiety, difficulty coping, difficulty with stress at the job, and difficulty sleeping.Id. Martin also objected to the conclusions drawn by Heinrich's physicians on the grounds that (1) Abeliuk's report revealed "no recorded abnormality with respect to weakness of the musculature" and "seems to mix the terms `tender' and `trigger' when he talks about girdle musculature as well as other muscles identified," id. at 5, (2) Madireddi's report did not list specific degree values associated with range of motion but rather described the range of motion in relation to "what is `expected of normal,'" id. at 6, (3) Madireddi used an "invalid test" to evaluate muscular strength, id., (4) Madireddi's report did not "address the typical 18 tender points that the American College of Rheumatology considers in this diagnosis," id., (5) Scopp failed to administer a particular neuropsychological test and instead used a "relatively poor test," id., and (6) the reports of Heinrich's psychologists or psychiatrists were "somewhat difficult to interpret," due in part to "handwriting quality," id. Martin expressed his belief that Heinrich "would have much more of a significant psychological or psychiatric problem than she would with the fibromyalgia." Id. at 9. He also acknowledged an "increased association" between fibromyalgia and "psychiatric difficulties such as depression and anxiety" without concluding that there is a causal relationship between the two. Id. Finally, he questioned whether Heinrich's treatment had been adequate or appropriate and suggested that having Heinrich "resume normal activities including that of work" would constitute treatment that is "just as important as any medication or rehabilitation program" for fibromyalgia. Id.
Brodsky agreed with Martin's conclusion that "fibromyalgia does not explain all of [Heinrich's] symptoms, the pattern of her symptoms, the duration of her symptoms, or the distribution of her physical symptoms." Silver Decl., Ex. 29 at 3. Brodsky stated that "there is no evidence that [Heinrich] has a physical disorder that is producing the level of disability that she describes." Id. Further, Brodsky concluded that, "[f]rom a psychiatric standpoint alone, except for her belief that she is unable to function and would be unable to function, there is no evidence that she would be unable to do the job that she did formerly." Id. Brodsky suggested that Heinrich may have an aversion to returning to her job because of a stressful relationship with her former supervisor and stated that there also may be "some disorganizing or obtunding effects" from Heinrich's medication. Id. at 4.
In response, Madireddi and Scopp prepared reports contesting the accuracy of Martin's and Brodsky's conclusions and reaffirming their respective opinions on Heinrich's condition. See Silver Decl., Exs. 30, 33. Abeliuk issued a similar report with respect to Martin's conclusions. See Silver Decl., Ex. 31. On February 5, 2004, Dr. Charles Casella, M.D. ("Casella"), a specialist in psychiatry and neurology, performed a psychiatric evaluation of Heinrich and concluded that she is "disabled for competitive employment by a combination of her psychiatric and physical disorders" and that "[h]er fibromyalgia disorder has exacerbated her preexistent depression." Silver Decl., Ex. 32. Casella noted, however, that Heinrich's "depression in and of itself would likely not be work-disabling." Id. He also refuted Brodsky's conclusions, remarking that "there is, in fact, a wealth of data which indicates that [Heinrich] does have multiple physical disorders" and that "her emotional and psychiatric disorders . . . interact with her physical disorders in a vicious cycle." Id.
On March 14, 2004, Heinrich was awarded disability benefits from the Social Security Administration ("SSA"). See Silver Decl., Ex. 34. The award letter states that the SSA "found that [Heinrich] became disabled under [their] rules on August 8, 2002," id., the day after her last day of work. However, there is no evidence in the record as to the SSA's guidelines for determining disability or the documents that the SSA relied upon in reaching its conclusions.
In a "SOAP Note" dated April 27, 2004, Prudential Claim Manager Jill Fallon, M.D. ("Fallon") concluded, based on a review of the medical record, that Heinrich's condition was not disabling. Fallon agreed with Martin's conclusion that "there is little if any objective evidence" to support a finding that Heinrich was incapable of performing "a light or medium duty job." Silver Decl., Ex. 35. Fallon further stated that Heinrich "appears to have personality traits resulting in strong orientation toward physical illnesses and somatic explanations of her difficulties with pain, weakness and fatigue beyond medical expectations for her current physical status" but that "these [difficulties] are not disabling." Id. Fallon suggested that external stressors, such as difficulty with a new supervisor, may have prompted Heinrich's physical complaints, and she noted that Heinrich had worked for years in spite of many of her symptoms. See id.
On May 24, 2004, Prudential denied Heinrich's appeal. See Silver Decl., Ex. 39. The denial letter concluded, based on the findings in the reports of Martin, Brodsky, and Fallon, that the
[m]edical documentation reviewed does not support that there has been a change in Ms. Heinrich's long-standing condition(s) with which she has worked in the past. Professional opinions regarding Ms. Heinrich's disability status that [Heinrich has] submitted on appeal are based on her self-reported symptoms and not on objective findings, such as decreased range of motion and/or strength or significant findings of cognitive dysfunction.Id. The denial letter also summarized the findings of the various medical reports submitted by Heinrich and referred Heinrich to her copies of Martin's and Brodsky's reports for "more detailed information." Id. Prudential primarily relied on Martin's report to conclude that Heinrich was not disabled from a physical standpoint and on Brodsky's report to conclude that Heinrich was not disabled from a psychiatric standpoint.
II. LEGAL STANDARDS
A. Standard for Summary JudgmentA motion for summary judgment should be granted if there is no genuine issue of material fact and the moving party is entitled to judgment as a matter of law. Fed.R.Civ.P. 56(c); Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 247-48 (1986). Material facts are those that might affect the outcome of the case under the governing law. Anderson, 477 U.S. at 248. There is a genuine dispute about a material fact if there is sufficient evidence for a reasonable jury to return a verdict for the nonmoving party. Id. The moving party bears the initial burden of informing the Court of the basis for the motion and identifying portions of the pleadings, depositions, answers to interrogatories, admissions, or affidavits that demonstrate the absence of a triable issue of material fact. Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986). Where the party moving for summary judgment would bear the burden of proof at trial, it has the initial burden of establishing the absence of a genuine issue of fact on each issue material to its case. C.A.R. Transp. Brokerage Co., Inc. v. Darden Restaurants, Inc., 213 F.3d 474, 480 (9th Cir. 2000). Where the party moving for summary judgment would not bear the ultimate burden of persuasion at trial, it must either produce evidence negating an essential element of the nonmoving party's claim or defense or show that the nonmoving party does not have enough evidence of an essential element to carry its ultimate burden of persuasion at trial. Nissan Fire Marine Ins. Co. v. Fritz Cos., 210 F.3d 1099, 1102 (9th Cir. 2000).
If the moving party meets its initial burden, the burden shifts to the nonmoving party to present specific facts showing that there is a genuine issue of material fact for trial. Fed.R.Civ.P. 56(e); Celotex Corp., 477 U.S. at 324. The nonmoving party may not rely on the mere allegations or denials in its pleading in order to preclude summary judgment. Fed.R.Civ.P. 56(e); Anderson, 477 U.S. at 248. The evidence and all reasonable inferences therefrom must be viewed in the light most favorable to the nonmoving party. T.W. Elec. Serv., Inc. v. Pac. Elec. Contractors Ass'n, 809 F.2d 626, 630-31 (9th Cir. 1987). Summary judgment thus is not appropriate if the nonmoving party presents evidence from which a reasonable jury could resolve the material issue in its favor. Anderson, 477 U.S. at 248-49; Barlow v. Ground, 943 F.2d 1132, 1134-36 (9th Cir. 1991).
B. Standard of Review for Denial of Benefits
A denial of benefits challenged under 29 U.S.C. § 1132(a)(1)(B) is reviewed under a de novo standard unless the benefit plan gives the administrator discretionary authority to determine eligibility for benefits or to construe the terms of the plan. Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). The default is that the administrator has no discretion, and the administrator has to show that the plan gives it discretionary authority in order to get any judicial deference to its decision. Kearney v. Standard Ins. Co., 175 F.3d 1084, 1089 (9th Cir. 1999). The presumption of de novo review can be overcome only when a plan's reservation of discretion is unambiguous. McDaniel v. Chevron Corp., 203 F.3d 1099, 1107 (9th Cir. 2000). Where the benefit plan does give the administrator such discretion, a deferential standard of review is appropriate. Firestone Tire Rubber Co., 489 U.S. at 111. The deferential standard of review is referred to interchangeably as "abuse of discretion" or "arbitrary and capricious," both of which have the same meaning in this context. Hensley v. Northwest Permanente P.C. Ret. Plan Trust, 258 F.3d 986, 994 n. 4 (9th Cir. 2001).
III. DISCUSSION
To determine the appropriate standard of review, the Court must determine whether the Plan grants Prudential discretionary authority to determine eligibility for benefits or to construe the terms of the plan. See Firestone Tire Rubber Co., 489 U.S. at 109. The policy at issue contains the following language: "You are disabled when Prudential determines that . . . you are unable to perform the material and substantial duties of your regular occupation. " Silver Decl., Ex. A2 at 12. Prudential argues that the phrase "You are disabled when Prudential determines that" constitutes a grant of discretionary authority sufficient to trigger the abuse-of-discretion standard. It relies on two Ninth Circuit cases to argue that the power to "determine" or "make a determination" regarding eligibility for benefits constitutes a grant of discretionary authority. See Bogue v. Ampex Corp., 976 F.2d 1319, 1324 (9th Cir. 1992); Eley v. Boeing Co., 945 F.2d 276, 278 (9th Cir. 1991). However, both of these cases pre-date Kearney v. Standard Insurance Co., in which the Ninth Circuit clarified that the grant of discretion must be unambiguous in order to trigger the abuse-of-discretion standard. See Kearney, 175 F.3d at 1089.
Since Kearney, the Ninth Circuit has held that an "allocation of decision-making authority . . . is not, without more, a grant of discretionary authority in making those decisions." Ingram v. Martin Marietta Long Term Disability Income Plan for Salaried Employees of Transferred GE Operations, 244 F.3d 1109, 1112-13 (9th Cir. 2001). The Ingram court emphasized that it is not difficult for insurance companies to use unambiguous language in order to retain discretionary authority if they wish to do so and that the absence of such explicit language consequently should trigger de novo review. See id. at 1114. Thus, in Ingram, the language "the management and control of the operation and administration of claims procedures under the Plan, including the review and payment or denial of claims . . . shall be vested in the carrier" was found not to grant unambiguous discretionary authority but merely to "make clear that [the carrier], rather than the employer or some other party, makes all administrative decisions to grant or deny claims." Id. at 1112. In the instant case, this Court similarly concludes that the Plan language does not constitute an unambiguous conferral of discretionary authority on Prudential, and it notes that other district courts, ruling on plan language identical to the language in the instant case, have reached the same conclusion. See Flores v. The Prudential Ins. Co., No. C-03-5589 MMC, 2004 U.S. Dist. LEXIS 19492, at *16 (N.D. Cal. Sept. 16, 2004); Urso v. Prudential Ins. Co. of Am., No. 03-024-JD, 2004 U.S. Dist. LEXIS 23930, at *10 (D.N.H. Nov. 23, 2004). Accordingly, the Court will review the denial of Heinrich's claim de novo.
The Plan also states that the claimant may be required to send proof of continuing disability "satisfactory to Prudential." Silver Decl., Ex. A2. Because Prudential does not argue that such language constitutes a conferral of discretionary authority, the Court does not address this language.
Reviewing the administrative record de novo, the Court must determine whether Heinrich was disabled under the terms of the Plan during the elimination period, thus entitling her to benefits. It is undisputed that Heinrich has fibromyalgia. The parties dispute only whether Heinrich's fibromyalgia and psychiatric conditions rendered her disabled under the terms of the Plan. The record contains medical reports from Heinrich's numerous physicians, all of whom, following a physical or psychiatric examination, have diagnosed her with fibromyalgia and/or concluded that her condition rendered her unfit to work. Among other things, Heinrich's physicians specifically have concluded that the chronic pain and severe sleep disturbance associated with fibromyalgia have prevented Heinrich from being able to function in a normal work environment or to keep a normal work schedule. In concluding otherwise, Prudential primarily has relied on the report of its own reviewing physician, Martin, whose main contention is that there is no objective evidence in Heinrich's file to substantiate the alleged severity of her condition — only Heinrich's subjective reports of her symptoms. Although Martin's opinion is not unreasonable in and of itself, the Court does not find it persuasive in light of the record as a whole.
First, although Prudential bases its denial of benefits principally on a lack of objective evidence of the severity of Heinrich's fibromyalgia claim, the terms of the Plan do not specifically require "objective" medical evidence as proof of disability. Second, even if the Plan contained such a requirement, the nature of fibromyalgia — a condition that manifests as what the Arthritis Foundation describes as "generalized muscular pain," Silver Decl., Ex. 20 — is such that neither its presence nor its severity can be verified by purely objective laboratory tests. The American College of Rheumatology states that "[d]iagnosis is based on the patient's description of chronic widespread pain and the finding of tender points at specific locations by a physician" and that "[t]here are no blood or x-ray tests that are abnormal in fibromyalgia." Silver Decl., Ex. 23. Yet, despite the subjectivity inherent in diagnosing fibromyalgia, which requires patients to report their own sensations of pain and tenderness, courts have held that claimants were entitled to disability benefits due to impaired functioning resulting from fibromyalgia. See, e.g., Lang v. Long-Term Disability Plan of Sponsor Applied Remote Tech., Inc., 125 F.3d 794, 799-800 (9th Cir. 1997); Hawkins v. First Union Corp. Long-Term Disability Plan, 326 F.2d 914, 919 (7th Cir. 2003); Ellis v. Egghead Software Short-Term Long-Term Disability Plans, 64 F. Supp. 2d 986, 993-94 (E.D. Wa. 1999).
Heinrich's examining physicians noted the presence of these tender points, as well as Heinrich's complaints of other fibromyalgia-related symptoms, and thus appear to have had a medically sound basis for their diagnoses and conclusions. In opposition to these findings, Prudential's physicians primarily asserted that the severity of Heinrich's condition was substantiated only by self-reported symptoms rather than by objective evidence. However, the fact that Heinrich's physicians could not use a completely objective test to evaluate the severity of her fibromyalgia does not undermine their considered medical opinions, based on their in-person examinations, that her condition rendered her incapable of performing her occupation. Moreover, Martin's objections to the adequacy of some of the other diagnostic techniques used by Heinrich's physicians are insufficient to negate the conclusions drawn by Heinrich's multiple examining physicians, who reaffirmed their medical opinions in response to the reports of Martin and Brodsky. Of particular significance is the fact that Prudential's physicians never examined Heinrich or even spoke to Heinrich's physicians. Martin, Brodsky, and Fallon appear to have concluded that Heinrich was not disabled based only upon a review of the reports by Heinrich's physicians. Although "plan administrators are not obliged to accord special deference to the opinions of treating physicians," Black Decker Disability Plan v. Nord, 538 U.S. 822, 825 (2003), the failure of Prudential's physicians to perform their own examinations of Heinrich entitles their opinions to less weight, because fibromyalgia produces symptoms that must be reported by the patient to the physician and that can be evaluated more fully through an actual examination than by a mere review of a patient's medical record.
In addition to asserting that there is a lack of objective evidence of disability, Prudential argues that Heinrich's ability to work for several years after being diagnosed with fibromyalgia demonstrates that her condition was not disabling enough to merit disability benefits. However, there is sufficient evidence in the record — specifically, the reports of Chaudhary and Abeliuk — indicating that Heinrich's condition worsened around the time she ceased working. Moreover, a "disabled person should not be punished for heroic efforts to work by being held to have forfeited his entitlement to disability benefits should he stop working." Hawkins, 326 F.3d at 918.
Finally, in the process of arguing about whether Heinrich was able "to perform the material and substantial duties of [her] regular occupation, " Silver Decl., Ex. A2 at 12, the parties dispute the appropriate characterization of Heinrich's occupation. Based on Beeman's report, Heinrich argues that her position at Knight-Ridder was a hybrid position that encompassed the responsibilities of a number of occupations as described in various occupation resource handbooks. See Silver Decl., Ex. 6 at 7. Beeman concluded that Heinrich's position was best classified as "medium exertional," occasionally rising to "heavy exertional." Id. Prudential's claim manager, Virgilio, acknowledged the accuracy of Beeman's analysis of the character of the tasks actually performed by Heinrich but asserted that Heinrich's occupation, as normally performed in the market rather than for Knight-Ridder specifically, should be classified as being in the "light work" range. Silver Decl., Ex. 26. This dispute need not be resolved by the Court for present purposes, as the reports from Heinrich's physicians appear to conclude that she was incapable of performing any duties of her occupation during the elimination period and thus was disabled under the terms of the Plan, regardless of the specific exertion level required by a given task. See Silver Decl., Exs. 13-19.
For the foregoing reasons, the Court concludes, based on a de novo review of the evidence in the administrative record, that Heinrich was disabled under the terms of the Plan for the duration of the elimination period and was entitled to disability benefits. The case will be remanded to Prudential for a determination of the scope of benefits owed to Heinrich in light of this conclusion. As the Court's review is limited to decisions actually made by Prudential — specifically, its conclusion that Heinrich was not disabled during the elimination period — the Court will not address the parties' arguments regarding potential limitations on the length of time Heinrich can receive benefits. Such matters properly should be determined by Prudential in the first instance, and Heinrich retains the right to challenge Prudential's decision administratively and, after exhausting her administrative remedies, through the courts. Defendants shall determine the scope of benefits owed to Heinrich within ninety days of the date of this Order, which is the same amount of time provided for a plan administrator to notify a claimant of a benefits determination. See 29 C.F.R. § 2560.503-1(f)(1).
For example, the Plan provides that "[t]he limited pay period for self-reported symptoms and mental illness combined is 24 months during your lifetime," Silver Decl., Ex. A2 at 21, and it gives Prudential the right to request proof of continuing disability, id. at 25.
At the hearing on the instant motions, Heinrich's counsel requested that, should Heinrich prevail on summary judgment, the time to file a motion for attorney's fees be extended to thirty days. A motion for attorney's fees normally must be filed within fourteen days of entry of judgment, though the time may be extended either by stipulation pursuant to Civil Local Rule 6-2 or by motion pursuant to Civil Local Rule 6-3. Civil L.R. 54-6(a). The Court will act on the request by Heinrich's counsel upon receipt of one of the aforementioned documents.
IV. ORDER
Good cause therefore appearing, IT IS HEREBY ORDERED that Heinrich's motion for summary judgment is GRANTED, Defendants' motion for summary judgment is DENIED, and the instant case is remanded for determination of benefits consistent with the findings and conclusions set forth herein.