Opinion
Case No. 1:01-CV-179
August 28, 2001
ORDER
In accordance with the opinion entered on this date, the Court hereby ORDERS that:
Defendant Medtronic, Inc's motion for judgment on the administrative record (Docket # 9) is DENIED; Plaintiff
Lamoreaux's motion for judgment on the administrative record (Docket # 10) is GRANTED; and the decision of the
ERISA board terminating Plaintiff's long-term disability benefits is REVERSED. Plaintiff's long-term disability benefits are REINSTATED retroactive to August 1, 1999.
OPINION
In this ERISA case the Court reviews the decision of the plan administrator, Defendant Medtronic, Inc., that Plaintiff is not disabled under the provisions of the ERISA plan. Plaintiff Susan Lamoreaux asserts that the plan administrator was in error when it decided that she was not disabled under the plan and consequently terminated her long-term disability benefits. Upon review of the administrative record, the Court finds that the great weight of the evidence indicates that Plaintiff is disabled under the provisions of the ERISA plan and that the plan administrator was in error. The decision of the plan administrator is reversed.
Facts
Plaintiff Susan Lamoreaux, 43 years old, began having back problems in 1982. In 1982 and 1987 she had lamenectomies to relieve her back pain. On March 23, 1995, she was hired by Medtronic, Inc., after a back exam showed her condition would not prevent her from performing the light assembly work required at Medtronic.
Excision of a portion of a vertebra to allow room for an exiting nerve root.
In May of 1995 Plaintiff began again to experience back pain. After pursuing medical care over the next year, in May of 1996 Plaintiff went on short-term disability and leave of absence for a third lamenectomy. That surgery was performed on May 15, 1996, by Dr. Vicente Garcias.
In August of 1996 Dr. Garcias noted that while Plaintiff's motor abilities were within tolerable limits, an MRI indicated "narrowing" where the two earlier lamenectomies had been performed. Dr. Garcias recommended non-surgical treatment for continued pain. Following consultation with Dr. Garcias, Plaintiff began receiving treatment for pain from Dr. Thomas Basch. In October 1996 Dr. Basch recommended Plaintiff not return to work.
On October 26, 1996, Plaintiff began twelve months of short-term disability under the terms of the ERISA plan. Under the ERISA plan, a beneficiary is eligible for short-term disability if the beneficiary is "prevented from performing the essential functions of your regular occupation because of an illness or accidental injury." See AR at 546. Those short-term disability benefits ran until October 26, 1997, when Medtronic informed Plaintiff that her short-term disability benefits were ending, and she should file for long-term disability.
In December 1996, Dr. Basch stated that Plaintiff could return to work, with certain limitations, for four hours a day, and that Plaintiff should return to work in January 1997.
On February 1, 1997, Plaintiff returned to work, and after two weeks had another consultation with Dr. Basch. At that time Dr. Basch recommended that because of Plaintiff s chronic pain she once again should go on medical leave.
On March 10, 1997, Medtronic arranged an Independent Medical Exam ("IME") with Dr. John Visser. That exam determined that Plaintiff could not return to her regular occupation because of its demands of sitting for ninety percent of the time. Dr. Visser concluded, in part:
Because of her limitations in terms of her low back and left leg pain, difficulty sitting, and inability to bend or stoop, I think she would be unable to perform any type of work, because almost any type of work requires the employee to be able to do some of these activities on a daily basis.
AR at 169 (emphasis added).
In June and July 1997, Plaintiff met with Dr. Raymond Jaglowski (who was her family physician), and an RN rehabilitation specialist. In July 1997 Dr. Jaglowski stated that Plaintiff could return to work with certain restrictions. After an MRI in October of 1997, Dr. Jaglowski referred Plaintiff to Dr. Joseph O'Donnell. In December 1997, a fourth lamenectomy was performed.
In May 1998, Medtronic scheduled a second IME with Dr. Samson Ho. Although the exam was completed, Dr. Ho never made a report to Medtronic.
In July 1998, after Plaintiff complained of more back pain, Dr. O'Donnell received a new MRI report on Plaintiff. The report indicated "further disk abnormalities" and that the "recurrent disk is now gone." AR at 161. Dr. O'Donnell also said that further surgery was not an option, and that if Plaintiff continued to experience severe pain, she was a candidate for insertion of an internal morphine pump (manufactured, ironically, by Medtronic, Inc.). On October 20, 1998, Plaintiff once again saw Dr. Jaglowski. Dr. Jaglowski reported that:
Because of the severity and progression of her pain, I've instituted an OxyContin program for her and am seriously considering referring her back to pain management anethesiologist in regards to the possibility of reflex sympathetic dystrophy. I think she'll be disabled for the rest of her life and hopefully will find some way of controlling her pain better.
AR at 140 (emphasis added).
During this time Medtronic arranged for a third IME on October 23, 1998, this time with Dr. Edward Trachtman. Dr. Trachtman concluded:
The patient has apparently not responded well to epidural injections and none of the other treatment appears to have helped much. She had four months of physical therapy and that did not help either. I think that she has probably reached her maximal medical improvement except for controlling her symptoms with medication. I really do not see where treatment would be of great benefit for her except for medications. . . . [H]er work activities would need to be sedentary with a sit/stand option. She should also do limited bending and lifting of no more than ten pounds. I would not expect these restrictions to change any time in the foreseeable future.
AR at 138.
As a follow-up to Dr. Trachtman's report, Plaintiff received a Functional Capacity Evaluation ("FCE") on December 7, 1998. The therapist who performed the FCE concluded that:
Tolerances offered during this evaluation were within "sedentary" Physical Demand Levels as defined by the U.S. Department of Labor. However, [Mrs. Lamoreaux] demonstrated inconsistencies and evidence of submaximal effort, and there is questionable validity of tolerances demonstrated today.
AR at 133.
On April 15, 1999, Dr. Trachtman concluded that Plaintiff could not perform any of the jobs listed at Medtronic.
On July 1, 1999, Dr. Jaglowski forwarded a letter to Plaintiff indicating that neither he nor Dr. O'Donnell felt that she was "malingering" in efforts to deal with her physical ailments. Dr. Jaglowski and Dr. O'Donnell suggested pursuing the option of a surgically-placed morphine pump. See AR at 124.
On July 17, 1999, Midwest Case Management provided an assessment in which it concluded that there were 202 occupations which Plaintiff could perform, based on the FCE. Midwest also listed six job leads in the Grand Rapids area in those occupational areas. These were
1. Appointment setter/telemarketer.
2. Parking operation attendant at Kent County Airport.
3. Alarm dispatcher.
4. Customer service at Michigan Bulb.
5. Gayle Corporation.
See AR at 36-37.
Plaintiff received long-term disability benefits from Defendant from October 26, 1997 until August 1, 1999, when Defendant terminated Plaintiff's long-term disability benefits.
See AR at 16. On October 20, 1999, Plaintiff filed an appeal with Medtronic's ERISA board, which was denied. Plaintiff subsequently filed this suit.
Analysis
The Court reviews de novo the plan administrator's denial of ERISA benefits, unless the plan provides discretionary authority to the administrator. Here, the plan does not provide such discretion, so the Court reviews the decision de novo. See Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101 (1989); Wilkins v. Baptist Healthcare Systems, Inc., 150 F.3d 609 (6th Cir. 1998). The de novo standard applies to both factual and legal determinations. See Rowan v. Unum Life Insurance Co., 119 F.3d 433 (6th Cir. 1997 ).
The Court is confined to the administrative record in making its determination. See Perry v. Simplicity Engineering, 900 F.2d 963 (6th Cir. 1990); see also Rowan, 119 F.3d 433.
The determination before the Court concerns Plaintiff's eligibility under the long-term disability clauses of Medtronic's ERISA plan. To be eligible for benefits, a beneficiary must be totally disabled. "Totally disabled" is defined in the plan:
To be considered totally disabled . . . your illness or injury must prevent you from working at any occupation for which you are, or could reasonably become, qualified by education, training, or experience.
AR at 546 (emphasis in original).
The question, then, is whether there is any occupation Plaintiff could perform, or whether the pain of her condition renders her disabled for any occupation. Doctors Jaglowski and Visser state that Plaintiff is disabled. Dr. Trachtman states that, so long as certain restrictions are followed, Plaintiff could perform some jobs.
In October of 1998 Dr. Trachtman evaluated Plaintiff s condition and concluded that although Plaintiff could not return to work at Medtronic, is was possible for her to work in some position with limitations. Medtronic was then able, through Midwest Case Management, Inc., to document six positions in the Grand Rapids area Plaintiff could perform within those restrictions. If that was all the administrative record contained, this would not be a close case.
Dr. Trachtman's opinion, however, is contradicted by two other medical opinions in the record, those of Dr. Jaglowski and Dr. Visser. Dr. Jaglowski's opinion that Plaintiff was totally disabled was issued at about the same time as Dr. Trachtman's opinion, while Dr. Visser's opinion that Plaintiff could not perform "any job" was issued in March of 1997, about one and a half years before Dr. Trachtman's opinion.
Defendant argues that Dr. Jaglowski's opinion must be discounted because it did not provide objective evidence of disability, and because Dr. Jaglowski is a family practitioner, not a medical specialist. The Court finds that Dr. Jaglowski's opinion is supported by the objective evidence in the record, that his opinion is supported by that of Dr. Visser, and that his opinion should be given some deference because of his familiarity with Plaintiff and Plaintiffs medical history.
Two cases, Marchetti, Jr. v. Sun Life Assurance Co. of Canada, 30 F. Supp.2d 2001 (M.D.Tenn. 1998), and Durr v. Metropolitan Life Ins. Co., 15 F. Supp.2d 205 (D.Conn. 1998), are particularly helpful in weighing conflicting medical opinions evaluating long-term disability.
In Marchetti a salesman was denied long-term disability benefits despite his treating physician's opinion that the condition rendered him disabled. The Marchetti court reversed the ERISA denial of long-term disability benefits, largely because it attributed greater weight to the opinion of the plaintiffs family physician over the opinion of the IME physician. Moreover, the court overturned the board despite applying the arbitrary and capricious standard. The court stated that "[a]s a general rule, more weight should be given to the opinion of a treating source than to the opinion of doctors who do not treat the claimant." Marchetti, 30 F. Supp.2d at 1009. The Marchetti court also gave greater weight to the family or treating physician because of what it called the "inherent self-interest" in denying benefits that occurs when the administrator engages independent medical examiners. Id. Here, Dr. Jaglowski is the treating or family physician. Furthermore, the Plaintiff has a lower de novo standard to meet here, rather than the arbitrary and capricious standard faced by the plaintiff in Marchetti.
Defendant points out, however, that in Marchetti the court also said that "where the treating doctor's opinion is not contradicted by another doctor, it may be rejected only for `clear and convincing' evidence." Marchetti, 30 F. Supp.2d at 1009. Defendant argues that in the present case, the IME physician's opinion is directly contrary to that of Dr. Jaglowski, the treating physician. Defendant overlooks the fact that after an earlier IME Dr. Visser stated that he did not think Plaintiff could perform "any type of work."
Similarly, in Durr v. Metropolitan Life Ins. Co., 15 F. Supp.2d 205 (D.Conn. 1998), the plaintiff was denied long-term disability benefits because independent medical examiners declared that plaintiff s susceptibility to aneurisms did not render him totally disabled. That court overturned the decision of the ERISA board despite applying the arbitrary and capricious standard. The Durr court gave the treating physician's opinion "substantial weight" in overturning the decision of the board.
Defendant argues that under Durr Dr. Jaglowski's opinion should not be given deference because he was not the "treating" physician. The Durr court, however, appears to use the term to differentiate the physician overseeing a patient's long-term care from a doctor brought in merely to take a snapshot of a patient's health at a point in time. The record indicates not only that Dr. Jaglowski was Plaintiffs family doctor, but also that he worked closely with the specialists and surgeons in recommending various avenues of treatment. It would appear that of the physicians mentioned in the record, Dr. Jaglowski comes closest to meeting the definition of a treating physician.
In addition, the Durr court enumerated five factors to use in determining the weight accorded to a treating physician's opinion:
(1) evidence in support of the opinion; (2) the opinion's consistency with the whole record; (3) the nature of the physician's relationship to the patient; (4) whether the opinion is from a specialist; and (5) other relevant factors. See Durr, 15 F. Supp.2d, at 213. Here, Dr. Jaglowski saw Plaintiff over a number of years, and knew her well; his opinion is consistent with Dr. Visser's report on the IME; the opinion is supported by the medical record; and, as an additional factor, there is no conflict of interest. Moreover, Dr. Trachtman's evaluation is a mere snapshot of Plaintiffs medical condition. The Court must consider not just one frame of Plaintiffs medical history, but the entire record. The objective evidence of that record supports the conclusions of Dr. Visser and Dr. Jaglowski that Plaintiff is disabled.
Defendant also asserts that Plaintiff is not disabled under the plan because there are at least six jobs in the Grand Rapids Area that Plaintiff is capable of performing. See AR at 36-37. Dr. Trachtman placed significant restrictions upon any work Plaintiff would be able to do, stating that she would need to be in a sedentary job with a sit/stand option and no lifting over 10 pounds. See AR at 138. Even without the medical opinions of Dr. Jaglowski and Dr. Visser, it is doubtful that Plaintiff could work at any of the positions listed by Midwest Case Management. Each of the positions requires sitting for a long period of time. Even the one that could allow some flexibility, a Kent Count Airport parking attendant, would require twisting to the window and leaning and reaching to collect the fees proffered by patrons of the airport.
If one factors in the restrictions imposed by Dr. Basch in January 1997, the list of positions seem even further outside the realm of possibility. Dr. Basch restricted Plaintiff to: No lifting over 15 pounds; No repetitive bending or twisting; Must be able to change position every half hour; Must have a sit/stand option; May work four hours a day; No over-head lifting; No repetitive reaching away from the body; and Must work at waist height. Certainly any of these positions fall outside the recommendations of Dr. Jaglowski and Dr. Visser. Based on these factors and other objective evidences in the record, the weight of the evidence indicates that Plaintiff simply could not perform these jobs.
See AR at 156.
Finally, Defendant's counsel stated at oral arguments that under the plan Plaintiff was required to pursue those positions listed by Medtronic that it believed Plaintiff could perform. The Court finds no such requirement in the plan. According to the record, Plaintiffs longterm disability benefits may be terminated if one of four conditions are met: (1) Beneficiary reaches age 65; (2) beneficiary no longer meets the plan's definition of disabled; (3) beneficiary refuses an IME by a company-selected physician; or (4) beneficiary refuses an offer of rehabilitation employment.
It is evident from the record that Plaintiff is not yet 65; meets the plan's definition of disabled; has completely cooperated in meeting with Medtronic-selected physicians; and has not been offered rehabilitation employment. Therefore, there was no basis under the plan to end Plaintiff's long-term disability benefits.
The great weight of the evidence favors Plaintiffs entitlement to long-term disability and the plan administrator's error. The Court finds that Plaintiff is disabled under Medtronic's ERISA plan. Accordingly, an order consistent with this opinion will be entered.