Opinion
CASE NUMBER: 05-74741.
March 20, 2007
ORDER
I. INTRODUCTION
This is an employee benefits case governed by the Employment Retirement Income Security Act of 1974, as amended, 29 U.S.C. 1001 et seq. ("ERISA"). Allen Perryman ("Plaintiff") is suing AVAYA, Inc. Long Term Disability Plan ("Defendant"). He claims that it wrongfully terminated and denied his long-term disability benefits. Plaintiff says he is unable to work as a result of suffering from Deep Vein Thrombosis and Pulmonary Embolus. Before the Court is Defendant's motion to affirm its administrative decision and Plaintiff's motion to reverse Defendant's administrative decision. For the reasons that follow, Defendant's motion is GRANTED; Plaintiff's motion is DENIED.
II. LEGAL STANDARD — ENTRY OF JUDGMENT
The Court will decide this matter under the guidelines set forth in Wilkins v. Baptist Healthcare Sys. Inc., 150 F.3d 609 (6th Cir. 1998). Findings of fact and conclusions of law are issued based solely on the administrative record. Id; see also Eriksen v. Metro. Life Ins. Co., 39 F.Supp.2d 864 (E.D.Mich. 1999).
III. ANALYSIS
A. Findings of Fact
For almost nine years, Plaintiff was employed by Defendant as an occupational employee holding the position of Senior Production Specialist. Plaintiff's position required him to stand for two hours, walk intermittently, and sit frequently for short time periods. As an employee, Plaintiff was eligible for and participated in a long-term disability ("LTD") plan. LTD benefits are self-funded by Defendant through a trust. GatesMcDonald is the claims administrator for LTD benefits.
Plaintiff was diagnosed with Deep Vein Thrombosis ("DVT") and Pulmonary Embolus ("PE"). On January 16, 2002, he applied for and received 52 weeks of short-term disability benefits pursuant to the terms of Defendant's Sickness and Accident Disability Plan. Prior to conclusion of his short-term benefits, on December 5, 2002, Plaintiff applied for LTD benefits. His treating physician, James Steier, D.O., provided documentation listing DVT and peripheral edema as the conditions contributing to or causing Plaintiff's disability. Dr. Steier stated that Plaintiff was unable to work because he was at risk for repeat DVT and PE, had severe leg pain and swelling, and edema in his legs, all of which was further complicated by Plaintiff's obesity. The documentation also indicated that Plaintiff's condition was so severe he was incapable of minimal sedentary activity.
Based upon this diagnosis, LTD benefits were approved and paid from January 16, 2002 through September 23, 2003. GatesMcDonald requested and received medical documents from Dr. Steier regarding Plaintiff's weight. The records revealed that Plaintiff suffered from obesity and was scheduled for gastric bypass surgery.
Under the LTD Plan, Plaintiff was periodically required to submit proof of his disability to the claims administrator. In June 2003, Karen Fletcher, a registered nurse and medical case manager ("MCM"), requested additional and updated medical records regarding Plaintiff's condition. She did not immediately receive a response. During this same time period, Plaintiff applied for and was denied social security disability benefits. The Social Security Administration ("SSA") stated the following as its reason for denial:
We also considered all information supplied by you, others you may have identified that know about your condition, and sources contacted during the adjudication of this claim.
You said you were unable to work because of deep vein thrombosis, pulmonary embolus, edema, SOB, pain and blisters. The evidence shows that you are overweight and have a history of treatment for these problems. Dr. Steier said that you were prevented from doing even minimal activity. We have considered his opinion, but are unable to let anyone decide for us if you are disabled. Other evidence shows that you are able to stand and walk normally, and you do not have blisters or open sores at the current time. You are unable to do work that requires lots of standing and walking and will require normal breaks to elevate your leg. You are able to do work that is mostly seated in nature. You are able to return to your past job in customer service, as the job is usually performed.
Further, SSA noted that other trained personnel and physicians reviewed the file and participated in the decision.
In July 2003, Plaintiff stated in a phone conversation with the MCM that he and his wife were moving from Nebraska to Michigan because she received new employment. The MCM noted that Plaintiff traveled several times by airplane to Michigan in search of a home. The MCM also noted that Plaintiff flew from Omaha, Nebraska to Dallas, Texas for a family reunion.
On July 29, 2003, August 4, 2003, and again on September 8, 2003, MCM Fletcher faxed Dr. Steier, requesting office notes and reports related to Plaintiff's condition and his most recent consultation in July. On September 16, 2003, the MCM spoke with Plaintiff and requested updated medical information. She also informed him that the current information was not sufficient to continue LTD benefits. It is unclear whether much of the information requested from Plaintiff on September 16, 2003, and again on September 23, 2003, was received prior to Defendant's benefit determination. However, Dr. Steier's medical records indicated that as of September 5, 2003 Plaintiff's condition was the "same" and he was continuing the "same" treatment.
On September 24, 2003, after reviewing Plaintiff's file, GatesMcDonald concluded that there was no objective evidence to support disability. Specifically, the letter stated "your LTD benefits are being denied because medical reports are not sufficient to support LTD. Also, the ability to travel via airplane to and from Nebraska to Michigan frequently in the past one-two months does not support a disability."
Under the LTD Plan, the party seeking benefits "must be unable to do any job for any employer for which [he is] qualified, or for which [he] may reasonably become qualified by training, education, or experience, other than one that pays less than 50% of [his] eligible base pay at the time you became disabled." Based on this definition, Defendant issued a letter to Plaintiff denying benefits and advising him of his right to appeal.
On November 24, 2003, Plaintiff did appeal the decision. In support of his appeal and in response to the MCM's request for updated information, he submitted an October 2, 2003 letter from Dr. Steier stating that he was totally disabled due to his DVT and PE; that his healthcare required bed rest and elevated legs; and that he needed gastric stapling for his chronic obesity.
In opposing the appeal, MCM Karen Fletcher provided a case summary and recommended as follows:
Initial LTD was supported by objective medical findings reported by the provider. The earlier complaints of skin changes, severe pain and skin warm to the touch are not noted in the more recent reports. Dr. Steier's letter of 10/2/03 stated that Mr. Perryman was "totally disabled." He provided diagnoses of DVT and severe peripheral edema with a complication of obesity. According to Presley Reed Medical Disability Guidelines, there are no specific disability ranges for DVT. Disability could range from "several weeks to several months . . . may be permanent." Guidelines for Obesity state that "some obese individuals, especially those who are morbidly obese, may no longer be able to perform their duties efficiently since obesity tends to tire them out more easily . . . accommodations may include the possibility of a more sedentary position or one that incorporates limited exertion." However, the office notes from July 2003 forward do not contain objective findings to support continued disability for either DVT or obesity.
Although the criteria for SSDI and LTD differ, the findings of the Social Security Administration support that Mr. Perryman would be able to work in a sedentary position. The lack of objective findings in the recent office notes would also tend to support the position that Mr. Perryman could work in [sic] sedentary type position.
It seems clear that Mr. Perryman is overweight and is at risk for DVT. According to the doctor, this will not resolve until he has lost weight. Mr. Perryman opted not to pursue gastric bypass surgery in July due to the move to Michigan. There is no evidence that he has scheduled the surgery at this time and there is no evidence that he sought treatment from a provider in Michigan. This delay, when taken together with the travel and lack of objective findings reported tend to support that Mr. Perryman's condition is not so severe as to be totally disabled. There is little evidence to indicate that Mr. Perryman is unable to work in, at least, a sedentary position at this time. The MCM is unable to recommend continued LTD at this time.
With this recommendation and findings from MCM Fletcher, the Benefits Claim and Appeal Committee ("BCAC") upheld the denial of benefits. On December 14, 2005, Plaintiff filed suit to reverse the final determination to deny benefits.
B. Conclusions of Law
1. Standard of Review
Sanford v. Harvard Indus., Inc.262 F.3d 590597 Shields v. Reader's Digest Ass'n Inc.331 F.3d 536541Daniel v. Eaton Corp.839 F.2d 263267Baker v. United Mine Workers of Am. Health Retirement Funds 929 F.2d 11401144
2. Long Term Disability Benefits
The administrative record supports the conclusion that Defendant's decision was both reasonable and "rational in light of the plan's provisions."
Defendant's stated reason for denying benefits was that Plaintiff's medical records did not substantiate that he was disabled and unable to work with restrictions. Plaintiff argues that the conclusions of his treating physician establish that he is disabled.
The administrative record indicates that Dr. Steier examined Plaintiff for his alleged disability in July 2003 and determined that his condition was the same as in December 2002. However, no objective medical evidence supported this conclusion as it had when Dr. Steier first reported Plaintiff's conditions of DVT and PE. Then, Dr. Steier noted severe leg pain, swelling, and edema. The earlier complaints of skin changes, severe pain and skin warm to touch are not noted in the more recent reports. Aside from this statement that Plaintiff's condition was the "same," Dr. Steier provided Defendant with no other objective medical evidence. From July, 2003 forward, Dr. Steier's office notes do not indicate swelling or severe leg pain. Rather, his July 22, 2003 office notes only state that Plaintiff's medicine dosage needs to be altered; that Plaintiff needs weight loss and probably will require surgery; and that Plaintiff was moving to Michigan.
Plaintiff admitted that he was able to travel and leave his house for extended-periods of time during the same time period. MCM Fletcher's notes indicate that from July 30, 2003 to September 16, 2003, Plaintiff stated he traveled by airplane to Michigan approximately every two weeks despite Dr. Steier's March 12, 2003 diagnosis that Plaintiff needed bed rest and to elevate his legs until he underwent gastric bypass surgery. The administrative record, however, indicates that Plaintiff decided to forego the surgery and did not seek out a new physician once he moved to Michigan. This evidence and Plaintiff's admissions undermine Dr. Steier's opinion. Therefore, Defendant concluded that Plaintiff's file showed a lack of "objective findings to support the disability reported."
Numerous courts hold that an administrator's decision to deny benefits is reasonable and rational in the absence of objective medical evidence to substantiate the claim of disability. Davis v. Broadspire Serv., Inc., No. 04-74792, 2006 WL 752602 (E.D.Mich. March 23, 2006) (plan administrators decision to deny benefits was rational when none of the plaintiff's treating physicians provided objective medical evidence to support their disability diagnosis); see also Mossoian v. DaimlerChrysler Co., No. 06-11272, 2006 WL 3206074 (E.D.Mich. November 3, 2006); Stano v. Lumberman Mut. Cas. Co., No. 06-10842, 2007 WL 171601 (E.D.Mich. Jan 18, 2007).
In reviewing a plan administrator's denial of benefits, this Court is not a "rubber stamp." Moon v. Unum Provident Corp., 405 F.3d 373, 379 (6th Cir. 2005). Defendant's denial of benefits must be upheld only if it is rational in light of the plan's provisions. Spangler v. Lockheed Martin Energy Sys., Inc., 313 F.3d 356, 361 (6th Cir. 2002). On this record, the Court finds that Defendant acted rationally to deny Plaintiff's benefits; no objective medical evidence indicated that he is unable to perform any occupation.
Nevertheless, Plaintiff argues that Defendant acted arbitrarily and capriciously in rejecting the opinion of Dr. Steier. Both parties agree that Defendant is not obligated to defer to Dr. Steier's opinion or findings of alleged disability. Black Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003) (rejecting the application of the "treating physician" rule to ERISA cases). Plaintiff, however, contends that, as his treating physician, Dr. Steier's findings should not be completely discounted. While it is true that Defendant did not embrace the disability conclusions of Dr. Steier, this Court does not agree that Defendant discounted them. Dr. Steier provided unsupported and unexplained statements that Plaintiff is "totally disabled." Defendant chose not to rely on this opinion because it was not supported by objective medical evidence.
"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." Black Decker Disability Plan, 538 U.S. at 834. Neither Defendant nor this Court must give special deference to Dr. Steier's opinion.
Moreover, "when a plan administrator chooses to rely upon the medical opinion of one doctor over that of another in determining whether a clai