ANDRÉ BIROTTE Jr., District Judge.
This Employment Retirement Income Security Act ("ERISA") action concerns the termination of Plaintiff Sandeep Hans's long-term disability ("LTD") benefits and life waiver of premium (LWOP) benefits, pursuant to 29 U.S.C. § 1132 et seq. (See Complaint, Dkt. No. 1.) Plaintiff seeks to overturn the termination of his ERISA-governed benefit plans (collectively the "Policy"). Defendant Unum Life Insurance Co. ("Unum"), acting on behalf of Plaintiff's former employer Defendant E & J Gallo Winery ("Gallo") terminated Plaintiff's disability benefits.
On March 9, 2015, the Parties submitted Opening Briefs. (Plaintiff Brief ("PB"), Dkt. No. 45; Unum Brief ("UB"), Dkt. No. 46.) The Administrative Record ("AR") was also submitted on March 9. (AR, Dkt. No. 44.) On March 23, 2015, the Parties submitted Responsive Briefs. (Plaintiff Response ("PR"), Dkt. No. 52; Unum Response ("UR"), Dkt. No. 53.) On March 31, the Parties submitted Findings of Fact and Conclusions of Law. (Unum ("UFL"), Dkt. No. 55; Plaintiff ("PFL"), Dkt. No. 56.) The Court, sitting without a jury, commenced a bench trial on April 7, 2015. (Bench Trial, Dkt. No. 60.)
Having heard oral argument and having considered the materials submitted by the Parties, the Court finds for Unum under the following findings of fact and conclusions of law pursuant to Federal Rule of Civil Procedure 52(a).
1. This Court has jurisdiction of this ERISA matter pursuant to 29 U.S.C. §§ 1132(a), (e), (f), (g), and 28 U.S.C § 1331. The matter concerns a dispute over Plaintiff's benefit plans.
2. On January 1, 2000, Unum, acting on behalf of Defendant E & J Gallo Winery, issued the Group LTD Policy Number 54954001 (the "LTD Policy").
3. To qualify for benefits under the LTD Policy, Unum must determine that you are disabled. To prove that you are disabled, one must prove:
(AR 837.)
(AR 837 (emphasis added).) "Gainful Occupation is one that within 12 months of your return to work is or can be expected to provide you with an income that is at least equal to 60% of your annual earnings in effect just before your date of disability began." (AR 6315, 6962.)
5. Unum will also evaluate the disability while one is working in another occupation.
(AR 837.)
6. Unum will stop sending you disability payments and your claim will end on the earliest of the following:
(AR 79-80, 837 (emphasis added).)
7. Unum's life insurance policies are Group Life Policies Number 549454 002 with a benefit of $200,000 ("the Base Life Policy") and Number 549454 002 with a benefit of $100,000 ("the Supplemental Life Policy"). (AR 6283-6317; 6919-6964.)
8. The Life Policies provide LWOP when an insured is disabled from any gainful occupation up to age 65. (AR 6302, 6945.) The Life Policies allow conversion of coverage within thirty-one (31) days after employment terminates. (AR 6303-6307, 6946-6953.)
9. From January 1999 to May 2002, Plaintiff worked as a computer programmer for Gallo. (AR 100, 121, 2809); (PFL ¶¶ 5-6.) The occupation of "programmer/analyst" is rated "sedentary" in physical strength demand. (UFL ¶ 21.) Plaintiff's job duties as a programmer/analyst at Gallo required sitting 5 hours a day, standing 2 hours a day and walking 1 hour a day, lifting up to 20 pounds, and frequently lifting less than 10 pounds. (UFL ¶ 22.)
10. Plaintiff earned a yearly salary of $71,000 until the date of his disability, May 8, 2002. (AR 11, 100, 349); (PFL ¶ 7.) Plaintiff's disability symptoms consisted of vertigo, fatigue, memory and concentration complaints, anxiety and depression. (AR 2706-3205.)
11. On May 2, 2002, Dr. Donald Howe treated Plaintiff for stiffness and soreness on his neck, body fatigue, and forgetfulness leading to nervousness. (AR 224); (PFL ¶ 10.) On May 7, 2002, Dr. Howe conducted an objective examination and a MRI on Plaintiff. (AR 229.) The results came back normal. (AR 173); (PFL ¶ 12.) Plaintiff was referred to a neurologist. (AR 229.) A neurological examination was taken and the results also came back normal. (AR 255-6.)
12. On May 20, 2002, Plaintiff returned back to Dr. Howe's office to be examined by a nurse. (PB 2.) The nurse noted that Plaintiff's symptoms were "bad enough that he is unable to work. He really wants to go back to work." (AR 240.) The nurse referred Plaintiff to have a ear, nose, and throat consultation (ENT).
13. Dr. C. Alan Yates is an ENT specialist. On May 29, 2002, Dr. Yates examined Plaintiff using an audiogram. The results showed that Plaintiff had mild hearing loss. (AR 280.)
14. On June 20, 2002, Dr. Howe completed Unum's Attending Physician Statement. (PB 3.) Due to Plaintiff's symptoms of dizziness, pain, and fatigue, Dr. Howe opined that Plaintiff was totally disabled. (AR 102.) The diagnosis confirmed Plaintiff's vertigo, otitis media (ear infection), and fatigue symptoms. (AR 102.) Dr. Howe stated Plaintiff could return back to full-time work by July 1, 2002. (Id.)
15. On June 28, 2002, Plaintiff returned back to Dr. Howe. (AR 193.) Due to Plaintiff's symptoms, Dr. Howe ordered Plaintiff to remain off work until August 1, 2002. (AR 199.)
16. In July 3, 2002, a bilateral carotid artery color doppler sonography came back normal. (AR 167.)
17. On October 25, 2002, Plaintiff began treating with Dr. Russell Porter, another physician in Dr. Howe's office. (AR 2928); (PFL ¶ 51.) Plaintiff informed Dr. Porter he was ready to return back to work. (Id.) Dr. Porter cleared Plaintiff to return back to work on November 1, 2002, and Plaintiff began working again on that day. (Id.) However, because of his symptoms, Plaintiff stopped working on November 7, 2002. (AR 384.)
18. Because Plaintiff's symptoms continued to persist, Plaintiff sought treatment in India from November 18, 2002 to January 31, 2003. (AR 383.) Dr. Ramakant Jagpal certified Plaintiff's need for rest during that period. (Id.) Subsequently, Plaintiff returned to the U.S. and resumed treatment with Dr. Porter in June 2003. (AR 617-618.)
19. To ensure that Plaintiff's symptoms were not cognitive, on August 11, 2003, Dr. James Wakefield conducted a psycho-diagnostic evaluation. (AR 1340.) Dr. Wakefield pointed to Plaintiff's difficulty in performing minimal activities including driving his son to school, walking the dog, helping his son study, and watching his children play. (AR 1340.) Dr. Wakefield continued to opine about Plaintiff's mood being "frustrated" because of his condition and inability to work. (AR 1341.) The results showed Plaintiff's intellectual ability to be in the average percentile. (AR 1343.)
20. After receiving results from the evaluation, Dr. Porter still found little explanation for Plaintiff's symptoms. Dr. Porter noted that anti-depressants were going to be prescribed to rule out somatization, which is a chronic disorder where psychological distress produces physical symptoms.
21. On March 1, 2004, the Social Security Administration ("SSA") determined Plaintiff had been disabled since May 7, 2002. (AR 564.) Dr. Susan Regan reviewed Plaintiff's medical records and concluded that Plaintiff suffered a loss in intellectual abilities. (AR 3008.) She also reviewed Dr. Wakefield's tests and concurred with his results. (Id.) The SSA medical consultant, Dr. Howard Crutcher, agreed with Dr. Regan's assessment.
22. On October 1, 2004, Dr. Porter diagnosed Plaintiff with "chronic vertigo, and [CFS]."
23. On May 9, 2007, Unum reassessed Plaintiff's claim and concurred that Plaintiff suffered from CFS. (AR 2486.) After completing the review of the file, Unum sent a letter to Plaintiff to confirm Plaintiff's disability as of May 8, 2002 thereby retroactively awarding him disability benefits as of that date. (AR 837.)
24. As part of Unum's ongoing handling of the claim, it requested an update on Plaintiff's medical status to determine if he remained eligible for continued benefits under the Plan's provisions. (AR 838); (PFL ¶ 123.)
25. In the Claimant's Statement Plaintiff completed on July 8, 2008, he described his present activities: "On better (good) days -> drop off/pick up kids from school, go to stores with spouse/dad. Help kids with homework, baby sit youngest son when feeling better, walk outside in evening/play with kids in front of house in evening." (AR 2599); (PFL ¶ 130.)
26. In June 2009, Unum "determined that we need updated certification of your continued disability." (AR 2608); (PFL ¶ 133.) Plaintiff provided all requested information. (AR 2613-19.)
27. In the forms Unum provided, Plaintiff described his current day-to-day activities as "[o]n better days, drop off kids/pick up kids from school, go to shopping with Dad. Help kids with homework, babysit the youngest son, take kids to park, evening walk, sit/play with kids outside of house in evening." (AR 2614); (PFL ¶ 134.)
28. In 2011, Unum began investigating Plaintiff's ongoing entitlement to LTD/LWOP. (AR 2673, 2687, 3216.) The investigation first focused on Plaintiff's depression and anxiety symptoms that was opined in Dr. Porter's reports.
29. On December 1, 2011, Plaintiff confirmed that in 2008 or 2009 he was referred to Dr. Epperson for a psychiatric evaluation during his divorce.
30. Between July 2008 to August 2011, Dr. Porter filled out Attending Physician Statements ("APS") in order to provide Unum with Plaintiff's updated health information. (AR 2601, 2617, 2641, 2648.) The APS stated the following:
(Id.)
31. On September 7, 2011, Unum called Plaintiff to discuss his claim. (AR 2665.) According to Plaintiff, he was able to cook dinner or take care of kids by transporting them to and from school on good days. (AR 2636-2640; 2666.) Plaintiff informed Unum that he was seeing Dr. Porter every six (6) months and he expressed his desire to return back to work one day. (Id.)
32. Based on Dr. Porter's APS above, on September 19, 2011, Unum determined that Plaintiff could perform sedentary work. (AR 2673.)
33. The following Unum physician reviews were conducted in 2012 while Unum was still paying Plaintiff's disability benefits.
34. Dr. Peter Gannon, M.D., is board-certified in neurology and internal medicine. (AR 3296-3297, 4338-4378.) In March 2012, Unum sent over Plaintiff's medical records. (AR 4365-4378.) On March 12, 2012, Dr. Gannon conducted an in-person Independent Medical Examination ("IME") of Plaintiff. (Id.)
35. In his March 15, 2012 report, Dr. Gannon concluded that Plaintiff did not suffer from vestibular disorder. (Id.) Plaintiff's physical and mental status exams all came back normal. (AR 4368 (noting that Plaintiff scored a 30 out of 30 on a mini-mental exam).) Based on Plaintiff's medical records, lab studies, MRIs, blood tests, etc., Dr. Gannon found no neurological disease or restrictions and limitations. (AR 4369 ("I am unable to find [any] objective evidence of any neurologic disease which has resulted in disability.").) However, Dr. Gannon was aware that Plaintiff "has marked difficulty concentrating on anything for more than a short period of time." (AR 4366); (PFL ¶ 171.)
36. Dr. Gannon noted that Plaintiff had not been on any medication for several years, contrary to Dr. Porter's anti-depressant prescriptions. (Id.) Dr. Gannon also opined that Plaintiff "certainly . . . has multiple chronic symptoms," which might be caused by depression. (AR 4369); (PFL ¶ 169.)
37. Unum sent Dr. Gannon's report to Dr. Porter and requested Dr. Porter send updated records. (AR 4401-4402.) Dr. Porter sent Unum an office visit note that indicated that Plaintiff was having good and bad days with regard to his chronic fatigue problems. (AR 4406.) Dr. Porter expected Plaintiff to be a year away from full recovery. (Id.)
38. Unum forwarded the updates to Dr. Gannon, but the new information did not change his position. (UFL ¶ 90); (AR 4416, 4423-4424.)
39. Unum's on-site physician, Dr. Larry LaClair, a board certified family medicine physician, also reviewed Plaintiff's records. (AR 4453-63; 4465-4474.) In June 2012, Dr. LaClair reported that Plaintiff's vestibular neuritis improved. (AR 4472.) Dr. LaClair concluded that Plaintiff was able to sit frequently and stand/walk occasionally. (AR 4462); (PFL ¶ 178.) Dr. LaClair attempted to discuss Plaintiff's condition with Dr. Porter, but Dr. Porter did not respond. (AR 4445-4447.) According to Dr. LaClair, Plaintiff had full time functional capacity and he agreed with Dr. Gannon's assessment. (AR 4474.)
40. Dr. LaClair noticed that Plaintiff's CFS and depression and anxiety had serious overlap. (Id.) Dr. LaClair wanted to examine more thoroughly Plaintiff's mental condition, but Plaintiff's counsel has refused to produce Dr. Epperson's evaluation.
41. Dr. Malcolm Spica is Unum's on-site clinical neuropsychologist and licensed clinical psychologist. (AR 4483-4487.) On July 11, 2012, Dr. Spica reviewed Plaintiff's medical records and concluded that Plaintiff did not suffer from any neurocognitive restrictions and limitations from 2002 to the date of the review. (Id.) He stated that Dr. Wakefield's testing indicated normal cognitive performance and Dr. Regan's opinions were purely based on Plaintiff's subjective complaints. (Id.) Dr. Spica also stated that Dr. Epperson's psychological evaluation of Plaintiff would have been helpful. (Id.)
42. On July 16, 2012, Unum referred Plaintiff's medical file to Dr. Joseph Sentef, M.D., board certified family and occupational medicine physician. (AR 4488-4493.) Dr. Sentef concluded that Plaintiff's activities—regularly exercising, driving, actively studying and playing with his children—were inconsistent with impairing fatigue. (Id.) He determined that CFS cannot be found under these circumstances. (Id.) Reviewing Dr. Porter and Dr. Gannon's reports, Dr. Sentef opined that Plaintiff had full-time light work capacity. (Id.)
43. On July 24, 2012, Unum conducted a vocational analysis of Plaintiff. (AR 4436; 4501-4505.) Considering the skills, abilities, education, work history, and medical history of Plaintiff, Unum concluded that Plaintiff has the functional ability to work at different suitable gainful occupations such as Computer Sales Representative, Auditor, Statistical Analyst, and a Manager of Merchandise.
44. The vocational analysis expressly stated that "[n]o special training, licensure or certification would be needed for the vocational alternatives." The vocational consultant confirmed that these occupations were available in Plaintiff's geographical area of Modesto and that they are performed with "occasional exertion up to 10 lbs and 20 lbs of force, frequent sitting with occasional stand/walk and climb stairs, kneel, bend/twist/stoop." (UFL ¶ 102.) It was also noted that the examples were not a complete list of occupations Plaintiff could perform. (Id.) The vocational consultant confirmed that the alternatives would allow Plaintiff to demonstrate a level of skills and achievement consistent with pre-disability work. (Id.)
45. On July 31, 2012, Unum terminated Plaintiff's LTD benefits. (AR 4517-4526.) On August 2, 2012, Unum terminated Plaintiff's LWOP benefits. (AR 6127-6132.) Based on the medical and vocational evidence above, Unum concluded that Plaintiff was no longer disabled in accordance with its LTD and Life Policies. (AR 4510, 4512.) Unum determined that Plaintiff's symptoms did not prevent him from working. (AR 4518, 4530.)
46. In March 2013, Plaintiff appealed Unum's decision with an updated record from Dr. Porter. (AR 4799; 4987-5003); (PFL ¶¶ 195-196.)
47. The updated record included Dr. Porter's Chronic Fatigue Syndrome Residual Functional Capacity Questionnaire which confirmed the existence of Plaintiff's previous symptoms. (AR 4851-52.) Among the other assessments that were inconsistent with a return to work, Dr. Porter opined that Plaintiff needed 20-30 minute breaks every hour (4853) and would be absent from work more than four days per month (4854). (PFL ¶ 205.)
48. In consideration of the administrative record and the examinations of the physicians below, Unum upheld its termination decision under the LTD Policy and Life Policies.
49. Unum communicated the denials to Plaintiff on June 20, 2013. (AR 5044-5056, 6259-6271, 6898-6910.) Unum explained the basis for its decision in a letter detailing that Plaintiff did not have physical restrictions and limitations precluding work in other gainful occupations. (UFL ¶ 119.) Unum explained that Plaintiff's conditions, collectively and individually, did not indicate he was precluded from engaging with reasonable continuity in the alternative gainful occupations previously identified by Unum's vocational staff. (Id.) Unum distinguished the SSA award, refuting the CFS diagnosis in light of several co-morbid conditions and Plaintiff's inconsistent reporting of substance abuse, and also noting that Unum had more current information.
50. In upholding its decision, Unum considered the Dr. Porter's updated opinions and the additional medical reviews below. (Id.)
51. Plaintiff produced a cardiopulmonary exercise testing (CPET) report
52. Plaintiff's CPET results were primarily based on self-report. (UFL ¶ 113; (AR 4856-5857, 4860, 4866.) The testing was designed to determine whether Plaintiff's subjective complaints of fatigue were consistent with observable signs of physical impairment. (PFL ¶ 210.)
53. The two-day exercise test determined that Plaintiff is "severely limited in his ability to engage in normal activities of daily living and [should be] [precluded] from full-time work of even a sedentary/stationary nature." (AR 4855); (PFL ¶ 212.)
54. The letter upholding the termination of Plaintiff's benefits does not reflect Unum addressing the CPET findings in substantial detail. (PFL ¶ 228.)
55. On August 7, 2012, after Plaintiff mentioned that his benefits were terminated, Dr. Porter encouraged Plaintiff to "re-engag[e] the workforce and see if [Plaintiff] does not get back to his normal self." (AR 4844.)
56. The next day Dr. Porter completed a Chronic Fatigue Syndrome Residual Functional Capacity Questionnaire. (AR 4851-54); (PFL ¶ 201.) There, Dr. Porter confirmed the presence of CFS symptoms, opined that Plaintiff could sit for 2 hours at a time for a total of about 4 hours in a day, and opined that Plaintiff was limited to standing about 15 minutes at a time for a total of less than 2 hours in a day. (AR 4851-4853); (PFL ¶¶ 202-203.)
57. In May 2013, Dr. Jana Zimmerman, a licensed psychologist, reviewed Plaintiff's records and concluded that cognitive deficits from a non-behavioral health condition were not supported. (AR 5010-5019); (UFL ¶ 115.)
58. Dr. Zimmerman noted that many of Plaintiff's symptoms may be derivative of his history of substance abuse. (AR 5010-5019.) Dr. Zimmerman attributes a majority of Plaintiff's symptoms to his drinking habits. (Id.) According to Dr. Zimmerman, Plaintiff had been drinking 3-4 whiskeys daily for 2 years. (Id.) The pattern of alcohol intake met the diagnostic criteria for alcohol abuse if not dependence, which is often associated with his symptoms. (UFL ¶ 115.) Dr. Zimmerman also noted that Plaintiff's memory and concentration complaints followed drinking heavy enough to cause a hangover the next day. (Id.)
59. In May 2013, Unum physician, Dr. Scott B. Norris, also reviewed Plaintiff's records and agreed that Plaintiff did not meet the criteria for CFS. (AR 5020-5029); (UFL ¶ 117.)
60. Specifically, Dr. Norris stated "[w]ith a reasonable degree of medical certainty, I find that the medical evidence supports that the insured had the physical capacity, as of 7/30/12 forward, to perform sustain, full-time (40 hours/week) `Light' occupational activity. . . ." (AR 5025.)
61. As a result of Unum's final ruling, Plaintiff commenced this action on April 10, 2014. (See Compl.)
1. The Court conducts a bench trial on the record,
2. On September 16, 2014, the Court granted the Parties' stipulation for a de novo standard of review. (Dkt. No. 31.)
3. Under the de novo standard of review, the Court gives no deference to Unum's decision in terminating Plaintiff's benefits. Muniz v. AMEC Constr. Mgmt., 623 F.3d 1290, 1295-96 (9th Cir. 2010) ("When conducting a de novo review of the record, the court does not give deference to the claim administrator's decision, but rather determines in the first instance if the claimant has adequately established that he or she is disabled under the terms of the plan.").
4. A plan administrator like Unum must adequately explain the reasons for the denial of benefits, or in this case, the reversal of benefits previously provided. See 29 U.S.C. § 1133 ("every employee benefit plan shall . . . provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan has been denied, setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant"); see also 29 C.F.R. § 2560.503-1(h)(2)(iv) (providing that "claims procedures [must] [p]rovide for a review that takes into account all comments, documents, records, and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination").
5. "When an administrator tacks on a new reason for denying benefits in a final decision, thereby precluding the plan participant from responding to that rationale for denial at the administrative level, the administrator violates ERISA's procedures." Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 974 (9th Cir. 2006). But, "[i]n an ERISA case involving de novo review, the plaintiff has the burden of showing entitlement to benefits." See Schramm v. CAN Fin. Corp. Insured Grp. Ben. Program, 718 F.Supp.2d 1151, 1162 (N.D. Cal. 2010); see also Muniz v. AMEC Constr. Mgmt., No. CV-07-8066 CAS (AJWx), 2009 WL 866843, at *5 (C.D. Cal. 2009) ("The parties dispute which party bears the burden of proof in this case. Generally, a plaintiff suing for benefits under ERISA, 29 U.S.C. § 1132(a)(1)(B), must establish his entitlement to benefits." citing Farley v. Benefit Trust Life Ins. Co., 979 F.2d 653, 658 (8th Cir. 1992)).
6. The Court analyzes the record anew and "evaluate[s] the persuasiveness of conflicting testimony and decides which is more likely true." Kearney, 175 F.3d at 195. The review is limited to the evidence in the administrative record unless it necessary to consider extrinsic evidence outside of the record. Opeta v. Nw. Airlines Pension Plan for Contract Employees, 484 F.3d 1211, 1217 (9th Cir. 2007).
The policy places the burden on Plaintiff to qualify for benefits. To prove that you are disabled, one must prove:
(AR 837.) In reviewing the Administrative Record and the Parties' contentions, Plaintiff has not satisfied his burden to establish that he was disabled throughout the relevant time period. As a preliminary matter, the Court finds it necessary to shed light on the difficulties of assessing ERISA cases involving CFS.
CFS is a subject of discussion and debate within this district. Holifield v. UNUM Life Ins. Co. of America, 640 F.Supp.2d 1224 (C.D. Cal. 2009) (ruling against the plaintiff when considering her CFS diagnosis); Whealen v. Hartford Life and Acc. Ins. Co., No. CV06-4948PSG (PLAX), 2007 WL 1891175 (C.D. Cal. 2007) (holding that the defendant abused its discretion in evaluating the plaintiff's CFS); Salomaa v. Honda Long Term Disability Plan, 542 F.Supp.2d 1068 (C.D. Cal. 2008) (affirming the administrator's denial of the plaintiff's LTD benefits considering his CFS), reversed and remanded en banc denied, 642 F.3d 666 (9th Cir. 2011) (holding administrator abused its discretion in denying long-term benefits to claimant who suffered from CFS). There is a "lively debate as to whether `there is a single cause or many causes [of CFS] and whether the cause is physical or psychologic[al]." Holifield, 640 F.Supp.2d at 1234 (citations omitted.). Irrespective of the CFS origins, the Court recognizes that the very nature of CFS causes a person to experience extreme fluctuation in his or her symptoms. See Dr. Majid Ali, Chronic Fatigue Syndrome, http://www.fibromyalgia-support.org/chronic-fatigue/cfs-definition.html (last visited April 3, 2015) ("CFS is a progressive immune disorder which affects all body organs and ecosystems."). Understanding that CFS tends to either progress or regress over time, the Court is very mindful of the demarcation between suffering from CFS and CFS rendering one disabled. See Denmark v. Liberty Life Assurance Co. of Boston, 481 F.3d 16, 37 (1st Cir. 2007) (highlighting the difference between "requiring objective evidence of the diagnosis, which is impermissible for a condition . . . that does not lend itself to objective verification, and requiring objective evidence that the plaintiff is unable to work, which is allowed."); Fitzpatrick v. Bayer Corp., No. 04 Civ. 5134, 2008 WL 169318, at *11 (S.D.N.Y. 2008) ("[T]he operative question in this case is not whether Plaintiff actually suffered from CFS and/or fibromyalgia, but instead whether the Plaintiff's CFS and/or fibromyalgia rendered her `totally disabled' . . . and thus unable to work.").
Thus, the issue before the Court is whether Plaintiff's medical condition and the effect of that condition rendered him disabled within the definition of the Policy. The Court next summarizes the Parties' contentions.
The Parties agree that Plaintiff was entitled to receive benefits from the Plans in May 2007 (the date Unum retroactively approved Plaintiff's benefits from May 2002) up to May 2012, due to the symptoms associated with CFS. (AR 837, 2486.) This means that Plaintiff was in fact disabled from May 2002 to July 2012 (termination of LTD benefits) and August 2012 (termination of LWOP benefits). (AR 837); (AR 4517-4526); (AR 6127-6132.) The dispute arises from Unum's termination of those benefits.
According to Plaintiff, Unum cannot point to significant medical evidence that suggests Plaintiff's condition has improved warranting Unum to terminate his benefits. (PB 19.) Plaintiff challenges Unum's termination of his benefits because when Unum received Plaintiff's updated medical records, Unum decided to continue Plaintiff's benefits. (PB 20.) The updated medical records included Dr. Porter's July 2008, 2009, and 2011 APS reports where he informed Unum that Plaintiff was able to frequently sit, occasionally stand, walk and lift/carry up to 20lbs. (AR 2601-02, 2617, 2641, 2648.) Plaintiff claims that these CFS symptoms did not change from July 2008 to August 2011 which means Unum must have relied on evidence that demonstrates a significant improvement in Plaintiff's condition in order to terminate his benefits. (PB 20.) But Plaintiff contends that the significant improvement is absent here. Plaintiff points the Court to Dr. Porter's medical evaluations and the CPET test which is the test Plaintiff believes is the most important piece of evidence in evaluating Plaintiff's condition. According to Plaintiff, Unum ignored the CPET test and did not seriously consider its findings before terminating Plaintiff's LTD benefits. (PB 21.)
According to Unum, it relied on a significant improvement in Plaintiff's condition justifying termination of the Policy. (UB 19.) Unum contends that its doctors reviewed Plaintiff's claims and concluded that the medical record did not support Plaintiff's CFS diagnosis. (UB 20.) Particularly, Unum focuses on Dr. Gannon who examined Plaintiff in-person and confirmed that Plaintiff had no neurological condition or restrictions and limitations. (Id. at 22.) Moreover, Unum's vocational analysis concludes that Plaintiff could work in "other gainful occupations including computer sales, IT auditor and systems analyst." (Id. at 20.) Lastly, Unum points out that the CPET is very inconsistent with the administrative record and should not be relied upon as objective evidence. (UR 2.)
Viewing the record through the lens of de novo review, the Court finds that Plaintiff has significantly improved compared to when he was first diagnosed with CFS.
The Court reminds Plaintiff "[t]hat a person has a true medical diagnosis does not by itself establish disability. . . . Sometimes [peoples'] medical conditions are so severe that they cannot work; sometimes people are able to work despite their condition; and sometimes people work to distract themselves from their conditions." Jordan v. Northrop Grumman Corp. Welfare Benefit Plan, 370 F.3d 869, 880 (9th Cir. 2004), overruled in part on other grounds, Abatie, 458 F.3d at 969 (9th Cir. 2006); Matthews v. Shalala, 10 F.3d 678, 680 (9th Cir. 1993) ("The mere existence of an impairment is insufficient proof of a disability. A claimant bears the burden of proving that an impairment is disabling."). In other words, the fact that Plaintiff has CFS, on its own, does not mean that he is disabled. Instead, it is the presence of ongoing disabling symptoms resulting from CFS that support the reversal of Unum's decision. Cf. Corry v. Liberty Life Assurance Co. of Boston, 499 F.3d 389, 401 (5th Cir. 2007) (finding administrator's actions proper where it accepted diagnosis of fibromyalgia, but did not accept claim of disabling effects of the condition).
The CFS diagnosis and the ongoing CFS symptoms are no longer present here which evinces significant improvement.
Focusing on the diagnosis, there is a question as to whether Plaintiff's symptoms derive from CFS or Plaintiff's mental health issues. It is difficult for health care providers to diagnose CFS, as no specific laboratory tests or biomarkers exist. Denmark, 481 F.3d at 37 ("[W]hile the diagnoses of chronic fatigue syndrome and fibromyalgia may not lend themselves to objective clinical findings, the physical limitations imposed by the symptoms of such illness do lend themselves to objective analysis." (quoting Boardman v. Prudential Ins. Co. of America, 337 F.3d 9, 17 n. 5 (1st Cir. 2003))). "Depression is often present as a secondary disorder in CFS patients; when it appears to be present, the CDC recommends a referral to a mental health professional." Holifield, 640 F.Supp.2d at 1235 (citing CDC, "Treatment Options," http://www.cdc.gov/cfs/cfstreatment HCP.html). Here, Unum's brief cites to several events from Plaintiff's past that question whether Plaintiff suffers from CFS or depression. (AR 5010-5019.) The events include Plaintiff's divorce, his history of substance abuse in Dr. Zimmerman's diagnosis, and there are also statements in the record that allude to Plaintiff's ex-wife allegedly poisoning him with arsenic. (Id.) Under these circumstances, there is a possibility Plaintiff suffers from mental health issues, including depression, in addition to CFS (or possibly, rather than CFS).
The Court understands that it is not in a position to firmly diagnose Plaintiff with or without CFS. However, in looking at the record, the Court notices that several physicians have concluded that Plaintiff may no longer have CFS. (AR 4471 (Dr. LaClair stating that the absence of certain symptoms "indicates that if [Plaintiff] [had] chronic fatigue syndrome between 2005-2007, it has improved and no longer meets the 1994 CDC criteria for this condition."); AR 5025-27 (Dr. Norris stating that "the diagnosis of CFS is not supported as of 7/30/12.").) That in of itself is an improvement and a significant change from 2002 to 2008 when Plaintiff's condition was at its worst. During that period (2002 to 2008), Plaintiff's physicians were attempting to identify the cause of Plaintiff's symptoms and Dr. Porter (Plaintiff's treating physician) ultimately diagnosed Plaintiff with "chronic vertigo, and [CFS]" in 2004, (AR 675), and Unum approved Plaintiff's benefits in 2007. (AR 2486) Then between 2008-2013, when Unum's doctors began reviewing Plaintiff's condition and his past substance abuse, they began to question his overall diagnosis. (AR 4490-4491 (in summarizing Plaintiff's symptoms, Dr. Sentef states that "[Plaintiff] has demonstrated fairly good activity and his symptoms do "not appear to be consistent with CFS"); AR 5010-5019 (Dr. Zimmerman concluding that Plaintiff's cognitive deficits are a result of his past substance abuse).) Because Plaintiff's CFS diagnosis is indiscernible by several physicians listed above, when in the past other physicians concluded Plaintiff suffered from CFS, the Court finds that to be evidence of a significant improvement. And even putting that aside, there are still grounds to find for Unum when assessing Plaintiff's symptoms.
During 2002 to 2008 (when Plaintiff's condition was at its worst), Plaintiff had extreme fatigue in performing daily chores like exercising or even driving his son to school. (AR 2735 (in 2006, a function report Plaintiff filled out for the SSA in which he indicated that he did not have physical strength to do chores around the house); AR 2737 (same report, Plaintiff indicating that he can watch movies in parts); AR 2743 (same function report stating on some days "[Plaintiff] can, for a short amount of time [take] kids [to] school [which] is 3-4 blocks away. . . .").) Plaintiff's symptoms consisted of vertigo, fatigue, memory and concentration complaints, anxiety and depression. (AR 2706-3205.) Many physicians concurred that Plaintiff was suffering tremendously from his ailment. For example, Dr. Howe opined that Plaintiff was totally disabled due to Plaintiff's symptoms of dizziness, pain, and fatigue. (AR 102.) Dr. Yates reported that Plaintiff had hearing loss. (AR 280.) Dr. Regan found that Plaintiff suffered a loss in intellectual abilities. (AR 3008.) And Dr. Porter also concurred that Plaintiff symptoms were becoming increasingly burdensome to his overall lifestyle and because Plaintiff's testing for other illnesses came back negative, Dr. Porter diagnosed Plaintiff with CFS in 2004. (AR 675.) Because Dr. Porter (for example) is Plaintiff's treating physician, his evaluations are generally entitled to greater weight than that of the non-treating physician. See Murray v. Heckler, 722 F.2d 499, 501-502 (9th Cir. 1983). But, as the Ninth Circuit has explained in the social security context, a physician's (especially a treating physician) opinion may be rejected "for `clear and convincing' reasons supported by substantial evidence in the record." Orn v. Astrue, 495 F.3d 625, 632 (9th Cir. 2007). Such reasons include where an opinion is "in the form of a checklist, did not have supportive objective evidence, [or] was contradicted by other statements and assessments of [the patient]'s medical condition." Batson v. Comm'r of Soc. Sec. Admin., 359 F.3d 1190, 1195 (9th Cir. 2004); see also Tuttle v. Standard Ins. Co., 459 F.Supp.2d 1063, 1072 (W.D. Wash. 2006) (noting insurer "was not required to give special weight to [claimant's] treating physicians, particularly where their opinions were mere unsupported conclusions"). Here, there are several indications of unreliability in the opinions supporting Plaintiff's position which justify Unum's termination decision.
First, the symptoms described by Dr. Porter's in the 2012 Residual Functional Capacity Questionnaire differ from other evaluations in that same timeframe.
Moreover, the record and Unum's physicians provide consistent findings that Plaintiff did not continuously suffer from CFS symptoms which are known to be disabling. The several doctors that reviewed Plaintiff's medical file for Unum: Drs. Gannon, Spica, LaClair, Sentef, Zimmerman, and Norris. They reviewed the information in Plaintiff's file, including Dr. Porter's reports. (AR 4483-4487 (Dr. Spica); AR 4453-63, 4465-4474 (Dr. LaClair; AR 4488-4493 (Dr. Sentef); AR 5010-5019 (Dr. Zimmerman); AR 5020-5029 (Dr. Norris).) Dr. Gannon conducted an in-person medical exam. (AR 4365-4378.) Dr. Gannon reviewed the file, conducted the IME on Plaintiff, and found no objective evidence supporting a disability. (AR 4369 ("I am unable to find [any] objective evidence of any neurologic disease which has resulted in disability.").) This conclusion is similar to Unum's other consulting physicians that concluded that Plaintiff was not totally disabled and did not suffer from CFS after reviewing the medical record. (AR 4471 (Dr. LaClair stating that Plaintiff's symptoms no longer meet CDC criteria); AR 5025-27 (Dr. Norris noting that the CFS diagnosis is no longer present); (AR 4490-4491 (Dr. Sentef stating the same).) Although Unum's medical examiners ultimately contradicted Plaintiff's treating physicians and Plaintiff's other medical support, Unum had every right to rely on and give substantial weight to such opinions in making its final decision. Andrews v. Shalala, 53 F.3d 1035, 1041 (9th Cir. 1995) ("Where the opinion of the claimant's treating physician is contradicted, and the opinion of a nontreating source is based on independent clinical findings that differ from those of the treating physician, the opinion of the nontreating source may itself be substantial evidence; it is then solely the province of the ALJ to resolve the conflict"); Saelee v. Chater, 94 F.3d 520, 522 (9th Cir. 1996) (per curium) (as amended) (holding that "the findings of a nontreating, nonexamining physician can amount to substantial evidence, so long as other evidence in the record supports those findings"); Hunt v. Metropolitan Life Insurance Company, 425 F.3d 489, 490-91 (8th Cir. 2005) ("Although we are mindful of [the plaintiff's] self-reported complaints of extreme tiredness, fatigue, mental confusion, loss of memory, anxiety attacks, and depression, and the opinion of Hunt's treating physician that RLS has rendered her totally disabled, MetLife was nevertheless entitled to rely on the opinions of two reviewing physicians who gave contrary opinions."); see also Conti v. Equitable Life Ins. Assurance Society, 227 F.Supp.2d 282, 292 (D.N.J. 2002) (concluding that an insurer's decision to deny benefits was not an abuse of discretion where it elected to accept the opinion of the physician who performed an independent medical review rather than the reports of plaintiff's treating physicians); DiPietro v. Prudential Ins. Co. of America, No. 03 C 1018, 2004 WL 626818, at *6 (N.D. Ill. 2004) ("Insurance providers are not required to seek independent medical evaluations, but an evaluation by the insurer is evidence of a thorough investigation into the claim").
It is also necessary to address Plaintiff's contentions with respect to the CPET examination. Plaintiff asserts that he did provide Unum with an objective medical evaluation called the CPET which according to Plaintiff, Unum did not accord sufficient weight to the CPET results in its decision to uphold its termination decision. Plaintiff contends that Unum is required to consider the CPET examination in its appeal of Plaintiff's benefits, and because the CPET test is hardly mentioned in the record, Plaintiff concludes that the CPET was not adequately considered in upholding the termination of Plaintiff's benefits. It is true that Unum is required to give the CPET consideration in evaluating Plaintiff's record, but that is exactly what happened here—the CPET was considered. (AR 4988 (a portion of Unum's appeal file review stating "[i]n support of [Plaintiff's] appeal, the attorney submitted . . . a 3/19/13 `Workwell Foundation Cardiopulmonary Exercise Test Evaluation Report' . . . ."); AR 5024 (Unum's appeal file review that outlines a timeline of events including the "[CPET] (two tests): 15 Watt/min bicycle ergometry w/expired gas collection was performed; . . . `abnormal' reduction in submaximal oxygen consumption between two tests noted. . . .").) These CPET references in Unum's appellate review were not overly elaborate nor did Unum fully explain its reasoning for disagreeing with the CPET results. But, there is no authority that Plaintiff points to that explicitly requires Unum to explain, point by point, why it disagreed with the CPET evaluations disagreements. Because the CPET is the so-called "gold standard" does not mean that Unum is somehow obligated to elaborate on what it believes is flawed with the CPET examination. Furthermore, in reviewing the record, such flaws are apparent for two major reasons. First, this evaluation was not conducted by a licensed physician, rather it is Plaintiff's subjective complaints that the CPET relies upon. (AR 4856-5857, 4860, 4866.) Plaintiff underwent a two-day exercise examination to which he, himself, recorded his results. (AR 4860 ("A post exercise test log was maintained by the patient."); AR 4866 (an example of an exercise recovery questionnaire that Plaintiff filled out).) There is no indication that a physician was present nor is there anything in the record that suggests any physician (including Dr. Porter) supports the CPET's findings. The Court sees no fault on the part of Unum for disagreeing with an examination this is primarily based on self-reporting. Second, the physical therapy evaluation included findings inconsistent with a finding of Dr. Porter's prior evaluations. (AR 4840 (On a February 6, 2013 note, Dr. Porter stated "[Plaintiff] is instructed to exercise regularly."); cf. (AR 4855 (CPET March 19, 2013 evaluation that concludes that based on the two-day exercise test, Plaintiff is "severely limited in his ability to engage in normal activities of daily living. . . .").) In one particular month, if Dr. Porter's medical evaluations are saying Plaintiff should exercise regularly, and the following month, the CPET results are saying Plaintiff is severely limited in his ability to engage everyday activities (which likely includes exercising), then the Court finds that such an inconsistency weighs heavily against the reliability Plaintiff's medical evaluations. Ultimately, the Court believes Unum rationally found the CPET results incredible in speaking to the disabling effect CFS had on Plaintiff.
The Administrative Record is clear that Unum's primary reason for terminating Plaintiff's benefits is because Unum disputes the impact CFS has on Plaintiff's ability to perform sedentary work. The Court finds that the medical file supports Plaintiff's ability to perform sedentary or light work.
The Parties are in dispute as the amount of time in one workday sedentary occupations require one to sit. Plaintiff contends that Unum may have relied on (or at least was aware of) sedentary definition that is attached to a "Unum Estimated Abilities Form" in which the form explicitly defines sedentary work as sitting "6/8 hours." (Dkt. No. 45, Ex. B.) Unum and Dr. Porter determined that Plaintiff could sit "frequently" and stand/walk "occasionally." (AR 4520.) According to Plaintiff's exhibit, Unum defines Frequently sitting as the ability to sit somewhere in between 34% (2.72) and 66% (5.28) hours in a work day, 8 hours. (Dkt. No. 45, Ex. B.) If 5.28 hours is the maximum amount of time Plaintiff can frequently sit, then Plaintiff cannot perform sedentary work if Unum relied on this exhibit in making its decision to terminate Plaintiff's benefits.
The Court sees no reason to quantify the minimum amount of hours one is required to sit in order to perform sedentary work because the record demonstrates that Plaintiff can perform in such an environment. As noted above, it appears that Plaintiff has significantly improved in his average daily activities which supports the proposition that Plaintiff is no longer disabled and ready to begin working again. As noted in Dr. Sentef's 2012 evaluation Plaintiff was improving and performing average daily activities. (AR 4491 (Dr. Sentef noting that by 2011 Plaintiff was "able to participate in regular exercise" and that Plaintiff could "walk and ride bicycles daily").) And these improvements were expected. (AR 4406 (2011 letter from Dr. Porter stating that "I do feel that [Plaintiff] is a year or so away from his maximum recovery."); AR 4851 (August 2012 Residual Functional Capacity Questionnaire to which Dr. Porter states that Plaintiff's fatigue "peaked in 2008" and is "slowly improving" now.).) The Court believes that based on the number of household duties Plaintiff currently performs coupled with the fact that Dr. Porter has encouraged him to start working again, Plaintiff does have the ability to perform sedentary work. As mentioned above, Plaintiff has not attempted to work at a another sedentary job since 2002 during his time at Gallo. His improvement in household chores and overall health signify that it is time for Plaintiff to extend his daily living abilities to a sedentary work environment. Plaintiff should not avoid what is apparent—it is time to "re-engag[e] the workforce." (AR 4844.)
The record, the policy, and the Parties' arguments do not support the assertion that Plaintiff was disabled as of July 2012 (termination of LTD benefits) and August 2012 (termination of LWOP benefits). The Court therefore has no alternative other than to affirm Unum's decision to deny Plaintiff's benefits.
For the foregoing findings of fact and conclusions of law, the Court finds that under de novo review, Plaintiff has not established, by the preponderance of the evidence, that he was disabled under the Policy. The Court therefore affirms the denial of Plaintiffs LTD benefits. Unum shall submit a proposed judgment no later than fourteen (14) days of the issuance of this decision. Once the proposed judgment is submitted, Plaintiff shall have five (5) days to file his objections. Each side is to bear their own costs.
