EDWARD J. DAVILA, District Judge.
In this action under the Employee Retirement Income Security Act of 1974, 29 U.S.C. §1001,
Plaintiff worked as a Senior Staff Systems Programmer with Ashton-Tate starting in 1989. In 1991, Ashton-Tate was purchased by Borland Software ("Borland") and Plaintiff worked for Borland until May 1, 2002. As a Borland employee, Plaintiff was eligible for LTD benefits through the Borland Software Corporation LTD Plan ("the Plan"), which is governed by ERISA. Defendant MetLife funded LTD benefits under the Plan and was also the claim administrator for the LTD claims. The Plan includes the following definition of "Disability," subject to all other Plan terms and conditions:
Administrative Record ("AR") at 001470. The Plan contains the following limitation for disabilities due to a mental or nervous disorder or disease:
AR at 001485.
On or about April 19, 2002, Plaintiff commenced a period of short term disability. He returned to work on May 1, 2002, but was terminated that same day due to performance issues and his behavior at a meeting with Human Resources about his performance issues. MetLife AR at 001412-13.
On October 22, 2009, seven years after Plaintiff allegedly became disabled, Plaintiff submitted a claim for LTD benefits for a disability beginning April 19, 2002. AR at 001440. He indicated on the claim form that he suffered from the following conditions that prevented him from performing his job: arthritis in the spine and joints; severe insomnia; collapsed thoracic vertebra; very large spinal osteophytes; herniated vertebral discs; severe cervical foraminal stenosis; depression; chronically active viruses; anxiety; ADD; heart palpitations; impaired short-term memory; migraine headaches; chronic system inflammation; left knee surgery; cervical spine surgery; left shoulder surgery; Apico/jaw surgery; sinus surgery; thoracic and lumbar disc disease; chronic esophagitis; and chronic sinusitis. AR at 001440-41. Accompanying Plaintiff's claim form was a note from his treating physician, Dr. Resneck-Sannes, dated October 15, 2009, which indicated that the most recent date of treatment was October 15, 2009, and stated that Plaintiff had "disabling back & neck pain for degenerative disc disease," "chronic migraine headaches," and "failed knee and shoulder surgery" since February of 2002.
In May of 2010, Defendant notified Plaintiff that it lacked "required Employer information to complete the initial review" of Plaintiff's claim. AR at 001079. More specifically, Defendant stated that it lacked verification from Borland that Plaintiff was eligible for LTD coverage. Defendant further indicated that Plaintiff's claim would be closed until it received the employer verification, but also stated Plaintiff could appeal the decision because the claim "was denied in whole or in part." AR at 001080. Plaintiff appealed Defendant's decision (AR at 001053), and initiated this action on November 29, 2010.
Pursuant to stipulation, the instant action was stayed while Defendant resolved Plaintiff's appeal. On March 30, 2012, Defendant determined that Plaintiff had coverage under the Borland Plan through May 1, 2002. AR at 000947. A few days later, Plaintiff faxed to Defendant certain forms Defendant required to determine his eligibility for benefits. AR at 000961.
On December 7, 2012, Defendant notified Plaintiff his LTD claim was denied because the information in the claim file did not support a finding of disability within the meaning of the Plan. AR at 000776. On May 7, 2013, Plaintiff appealed Defendant's decision. Defendant has not issued a formal decision on Plaintiff's appeal.
The court lifted the stay and restored this case to active litigation on January 2, 2015.
Plaintiff now moves for summary judgment, contending that he has been disabled within the meaning of the Plan since he stopped working on April 19, 2002. Defendant opposes Plaintiff's motion for summary judgment and also moves for summary judgment in its favor, contending that its determination was reasonable, supported by the evidence, and not an abuse of discretion.
Ordinarily, a motion for summary judgment should be granted if "there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Fed.R.Civ.P. 56(a);
Under the abuse of discretion standard of review, "the plan administrator's interpretation of the plan `will not be disturbed if reasonable.'"
The Administrative record shows that Plaintiff suffered mentally and emotionally as of April 19, 2002, and there is evidence that Plaintiff's condition was directly related to issues at his workplace and with his supervisor. There is also evidence that Plaintiff suffered from chronic pain. The issue before the court, however, is not whether Plaintiff suffered from these medical challenges. Instead, the proper inquiry is whether Defendant's disability determination was reasonable.
The Administrative Record contains conflicting medical opinions regarding whether Plaintiff's mental condition and chronic pain rendered Plaintiff disabled within the meaning of the Plan as of April 19, 2002. Nevertheless, Defendant's determination that Plaintiff was not "disabled" within the meaning of the Plan cannot be characterized as illogical, implausible or without support in inferences that may be drawn from the record.
Defendant's medical reviewers conducted a lengthy and thorough review of Plaintiff's records. These records confirm that Plaintiff suffered from multiple medical conditions as of April 19, 2002. A diagnosis alone, however, does not necessarily establish a disability.
Included in the Administrative Record is an April 19, 2002 workers' compensation report by Dr. Jane Koopman with the Santa Cruz Medical Clinic. AR at 001111-12. Dr. Koopman described Plaintiff as "a 49-year old staff systems programmer at Borland who presents complaining of emotional distress" arising out of Plaintiff's working conditions and a hostile supervisor. AR at 001111. Specifically, Dr. Koopman's notes included the following description of Plaintiff's work conditions:
AR at 001111. Dr. Koopman noted that Plaintiff was taking blood pressure medication, Ativan and Topamax; that he was having difficulty falling asleep and waking up; that he has been having trouble concentrating and difficulty with his memory; that he reported feeling depressed; and that "heart racing episodes" have been occurring for several days, but these episodes do not involve shortness of breath, chest pain or nausea. AR at 001111-12. Dr. Koopman observed that Plaintiff initially had difficulty even starting to speak and appeared very stressed. Dr. Koopman's assessment was that Plaintiff had "1. Stress reaction with both anxiety and depressive features. 2. hypertension. 3. Complaints of palpitations-probably part of his anxiety but would like to rule out arrhythmia." AR at 001112. Testing later confirmed that Plaintiff had no heart condition. AR at 001118.
According to a Doctor's First Report of "Occupational Injury or Illness" dated April 22, 2002, Plaintiff reported to Dr. Koopman that constant threats and harassment from his boss caused him to feel faint and nauseated, and to suffer elevated blood pressure, rapid heartbeat and sweating. AR at 001132. On April 26, 2002, Plaintiff had a follow up visit with Dr. Koopman. The notes of the visit indicate that a Worker's Compensation attorney recommended that Plaintiff return to work if he could be transferred to another department, and that Plaintiff planned to return to work the following Monday. Dr. Koopman's assessment was that Plaintiff had: "1. Stress reaction with both anxiety and depressive features. 2. Hypertension in good control today. 3. History of palpitations; pending Holter results." AR at 001113.
On April 29, 2002, Plaintiff was seen by Dr. Dean G. Zweng at the Santa Cruz Medical Clinic, who noted the following:
AR at 001116. Dr. Zweng's assessment was that Plaintiff had "[a]djustment reaction with anxiety and depression with probably underlying major depression."
Clinic. Dr. Mears noted that Plaintiff "continues with anxiety, rapid heartbeat, unable to sleep. . . . Also increased anxiety at work. He said that he was suspended today." AR at 001119. Dr. Mears' assessment was that Plaintiff had: "1. Palpitations; work-up in progress. 1. Adjustment disorder with anxiety and depression related to job stressors. 3. Insomnia, possibly related to his Paxil."
Plaintiff was seen for the third time by Dr. Koopman on May 4, 2002. The notes from this visit describe the following:
AR at 001122. Dr. Koopman's assessment was that Plaintiff suffered from anxiety/depression and diarrhea.
Plaintiff returned to Dr. Mears on May 11, 2002, at which time Dr. Mears noted that Plaintiff's palpitations seem to be better; that Plaintiff was suffering from diarrhea; and that Plaintiff's "stress has increased" and that he "is still feeling as anxious and depressed as he was before." AR at 001126. Dr. Mears made the following assessment: "1. Palpitations; improved on Tenormin. 2. Diarrhea, possibly secondary to the Tenormin (Atenolol) versus secondary to Blastocystis. 3. Adjustment disorder, anxiety and depression due to job stress."
In a March 21, 2003 Workers' Compensation Report, Dr. Michael G. Meade summarized Plaintiff's history (as told by Plaintiff) as follows. Plaintiff was hired at Ashton-Tate through a vocational rehabilitation program after a back injury. AR at 001146. Plaintiff was happy working as a systems software worker until 2000, when a new CEO was hired.
Dr. Meade opined that Plaintiff was "suffering from an episode of major depression, which is of severe nature, and is characterized by serious generalized anxiety and discrete panic attacks." AR at 001155. Further, Dr. Meade opined that Plaintiff's depression "is superimposed on an underlying dysthymia, and chronic, probable lifelong Attention Deficit Hyperactivity Disorder."
In August of 2003, Plaintiff was evaluated by Dr. Michael D. Butcher for multiple musculoskeletal complaints including in the following order of severity: neck pain, upper back pain, shoulder pain, left knee pain and hip pain. Dr. Butcher determined that Plaintiff appeared to have stiffness and limited range of motion in the neck and back, and swelling in the left knee. AR at 001159. Plaintiff had MRIs taken of his spine, left and right shoulders, and left knee. On August 29, 2003, Dr. Samir Sharma reported that the MRI of the cervical spine showed cervical spondylosis markedly at C5-6 with disc involvement and root involvement at the C5-6 level. On the lumbosacral MRI, Dr. Sharma saw evidence of lumbar stenosis, particularly at L4-5 and L3-4 levels. AR at 001180.
Included in the Administrative Record is a "To Whom It May Concern" letter written by Dr. Butcher dated September 17, 2003, in which Dr. Butcher opined that Plaintiff is unable to work due to multiple musculoskeletal problems, including degenerative disc disease of the neck and lower back, arthritis in the right shoulder and torn cartilage in the left knee. AR at 001193. On October 28, 2003, Dr. Butcher prepared another report in which he opined again that Plaintiff was disabled from gainful employment. AR at 001198. There is also a letter dated November 14, 2003 from Dr. Rosemaria Gennuso to Dr. Butcher, stating that Plaintiff had "neck pain notable in all directions, worse with extension." AR at 001201. Dr. Gennuso noted, however, that although Plaintiff has had longstanding trouble with his neck, Plaintiff had no treatment for his neck for the past eighteen months. AR at 001200.
Included in the Administrative Record are two evaluations by Dr. Chris Summa, a spinal and orthopedic surgeon. The New Patient Evaluation dated September 2, 2010 stated that Plaintiff suffered a severe cycling accident approximately 20 years ago in which he fell off a cliff, and that Plaintiff had back pain for many years. AR at 000807. Plaintiff reported that his back pain worsened over the last five years, and that he could not stand or sit for very long, and that his daily activities, such as washing dishes and doing laundry, had become difficult.
Plaintiff returned to Dr. Summa on May 31, 2012. Dr. Summa reported that Plaintiff was experiencing worsening difficulties with sitting and standing despite eighteen sessions of "Rolfing." AR at 000810. Dr. Summa's medical impression was that Plaintiff had L3-L4 and L4-L5 advanced degenerative disc disease.
Defendant retained three Independent Physician Consultants ("IPC"), Dr. Lee Becker, Dr. Sugerman and Dr. Jane St. Clair, to review Plaintiff's medical records. Each of the consultants concluded that Plaintiff was not disabled within the meaning of the Plan.
On July 3, 2012, Defendant obtained a review from Dr. Lee Becker, a Board-certified psychiatrist. AR at 00935-945. Dr. Becker summarized Plaintiff's medical records, and opined that "[o]verall, the information available to review did not support significant, global psychiatric functional limitations, along with objective findings, to preclude full-time occupational functioning from the date in question forward on an ongoing basis." AR at 000942.
Dr. Becker's IPC report was sent to Dr. Andrew Abarbanel, one of Plaintiff's treating psychiatrists. Dr. Abarbanel described Dr. Becker's report as accurate, and acknowledged that Plaintiff's difficulties were largely the result of workplace mistreatment. Dr. Abarbanel, however, opined that "the nature of the psychiatric injuries resulting from the abusive treatment make it very likely, in my estimation, that [Plaintiff] sustained an ongoing disability." AR at 00874. Dr. Abarbanel reasoned as follows:
AR at 000874-75.
On October 9, 2012, Dr. Becker prepared an addendum to his initial report to discuss Dr. Abarbanel's letter. Dr. Becker determined that the additional information from Dr. Abarbanel did not impact the initial report, stating:
AR at 000797.
After Plaintiff filed an appeal, Defendant retained Dr. Peter Sugerman, a Board-certified psychiatrist, to prepare an IPC report dated July 16, 2013. Dr. Sugerman determined that there was insufficient evidence of a psychiatric functional impairment. AR at 671. In an addendum dated January 28, 2014, Dr. Sugerman reiterated his original opinion that from the outset, Plaintiff's condition was viewed as chronic and reflective of situational factors, but not of such a severity that required intensive treatment. AR at 000581-82. In another addendum dated March 14, 2014, Dr. Sugerman considered additional information submitted by Dr. Abarbanel, but concluded that the new information amounted to opinion only, without detailed, objective, global mental health data. AR at 000552 . Dr. Sugerman prepared another addendum dated August 18, 2014, in which he confirmed his prior assessment. AR at 000359-364.
On August 2, 2013, Dr. Jane St. Clair prepared an IPC report. Dr. St. Clair, who is Board-certified in Occupational Medicine, focused her review on Plaintiff's alleged shoulder, knee and spinal impairments. Dr. St. Clair concluded that there was no documentation to show that Plaintiff's musculoskeletal complaints existed with such severity as to cause restrictions and limitations on April 19, 2002. AR at 675-683.
After speaking to Plaintiff's physician, Dr. Resneck-Sannes, Dr. St. Clair prepared an addendum dated August 25, 2013. AR at 655-656. According to the addendum, Dr. Resneck-Sannes told Dr. Clair that Plaintiff had had various musculoskeletal complaints for as long as he had known Plaintiff, and confirmed that he did not have any records for April through December of 2002. Plaintiff was seen by Dr. Resneck-Sannes on February 5, 2002, and again on June 23, 2003: there are no records of Plaintiff having been seen by Dr. Resneck-Sannes between February 2002 and June 2003. AR at 00656. Dr. St. Clair prepared additional addendums dated January 28, 2014 (AR at 000592-93), March 22, 2014 (AR at 000564-567), and June 29, 2014 (AR at 000390-92).
In light of the assessments prepared by Dr. Becker, Dr. Sugerman and Dr. St. Clair, Defendant could reasonably conclude that despite Plaintiff's medical ailments, he could perform his Own Occupation for a different employer.
To substantiate his claim of disability, Plaintiff relies on, among other things, the opinion of Dr. Steven Padgitt dated December 9, 2002, approximately six months after Plaintiff's termination, which stated:
AR at 000713. Plaintiff also relies on a psychiatric evaluation of Dr. Michael Meade stating that Plaintiff was temporarily totally disabled on a psychiatric basis. AR at 001155. These diagnoses alone, however, do not necessarily establish eligibility for benefits.
Furthermore, Dr. Becker considered both Dr. Padgitt's and Dr. Meade's opinions and set forth several reasonable bases to support his conclusion that Plaintiff was not disabled under the Plan. Among other things, Dr. Becker noted that Plaintiff was able to attend to his chronically bedridden child and spent time writing software, playing on his computer, reading, and attending to various household chores. AR at 000943. Dr. Becker also noted that the "[m]ental status examination findings showed no significant lability or agitation, speech within normal limits, and no significant abnormalities in thought processing, or reality testing, immediate or remote recall, abstraction, intellect, or insight and judgment." AR at 000943-44. Dr. Becker' report stated that "[m]ild decrease in recent recall was noted and difficulties with calculations noted." AR at 000944. Dr. Becker, however, determined that "there was no indication that additional psychological or neuropsychological testing was pursued to further assess cognitive and executive functioning. Furthermore, the GAF score was noted to be 61 with the highest in the past year of 81, which did not appear to be supportive of continuous, severe regression in daily functioning."
Dr. Becker's addendum also sets forth an additional reasonable basis for rejecting Plaintiff's claim of disability based on a psychiatric condition. Specifically, Dr. Becker stated that the documentation Plaintiff submitted after Dr. Becker's initial review did not contain any additional psychiatric clinical information, such as additional detailed objective mental health findings, progress notes or psychological testing and ongoing treatment by the psychiatrist. AR at 000796.
Plaintiff next takes issue with Dr. Sugerman's report dated July 16, 2013, and contends that the report should be disregarded because Dr. Sugerman "exclude[d] the concept of psychological injury due to a work situation." AR at 00604. Dr. Sugerman, however, explained his analysis and reasoning on this point as follows:
AR at 000604-05. Thus, Dr. Sugerman was distinguishing between a psychological injury and a severe psychiatric condition that would require psychiatric limitations or restrictions. Defendant's reliance on Dr. Sugerman's opinion was not unreasonable.
Next, Plaintiff contends that the opinion of Plaintiff's treating physician, Dr. Abarbanel, establishes Plaintiff's disability. In a letter dated January 16, 2014, Dr. Abarbanel stated:
AR at 000576. On April 18, 2014, Dr. Abarbanel opined that Plaintiff was "totally disabled from his job." AR at 000330.
Dr. Sugerman considered Dr. Abarbanel's letters, and acknowledged that Plaintiff suffered from a psychiatric condition. Dr. Sugerman, however, disagreed with Dr. Abarbanel's conclusion that the psychiatric condition rendered Plaintiff totally disabled within the meaning of the Plan. A disagreement among two physicians does not render Defendant's disability determination unreasonable.
Plaintiff next takes issue with Defendant's determination that Plaintiff did not suffer from a disabling degree of pain. Among other things, Plaintiff points to the opinion of Plaintiff's opinion, Dr. Resneck-Sannes opined that in February of 2002, Plaintiff suffered from disabling back pain for degenerative disc disease, chronic migraine headaches and failed knee and shoulder surgery. Plaintiff also relies on a letter dated January 22, 2014 in which Dr. Resneck-Sannes stated:
AR at 000574. Dr. Resneck-Sannes prepared another letter dated May 15, 2014 in which he stated that he had treated Plaintiff for back pain for over twelve years and that Plaintiff's back pain was severe enough to prevent him from working. AR at 000399.
Dr. Jane St. Clair, however, reviewed Dr. Resneck-Sannes' records, as well as the records of Plaintiff's other treating physicians, and reasonably concluded that the medical records did not support functional physical limitations for the continuous time period from April 19, 2002 to the date of her report. While acknowledging that Plaintiff had dealt with many chronic medical conditions throughout the years and had taken various medications, Dr. St. Clair determined that "[t]here is no documentation that severity of his musculoskeletal complaints existed at the time of disability (4/19/02)." AR at 000680. Dr. St. Clair reviewed Plaintiff's medical records at least twice in search of evidence of treatment for pain management, and noted that Dr. Resnick-Sannes saw Plaintiff on February 5, 2002, and then not again until June 23, 2003. AR at 000656. In an addendum, Dr. Jane St. Clair concluded:
AR at 000389. Thus, Dr. St. Clair repeatedly acknowledged that Plaintiff suffered from chronic pain. What is missing from Plaintiff's medical records, however, is documentation of pain management treatment to show that the severity of Plaintiff's pain rendered him disabled within the meaning of the Plan. In the absence of such documentation, it was not unreasonable for Defendant to conclude that Plaintiff was not disabled within the meaning of the Plan.
Plaintiff's multiple criticisms of Dr. St. Clair's evaluation, which border on unprofessional, are unfounded. Dr. St. Clair clarified her analysis in an addendum dated June 29, 2014:
AR at 000353. There is evidence in the record to show that Plaintiff desired to work and was released to work by both Dr. Koopman and Dr. Zweng; it was not unreasonable for Dr. St. Clair to infer from these facts that Plaintiff had the capacity to work in a different setting.
Plaintiff attempts to discredit each of Defendant's medical reviewers by highlighting how much money Defendant has paid them. The fact that the medical reviewers are compensated for their services, however, is unremarkable in and of itself.
Lastly, Plaintiff faults Defendant for relying upon the opinions of medical reviewers who never examined Plaintiff. In-person medical examinations, however, are not mandated under ERISA. Rather, a failure to obtain an in-person medical examination "is merely a factor to be considered when determining whether a plan administrator abused its discretion."
The reports by Defendant's examiners demonstrate a thorough consideration of Plaintiff's medical records and a rational basis for concluding that Plaintiff was not disabled within the meaning of the Plan. Plaintiff has not carried his burden to show that Defendant's denial of benefits was illogical, implausible or unsupported by inferences from the record. Accordingly, Defendant's motion for summary judgment is GRANTED, and Plaintiff's motion for summary judgment is DENIED.
