TOM S. LEE, District Judge.
This cause is before the court on the motion of plaintiff Theresa A. Taylor for summary judgment and to vacate termination and denial of long term disability benefits and on the crossmotion of defendant The Prudential Insurance Company of America (Prudential) for summary judgment. Both motions have been fully briefed by the parties. The court, having considered the memoranda of authorities submitted by the parties and having carefully reviewed the administrative record, concludes that Prudential is entitled to summary judgment. Accordingly, Prudential's motion will be granted and plaintiff's motion will be denied.
Prior to February 2, 2011, when she stopped working due to symptoms associated with fibromyalgia, sleep apnea and worsening of spinal disease, Theresa Taylor was employed by the Wm. Wrigley Jr. Company as a Territorial Sales Manager. Through her employment, Taylor was a participant in an employee welfare benefit plan that provided disability coverage. The Plan was administered by Prudential. Under the terms of the Plan's shortterm disability coverage, a claimant is entitled to receive benefits for a period of up to fifty-two weeks if she is "unable to perform the material and substantial duties of your regular occupation due to your sickness or injury. . . ." The Plan's longterm disability coverage provides for continued payment of benefits for up to twelve months to a participant who remains unable to perform the material and substantial duties of her regular occupation. After twelve months, she is considered disabled and entitled to continued long-term disability benefits if she is unable to perform the duties of any "gainful occupation for which [she is] reasonably fitted by education, training or experience." "Gainful occupation" is defined as "an occupation, including self-employment, that is or can be expected to provide you with an income equal to at least 60% of your indexed monthly earnings within 12 months of your return to work."
After she stopped work, Taylor submitted a claim for disability benefits to Prudential. Initially, on March 11, 2011, Prudential denied her claim, citing a lack of objective medical evidence to support a finding that she met the Plan definition of disabled. After Taylor appealed, Prudential found she was entitled to receive short-term disability benefits for a period of thirty days, through March 3, 2011, for diagnostic testing, treatment and evaluation by specialists, and for physical therapy due to an exacerbation of chronic low back pain. It denied her claim for additional benefits. Following unsuccessful administrative appeals of Prudential's decision,
By memorandum opinion and order entered July 1, 2013, the court found that Taylor had failed to exhaust the administrative process on her claim for long-term disability benefits and so stayed the case so she could pursue her claim for long-term disability benefits through the administrative process.
In the meantime, on February 22, 2013, Taylor was awarded Social Security disability benefits, retroactive to February 11, 2011. Thereafter, on July 22, 2013, Taylor filed her formal claim for long-term disability benefits. As support for her claim that she was disabled from performing the duties of her job at Wrigley, Taylor noted her diagnoses of multiple illnesses and conditions which included fibromyalgia syndrome; shoulder pain and calcific tendinitis; history of C5-C6 anterior cervical discectomy and fusion and history of lumbar surgery times two at the L4-5 level on the left; low back pain with radiation to the left lower limb; irritable bowel syndrome; and sleep apnea. She cited medical records from her various medical providers, including her primary care provider, Dr. Massie Headley; her physical medicine and rehabilitation specialist, Dr. Rahul Vohra; and her rheumatologist, Dr. James Hensarling. In addition, she provided her award of Social Security disability benefits and a June 2011 Functional Capacity Evaluation (FCE) which indicated she was "capable of performing physical work at a Light level" but should not lift or carry weight greater than 25 pounds and 15 pounds overhead, and would do well to limit "sitting, twisting, kneeling, elevated work, and forward bending work to occasionally."
Upon receipt of Taylor's claim, Prudential had an in-house physician, Dr. Jonathan Mittelman, review her file. Based on his review, Dr. Mittelman agreed with the conclusions of the FCE that she could work in a light capacity. With regard to Taylor's back pain, Dr. Mittelman noted that she had a remote history of a cervical fusion in 2008 and a lumbar surgery in 2000 and 2007; and though she had complaints of pain, she had been able to work following those surgeries. He noted the limitations identified in the FCE were consistent with her past surgical history. He further acknowledged that the clinical data was consistent with her diagnosis of fibromyalgia. He explained that fibromyalgia is a chronic condition and is not progressive. "It does not cause damage to any joints, muscles, or organs and with multidisciplinary treatment, including life style management (good sleep habits, regular exercise and stretching, ensuring ergonomic work activity, attention to good nutrition) most people with this condition would be expected to maintain the ability to perform gainful work activity on a reliable basis." He observed that Taylor had been "largely stable in her complaints over the course of 2013," and he found "no reason to alter the limitations determined in her 2011."
On February 5, 2014, Prudential notified Taylor that her claim for long-term disability benefits was denied. Prudential advised that based on the limitations identified in the FCE and Dr. Mittelman's report, Taylor had the capacity for light work; that her job at Wrigley was in the light category; and therefore, she did not meet the policy definition of disabled. Taylor appealed this decision, and on July 14, 2013, Prudential reversed its initial decision and awarded Taylor long-term disability benefits through February 13, 2011. Prudential found that Taylor's job at Wrigley was more accurately classified as medium rather than light, and that, given the findings of the FCE, she met the policy's "regular occupation" definition of disability applicable for the initial twelve months. Prudential denied further benefits from and after February 16, 2013, but advised that it was continuing its review of Taylor's claim to determine whether she was eligible for long-term disability benefits beyond the initial twelve-month period, i.e., under the "gainful occupation" standard.
As part of that review, Prudential requested that Taylor submit to an Independent Medical Examination (IME). Taylor agreed, and on October 31, 2014, was examined by Dr. Philip J. Blount. Following the examination, and after spending approximately two hours reviewing Taylor's medical records, Dr. Blount issued his report detailing her medical history and diagnoses, the results of his examination and his findings and opinions. As part of the evaluation, Dr. Blount was asked to identify appropriate restrictions and/or limitations in view of her functional limitations. He responded,
Asked whether her "self-reported level of chronic pain" was "supported and/or consistent with the results of diagnostic testing," Dr. Blount responded that her examination was "completely consistent with a fibromyalgia syndrome" and that "[f]ibromyalgia syndrome cannot be objectively measured. Pain cannot be objectively measured." He opined that while Taylor had a cervical spine procedure previously, this condition "was stable and not the cause of her chronic symptoms." She also had a history of two prior lumbar procedures, "but her presentation today was not indicative of any active radicuolopathy," which, he noted, was "supported by her negative electrodiagnostic evaluation performed by her treating physician and her MRI findings of stability." Thus, he considered that the primary condition causing her symptoms was fibromyalgia. Regarding that condition, he wrote:
On November 24, 2014, after receiving Dr. Blount's report, Prudential requested a vocational assessment to identify alternative occupations which would provide earnings of at least $15.63 per hour
Taylor appealed Prudential's decision, arguing that Prudential had given insufficient weight and consideration to the SSA's determination; that the IME was unduly focused on the fibromyalgia and failed to consider the multiplicity of illnesses and conditions from which she suffers; that the vocational/ employability assessment was flawed, as she was a salaried, not hourly, employee; and that restrictions and limitations cited by Prudential in its decision were incorrectly stated and contradicted restrictions identified by Dr. Vohra.
Upon receipt of her appeal, Prudential submitted Taylor's records (including her medical records, the 2011 FCE report, the Social Security determination and Dr. Blount's IME report) for review by an independent physician, Dr. Lucien Parrillo. Dr. Parrillo concluded that "[b]ased on the documentation reviewed, the claimant does not have any medically necessary restrictions or limitations from any condition or combination of conditions from 02/17/2013 forward. . . ." He opined:
Accordingly, Prudential upheld its denial decision and so notified Taylor by letter dated August 20, 2015. Prudential rejected Taylor's claim that it had failed to give adequate consideration to the Social Security disability determination, again explaining that its decision was based on information the SSA did not have at the time of its decision. It denied that it had failed to consider her "multiplicity of symptoms," noting that Dr. Blount's IME had been thorough and considered all of her diagnoses and symptoms. As to her assertion that Prudential had wrongly considered hourly rather than salaried positions in identifying alternative jobs, Prudential responded that this approach was not inconsistent with the Plan's definition of "gainful occupation," which did not "state that if one is salar[ied], a salar[ied] occupation need be identified or vice versa."
Taylor again appealed, making the same arguments as before. In connection with her appeal, Taylor provided a vocational assessment performed by Dr. Larry Stokes in which he concluded that she was "not competitively employable in the labor market, nor could she perform in a gainful occupation and achieve 60% of her monthly salary, which would equate to $2,710.00 per month. Her functional ability does not translate into an ability to maintain gainful employment." In identifying her functional limitations, Dr. Stokes relied almost exclusively on an August 12, 2012 Medical Source Statement completed by one of plaintiff's treating physicians, Dr. Rahul Vohra, in connection with Taylor's claim for Social Security disability benefits. In that Medical Source Statement, Dr. Vohra indicated that Taylor could sit about four hours per day and stand/walk less than two hours per day. Dr. Stokes noted that these restrictions would place her "at a part-time position of a maximum of six hours a day." Further, Dr. Vohra's Medical Source Statement indicated she could lift 10 pounds "occasionally,"
In response to Taylor's appeal, Prudential requested another independent records review, which was done by r. Philip J. Marion. Dr. Marion issued a report on August 2, 2016 finding there "remains no impairment that translates into occupational restrictions and/or limitations for the time period under review." In addition to requesting the file review, Prudential also requested that its Vocational Specialist review Dr. Stokes' report. Upon review, he advised that the jobs he had previously identified remained valid alternative occupations based on the report of the IME.
On August 11, 2016, Prudential again denied Taylor's appeal, stating it was "not disputing her diagnoses," but found that "the clinical documentation does not support her inability to perform any gainful occupation." In so finding, Prudential rejected Dr. Stokes' conclusions, stating:
Upon this final denial of her claim, Taylor returned to this court to pursue her claim for wrongful termination and denial of longterm disability benefits.
A person who has been denied benefits under an employee benefit plan governed by ERISA may challenge that denial in federal court.
An ERISA claimant bears the burden to show that the administrator abused its discretion.
In determining whether there was an abuse of discretion, the court must also consider whether the plan administrator had a conflict of interest.
Here, Taylor points to the conflict of interest inherent in Prudential's acting as both the plan administrator and insurer of benefits; but she does not specifically argue that Prudential's administration of her claim was procedurally unreasonable. However, one or more of the bases on which she challenges Prudential's decision, if established, could tend to suggest procedural unreasonableness. Taylor offers the following reasons Prudential's decision to deny her long-term disability payments was unreasonable and hence an abuse of discretion: (1) Prudential did not afford due consideration to the findings and conclusions of the Social Security Administration that she suffers severe impairments which render her totally and permanently disabled from any gainful employment; (2) Prudential's reliance on Dr. Blount's IME to support its denial decision was "misguided"; (3) Prudential's decision is based on medical records reviews obtained by Prudential which misconstrue and/or mischaracterize the treatment records of her treating physicians; and (3) Prudential's decision is based on a vocational assessment that is flawed. The court evaluates Taylor's claims both for procedural unreasonableness and abuse of discretion.
In February 2013, the Social Security Administration (SSA) found that Taylor was disabled under applicable Social Security standards. The Social Security Administrative Law Judge (ALJ) found she had severe impairments, including fibromyalgia, generalized osteoarthritis, lumbar degenerative disc disease with radiculopathy, sacroilliac syndrome/joint dysfunction, activityrelated back pain, mechanical right shoulder pain (with continued impingement), irritable bowl syndrome, chronic fatigue syndrome, right elbow pain with lateral epicondylitis and neck pain. He concluded that the combination of these impairments significantly limited her ability to perform basic work activities. In so finding, the ALJ accepted the conclusions offered by Dr. Vohra in his August 2012 Medical Source Statement regarding Taylor's residual functional capacity, finding they were "supported by objective medical findings and . . . consistent with his documented treating progress notes in the record" and hence entitled to be given controlling weight as he was her treating physician. The ALJ concluded that Taylor retained the residual functional capacity for sedentary work, subject to the limitations noted in the Medical Source Statement, including lift/carry ten pounds occasionally; stand or walk less than two hours in an eight-hour day; sit for four hours in an eight-hour day with a need for shifting positions at will; reach, handle or finger only occasionally; and balance, bend, stoop, kneel, crawl, squat, and/or twist rarely. Given her residual functional capacity for limited sedentary work, the ALJ found that Taylor could not perform her past relevant work and that considering her age, education, work experience and residual functional capacity, there were no jobs that exist in significant numbers in the national economy that she could perform.
Taylor contends that Prudential abused its discretion by ignoring SSA's finding that she was totally disabled "in favor of the opinions of their own paid doctors' conclusory opinions that [she] is not disabled." "[W]hile an ERISA . . . administrator might find a social security disability determination relevant or persuasive, the plan administrator is not bound by the social security determination."
Taylor contends Prudential's use of Dr. Blount's report as a basis for denial of her claim was "misguided" inasmuch as Dr. Blount did not disagree with the restrictions and limitations imposed by Dr. Vohra or any of her treating physicians. On the contrary, he agreed with and deferred to the restrictions and limitations on physical activities advised by Dr. Vohra. She contends that Dr. Blount's report is at best "neutral" and does not provide clear evidence to support Prudential's denial of benefits.
Dr. Blount's opinion, based on his review of the medical records and the 2011 FCE and on his examination of Taylor, is briefly summarized: She has diagnoses of multiple conditions and a history of previous back surgeries; the condition causing the symptoms she was experiencing at the time of the IME was likely fibromyalgia; her presentation was "completely consistent" with fibromyalgia and other potential causes of her symptoms had been ruled out; fibromyalgia, as a condition, does not have specific limitations or restrictions, rather, the patient's tolerance of her symptoms is what determines her limitations or restrictions; he had limited experience with Taylor, having seen her only once and for a short time and therefore would not offer formal restrictions or limitations; her treating physicians had given her restrictions and limitations and requested that she be given light duty status; the 2011 FCE concluded she could have light-duty status; and he agreed with the FCE and her treating physicians that she should be able to perform light-duty work.
This is not a "neutral" report. Dr. Blount concluded that Taylor "should be able to perform light duty work," at least as the 2011 FCE defined or described the concept of "light duty." He agreed with her treating physicians that she should not be required to "climb ladders, ropes, and scaffolds given her balance issues . . . and medications. . .", and agreed, implicitly, with the limitations noted in the FCE; but most significantly, he agreed with her treating providers that she could work, albeit with limitations.
This was not an unreasonable conclusion, nor was it unreasonable for Prudential to rely on Dr. Blount's opinion. The 2011 FCE report concluded that Taylor was able to perform light duty work. On August 8, 2011, shortly following the FCE, Dr. Vohra noted that the FCE limitations placed her at a "very light level of work," and he restricted Taylor's physical activities to only occasionally doing the following: lifting floor to waist 15 pounds; lifting waist to crown 10 pounds; overhead work, forward bending and stooping. In a September 15, 2011 treatment note, he wrote that he "concur[red] with the restrictions as put forth in the functional capacity evaluation, which precludes her from her regular occupation." Dr. James Hensarling, who treated Taylor for fibromyalgia, also expressed agreement with the results of the FCE. On August 10, Dr. Massie Headley, who treated Taylor for fibromyalgia, prescribed the same restrictions as Dr. Vohra; and in a September 8, 2011 letter, Dr. Headley, citing the results of the FCE and the recent restrictions he and Dr. Vohra had ordered, agreed that Taylor could not perform the duties of her job at Wrigley. However, the limitations prescribed by Dr. Vohra and Dr. Headley did not preclude Taylor from performing work altogether but rather limited her to light, very light or sedentary work — which is precisely what Prudential concluded she was capable of performing.
The court does recognize that Dr. Vohra's August 2012 Medical Source Statement, which he provided in connection with Taylor's claim for Social Security disability benefits, indicated substantial limitations on Taylor's functional capacity.
Taylor's arguments that she was wrongly denied benefits are based in no small part on Dr. Vohra's Medical Source Statement — or rather on Dr. Stokes' vocation assessment, which is in turn based on the limitations identified in this Medical Source Statement. Citing the restrictions noted in the Medical Source Statement, she argues that Prudential's vocational assessment "does not fairly address the combination of limitations and restrictions placed on Ms. Taylor by her treating physicians, which are addressed in the report of . . . Dr. Stokes." In the court's opinion, however, Prudential did not abuse its discretion in disregarding Dr. Vohra's Medical Source Statement as unsupported by the medical record.
Taylor further argues that Prudential's reliance on the records reviews performed by Dr. Parrillo and Dr. Manion to support its denial was unreasonable and an abuse of discretion. It was not unreasonable for Prudential to seek independent review of Taylor's medical records.
Taylor objects that Prudential's vocational assessment is flawed and does not support Prudential's position that she does not meet the Plan's definition of disability because the positions it identified are hourly, not salaried positions. Prudential's vocational assessment identified alternative sedentary positions in which Taylor could earn a minimum of $15.63 per hour. Under the plan, a claimant is disabled under the "gainful occupation" standard if she is not reasonably fitted by education, training or experience for any "gainful occupation." "Gainful occupation" is defined as an occupation in which she could be expected to earn at least 60% of her earnings from her regular occupation. Prudential arrived at the $15.63 per hour figure by converting Taylor's annual salary at Wrigley to an equivalent hourly wage. Prudential correctly points out that this is not inconsistent with the Plan's definition of "gainful occupation," which does not require that a salaried employee be found disabled only if there is no other salaried occupation in which she could earn at least 60% of her previous earnings. Taylor's position is thus rejected.
Based on all of the foregoing, it is ordered that Prudential's motion for summary judgment is granted, and Taylor's motion for summary judgment and to vacate termination and denial of long term disability benefits is denied.
A separate judgment will be entered in accordance with Rule 58 of the Federal Rules of Civil Procedure.
SO ORDERED.
20 C.F.R. § 404.1567(a). To determine whether an individual has the ability to perform the full range of sedentary work from an exertional standpoint, Program Policy Statement (PPS) 101 elaborates:
Titles II & XVI: Determining Capability to do Other Work—The Medical-Vocational Rules of Appendix 2, SSR 83-10 (PPS-101), 1983 WL 31251, at *5 (S.S.A. Jan. 1, 1983).