WILLIAM M. HOEVELER, Senior District Judge.
THIS CAUSE comes before the Court on the parties' motions for summary judgment
This lawsuit was filed pursuant to the Employee Retirement Income Security Act (ERISA), 29 U.S.C. § 1001 et seq., on September 18, 2008, seeking to recover benefits pursuant to the American Airlines, Inc., Pilot Retirement Benefit Program (the "Plan"). Plaintiff Emery was employed by Defendant as an airline pilot and eligible to participate in the benefits of the Plan.
The Plan
From March 18, 2003, until January 25, 2007, Emery received long term disability benefits from Defendant as a result of her suffering from depression and performance anxiety; in early 2007 Emery's benefits were terminated when Defendant determined that "verification of [Emery's] continued disability and necessity of continued medical treatment cannot be established." AA541. Emery administratively appealed that decision and the appeal was submitted to an independent clinical authority, Western Medical Evaluators ("WME"), which had been jointly selected by Defendant and the pilots' union to handle such disputes. As the pilots' union and American Airlines had agreed that the medical opinions of WME would be final and binding, the PBAC was bound to accept WME's ultimate determination that Emery had not submitted evidence that she was disabled. After the denial of her appeal by the PBAC, Emery then filed this action.
The Eleventh Circuit has adopted a six-step test for the review of ERISA disputes:
Blankenship v. Metro. Life Ins. Co., 644 F.3d 1350, 1355 (11th Cir.), cert. denied, ___ U.S. ___, 132 S.Ct. 849, 181 L.Ed.2d 549 (2011).
In this case, the Plan specifies that its Administrator is American Airlines.
In light of this grant of discretion, even if the Court finds that the decision to deny benefits to Emery was "wrong," (step one of the relevant test) the Court will not disturb that decision if the record reveals a reasonable basis for that decision (step three of the test), unless the Court determines that a conflict of interest was present (step four) and that the decision was arbitrary and capricious (step six).
The Court has, for the purposes of analysis, assumed that the decision by American Airlines to discontinue Emery's benefits was wrong; as such, and in light of the clear evidence that the Administrator (American Airlines or PBAC) had discretion in reviewing claims, the Court proceeds directly to the question of whether there exist reasonable grounds for the Administrator's decision, i.e. the Court proceeds to the third step of the test adopted in this Circuit. In making my determination, I am limited to reviewing the evidence in the administrative record,
Before addressing the question of whether the decision was based on reasonable grounds, the Court has examined whether or not Plaintiff has established that Defendant operated under a conflict of interest. While this may appear to be a departure from the enumerated steps of the governing test, i.e., a casual observer might suggest that the Court has skipped step three, instead this approach has the benefit of allowing the Court—if Emery has proven
Although Plaintiffs attorneys claim that "[r]arely is evidence of bias and self-interest seen as blatant as it is in this case," ECF No. 119, p. 20, the Court disagrees. Plaintiffs accusations of bias are directed solely at Dr. Thomas Bettes, the Manager of Occupational Health Services (also referred to as the Medical Director) for American Airlines. Dr. Bettes was responsible for adjudicating Emery's initial application for disability benefits—which he approved in July 2003.
Plaintiff rests her allegations of bias on strained interpretations of statements made by Dr. Bettes. For example, Emery points to an email dated June 17, 2003, from Dr. Bettes to two employees of American Airlines, related to a request for a psychologist to refer to Emery. In that message, Dr. Bettes wrote that the reference being requested was for:
AA1019 (found in ECF No. 122-3). One month later, Dr. Bettes noted that it would be the responsibility of his department "to carefully manage and monitor [Emery] to ensure the goal remains to improve and eventually be cleared rather than to remain on disability.... I will make this case a priority to hopefully ensure it does not become a costly permanent medical disability case." AA1117. In that same message he noted that Emery would "need to apply for and be administratively approved for [disability benefits] but as long as she is fully compliant with the treatment I would have to medically certify." AA1116. These comments and others
As to the alleged self-interest or structural conflict of interest, i.e., the allegation that the Plan's structure presented an inherent conflict of interest, the Court's review indicates that the use of a trust structure with non-reversionary required periodic contributions from American Airlines presents, at most, an attenuated self-interest on the part of American.
Supplement F to Collective Bargaining Agreement, ¶ 5(h), AA278-80.
At least two other judges in this District already have addressed the question of whether this same ERISA Plan is operated by American Airlines under a conflict of interest. Meadows v. American Airlines, 2011 WL 1102774, 2011 U.S. Dist. LEXIS 30839 (S.D.Fla. March 24, 2011), aff'd 520 Fed.Appx. 787 (11th Cir.2013); Turner v. American Airlines, 2011 WL 1542078, 2011 U.S. Dist. LEXIS 43242 (S.D.Fla. April 21, 2011). In each of those cases, the court concluded that even if a conflict of interest was present, it did not operate in such a manner to disturb the court's determination that the administrator's decision was reasonable. In other words, those courts found that weighing the factor of a conflict of interest on the part of the Plan Administrator would only slightly favor the employee and was insufficient to demonstrate that the benefits denial was arbitrary and capricious.
Meadows (citations omitted). Having reviewed the evidence presented by Emery as to the question of a conflict of interest, I am in agreement with the observation of my colleague, noted above. However, for purposes of analysis, I will assume that Emery has shown the potential for some structural conflict of interest to have been a factor in the decision.
The Court now proceeds to address the evidence before me in order to determine whether there was a reasonable basis for Defendant's decision, weighing any alleged conflict of interest as, at most, a slight factor in that decision—consistent with the discussion, above.
The parties' motions for summary judgment address the essential question before the Court: was the Defendant's denial of Plaintiff's request for benefits arbitrary and capricious? The parties agree as to the following facts, unless otherwise noted.
Emery worked for Defendant starting in September 1992, and it is undisputed that she was eligible to participate in the Plan's benefits. Answer, ¶ 6. The Plan, which is subject to the provisions of ERISA, provides retirement benefits to participants and their beneficiaries, including a Disability Retirement Benefit, available to those who meet the terms of the Plan.
The Plan defines a "Disability" as "an illness or injury, verified through qualified medical authority (as provided in Section 5.4) which prevents a Member from continuing to act as an Active Pilot Employee in the Service of the Employer." Plan, § 2.1(af). Section 5.4 of the Plan provides that the existence of a pilot's disability "shall be determined in accordance" with a set of rules, which include the following: "A Member's disability will be considered to cease to exist if (I) his health is restored so as not to prevent him from acting as an Active Pilot Employee in the service of the Company, (ii) verification of such disability can no longer be established or (iii) appropriate medical care is wantonly disregarded by such Member." Plan, § 5.4(c).
In order to be qualified to serve as a Pilot for Defendant, an individual must obtain a "Valid First Class Medical Certificate" from the Federal Aviation Administration ("FAA"). The Plan's definition of disability, however, does not equate "disability" with a failure to obtain such a Certificate from the FAA.
In late 2002, Emery was referred to the medical department of American Airlines after she failed to complete a required training program related to her position as a pilot. Dr. Bettes, the Defendant's Medical Director, directed that Plaintiff be evaluated by Dr. Gary Kay, a clinical neuropsychologist. After evaluating Emery on October 7, 2002, Dr. Kay noted evidence of "specific cognitive deficits" and opined that several of the deficient abilities "are essential mental abilities for aviation performance." AA646-648. Dr. Kay indicated that "[c]omprehensive neuropsychological [testing] may be indicated to confirm deficits in the areas where deficits were found. . . ." Id.
Dr. Bettes also referred Emery for a "fitness for duty" examination by Dr. Elizabeth Jennison, a board-certified physician. Dr. Jennison reported on October 22, 2002,
Based on the evaluations submitted by Dr. Kay and Dr. Hill, Dr. Bettes decided to remove Emery from active pilot duty. Although Dr. Bettes determined that Emery was medically disqualified from flight duty, AA620, she was not yet approved for long-term disability benefits at that time.
On her own initiative Emery began seeing a psychiatrist, Dr. Barry Kaplowitz, in November 2002 for depression and anxiety, and Emery communicated this information to American Airlines.
On June 19, 2003, Dr. Bettes wrote to Emery that she would need to comply with a directive from the flight office of American Airlines, which required her to initiate and document "an active course of therapy" to address her symptoms of depression and performance anxiety. AA1115, found at ECF No. 123-1. Dr. Bettes requested that Emery direct Dr. Kaplowitz to submit records detailing the current course of treatment, and Dr. Bettes noted that it was anticipated that "after an appropriate and time-limited course of treatment you may be cleared by [American Airlines] Medical to resume training as determined appropriate by the Flight Office." Id. Emery sent a letter to Dr. Bettes on June 23, 2003, stating that she had not received a "treatment plan" from American Airlines and asking whether it was mandatory that she be treated by a psychologist (Dr. Rick Suarez) whom had been referred to her by Dr. Bettes' staff. AA1000-01, found at ECF No. 122-3. Dr. Bettes responded by directing Emery to contact Dr. Suarez "to initiate and begin treatments for your symptoms of depression and performance anxiety" and noted that "[i]n addition, you will need to have your Psychiatrist, Dr. Barry Kaplowitz forward to me for review complete records detailing your recent treatments with
AA602.
Emery began seeing Dr. Suarez in July 2003. In a Psychological Treatment Summary dated Oct. 21, 2003, AA520-21, Dr. Suarez reports that Emery was "temporarily totally disabled to perform her job as a pilot." He notes that her observed condition, after nine two-hour sessions every other week, was consistent with a diagnosis of "Mood Disorder, Not Otherwise Specified, with Anxiety Features," and "Personality Disorder, Provisional." Id. Dr. Suarez noted that he contacted Dr. Kaplowitz and suggested that Emery might be "an appropriate candidate for psychotropic medication to help elevate her mood, reduce her anxiety and help her sleep pattern." AA521.
In a letter dated October 17, 2003, Emery was advised by American Airlines that she had been approved for long term disability benefits because of her "medical inability to act as a Pilot," and that such benefits were retroactive to October 9, 2003. AA765. Defendant sent a similar letter to Emery on January 7, 2004, indicating that the benefits period had been modified to be retroactive to March 18, 2003. AA756.
Dr. Suarez provided another Treatment Summary, dated Jan. 22, 2004, which noted that Emery had begun taking Zoloft in mid-January 2004
At a treatment session with Dr. Kaplowitz in early 2003, Dr. Kaplowitz noted that Emery was "seeking advice about Strabismus." AA546. He mentions strabismus
In a report dated April 8, 2005, Dr. Suarez observed that Emery "will maintain her therapeutic gains and functional abilities without medication" and that she should be able to return to training the following month. AA529-30. Dr. Suarez's report dated Nov. 27, 2005, observes that Emery continued to attend therapy with Dr. Suarez while being weaned off Zoloft by Dr. Kaplowitz. AA531-32. Dr. Suarez anticipated that Emery would be able to return to flight training "once her medication is discontinued." AA532. In other words, Dr. Suarez appears to tie Emery's inability to return to flight training to the fact of her continued use of Zoloft.
On Oct. 7, 2005, Dr. Kaplowitz reported that Emery had "become very upset at receiving news of disturbance of vision from Dr. Chao." AA552. The record indicates that Emery saw Dr. Chao, an optometrist/acupuncturist, on March 31, 2005. In a report dated Sept. 13, 2005, Dr. Chao noted that his examination of Emery in March 2005 revealed that "Emery's eyes are healthy . . . [but that she] shows extremely fragile and unstable binocular vision [from what appears to be] a long-standing condition." Dr. Chao noted that Emery had "marked binocular problems" and that such problems "are significant to her career as a pilot." AA510-12. He also reported that Emery was being treated by Dr. Thomas Weiss, for "posterior vitreous detachment" with symptoms which had started in approximately July 2004. AA510.
On March 21, 2006, Dr. Kaplowitz treated Emery and remarked that she was continuing to "deal with lack of ability to fly [due] to sight [and medicine] management" but that he was not able to reduce her dose of Zoloft at that time. AA552 (emphasis added).
On April 4, 2006, American Airlines requested that Emery instruct Dr. Suarez and Dr. Kaplowitz to submit progress reports with diagnosis and treatment, noting that "[t]he medical documentation is required to substantiate continued medical disability benefits." AA584. On April 21, 2006, Dr. Kaplowitz reported to American Airlines that Emery "continues to be seen on a regular basis and medications will be considered to be lowered at our next visit in June. She was last seen on [April 19, 2006]." AA582. Dr. Kaplowitz opined that Emery's diagnosis at that time was "Major Depression, Generalized anxiety
Dr. Suarez provided his records which demonstrated that Emery was treated by Dr. Suarez on three occasions between November 2005 and May 2006. Dr. Suarez reports in a Treatment Summary dated May 28, 2006, that he will follow Emery on a "supportive and/or as needed basis until such time as she is medication free." AA534. Significantly, he noted that he had seen Emery in January and April 2006, and Emery had "maintained her therapeutic gains and has not manifested any reoccurrence of her clinical depression." AA533. Emery was treated by Dr. Suarez on only one other occasion in 2006: at an appointment on September 20, 2006, Dr. Suarez observed that Emery appeared to be maintaining her "therapeutic gains" and had a "stable mood and affect." AA515. Progress notes from Dr. Suarez's treatment of Emery during sessions in 2005-2006 do not mention her vision. Emery apparently only discussed her vision with Dr. Kaplowitz.
At treatment sessions in late 2006 and early 2007, Dr. Kaplowitz indicated that Emery was "unable to stay focused, easily distracted" (Nov. 27, 2006), was "unable to stop cycle of apathy in life very unmotivated" (Jan. 31, 2007), and continued to need Zoloft "for a labile mood" (March 16, 2007). AA555. At a session in mid-2007, he observed that Emery was "in process of getting help from legal/psychological/financial advisement [sic] in order to rectify all social/business matters that ail her," and that he would continue to provide medication and supportive therapy. AA556. Dr. Kaplowitz makes no observations about Emery's vision in his Progress Notes related to visits after March 21, 2006.
Dr. Suarez treated Emery on January 18, 2007, noting that "overall she appears stable." AA516.
On January 25, 2007, Dr. Bettes sent a letter to Emery notifying her that "verification of your continued disability and necessity of continued medical treatment cannot be established." AA541-42. The letter informs Emery that her disability benefits "are being terminated because it can not be established that you continue to remain disabled and unable to pursue obtaining your FAA medical certificate with the goal of returning to your job as a pilot for American Airlines." Id. Dr. Bettes explained that the Plan provides that a pilot's disability "will be considered to continue to exist only if the Pilot Employee. . . . [sic] continues to receive qualified medical care consistent with the nature of the illness or injury that gives rise" to the disability.
Dr. Bettes advised Emery of her right to appeal the decision to the PBAC for review, and provided instructions on how to submit her appeal. Id.
After Emery's benefits were terminated she received an email from a union representative providing instructions for submitting an appeal. AA503 (email dated Feb. 16, 2007). In a letter dated March 3, 2007, addressed to "American Airlines, Inc., Employee Services" Emery requested copies of "all documents, records, and other information relevant to the termination of my disability benefits." AA502. Defendant asserts that the letter was not received by the PBAC prior to the filing of Emery's appeal,
On June 29, 2007, Dr. Kaplowitz sent a letter to the PBAC on Emery's behalf. AA569. In that letter Dr. Kaplowitz reports that Emery has been under his psychiatric care since November 2002, and that his "initial treatment consisted of solely psychotherapy for anxiety/depression caused by her performance related stress" due to the rules disallowing a pilot's reliance on a psychotropic medication. According to Dr. Kaplowitz, during this treatment period, i.e., November 2002 through June 2007, "it became apparent" that Emery had a "visual strabismus" and, after referral to eye specialists (Dr. Thomas Weiss, ophthalmologist, and Dr. Herbert Weiss, optometrist), Emery was diagnosed with "Vitreous floaters/Alternating Esophoria" and was prescribed eye exercises and rest. Id.
Dr. Kaplowitz notes that Emery was referred by American Airlines to Dr. Suarez,
On July 17, 2007, American Airlines, through Deborah Jameson on behalf of the PBAC, acknowledged receipt of Dr. Kaplowitz's letter and that it appeared to be Emery's initial effort to file an appeal. Defendant's letter noted that it was granting Emery an additional 30 days (which apparently had not been requested by Emery) in which to submit an appeal with supporting documentation. AA566-67.
On August 13, 2007, Emery sent an email to a representative at the union, with a copy to Dr. Bettes, which included a document titled "AA disability appeal." AA87-92 as found in ECF No. 117. Emery describes her illness as "Generalized Anxiety Disorder and Major Depression," and notes that she is taking Zoloft and receiving "medical treatment consistent with the nature of the illness." AA89 in ECF No. 117. Emery makes no mention of her eyesight, nor any vision problems, nor does she reference any treatment being provided by a vision-related medical professional. In a letter dated August 16, 2007, American Airlines, through the office of the PBAC's Appeal Coordinator, advised Emery that they had received her appeal. AA476.
Emery also submitted an appeal on the Defendant's appeal form, which was received by the PBAC on August 17, 2007. AA490. With that appeal, Emery included an "Amended Supplement to Disability Appeal," AA492-495, and a copy of the letter from Emery to Defendant dated March 3, 2007, requesting "documents, records, and other information" relevant to the termination of her disability benefits. AA502. The PBAC also received thirteen pages of notes from her treatment by Dr. Kaplowitz. AA544-556. The handwritten "Progress Notes" include brief statements
The record reflects that Emery spoke by telephone with Jameson, of the PBAC, on August 22, 2007. Jameson's notes of that conversation are as follows:
AA.487-88. Despite Emery's comments to Ms. Jameson, it appears that Emery did, in fact, submit further medical records in support of her appeal.
On August 23, 2007, Emery faxed to the PBAC a copy of the report by Dr. Chao (optometrist/acupuncturist), dated Sept. 13, 2005,
On August 29, 2007, Dr. Suarez provided the PBAC with his treatment summaries and his progress notes as to Emery. AA514-17. Dr. Suarez opined in a report dated August 8, 2007, that in her current condition, Emery was "disabled from functioning in her job as a pilot or returning to training" but that it was "quite possible that with continued treatment, which includes the discontinuation of her current medications" she might be restored to functionality as to her employment and training. AA518-19 (emphasis added).
Jameson, on behalf of the PBAC, collected the relevant medical submissions from Emery and her treating physicians, as well as the information from her claim file, and delivered the compiled information to WME, which—as noted above—had been jointly selected by the pilots' union and American Airlines.
AA652. The letter identifies Jameson as the point of contact for American Airlines.
As noted above, WME was asked to perform a "peer review" of the medical file and provide a written report and recommendations as to whether Emery was disabled. Two medical professionals from WME, Dr. Jack Greener (a board certified psychiatrist) and Dr. Karen Grant (a Senior Aviation Medical Examiner), performed the peer review, and submitted a written report.
The initial WME report, ten pages in length, noted that Dr. Kaplowitz's psychiatric conclusions (that Emery needed to take Zoloft) were probably unreliable and biased because he had a sympathetic relationship with Emery and had become her "advocate." AA663. The WME reviewers observed that Dr. Kaplowitz's notes from January 2007 forward "do not provide any diagnoses." AA662. Also, they noted that Dr. Suarez's notes from February 2007 forward did not provide significant objective findings "in the very few occasions on which he has seen the subject in 2007." AA663.
According to Dr. Greener and Dr. Grant, "[Emery] has sought and received treatment, but if return to work was part of the [treatment] plan, treatment was not appropriate." AA664.
AA664 (emphasis added). The WME doctors noted that the mental status evaluations conducted by Drs. Kaplowitz and Suarez were very limited in their description and did not demonstrate that Emery was unable to perform activities of daily living nor had her treating physicians documented that she was having "thought disorder [and Emery's treating physicians' evaluations of Emery] did not demonstrate severe affective disorder, did not demonstrate postraumatic stress disorder, did not demonstrate possible harm to self or others, cognitive disorganization or dysfunction or substance abuse." AA664.
After addressing the evidence presented to them, Dr. Greener and Dr. Grant concluded:
AA664 (italics added). Finally, they opined that:
AA665 (italics added).
After receiving a copy of the WME report by facsimile on Sept. 28, 2007, Jameson phoned WME two weeks later to discuss the report. According to Jameson's notes of the conversation, she advised WME as follows:
AA655 (handwritten notes dated Oct. 11, 2007).
On October 17, 2007, WME provided a revised copy of its report to Jameson—the sole revision was as to the concluding paragraph:
AA677 (italics added). The following day, Jameson called to ask "Dr. Greener to clarify [whether a particular statement in the report was as to] a fitness for duty issue or a disability issue." AA666. Dr. Greener revised the report, finally, to state:
AA687 (italics added). Notably, each version of the WME report includes the observation that there "is no other documentation
Defendant, through the PBAC, notified Emery on October 22, 2007, that her appeal had been denied and that the discontinuance of her long term disability benefits was "proper and in accordance with the provisions of the Plan." AA467-74. Defendant stated that the reason for the decision was the "inability to verify the continuance of [Emery's] disability (resulting from your psychiatric disorders) and inability to verify your continuance of and compliance with qualified appropriate medical care for your psychiatric disorders." AA469.
In a letter dated Jan. 16, 2008, Emery requested a copy of "all documents and other information relevant to my disability claim and the termination of my disability benefits." AA689-90. American Airlines responded by letter dated January 22, 2008, from the PBAC, providing copies of the requested documents relating to Emery's appeal, AA698, and by letter dated January 28, 2008, from the office of Human Resources, by providing a copy of the Plan. AA694. Neither letter addresses the concern raised by Emery in her letter of January 16: that she had made an initial request for information on March 3, 2007. AA690.
It is undisputed that the Plan vests the PBAC with discretion to review and decide appeals from the denial of benefits.
Even if this Court finds that a conflict of interest existed, Emery still must demonstrate that the decision to deny her benefits claim was arbitrary and capricious. Simply stated, after weighing all of the evidence, I must determine whether the PBAC had reasonable grounds to support its decision to discontinue Emery's benefits, and I must uphold the PBAC's decision if there is substantial evidence to
The Court has reviewed the medical evidence contained in the Administrative Record—all of which, of course, was available to Defendant for review when making its determination as to Emery's appeal. The Court has identified some of that evidence specifically, above, and the evidence is summarized, below.
From late 2002 through 2007, Emery received periodic psychiatric treatment from her personal psychiatrist, Dr. Kaplowitz, and from early 2003 through 2007, Emery was treated by a psychologist recommended by American Airlines, Dr. Suarez. At Dr. Suarez's suggestion, Dr. Kaplowitz prescribed the anti-depressant drug Zoloft as an aid in Emery's recovery; it appears that the approach was to stabilize her condition, at which point she could discontinue taking the drug and then return to active pilot duty.
Emery began taking Zoloft in January 2004 and continued taking it for at least the next three years. Dr. Kaplowitz reported that he attempted to wean Emery off Zoloft or reduce her dosage, but was not successful, as Emery reported that her depression and anxiety worsened at those times. He noted that her symptoms were exacerbated by deaths in the family, property damage from Hurricane Katrina, and her fear that she would not be able to return to flying.
Dr. Kaplowitz summarized his course of treatment of Emery and opined that, in his opinion, she was disabled; specifically, he noted that Emery was not yet ready to discontinue Zoloft, especially considering that her depression and anxiety symptoms seemed to be getting worse. Dr. Suarez also submitted medical reports which included a summary of his opinion on Emery's condition.
Both of Emery's treating doctors' evaluations can be understood as suggesting that Emery's disabling condition was the fact of her taking Zoloft, i.e., that she was disabled because of the medication she was taking. In other words, they appear to have conflated the question of whether she would be eligible for a pilot's license with the question of whether she was disabled and unable to return to work.
The WME doctors reviewed several items before delivering their report: Emery's appeal letter, the medical reports from Dr. Kaplowitz and Dr. Suarez, the report from Dr. Chao, the prescription from Dr. Weiss, the terms and conditions of the Plan, correspondence in the claims file, and the reports of Dr. Kay, Dr. Jennison and Dr. Hill. AA656-61. WME ultimately determined that the record did not support a finding that Emery had an underlying condition for which Zoloft was medically necessary and that Emery had not established that she was disabled according to the Plan. The PBAC accepted the conclusion of the WME, and denied Emery's appeal.
Emery argues that the decision to deny her administrative appeal was arbitrary and capricious because the PBAC, in reaching its decisions, relied at least in part upon statements and/or conclusions that Dr. Bettes had expressed in his original decision to discontinue Emery's benefits in January 2007. According to Emery, Dr. Bettes's conclusions were false and not reliable because when he formulated his decision, he had not reviewed the most recent updates from Dr. Suarez and Dr. Kaplowitz about Emery's medical condition. Defendant argues that, even if Dr. Bettes had behaved improperly in reaching his decision—a point which Defendant strongly contests—such factor is not relevant, as the only relevant decision is the appellate decision when examining an ERISA-governed dispute.
To file an ERISA action a plaintiff must first exhaust her administrative remedies, which includes the filing of any relevant administrative appeal. In this case, the PBAC, through its reliance on a peer review conducted by WME, made a determination on appeal as to whether Emery was "disabled" based on the evidence in the administrative record. Emery, of course, bore the burden of producing evidence to support her claim for long term disability benefits. Upon reviewing the evidence presented, the PBAC was free to accept or reject Dr. Bettes's decision in January 2007 to deny benefits.
Plaintiff urges this Court to find that the decision was arbitrary and capricious because it failed to account for her treating physician's opinions that she was disabled. The record of their diagnosis and treatment of Emery, however, was underwhelming as to its comprehensiveness or effectiveness. The WME doctors addressed the treating physician's reports, and made specific criticisms of the conclusions therein, and Plaintiff has failed to establish that the WME doctors' opinions were unreliable.
Emery also argues that the Defendant's decision was arbitrary and capricious because Defendant failed to address Emery's vision problems, which she claims could have been a disability that would have prevented Emery from resuming her job as a pilot. While it is true that Defendant's October 2007 letter denying her claim does not explicitly identify and reject a claim for disability based on a vision problem, the WME letter references a review of Dr. Kaplowitz's report that Emery had been referred to eye specialists and that the treatment recommendation was "eye exercises and rest." Moreover, the record before the WME was devoid of evidence that Emery's vision had been evaluated or treated at any time after March 2005.
Notably, Emery's prepared appeal did not focus on her vision, and Emery told Jameson by telephone that Emery's disability claim was only related to her psychiatric problems, not her vision. Emery later supplemented her appeal with a letter from Dr. Chao concerning her potential vision issue, which was reviewed by WME. Emery advised Jameson that Emery had "recently received this report" from the pilots' union, and it "was not considered a factor in American Airlines's initial decision to medically disqualify me." She added that since Dr. Kaplowitz "mentions it in his report, I decided to submit it."
Emery bears the burden of producing evidence that she is disabled according to the terms of the Plan. The Plan does not require the Administrator to take affirmative steps to contact Emery's medical professionals in order to obtain additional information on her behalf. While an ERISA
As another argument in support of her claim that the Defendant's decision was arbitrary and capricious, Plaintiff alleges that the relationship between the PBAC and the WME was not entirely independent and that the exchange between Jameson and WME regarding the language in the report is evidence that WME was controlled by PBAC. The Court disagrees. As described above, Jameson asked that WME clarify its report as to whether or not Emery would be considered "disabled" under the Plan because of her use of Zoloft. In the first version of the WME report, the doctors clearly found that Emery was not disabled other than "if the administration of [Zoloft] prevents the pilot from performing her duties." AA665. "[T]he only reason at this time and from January 31, 2007 forward for this pilot to be considered disabled, is the fact that she is taking [Zoloft], even though over the years of treatment this medication does not appear to have been of significant [sic]." AA664 (emphasis added). Nothing said by Jameson convinced the WME doctors to alter that conclusion in any substantive manner and, in the context of the full WME report, it is not clear that the revisions prompted by communication from Jameson were significant. From their initial report to the third and final version of the WME report, it is clear that the WME doctors did not find that the record supported a finding that Emery had an "illness or injury" which met the terms of the Plan.
In a further effort to support her argument that the WME was controlled improperly by Defendant, or that the decision rendered by Defendant was arbitrary and capricious, Plaintiff has asked that this Court grant permission for Plaintiff to introduce "new" evidence: a statement from Dr. Grant as to whether she recalls being consulted for the changes in the WME report. Defendant objects to the introduction of such evidence. The Court finds that even if the evidence is "new," it is not persuasive. Dr. Grant simply states that, to the best of her knowledge, she was not consulted for the changes made to the report after September 21, 2007. Such evidence is insufficient to establish that a conflict of interest exists, nor does it suggest that the decision was arbitrary and capricious. As Plaintiff has failed to establish a basis for admission of such evidence at this time, Plaintiffs Motion for leave to file this evidence is DENIED.
Finally, although the Court has not concluded that Emery has demonstrated that a conflict of interest was present, the Court has, in an abundance of caution, reviewed the evidence with a careful regard to any possible taint of bias or self-interest. The record does not reflect that Defendant suffers from a conflict of interest, or even if any such conflict does exist, it is so minimized by the Plan's structure and the reliance on WME, so as not to be significant.
In Count II of her Complaint, Emery claims that Defendant violated ERISA by refusing to timely provide her with a copy of the Plan description in response to her request on March 3, 2007, Complaint, ¶¶ 14, 26-28. According to Section 1132 of ERISA, a plan administrator may be liable for a fine if the administrator does not timely (within thirty days) comply with a plan participant's request for information "which such administrator is required by this title to furnish to a participant." 29 U.S.C. § 1132(c)(1)(B). In addition, 29 U.S.C. § 1024(b)(4) provides that a plan administrator shall furnish a copy of the latest updated summary plan description "upon written request of any participant or beneficiary."
According to Emery, after Dr. Bettes initially terminated Emery's disability benefits in January 2007, Emery sent a letter to American on March 3, 2007, requesting copies of "all documents, records, and other information relevant to the termination of my disability benefits." AA502. Defendant denies receiving that letter in March 2007. Emery's request for information was broad, in that she asked for everything relevant to her termination of benefits; while she did not explicitly request a copy of the Plan, she did request "copies of established procedures for the verification of a disability as it relates to the Plan/Program." Id.
In an email to her union representative, dated August 13, 2007, Emery provided a copy of the March 2007 letter, and she copied Dr. Bettes on that message. AA87 (found at ECF No. 117-8). The administrative record includes a copy of Emery's letter which is marked "RECEIVED AUG 17 2007." AA502. In addition, Defendant has provided a copy of handwritten notes, prepared by Jameson, dated November 13, 2007, which state: "Please send [Emery] copies of her disability claim file. . . . She called me last Thursday (Nov 8) advising that she never got this info, although she requested it from Employee Services." AA126 (found at ECF No. 117-14). American admits that it did not provide Emery with a copy of the Plan description until January 23, 2008, in response to Emery's letter of January 16, 2008.
According to ERISA, if a covered employee makes a written request for a copy of the plan to her plan administrator, the plan administrator is required to provide a
I have reviewed the letter sent by Emery in March 2007 and find that the request was sufficiently specific to have triggered an obligation by American—if the letter had been received. Indeed, the text in the letter is nearly identical to the language found in the Summary Description of the Plan, where instructions are provided to Plan participants. AA504.
In light of the disturbing
The Court has reviewed the administrative record and the evidence presented by the parties, and finds that Emery has failed to establish that the Defendant's decision was arbitrary and capricious. The Court finds that there were reasonable grounds for the Defendant's decision to deny Emery's claim for benefits, even though there is some evidence contrary to Defendant's ultimate determination as to Emery's disability; moreover, Emery has failed to demonstrate sufficient evidence of a bias in Defendant's approach to her claim, nor has she demonstrated that any conflict under which American Airlines may have operated resulted in an abuse of discretion in the decision to deny Emery's appeal.
ORDERED AND ADJUDGED that the Defendant's Motion for Summary Judgment is GRANTED, in part. Defendant is entitled to Summary Judgment as to Counts I, III, and IV of the Complaint. Plaintiffs Motion for Judgment is GRANTED, in part—Plaintiff is entitled to judgment in the amount of $14,080 as to her claim in Count II of the Complaint; in all other respects Plaintiffs motion is DENIED. Attorney's fees are DENIED as to both parties.
Final judgment will be issued by separate order on this date.
AA637.