WILLIAM T. LAWRENCE, District Judge.
This cause is before the Court on the parties' cross-motions for summary judgment. The motions are fully briefed, and the Court, being duly advised,
Federal Rule of Civil Procedure 56(a) provides that summary judgment is appropriate "if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." In ruling on a motion for summary judgment, the admissible evidence presented by the non-moving party must be believed and all reasonable inferences must be drawn in the non-movant's favor. Hemsworth v. Quotesmith.com, Inc., 476 F.3d 487, 490 (7th Cir.2007); Zerante v. DeLuca, 555 F.3d 582, 584 (7th Cir.2009) ("We view the record in the light most favorable to the nonmoving party and draw all reasonable inferences in that party's favor."). However, "[a] party who bears the burden of proof on a particular issue may not rest on its pleadings, but must affirmatively demonstrate, by specific factual allegations, that there is a genuine issue of material fact that requires trial." Id. Finally, the non-moving party bears the burden of specifically identifying the relevant evidence of record, and "the court is not required to scour the record in search of evidence to defeat a motion for summary judgment." Ritchie v. Glidden Co., 242 F.3d 713, 723 (7th Cir.2001).
The fact that the parties have filed cross-motions for summary judgment does not alter the standard set forth in Federal Rule of Civil Procedure 56. When evaluating each side's motion, the Court simply "construe[s] all inferences in favor of the party against whom the motion under consideration is made." Metro. Life. Ins. Co. v. Johnson, 297 F.3d 558, 561-62 (7th Cir. 2002) (quoting Hendricks-Robinson v. Excel Corp., 154 F.3d 685, 692 (7th Cir.1998)).
Defendant Liberty Mutual Short-Term Disability Plan (the "STD Plan") is an employee welfare benefit plan that provides benefits for eligible employees in the Liberty Mutual Group of companies. The Summary Plan Description ("SPD") for the STD Plan states that the STD Plan "is designed to continue all or part of [your] pay when a non-work-related disability due to sickness or accident prevents [you] from working for more than seven (7) consecutive days and for up to 25 weeks." Benefits are provided by, and are subject to, the STD Plan Formal Plan Document and the SPD.
The STD Formal Plan Document contains a broad reservation of discretionary authority provision for benefit decisions and plan interpretation by the Plan Administrator. Liberty Mutual Insurance Company has delegated final authority for such decisions with respect to benefit claims and appeals to the Group Market Disability Claims department of Liberty Life. Liberty Mutual Group, Inc., is responsible for paying short-term disability benefits from the general assets of Liberty Mutual Group, Inc.
Liberty Mutual Long-Term Disability Plan (the "LTD Plan") is an employee welfare benefit plan that provides benefits for eligible employees of participating employers. According to the LTD Plan's Summary Plan Description, the LTD Plan is designed to continue a portion of a covered employee's pay when a disability due to injury or sickness keeps the employee away from work for more than twenty-six weeks.
Defendant the Group Disability Income Policy (the "Policy") is part of the LTD Plan. It is a fully-insured policy issued by Liberty Life to Liberty Mutual Group, Inc. that provides long-term disability benefits to eligible participants who, due to injury
Plaintiff Leona Kirkpatrick is a participant of both the STD Plan and the LTD Plan. Kirkpatrick was employed as a "Claims Specialist I" by Liberty Mutual Insurance Company from December 17, 2007, through December 30, 2010. Prior to her employment with Liberty Mutual Insurance Company, Kirkpatrick was employed as a claims adjuster with Indiana Insurance, a subsidiary company of Liberty Mutual Group, Inc. In total, Kirkpatrick's employment with Liberty Mutual Group, Inc.'s subsidiary companies lasted more than fourteen years.
In her position as Claims Specialist I, Kirkpatrick was responsible for evaluating liability based on investigation of claims and utilizing the correct workflow in order to ensure that vehicles and property were inspected in a timely and accurate manner. Kirkpatrick's position required constant (defined as 6-plus hours) sitting and intermittent (defined as less than one hour) walking and standing. Keyboarding, telephone use, and keyboarding while on the telephone were also performed constantly. In addition, Kirkpatrick answered customer complaints fifty percent of the time, and her position required her to perform her job activities at a rapid pace one-hundred percent of the time due to a moderate to high volume. Persons performing the job of a Claims Specialist I are subject to a moderate degree of emotional stress during performance of this position.
Kirkpatrick has a complex medical history including a diagnosis of systemic lupus erythematosus ("SLE")
In August 2007, Kirkpatrick suffered a massive bilateral pulmonary embolism that resulted in a lengthy hospitalization from August 20, 2007, through September 13, 2007, during which time she underwent substantial testing and evaluation. During her hospitalization, Kirkpatrick was evaluated by Dr. Joseph Kwakye, a nephrologist, for proteinuria, or excess protein in the urine. Dr. Kwakye advised that Kirkpatrick likely had nephrotic syndrome
Kirkpatrick was also seen for a rheumatology consultation on September 12, 2007, by Dr. James Ehlich. Although he noted her "propensity to autoimmunity on the basis of her blood tests," Dr. Ehlich did not suspect active lupus at that time. However, he recommended annual follow-up testing for lupus.
On June 12, 2008, laboratory testing suggested a diagnosis of lupus. Specifically, the lab results noted an atypical speckled ANA pattern, which patterns are found in 30-40% of patients with SLE. At that time, Kirkpatrick was suffering from lower back pain, ankle swelling and pain, rashes, and joint pain. However, her pain was controlled by medication, and she was able to continue working in her position as a Claims Specialist at Liberty Mutual.
Throughout 2008 and 2009, Kirkpatrick was seen by Dr. Kwakye for treatment of her nephrotic syndrome. Dr. Kwakye attributed Kirkpatrick's history of excessive blood clotting to nephrotic syndrome and lupus-related membranous nephropathy.
In an office visit with Dr. Kwakye in May 2008, Kirkpatrick reported low back pain, but she also reported no lower extremity swelling at that time, nor at several visits in 2009. Kirkpatrick reported musculoskeletal discomfort to her pulmonologist, Dr. Frederick Tolle, who had continued to follow Kirkpatrick following her pulmonary embolism in 2007.
In 2008, Kirkpatrick began treatment with Dr. Steven Neucks, a rheumatologist. Prior to treatment with Dr. Neucks, Kirkpatrick had been treated by Dr. Neucks' medical partner, Dr. Ehlich, since her rheumatology consultation with him during her hospitalization in 2007.
On September 5, 2008, Dr. Neucks reported to Kirkpatrick's primary care physician, Dr. Danyelle Loveless, and nephrologist, Dr. Kwakye, that Kirkpatrick was having considerably more morning stiffness, increased joint pain, and a little joint swelling. He also noted that she had a rash on her back. Dr. Neucks expressed concern that Kirkpatrick was having a flare of lupus.
Late in October 2008, Dr. Tolle remarked that Kirkpatrick had "clinically recovered" from her pulmonary embolus.
At an office visit on January 8, 2009, Kirkpatrick reported burning and discoloration in her ankles to Dr. Neucks. On April 6, 2009, Kirkpatrick reported joint
In September 2009, Kirkpatrick was diagnosed with new onset diabetes following emergency treatment for elevated blood sugar. She was started on prescription Metformin and advised to follow up with her primary care physician, Dr. Loveless.
Kirkpatrick reported periods of muscle stiffness and leg cramps in the fall of 2009. While she denied joint pain and swelling in mid-September 2009, she reported stiffness and cramping during another visit with Dr. Neucks two weeks later. In late October 2009, she again denied joint paint and swelling.
In February 2010, Dr. Loveless ordered a CT scan of Kirkpatrick's chest after she had experienced pain with inspiration for about a week. The chest CT scan found "no evidence for diagnosis of pulmonary embolism," although it noted that she had a history of pulmonary embolism.
In early March 2010, Kirkpatrick again denied joint pain and swelling, but she reported "generalized bodily pain" during a later follow-up visit with her nephrologist, Dr. Kwakye, on March 18, 2010. Dr. Kwakye also noted at this appointment that Kirkpatrick's "nephrotic syndrome has currently resolved" and "[h]er proteinuria has been improving on lisinopril."
On Monday, March 29, 2010, Kirkpatrick was seen by Dr. Neucks. Kirkpatrick reported "a lot of early morning stiffness and noted that she was beginning to miss work because of the physical problems she was having." According to Dr. Neucks, as a result of this discussion and consultation, "we felt that her illness had indeed worsened.... At [that] point we felt that the symptoms had overwhelmed the patient and had become significant enough to warrant disability."
In the office visit note dated March 29, 2010, Kirkpatrick's reported chief complaint was "needs to know correct diagnosis;" however, Dr. Neucks also reported that Kirkpatrick's condition had worsened since her last office visit in September 2009.
Kirkpatrick ceased working
During an April 7, 2010, office visit with Dr. Elsayed Aly, whom Kirkpatrick saw for her prior pulmonary embolism, Kirkpatrick reported moderate to severe low back pain and lower extremity pain, which began five months following discontinuation of certain medications. Dr. Aly ordered a skeletal survey for the evaluation of the "new onset" of lower back pain and leg pain.
On April 11, 2010, Dr. Neucks completed an Attending Physician's Assessment of Capacity for Kirkpatrick at the request of Liberty Life. In the Attending Physician Statement, Dr. Neucks identified Kirkpatrick's diagnoses as "Lupus, Soft Tissue
In addition to the Assessment of Capacity report, Dr. Neucks also completed a Restrictions Form on April 11, 2010. Dr. Neucks advised that Kirkpatrick was restricted due to fatigue, stiffness and joint pain, and he imposed restrictions from 3/29/10 to 4/25/10. Dr. Neucks stated that Kirkpatrick's treatment plan included "medications, office visits, lab monitoring and tests as indicated." When asked to indicate what level of work Kirkpatrick was capable of performing occupationally on a full-time basis, Dr. Neucks marked the box indicating sedentary work. Dr. Neucks listed his medical findings supporting his restrictions as "abnormal lab tests, physical exams, joint pain and swelling, positive trigger points, increased pain."
On April 15, 2010, a nurse case manager for Liberty Life, Tammy Scarponi, contacted Dr. Neucks' office regarding Kirkpatrick and spoke with "Kate." Scarponi did not speak with Dr. Neucks directly. In a letter dated April 15, 2010, addressed to Dr. Neucks, Scarponi memorialized her telephone conversation with Kate as follows:
Scarponi also asked Dr. Neucks the following specific questions, to which he provided the following answers (in italics) on April 19, 2010:
Also on April 19, 2010, Liberty Life received additional lab work from Dr. Neucks' office, and Liberty Life obtained medical records from Kirkpatrick's primary care physician, Dr. Loveless, her nephrologist, Dr. Kwakye, and Dr. Aly, who specializes in oncology-hematology. Liberty Life specifically requested the providers' medical records from March 1, 2010, through the present date, April 19, 2010. Liberty Life did not request records from these physicians prior to March 1, 2010.
On April 21 and 22, 2010, Liberty Life received additional medical records that it had requested, showing Kirkpatrick's history of pulmonary embolism, membranous glomerulonephritis, and musculoskeletal pain. Liberty Life noted Kirkpatrick's moderate to severe low back pain and leg pain. However, Liberty Life concluded that the additional information "notes diagnosis and treatment prior to [date of disability] and would not support current impairment."
Dr. Neucks wrote a letter reviewing Kirkpatrick's disability status to Liberty Mutual on April 26, 2010, in which he noted that Kirkpatrick had reported a number of symptoms, including joint symptoms, neck pain, and low back pain, during her last visit to Dr. Neucks in September 2009. Dr. Neucks explained
On May 7, 2010, Scarponi conducted a file review, concluding that "[a]lthough a lupus diagnosis would support intermittent flares of condition, available medical information fails to support a significant change of condition around 3/29/10 which would support [restriction and limitations]. Attempts have been made to secure additional information and diagnostic testing which has not been [received]. There are no [restrictions and limitations] from additional providers."
On the morning of May 11, 2010, Kirkpatrick called Liberty Life and spoke with claims manager Ouellette, who informed her that Liberty Life was not able to approve her claim. Ouellette explained why Kirkpatrick's claim was not approved,
On May 12, 2010, Ouellette requested Kirkpatrick's job description, which was received and added to Kirkpatrick's file notes that same day. Later that day, Liberty Life manager Sharon McKinney entered a claim note agreeing with Ouellette's earlier recommendation that Kirkpatrick's claim be denied. McKinney noted that the medical records "do[] not support a severity of impairment to preclude functional capacity."
On May 13, 2010, Liberty Life issued a denial of Kirkpatrick's claim for short-term disability benefits. Liberty Life explained its determination in the letter:
On May 12, 2010, Dr. Neucks reported again that Kirkpatrick's condition was worsening. Kirkpatrick reported back pain, and Dr. Neucks noted back spasms upon physical examination.
On May 25, 2010, Kirkpatrick underwent an EMG and nerve conduction study due to pain in her low back with occasional migration into her buttocks and knee. Kirkpatrick reported that sitting, standing, and walking for prolonged periods of time increase her pain. Both the EMG and nerve conduction studies were within normal limits; however, an exam suggested sacroiliitis might be a cause of the paresthesias in Kirkpatrick's legs.
Kirkpatrick returned to see Dr. Neucks again on May 27, 2010, wherein he reported that her condition remained "unchanged."
Kirkpatrick appealed Liberty Life's denial of her short-term disability claim on June 2, 2010. She included medical records and documentation from her treating physicians, including both past and current medical records, totaling 110 pages, with her appeal.
Following receipt of Kirkpatrick's appeal for short-term disability benefits, Liberty Life entered the following claim note on June 10, 2010:
Contrary to Liberty Life's claim note, additional office visit notes from Dr. Neucks for Kirkpatrick for May 12, 2010, and May 27, 2010, were submitted to Liberty Life with Kirkpatrick's appeal.
On June 24, 2010, Kirkpatrick's file was referred to Behavioral Medical for a peer review. On July 9, 2010, Dr. Hal Martens issued his peer review report to Liberty Life. Dr. Martens reported that "his review of the medical record shows that [Kirkpatrick] has been quite stable recently regarding her lupus." Dr. Martens then reports, "There are no progress notes in the medical record from Dr. Neucks since 9/28/09." Dr. Marten concludes, "Reviewing Dr. Neucks' physical exam findings from the three progress notes available in the medical record shows no abnormal joints. There were no swollen joints or tender joints. There was documentation of neck and back pain."
Dr. Martens reported that his "opinion, after reviewing the medical record, is that Kirkpatrick has lupus, but it has not been active for quite some time, and the most recent laboratory and physical exam findings in the medical record would suggest that her lupus is quiet presently with progress notes documenting normal joint examinations and only some back and neck pain." Dr. Martens further stated, "Upon review of the medical record, the last rheumatology note is dated 9/28/09 and as of that date, there is no evidence in the record of active lupus." He concluded that "there is no reason that [Kirkpatrick]
On July 21, 2010, Liberty Life upheld its denial of Kirkpatrick's short-term disability claim, stating that the additional information received on appeal and the file review conducted by Dr. Martens did not support disability.
On July 26, 2010, Kirkpatrick sent a request to Liberty Mutual for an application for long-term disability benefits. Kirkpatrick received no response from Liberty Mutual or Liberty Life.
On August 29, 2010, Dr. Neucks explained in a letter to Liberty Life that Kirkpatrick's impairment or group of impairments prevents her from performing any functions of her job. He did "not believe that combinations will allow the patient to perform gainful employment. One possibility might be to work a substantially limited number of hours such as six to eight hours a week.... I do not believe there are attractive alternative accommodations available that would allow [Kirkpatrick] to return to gainful employment."
On September 3, 2010, Kirkpatrick sent another request for an LTD application to the Director of Human Resources for Liberty Mutual Insurance Company, stating: "I have made several requests to have an application for a long term disability benefits mailed to my attention. As of September 3, 2010, I have not received an application nor have I been advised of the process of filing a long term disability claim. Please consider this letter to be my application for long term disability benefits." Kirkpatrick did not include any supporting documentation. Accordingly, on September 15, 2010, Liberty Life entered a claim note indicating that Kirkpatrick had requested to file a long-term disability claim. Liberty Life conducted a phone interview with Kirkpatrick the same day. Kirkpatrick reported her symptoms, medications, attending doctors, and test results, among other information.
Six days later, Liberty Life denied Kirkpatrick's claim for long-term disability benefits because Kirkpatrick "[did] not meet Liberty Mutual's plan definition of disability during the entire Elimination Period."
Dr. Loveless also completed a Physician's Statement of Disability dated February 8, 2011, opining that Kirkpatrick has been unable to perform the material and substantial duties of her own occupation as of March 29, 2010, and was currently disabled from performing any occupation.
On April 8, 2011, Liberty Life employee and Appeal Review Consultant, Lindsay Mack, sent an email to Behavioral Medical, Inc., requesting an addendum to Dr. Martens' July 9, 2010, record review that was conducted during Kirkpatrick's short-term disability claim. Mack wrote:
On April 13, 2011, Dr. Martens provided his addendum, stating:
Liberty Life requested MLS Peer Review Services conduct a second record review of Kirkpatrick's claim, which was conducted on April 27, 2011, by Dr. Raymond J. Chagnon. Dr. Chagnon did not examine Kirkpatrick and did not speak with Kirkpatrick or contact any of her treating physicians, but he reviewed extensive medical documentation, including Kirkpatrick's job description, two opinion letters from Dr. Neucks, the Attending Physician Statement and Restrictions form completed by Dr. Neucks, and notes from every office visit to Dr. Neucks since Kirkpatrick's date of disability. Dr. Chagnon concluded, based on his review of Kirkpatrick's medical records, that Kirkpatrick had been capable of working in a full-time sedentary occupation since March 29, 2010.
Dr. Chagnon reviewed Kirkpatrick's impairments and outlined how her impairments translated to restrictions and limitations. He noted that "from 03/29/10 forward, she did have impairments with neck and back pain, and she did have restrictions and limitations" before listing in detail Kirkpatrick's ability to sit, stand, climb stairs, and walk, in addition to other activities. In conclusion, he determined that Kirkpatrick was able to work full-time
Although Kirkpatrick, through counsel, requested an opportunity to review any medical consultant's report generated during her appeal, Liberty Life refused to provide a copy of Dr. Chagnon's record review prior to issuing its final denial of benefits.
On April 28, 2011, Liberty Life issued its denial of Kirkpatrick's long-term disability claim appeal. The letter explained that two board-certified peer reviewers had concluded, after reviewing the medical records, that Kirkpatrick did not have any restrictions or limitations that prevented her from performing her own sedentary occupation of a claims adjuster. According to a claim note entered by Liberty Life, "The review of the file and the information received on appeal does not offer findings that would alter the previous claim determination."
On November 2, 2010, Kirkpatrick filed her Complaint for the wrongful denial of her short-term disability benefits. Kirkpatrick filed an Amended Complaint on December 15, 2010. On April 27, 2011, an Entry and Order from Status Conference was entered by the Court, vacating the briefing schedule pending a determination on Kirkpatrick's long-term disability application.
Kirkpatrick subsequently filed a Second Amended Complaint against the Defendants on June 1, 2011, to include the wrongful denial of Kirkpatrick's long-term disability benefits. Kirkpatrick and the Defendants now both move for summary judgment.
Kirkpatrick filed this action pursuant to the applicable provision of the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1132, seeking the Court's review of the Defendants' decisions to deny her short- and long-term disability benefits. The parties agree that it is appropriate for this Court to review the Defendants' decision under the arbitrary and capricious, or abuse of discretion, standard
The arbitrary and capricious standard of review is deferential, of course, but it "is not a euphemism for a rubber-stamp." Majeski v. Metro. Life Ins. Co., 590 F.3d 478, 483 (7th Cir.2009). The Seventh Circuit has explained that "arbitrary-and-capricious review turns on whether the plan administrator communicated `specific reasons' for its determination to the claimant, whether the plan administrator afforded the claimant `an opportunity for full and fair review,' and `whether there is an absence of reasoning to support the plan administrator's determination.'" Id. at 484 (quoting Leger v. Tribute Co. Long Term Disability Benefit Plan, 557 F.3d 823, 832-33 (7th Cir.2009)). In Majeski, the court explained that "a plan administrator's procedures are not reasonable if its determination ignores, without explanation, substantial evidence that the claimant has submitted that addresses what the
Kirkpatrick asserts that Liberty Life's initial short-term claim determination, its short-term appeal determination, its initial long-term claim determination, and its long-term appeal determination each were arbitrary and capricious. She argues that each of these determinations was also flawed in that each failed to consider the totality of her medical condition and her chronic pain. Kirkpatrick also contends that there is a structural conflict of interest as to Liberty Life's determination of Kirkpatrick's long-term benefits because Liberty Life is both plan administrator and insurer of the long-term disability plan. The Court will address each of these challenges in turn.
Kirkpatrick argues that Liberty Life's initial short-term benefit determination ignored the substantive merits of her claim when it disregarded Dr. Neucks' opinion that she was disabled. In response, the Defendants argue that Liberty Life did not ignore the Dr. Neucks' opinion, but rather simply reached a different conclusion.
"Bare conclusions are not a rationale." Love v. Nat'l City Corp. Welfare Benefits Plan, 574 F.3d 392, 397 (7th Cir. 2009) (citing Halpin v. W.W. Grainger, Inc., 962 F.2d 685, 693 (7th Cir.1992)). In making claims determinations, the plan administrator "must provide a reasonable explanation for its determination and must address any reliable, contrary evidence presented by the claimant," and it may not simply ignore or dismiss without explanation treating physicians' medical conclusions. Love, 574 F.3d at 397. It is true that the Defendants did not entirely ignore Dr. Neucks' opinion, but it is also true that, in rejecting Dr. Neucks' opinion that Kirkpatrick was disabled, Liberty Life never explained its basis for doing so.
Liberty Life also erred in its determination, Kirkpatrick argues, because its determination that the evidence fails to support a "significant change of condition" around March 29, 2010, is inconsistent with the medical evidence. Specifically, Dr. Neucks' April 26, 2010, letter indicates that "we felt that her illness had indeed worsened," but it is not cited by Liberty Life at all. Furthermore, Liberty Life notes in its denial letter that Dr. Neucks' treatment notes indicated that Kirkpatrick's condition had worsened between office visits, and it also explains that Dr. Neucks responded to its request for findings supporting a change of condition that Kirkpatrick experienced "increased joint pain, swelling, and fatigue." However, Liberty Life then concludes that the "available medical information fails to support a significant change of condition," but it does not address the apparent contradiction between this conclusion and the medical evidence and does not explain or even indicate its apparent rejection of Dr. Neucks' treatment records and letters.
Furthermore, Kirkpatrick points out that the fact that she continued to work for two years prior to her last day of work does not necessarily preclude a finding that she is disabled. As the Seventh Circuit explained in Hawkins v. First Union Corp. Long-Term Disability Plan:
326 F.3d 914, 918 (7th Cir.2003). The Court agrees. In this respect, Liberty Life's search for a "significant change in condition" indicates that it assumed that Kirkpatrick was not disabled before her last day of work. To the extent Liberty Life made this assumption without explicitly explaining its conclusion or basing its conclusion on the evidence of record, this decision is also in error.
Kirkpatrick also argues that Liberty Life failed to identify what additional medical information would be needed in order to approve her claim. Pursuant to 29 C.F.R. 2560.503-1(g), a plan administrator must provide a claimant with a notification of an adverse benefit determination setting forth, among other things, "[a] description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary." However, because there is no indication that the Defendants required more information to review Kirkpatrick's claim,
In order to be eligible for short-term disability benefits, the STD Plan requires plan participants to meet the following definition of disability: "the inability to perform all the material and substantial duties of his or her Own Job at his or her pre-disability regular schedule because of Injury or Sickness." "Own Job" means the job that the covered employee was performing when total disability or partial disability began. Kirkpatrick challenges Liberty Life's determination that she was not disabled within the meaning of the STD Plan because, she argues, that determination was made prior to obtaining her job description and assessing whether she was able to perform all the material and substantial duties of her job. In addition, Kirkpatrick argues that Liberty Life undertook no substantive analysis as to whether Kirkpatrick would be precluded by her impairments from performing the material and substantial duties of her job.
The Defendants argue that Kirkpatrick simply distorts the facts: while the claims manager made her recommendation that Liberty Life deny the claim before requesting Kirkpatrick's job description information, the final decision as to Kirkpatrick's claim was not made until after her job description information had been entered into her claim note file and a Liberty Life manager reviewed the file and approved the denial. The Defendants also point out that claims manager Ouellette had entered job information in Kirkpatrick's file on April 1, 2010, indicating that Kirkpatrick's job was a sedentary one, which information "shaped the entire claim assessment."
A plan administrator's review is arbitrary and capricious when the reviewer fails to make reasonable inquiry into the requirements of the claimant's occupation according to its own definitional parameters. Quinn v. Blue Cross & Blue Shield Ass'n, 161 F.3d 472, 476-77 (7th Cir.1998) (noting that, where plan's definition of "disabled" included evaluation of whether claimant was capable of "engaging in any occupation comparable to that in which he was engaged," reviewer was under duty to make reasonable inquiry into skills claimant possessed and whether those skills may be used at another job that could pay him within same salary range as his previous job).
As a preliminary matter, the Defendants' assertion that the job description entered by Ouellette on April 1 "shaped the entire claim assessment" suggests that Liberty Life failed to adequately review Kirkpatrick's job duties. Notably, the definition of "disabled" under the plan requires an assessment of whether the claimant can perform her "material and substantial duties," but the April 1 claim note simply provides "sed[entary] job, right/left handed," information which can hardly be characterized as illuminating the "material and substantial duties" of Kirkpatrick's job as a claims specialist. If this information "shaped the entire claim assessment," then the claim assessment proceeded nearly to completion without any information as to Kirkpatrick's job duties at all.
However, the Defendants argue that Liberty Life did later consider Kirkpatrick's job duties, as Ouellette requested the job description form for a Claims Specialist I and entered the information into
The Defendants' argument ignores the fact that Ouellette told Kirkpatrick that Liberty Life was not able to approve her claim before Ouellette even entered the recommendation into Kirkpatrick's claim file, much less before the manager gave "final" approval of Ouellette's recommendation. This fact belies the Defendants' assertion that Ouellette's entry suggesting denial before receiving Kirkpatrick's job description was truly a "recommendation," regardless of the fact that it was labeled as such. Furthermore, even if Ouellette's recommendation was just that and she exceeded her authority in advising Kirkpatrick of the claim denial before final approval, the "recommendation" upon which the Liberty Life manager based her "final" decision was made without the benefit of all necessary information: it made a conclusion that "information that came back was not conclusive of R & L that would prevent [Kirkpatrick] from doing her job duties" before Ouellette even knew what Kirkpatrick's job duties were. In addition, because any substantive "analysis" of job duties conducted by Liberty Life occurred before Ouellette requested documentation of Kirkpatrick's job duties, any "analysis" of Kirkpatrick's job duties is likewise deficient. For these reasons, Liberty Life's decision as to Kirkpatrick's ability to perform all of her material and substantial job duties was arbitrary and capricious.
Kirkpatrick argues that Liberty Life abused its discretion when it selectively relied on Dr. Martens' "faulty record review in favor of the overwhelming evidence of disability provided by Ms. Kirkpatrick's treating physicians." Liberty Life should not have relied on Dr. Martens' opinion, Kirkpatrick argues, because (1) he clearly overlooked key pieces of evidence; (2) he contradicted himself; and (3) he provided no analysis whatsoever as to how Kirkpatrick's disease impacted her ability to perform her own job.
While there is no "treating physician rule" that applies to ERISA cases,
Liberty Life appears to have relied entirely on Dr. Martens' record review in making its determination on Kirkpatrick's appeal, as it cites only from his report in its denial letter. In fact, it does not address any of the extensive contrary evidence
The deficiency of Liberty Life's appeal review is only compounded on review of Dr. Martens' report. Indeed, the sole support Liberty Life cites for its decision is itself riddled with errors and inconsistencies. Dr. Martens repeatedly notes that there are no progress notes from Dr. Neucks after September 29, 2009, when in fact several key medical records were present, including Dr. Neucks' April 26, 2010, note explaining Kirkpatrick's continued complaints of joint pain and muscle pain, her increasing stiffness and pain and generalized fatigue between September 29, 2009, and March 2010. This key record also includes Dr. Neucks' impression that "we felt that her illness had indeed worsened." In overlooking these documents, Dr. Martens formed an opinion without considering evidence of Kirkpatrick's condition in the months immediately preceding her last day of work and thereafter.
Dr. Martens' report also fails to address Kirkpatrick's job duties in any meaningful way. While Dr. Martens lists "job duties" as a document reviewed in preparation of his report, he does not engage in any discussion of the specific duties of Kirkpatrick's occupation other than to state that "there is no reason that [Kirkpatrick] should not be able to perform a sedentary occupation." Furthermore, even this conclusion is only based on rheumatology notes through September 29, 2009, and fails to consider later relevant records by Dr. Neucks with respect to Kirkpatrick's job duties.
Dr. Martens' report is also faulty because it is inconsistent. Dr. Martens opines that Kirkpatrick "may have a problem with sustained capacity to perform a sedentary job because of her lupus," because "Lupus is a highly variable and unpredictable disease, and therefore [Kirkpatrick] may have periods of time where she is incapable of working due to flare-ups in her autoimmune disease process." Yet he later concludes that "there is no
While Liberty Life argues that any errors in Dr. Martens' report were corrected by his April 13, 2011, addendum, Kirkpatrick argues that even this addendum is incompatible with the medical evidence Dr. Martens reviewed. Specifically, Kirkpatrick points out that the records Dr. Martens reviewed for his addendum indicated pain scores as high as 10, swelling ankles, burning and throbbing in her back, and a generally worsening condition. While it is true, as Dr. Martens explains, that these records do not show abnormal joints, an observation that supports his initial record review, the doctor's summary that there is "nothing new" in these records glosses over the content of the records. Dr. Martens noted in his initial report that there was no swelling of joints, but these records do indicate ankle swelling. Furthermore, these records indicate severe pain and a treating physician's observations that the patient's condition was worsening. At a minimum, Dr. Martens should have acknowledged this contrary evidence and addressed its effect on his initial record review determination. Furthermore, Dr. Martens again completely overlooks Dr. Neuck's April 26, 2010, narrative that explains Kirkpatrick's progression, despite Liberty Life's specific request that he review and address this record in his addendum. In sum, Liberty Life's reliance on a record review report filled with errors and inconsistencies cannot pass muster even on deferential abuse of discretion review.
In order to be eligible for benefits under the Group Disability Income Policy, a claimant must meet the following definition of disability:
Kirkpatrick argues that Liberty Life's initial long-term benefit determination is arbitrary and capricious because Liberty Life relied solely on the faulty record review
Kirkpatrick argues that Liberty Life's denial of her long-term benefit appeal was unreasonable because it was based on unreliable record reviews; specifically (1) Dr. Martens' supplemental review continued to overlook key evidence; and (2) Dr. Chagnon's record review was deficient because he overlooked key evidence, failed to qualify his rejection of Kirkpatrick's treating physicians' opinions, and conducted no analysis of Kirkpatrick's occupation. The Defendants respond that Kirkpatrick's argument simply distorts the evidence.
While it is true that Dr. Martens performed a supplemental review of the file at Liberty Life's request after it discovered that he overlooked key evidence, Dr. Martens' second record review is nonetheless deficient, as the Court has described above.
In comparison to Dr. Martens' review, Dr. Chagnon's review is certainly more detailed and appears to be more thorough, but it too suffers from critical deficiencies. The Court notes that a reviewing physician is not required to address every single piece of evidence produced by a claimant, see Davis v. Unum Life Ins. Co. of America, 444 F.3d 569, 578 (7th Cir.2006) (explaining that, while the claimant criticized the brevity of the consulting physicians' medical writings and the summary nature of some of their conclusions, reviewing doctors need not draft "lengthy, lawyer-like opinions"), and in this respect Kirkpatrick's argument that Dr. Chagnon did not address certain medical records falls short. However, to the extent that the medical records Dr. Chagnon did not summarize provide key supporting evidence for Kirkpatrick's claim, his failure to address these
Furthermore, while concluding that Kirkpatrick is capable of working full-time in a sedentary position, Dr. Chagnon never mentions Dr. Neucks' contrary opinion as outlined in his April 26, 2010, letter, nor does he address why he has rejected this opinion.
Finally, Kirkpatrick argues that Liberty Life's reviews of her short- and long-term disability claims were an abuse of discretion because Liberty Life "failed to consider the totality of Ms. Kirkpatrick's medical history and the cumulative effect that her comorbid conditions have on her ability to function in the workforce on a full-time basis." Indeed, throughout the Defendants' Statement of Disputed Facts, they dispute Kirkpatrick's factual statements regarding her pulmonary embolism, diabetes, and nephrotic syndrome, as "neither relevant nor material to the disability claim [Kirkpatrick] filed in 2010 based on lupus." Contrary to their assertions in this Statement, however, the Defendants argue in the body of their Reply that Liberty Life considered these conditions and then determined them to be non-contributing because they were currently resolved or inactive.
A claimant's overall objective medical history is highly relevant in a claim for disability benefits. Holmstrom, 615 F.3d at 773. "While the significance of a procedure or a prescription can be disputed, the existence of such things when established in the record can not be," and "a plan administrator must address it and provide a reasonable explanation for discounting
Kirkpatrick also argues that Liberty Life abused its discretion when it failed to consider the effects of her chronic pain on her ability to perform her job. In response, the Defendants assert that Kirkpatrick's pain was considered, yet the Defendants only point to Dr. Chagnon's consideration of Kirkpatrick's pain. Dr. Chagnon did specifically consider Kirkpatrick's chronic neck and back pain before describing its effect on Kirkpatrick's ability to sit, stand, walk, and perform other daily activities.
The Defendants make no mention of Dr. Martens' report. This is not surprising, as Dr. Martens did not address the possible effects of Kirkpatrick's pain on her restrictions and limitations. What little attention Dr. Martens does pay to Kirkpatrick's pain is incredulous, for in the same sentence where he acknowledges that Kirkpatrick experiences "some back and neck pain," he concludes that "there is no evidence to support total disability." While "a plan may not deny benefits solely on the basis that the symptoms of the claimed disability are subjective, a plan may deny benefits because a claimant has failed properly to document pain-induced functional limitations." Majeski, 590 F.3d at 485. However, in this case, the issue is not that Dr. Martens has rejected Kirkpatrick's subjective reports of pain, and Dr. Martens does not suggest that he rejects Kirkpatrick's complaints of pain because of a failure to properly document her pain-induced functional limitations; in fact, Dr. Martens appears to accept that Kirkpatrick experiences pain. Rather, the issue is that he did not consider at all how this pain might interfere with her ability to perform her job. In this way, Dr. Martens' report failed to consider relevant aspects of Kirkpatrick's medical condition and rendered an arbitrary opinion upon which Liberty Life relied.
Kirkpatrick asks this Court to award her benefits directly rather than remanding for further proceedings. "When a plan administrator fails to provide adequate reasoning for its determination, [the] typical remedy is to remand to the plan administrator for further findings or explanations." Majeski, 590 F.3d at 484. A direct award of benefits is appropriate only in "the rare case where the record ... contains such powerfully persuasive evidence that the only determination the plan administrator could reasonably make is that the claimant is disabled." Id. While Kirkpatrick has demonstrated that Liberty Life acted arbitrarily and capriciously,
On remand, Liberty Life should conduct a more reasoned inquiry into whether Kirkpatrick meets the Plans' definitions of "total disability." If it concludes that she does not meet these definitions, it must adequately explain the reasons supporting its decisions, including at a minimum why it is discounting the medical opinions of Kirkpatrick's treating physicians. In addition, Liberty Life should ensure that it considers and addresses Kirkpatrick's physical condition as a whole, including her chronic pain.
The Defendants move for summary judgment on Kirkpatrick's claims against Liberty Mutual Group, Inc. While Kirkpatrick objects to the Defendants' method, she does not object to the dismissal of Liberty Mutual Group, Inc.
Kirkpatrick's Second Amended Complaint asserts a cause of action for wrongful denial of employee benefits allegedly due pursuant to 29 U.S.C. § 1132(a)(1)(B) against Liberty Mutual Group, Inc., but "ERISA permits suits to recover benefits only against the Plan as an entity." Neuma, Inc. v. AMP, Inc., 259 F.3d 864, 872 n. 4 (7th Cir.2001). Here, the issue is not that there is no genuine issue of material fact as to Kirkpatrick's claim against Liberty Mutual; the issue is that there is no cause of action stated under ERISA as to Liberty Mutual because Liberty Mutual is not one of the plans. Because there is no claim against Liberty Mutual, there is no claim on which to enter summary judgment. Rather, Liberty Mutual is entitled to be dismissed from this action because Kirkpatrick has failed to assert a claim against it upon which relief can be granted.
Liberty Life engaged in arbitrary and capricious decisionmaking at nearly every turn.
Defendant Liberty Mutual Group, Inc., is
SO ORDERED.
It is important to note, however, that while the Defendants argue that Dr. Martens specifically explained what was lacking in Dr. Neucks' evidence, the letter the Defendants cite for support indicates that Dr. Martens was perhaps quick to jump to conclusions without waiting for clarification. Dr. Martens' report indicates that he requested clarification and additional evidence from Dr. Neucks regarding certain medical records, including the discrepancy in occupational abilities between Dr. Neucks' Assessment of Capacity form and his Restrictions form. Yet this written clarification request was sent to Dr. Neucks on July 9, 2010, the same day that Dr. Martens' issued his "completed" report to Liberty Life. The record does not divulge whether any response from Dr. Neucks was ever received or considered.