ORDER
ELIZABETH A. KOVACHEVICH, District Judge.
This cause is before the Court on:
In the Complaint, Plaintiff Barbara J. MacDonald seeks the payment of long term disability benefits, reinstatement of all other benefits, including the waiver of premiums as if benefits had never been terminated, the award of attorney's fees and costs, and other appropriate relief.
Defendant Anthem Life Insurance Company ("Anthem") moves for entry of summary judgment affirming the termination of Plaintiff's long term disability benefits at the end of the 24-month "own occupation" period. Defendant Anthem determined that Plaintiff MacDonald was capable of performing other gainful occupations and no longer met the Policy's definition of disability. During the initial and appeal review, Plaintiff did not submit any proof of her inability to perform other gainful occupations; Defendant Anthem relied on current evidence of Plaintiffs functional capacity.
Plaintiff MacDonald moves for entry of summary judgment in favor of Plaintiff, on the basis that it was wrong and arbitrary and capricious for Defendant to have relied, in part, on the restrictions and limitations provided by Dr. Krost, but not to have conducted a new TSA (Transferable Skills Assessment) to determine whether the new restrictions would prevent Plaintiff from working at any gainful occupation.
Plaintiff MacDonald also contends that Defendant's decision was wrong and arbitrary and capricious because, in Defendant's denial letter, Defendant Anthem relied only on a portion of the limitations expressed by Dr. Krost, ignoring the restrictions and limitations most damaging to Defendant's position. Dr. Krost completed a PCA (Physical Capacity Assessment) which included restrictions which would prevent Plaintiff from using her left hand for all work activities. Dr. Krost's PCA indicates that Plaintiff could not use her left hand for any of the activities specified, and found that Plaintiff could not return to her own sedentary occupation. Defendant ignored how Plaintiffs inability to use her left hand affected her ability to work at any level (sedentary or light) and the more extensive restrictions and limitations were never submitted for occupational review.
Summary judgment should be rendered if the pleadings, the discovery and disclosure materials on file, and any affidavits, show that there is no genuine issue as to any material fact and that the movant is entitled to judgment as a matter of law.
The appropriate substantive law will guide the determination of which facts are material and which facts are ... irrelevant.
The Court notes the discussion in
In reviewing a plan administrator's benefits decision, the Court performs the following analysis:
The Court's review of an ERISA benefits decision is "limited to consideration of the material available to the administrator at the time it made its decision."
1. Plaintiff Barbara J. MacDonald was employed by Wellpoint, Inc. as a medical claims processor commencing on September 4, 2007. Plaintiffs last day worked was May 23, 2009.
2. Plaintiff MacDonald was a participant in an employee welfare benefit plan sponsored by Wellpoint, Inc., which included Wellpoint Group Long Term Disability Plan.
3. The Wellpoint Group Long Term Disability Plan is governed by ERISA.
4. Wellpoint Group Long Term Disability Plan is funded through policy of insurance issued by Anthem Life Insurance Company.
5. Anthem Life was the claim administrator and administered benefits under the terms of the Policy.
6. The Policy defines "Disability" as meaning, during the Elimination Period and the next 24 months because of Your injury or sickness, all of the following are true:
7. After 24 months, "Disabled" and "Disability" mean because of Your injury and sickness all of the following are true:
8. The Policy defines "Injury" and "sickness":
9. The Policy defines Regular Care:
10. The Policy provides that disability payments will stop on the earliest of the following dates:
11. "Material and Substantial Duties" are duties that:
12. The Policy defines "Own Occupation":
13. The Policy defines "Gainful Occupation":
14. The Policy defines "Disability Work Earnings":
15. Plaintiff's salary was $2,028.22 per month and her gross monthly disability payment was $1216.93, 60% of pre-disability earnings. A "Gainful wage" is $14,603.00 per year.
16. The Policy limits benefit payments to 24 months for "disability due to mental illness, substance abuse, or self-reported symptoms."
17. Under the Policy, Anthem Life is authorized to determine eligibility for benefits. The Policy states:
18. Plaintiff MacDonald had a motorcycle accident on May 23, 2009, in which Plaintiff sustained injuries. Plaintiff's first day of disability was May 26, 2009.
19. Wellpoint, Inc. approved Plaintiff's request for FMLA leave commencing on May 23, 2009 and approved Plaintiff's application for salary continuation/STD benefits.
20. Plaintiff MacDonald saw Dr. Martha Aliwalas, Plaintiffs primary care physician, on May 26, 2009. Dr. Aliwalas certified Plaintiff was unable to work due to severity of pain, and multiple contusions and abrasions, as to Plaintiff's FMLA leave through June 30, 2009. Dr. Aliwalas prescribed physical therapy and pain medication. Plaintiff saw Dr. Michael Vella, Syracuse Orthopedic Specialists on June 10, 2009; Dr. Vella recommended a bone scan. Plaintiff had a bone scan on June 15, 2009, and saw Dr. Daniel Murphy, Syracuse Orthopedic Specialists, on June 16, 2009 for pain in her left shoulder and stiffness, swelling and pain in the hand.
21. The bone scan of June 15, 2009 showed increased activity in the left acromioclavicular joint (joint at top of shoulder). On June 19, 2009, after review of x-rays and an examination, Dr. Daniel Murphy found a Grade II AC separation in Plaintiff's shoulder, a contusion sprain of Plaintiff's left hand and "Plaintiff is developing an early RSD." Dr. Murphy recommended referral for evaluation for possible sympathetic block.
22. The APS of Dr. Aliwalas reflects treatment on July 24, 2009, August 14, 2009, and August 31, 2009 for left elbow, left wrist, and left shoulder pain evidenced by swelling, decreased range of motion and decreased strength. Dr. Aliwalas further certified Plaintiff as unable to work for July 24, 2009 through August 31, 2009 for FMLA leave.
23. On July 22, 2009, Plaintiff MacDonald saw Pain Management Consultant Dr. Rina Davis, New York Spine and Wellness Center, July 29, 2009, on referral from Dr. Murphy. Dr. Davis prescribed medication and recommended nerve blocks. Plaintiff had trigger point injections to left trapezius and posterior cervical paraspinals. Plaintiff was to continue physical therapy.
24. On July 30, 2009, Plaintiff scheduled an appointment with Dr. Kevin Setter, Upstate Medical University, State University of New York, for September 17, 2009. An NCV was scheduled for September 9, 2009.
25. On August 7, 2009, Plaintiff MacDonald submitted Plaintiffs Supplemental Disability Application.
26. On August 31, 2009, Dr. Aliwalas requested Plaintiff be excused from work from August 31, 2009 through September 30, 2009, and submitted a Supplemental Physician's Statement of Disability on September 6, 2009.
27. Plaintiff submitted a Supplemental Disability Application on August 31, 2009.
28. Plaintiff continued to receive STD, and was notified that Plaintiff would need to apply for LTD; Plaintiff submitted records from Dr. Aliwalas, Dr. Davis and Dr. Setter.
29. On September 17, 2009, Dr. Kevin Setter examined Plaintiff, and injected the left subacromial region with a mixture of Marcaine, lidocaine and Depo-Medrol. Dr. Setter's impression was Complex Regional Pain Syndrome, or a variant thereof; Dr. Setter also noted signs of impingement syndrome.
30. Nerve blocks were scheduled at New York Spine and Wellness Center on October 1, 2009, October 15, 2009, October 29,2009 and November 12, 2009.
31. Dr. Aliwalas requested that Plaintiff be excused from work from September 30, 2009 through December 31, 2009.
32. In a letter dated October 19, 2009, Anthem Life acknowledged a request for Long Term Disability benefits from Wellpoint on behalf of Plaintiff, and sent forms to Plaintiff to complete and return by November 15, 2009.
33. On October 19, 2009, Dr. Aliwalas provided a letter which certified Plaintiffs temporary total disability due to injuries to bilateral upper extremities especially to the left shoulder:
34. Plaintiff saw Dr. Kevin Setter on October 22, 2009. Dr. Setter noted continued pain and CRPS. Dr. Setter deferred to New York Spine and Wellness Center as to treatment of CRPS, and deferred any surgical intervention or injections until after Plaintiffs pain is under better control; Dr. Setter would see Plaintiff on a p.m. basis.
35. On October 28, 2009, Plaintiff saw Dr. Aliwalas for re-evaluation of her wrist pain, shoulder pain and elbow pain, and for treatment for depression, anxiety and panic related to the motorcycle accident. Dr. Aliwalas noted decreased grip strength, shiny skin, edema in hand and wrist, and skin discoloration in the fingers. Dr. Aliwalas prescribed Cymbalta.
36. Plaintiffs Claim for LTD benefits was approved on November 13, 2009. The notes of the claim approval state:
37. Plaintiff applied for Social Security Disability benefits on November 24, 2009.
38. The LTD Policy includes an 180 day elimination period. LTD Benefits began November 22, 2009, and terminated on November 21, 2011.
39. Dr. Setter submitted an APS dated November 18, 2009, noting that Plaintiff was being treated for continued pain, CRPS, by the New York Spine and Wellness Center.
40. Dr. Aliwalas saw Plaintiff on November 30, 2009 and on January 4, 2010, for depression/anxiety/pain and complex regional pain syndrome.
41. On February 13, 2010, Plaintiff's application for Social Security Disability Benefits was approved, and Plaintiff was determined to be entitled to benefits starting on November 1, 2009.
42. On March 1, 2010, Anthem acknowledged receipt of the Social Security Disability Income Award, and requested a refund of the overpayment of $2,361.00.
43. On February 10, 2010, Plaintiff was evaluated by Dr. Kevin Barrett, Mayo Clinic, for the Chiari malformation. Dr. Barrett referred Plaintiff for an MRI, for a pain medicine consultation, and for a consultation with Dr. William Cheshire.
44. On February 10, 2010, Plaintiff was evaluated by Dr. Scott Palmer at the Mayo Clinic for a pain consultation. Dr. Palmer's report states:
Dr. Palmer provided a topical compounded cream for pain in the left upper extremity, a prescription for amitryptiline, ordered consultation with Dr. Sletten, Pain Psychology, and consultation with Physical Medicine and Rehabilitation.
45. Plaintiff had an MRI of the cervical spine at the Mayo Clinic on February 17, 2010, and a neurology consultation with Dr. William Cheshire, Mayo Clinic, on February 25, 2010. The MRI report states:
46. The report of Dr. Cheshire states:
47. Surgery to correct the Chiari one malformation was performed on March 16, 2010 at the Mayo Clinic.
48. Dr. Aliwalas submitted an APS dated April 9, 2010, which stated that Plaintiff is unable to work due to constant pain from June 16, 2009 onward; the APS states that Plaintiff is disabled from Plaintiff's job and any other work, and Dr. Aliwalas does not expect a fundamental change in the future.
49. Dr. John H. Kalosis, Jr., American Medic of Charlotte County, PA, submitted medical records of an evaluation dated July 26, 2010, which states Dr. Kalosis' assessment of CRPS and Chiari malformation, and associated stress, anxiety and depression.
50. On August 4, 2010, Plaintiff was evaluated by Dr. Saeed Shahzad on referral from Dr. Kalosis, for left arm pain, and complex regional pain syndrome. Dr. Shahzad's report states:
HISTORY OF PRESENT ILLNESS:
. . . . The patient states her left arm has pain, she does not use it. She is disabled because of the pain and weakness of that arm. The patient states if she tries to use that arm it swells up, becomes red and very painful. The patient is on disability now. The patient denies pain in right upper or both lower extremities. The patient states once in a while she does feel some pain in neck. She is status post cervical fusion many years ago. The patient denies any difficulty with gait or balance. The patient denies any difficulty with sleep. The patient denies any dysarthria, diplopia or dysphagia.
ASSESSMENT AND PLAN:
Her left arm pain is under good control with medications, including amitriptyline, Flexeril, Xanax and hydrocodone p.m. Her headaches have improved. We will continue her Topamax 75 mg daily for prevention of headache episodes. The patient can continue to take her amitriptyline 25 mg one tablet at night. I will followup and see patient in three months.
Dr. Shah submitted an APS dated February 3, 2011, reflecting his opinion that Plaintiff is totally disabled from Plaintiffs job and any other work, and Dr. Shah does not expect a fundamental or marked change in the future. Dr. Shah treated Plaintiff on August 4, 2010, and November 22, 2010, with a next appointment scheduled on February 22, 2011. Dr. Shah prescribed medication to treat Plaintiff: amitriptyline, Flexeril, Xanax and hydrocodone. Dr. Shah states a DOT Class 5 physical impairment: severe limitation of functional capacity; incapable of minimum (sedentary) activity (75-100%). Dr. Shah further states a DOT Class 3 mental/nervous impairment: Patient is able to engage in only limited stress situations and engage in only limited interpersonal relations (moderate limitations), defining "stress" as "under stress from left arm pain". Dr. Shah indicates Plaintiff is unable to work from August 4, 2010 onward because of continuing pain and medication. As to Question 9, "Work Limitations," Dr. Shah indicates only: Other: Patient unable to work. Dr. Shah indicates that Plaintiff is not suitable for rehabilitation services, and did not recommend vocational counseling or retraining.
51. On April 5, 2011, Plaintiff saw Dr. Amy Mellor, Neurology Associates of Charlotte County, for a second opinion as to Complex Regional Pain Syndrome. Dr. Mellor's records state "current pain control satisfactory." Dr. Mellor observed edema in Plaintiffs left upper extremity. Dr. Mellor prescribed medication, and scheduled a follow up visit in three months. Plaintiff returned on July 12, 2011.
52. Dr. Mellor submitted an APS on September 16, 2011, which reflects treatment with medication for CRPS and depression/anxiety. Dr. Mellor states Plaintiff's Physical Impairment as a Class 5 DOT impairment: Severe limitation of functional capacity; incapable of minimum (sedentary) activity (75-100%). Dr. Mellor states a Class 3 mental/nervous impairment: Patient is able to engage in only limited stress situations and engage in only limited interpersonal relations (marked limitations), defining "stress" as "depression, anxiety over disability." Dr. Mellor states that Plaintiff is unable to perform Plaintiffs job or any other work, and Dr. Mellor does not expect a fundamental or marked change in the future. Dr. Mellor states Plaintiff is unable to work from April 4, 2011 onward due to continuing pain. As to "work limitations," Dr. Mellor states only: Other: Unable to work. Dr. Mellor indicates Plaintiff is not a candidate for rehabilitation services, and does not recommend vocational counseling and/or retraining.
53. On August 29, 2011, Anthem Life advised of Plaintiff MacDonald that under the terms of Plan, beyond 24 months Plaintiff must be disabled not only from her own occupation but also from any occupation, and notified Plaintiff of the transition date was November 22, 2011. Defendant requested a completed Attending Physician Statement, a completed Claimant Questionnaire form, Medical records from all treating physicians from December 1, 2010 to present, a signed Authorization for Release of Information form, and a current resume or detailed work history summary. Plaintiff responded to Defendant's request by providing the requested documents.
54. On September 30, 2011, Beth Szopinski, R.N., noted that the current available clinical records did not support the presence of a functional impairment:
55. On September 30, 2011, Anthem Life requested a prescription/release for a Functional Capacity Evaluation from Dr. Mellor.
56. Anthem Life referred Plaintiff for a Functional Capacity Evaluation (FCE), which was conducted on 10/18/2011 to determine Plaintiffs general abilities and limitations. The FCE was performed by Gabriel A. Weber, P.T/Cert. MDT.
57. The only listed defects in the FCE were "limited range of motion and strength in the left arm", "guarded left arm and hand movements", and "decreased left arm swing during ambulation."
58. On October 20, 2011, Nancy O'Reilly reviewed the FCE, but noted no handling or fingering was indicated in the testing performed; she requested an update from the provider.
59. On October 21, 2011, the provider responded to the request, pointing out information on pages 3 and 9, and further providing a corrected copy of the report.
60. On October 25, 2011, the provider responded that the information requested was not tested and not included in the FCE protocol.
61. Plaintiff was not rescheduled for additional testing as to handling and fingering.
62. On October 27, 2011, Nancy O'Reilly noted that the FCE states "light work" capacity, but the "own occupation" is "sedentary."
63. Nancy O'Reilly, M.S., CRC, CCM performed a Transferable Skills Assessment (TSA) and Labor Market Survey (LMS) on October 27, 2011. The TSA states the following transferable skills:
The TSA states:
In the TSA, Nancy O'Reilly identifies five examples of occupations that Plaintiff had the potential to perform, based on her education, work history and physical capacity. Two of those examples are classified as sedentary, and three are classified as light work:
64. On November 8, 2011, Defendant Anthem Life determined that Plaintiff MacDonald was not disabled from any gainful occupation, and therefore LTD benefits were terminated effective November 22, 2011.
65. Plaintiff MacDonald appealed the decision terminating her claim in a letter of March 21, 2012.
66. Anthem Life acknowledged receipt of Plaintiffs request for review on March 30, 2012.
67. On appeal, Anthem Life scheduled an IME to be performed by Dr. Stuart B. Krost; Dr. Krost completed a Physical Capacities Assessment (PCA) form dated May 24, 2012, and furnished a separate IME report dated May 4, 2012.
68. In a letter of July 9, 2012, Defendant upheld its decision to terminate Plaintiffs benefits. Anthem Life acknowledged Plaintiff's functional restrictions and limitations as supported by the available clinical evidence:
69. The DOT defines light work:
70. On appeal, Plaintiff provided additional medical information, photographs of the severe swelling in her left hand, and articles related to CRPS.
71. In the IME report, Dr. Stuart B. Krost states:
Dr. Krost's IME Report incorporates the FCE dated October 18, 2011.
____ Dr. Krost's Physical Capacities Assessment of May 24, 2012 states:
In the PCA, Dr. Krost estimates Plaintiff's abilities as to lifting and carrying, climbing, balance, stooping, kneeling, crouching, crawling, immediate reach, reach above shoulders, handling, fingering and feeling. Dr. Krost states that Plaintiff can perform repetitive actions with right upper extremity only; Plaintiff can "simple grasp" with her right hand, but not left hand, can "firm grasp" with her right hand, but not left hand, and can perform "fine manipulation" with her right hand, but not left hand. Dr. Krost further states Plaintiff cannot return to her former occupation, but can return to work full-time according to the restrictions defined above [in the PCA form].
72. Dr. Krost specified different restrictions in the PCA compared with the restrictions and limitations previously used to perform the October 27, 2011 TSA. That TSA was based only on the following restrictions:
73. On May 22, 2014, Kelly Tillotson, Sr. Appeals Specialist, Custom Disability Solutions, recommended to Kristie Woods, Quality Management Specialist/Appeal Coordinator, that Plaintiff be referred to independent vocational specialist for TSA/LMS, since Wellpoint already completed a TSA/LMS.
74. On May 24, 2012, Kristie Woods referred Plaintiff's appeal Wright Rehabilitation Services for an "any occupation" analysis based on the restrictions/limitations in the IME report of Dr. Krost.
75. A new TSA was never performed; on June 15, 2012, Wright Rehabilitation Services performed only a second LMS, based on the restrictions in the FCE of October 18, 2011. The LMS states:
76. Information Clerk positions were not found in the targeted area.
77. The position of Hotel Clerk described in the second LMS includes tasks that may be done by computer, or may be done manually. The 4Points Sheraton lists "basic computer skills/mouse" among its requirements.
78. The position of Weight Reduction Specialist includes "entering data on client record" but does not specify by what means.
79. The position of Tanning Salon Attendant includes the requirement of "inputting computer commands for tanning."
80. The position of Tourist Information Assistant requires customer service, light clerical and phone tasks. "Light clerical'' tasks such as composing letters in response to inquiries, and maintaining personnel, license-sales and other records are tasks that may or may not involve computer use.
The parties disagree as to the standard of review that applies to Defendant Anthem Life's decision to deny LTD benefits to Plaintiff MacDonald under the "any occupation" definition of disability.
Plaintiff MacDonald admits that Defendant Anthem Life has discretionary authority to determine eligibility for benefits and to interpret the terms and provisions of the policy. Plaintiff MacDonald further argues that the final decision to deny LTD benefits under the "any occupation" provision was made by Kristie Y. Woods, who is employed by Wellpoint, the parent company of Defendant Anthem Life.
Defendant Anthem Life responds that an entity vested with discretionary authority may delegate that authority to another entity without losing discretion.
The Court finds that the final benefits decision was made by an authorized agent of Defendant Anthem Life. The insurance policy conferred discretionary authority on Anthem Life to determine eligibility for benefits, and to construe the terms of the policy to make a benefits decision. The Court will therefore review the decision of the administrator under the arbitrary and capricious standard of review.
Under ERISA, the plaintiff has the burden of showing she is entitled to benefits under the terms of the Plan.
Indicia of arbitrary and capricious decision may include a lack of substantial evidence, procedural irregularities, a mistake of law, bad faith and conflict of interest by the fiduciary.
A pertinent conflict of interest exists where the ERISA plan administrator both makes eligibility decisions and pays awarded benefits out of its own funds.
Even where a conflict of interest exists, courts still "owe deference" to the plan administrator's "discretionary decision-making" as a whole.
Plaintiff MacDonald was granted LTD benefits based on Plaintiffs inability to perform the duties of her own occupation; after her accident, Plaintiff was treated for complex regional pain syndrome and impingement in her left arm. Plaintiff's work as a medical claims processor included constant keyboarding, which Plaintiff could not do.
After twenty-four months, under the Policy, the definition of disability becomes disability from performing "any occupation" rather than "own occupation." Defendant Anthem Life argues that Defendant accepted the limitations identified in two current medical examinations, and obtained detailed vocational analyses which confirmed the existence of several jobs that Plaintiff could perform within those limitations. The denial of LTD benefits under the "any occupation" definition of disability was based on the FCE, the TSA, the LMS and the IME, which provide a reasonable basis for Anthem Life's conclusion that Plaintiff could perform other gainful occupations. Defendant argues that Plaintiff did not provide updated medical evidence to support her claim, the most updated medical evidence supported Plaintiffs ability to perform up to a light level of work (in excess of the sedentary level of Plaintiff's own occupation).
Courts have recognized that plan administrators routinely rely on FCE's.
Defendant Anthem Life argues that Dr. Krost's findings in the IME and PCA are consistent with the FCE findings as to Plaintiffs ability to perform light work, and Defendant Anthem Life obtained a more in-depth vocational assessment on appeal. Rehabilitation Counselor Jane Lynn Veal, LA, CRC, spoke with fifteen employers within fifty miles of Plaintiffs home to confirm that, with her restrictions, Plaintiff could perform the five occupations identified, that jobs existed in the targeted area, and that the wages exceed that of the target wage for "gainful" employment under the Policy.
Defendant Anthem Life argues that the medical and vocational evidence on which Defendant relied was undisputed; Anthem Life's decision represents an informed judgment, and articulates an explanation consistent with the relevant facts surrounding Plaintiff's claim for benefits. Defendant argues that Defendant's decision is reasonable and should be upheld.
Vocational evidence, such as the TSA and LMS, is an "effective method of reaching an informed decision as to a claimant's work capability."
Defendant Anthem Life argues the opinions of Plaintiffs treating physicians were outdated, inconsistent with the rest of the medical evidence, and did not address Plaintiffs current level of functioning. Defendant Anthem argues that, where the opinion of the treating physician is conclusory, and the medical consultant provided a detailed explanation of why the plaintiff was capable of work, the reliance of the claim administrator on the opinion of the medical consultant was reasonable and correct.
To the extent that other evidence in the record suggests Plaintiff is disabled, the plan administrator is entitled to weigh the evidence and resolve conflicting evidence about the claimant's disability.
Defendant Anthem Life argues that the approval of Social Security benefits may be considered, but is not conclusive on whether a claimant is also disabled under the terms of an ERISA plan.
In the July 9, 2012 determination letter, Defendant Anthem Life explained that entitlement to Social Security Disability Income benefits is based on a different set of guidelines, and often different medical evidence, which can lead to differing conclusions.
Plaintiff Macdonald argues that, in her file review, Nurse Szopinski ignored the medical records of Dr. Mellor, which include objective evidence of complex regional pain syndrome, edema and decreased range of motion, as of July, 2011.
Plaintiff argues that when Dr. Krost completed a PCA, Dr. Krost provided a new set of limitations; therefore Defendant Anthem Life should have referred the file for a new TSA to determine whether Plaintiff could perform the previously identified occupations or any other occupations. Plaintiff argues that this case is just like
Plaintiff MacDonald argues that, without the use of her left hand, Plaintiff could not perform the five occupations identified in the claim file, which are defined by the DOT, the Occupational Access System (OASYS), the U.S. Department of Labor's 0*Net, and America's Career InfoNet. Plaintiff argues that three of the occupations require computer usage, and the other two require extensive use of hands to clean and maintain equipment, physically assist customers, carry baggage, and perform other such tasks.
Defendant Anthem Life responds that Dr. Krost explicitly found that Plaintiff could perform full-time light work despite some limitations in the use of her left arm. During the FCE, Plaintiff MacDonald admitted to some use of her left arm, despite some limitations in use. Dr. Krost's PCA contains more specific limitations, but Dr. Krost does not opine that Plaintiff MacDonald could not use her left arm at all. Dr. Krost states that Plaintiff needed to limit the use of her left arm, and that Plaintiff could work full-time at a light level with that limitation. Dr. Krost's clinical findings reflect restrictions, not a complete inability to use the left arm.
In light of the consistency of Dr. Krost's limitations and clinical findings with the FCE, the Court finds it was reasonable for Defendant Anthem Life to rely on the jobs identified in the TSA. Plaintiff did not submit contrary vocational evidence and did not contest the jobs identified in the TSA during her appeal. Plaintiff MacDonald did not assert Plaintiff could not use her left arm at all, and did not provide medical records supporting that extreme limitation.
Other courts have held that the consideration of vocational evidence is not necessary where the evidence in the administrative record supports the conclusion that the claimant does not have a disability which prevents her from performing some identifiable job.
Defendant Anthem Life argues that, in considering whether a structural conflict of interest affected Defendant's's benefit determination, the burden remains on Plaintiff to show the decision is arbitrary; it is not Defendant's burden to prove its decision is not tainted by its self interest. Defendant Anthem Life argues that, in this case, the decision to terminate LTD benefits under the "any occupation" definition was supported by corroborating medical and vocational reviews. Plaintiff has not marshaled any evidence that the structural conflict affected the claim decision.
Wellpoint delegated discretion to Anthem Life to determine eligibility for LTD benefits, and to determine claims. The Court concludes that Defendant's decision to deny LTD benefits under the "any occupation" definition of disability to Plaintiff MacDonald was not "wrong"; if the decision is found to be "wrong," the decision to deny further LTD benefits was reasonable. The Court therefore grants Defendant's Motion for Summary Judgment.
In determining the standard of review, the Court examined the Plan documents, and found that Wellpoint delegated discretion to Defendant Anthem Life. The Court has concluded that Anthem Life's decision to deny LTD benefits to Plaintiff MacDonald was not wrong. The Court therefore denies Plaintiffs Motion for Summary Judgment. Accordingly, it is