SUE E. MYERSCOUGH, District Judge.
This cause is before the Court on the parties' cross-motions for summary judgment. Because Defendant National Electrical Benefit Fund's (NEBF) denial of benefits was not arbitrary and capricious, NEBF's Second Motion for Summary Judgment (d/e 26) is GRANTED and Plaintiff Dennis Hilderbrand's Motion for Summary Judgment Following Remand and Motion for Sanctions (d/e 22) is DENIED.
The following facts are taken from NEBF's Statement of Undisputed Facts and other evidence in the record.
The NEBF is a multi-employer employee pension benefit plan within the meaning of Section 3(2) of the Employee Retirement Income Security Act of 1974 (ERISA) (29 U.S.C. § 1002(2)). NEBF's Statement of Undisputed Fact No. 1. The NEBF was established pursuant to an agreement between the International Brotherhood of Electrical Workers and the National Electrical Contractors Association providing retirement benefits to participants upon their retirement from the electrical industry.
On October 9, 2002, Hilderbrand (d/o/b October 22, 1958) was injured at work while operating a piece of machinery.
In November 2004, Hilderbrand had surgery on his leg to release the right peroneal nerve.
On December 8, 2004, Hilderbrand saw Dr. Mackinnon, who reported that Hilderbrand was "doing well." R. 209. She prescribed him a Lidoderm patch for the dorsal aspect of his foot. She recommended start physical therapy and recommended that he follow up with his pain management physician.
On December 27, 2004, Dr. Mackinnon noted that Hilderbrand was still having some discomfort but that there was nothing more she could offer him from a surgical point of view. R. 211. Dr. Mackinnon recommended that Hilderbrand be evaluated by the pain management team as a candidate for a dorsal column stimulator.
On January 25, 2005, Hilderbrand saw Dr. Muhammad Munir, Instructor in Anesthesiology, Barnes-Jewish Hospital, Washington University Pain Management Center. R. 213. Dr. Munir noted that, after the surgery, Hilderbrand had relief of his pain in the back of his calf but continued to have persistent pain in the top of his leg and top of his foot. R. 213. Hilderbrand reported that, since the surgery, Hilderbrand "felt a sharp shooting and stabbing pain, like electrical sensation going down on the lateral and top part of his leg and into the foot."
On March 1, 2005, Hilderbrand underwent a psychological evaluation. R. 217. During the evaluation, Hilderbrand complained of pain and reported that activity, standing, and walking increased his pain. R. 217. He expressed an interest in returning to work. R. 219.
On August 1, 2005, Hilderbrand saw Dr. Munir regarding back pain he was experiencing. Dr. Munir did not know the cause of Hilderbrand's "back injury." R. 224.
On November 9, 2005, Hilderbrand saw Dr. Robert Swarm, Chief, Clinical Pain Management, Barnes-Jewish Hospital, Washington University Pain Management Center. R. 221. Hilderbrand continued to have significant right lower extremity neuropathic pain. Hilderbrand described right lower leg and ankle pain that was continually present. R. 221. The pain worsened with activity. R. 21. Elevation of the right lower leg gave him some relief, as did rest.
On June 12, 2006, Hilderbrand returned to see Dr. Swarm at the Pain Clinic. R. 226. Hilderbrand complained of pain in the right anterior foot as well as the right anterior and lateral ankle. The pain was always present but worsened by having the foot in a dependent position and with standing and walking.
R. 227. The work restrictions were permanent.
On November 27, 2006, Hilderbrand returned to the Pain Center complaining of pain. R. 229. Dr. Swarm again noted Hilderbrand's work restrictions:
R. 229.
On January 19, 2007, Hilderbrand underwent a spinal cord stimulation. R. 232. At a visit to the Pain Center on April 18, 2007, Hilderbrand continued to complain of pain. R. 234. Dr. Swarm indicated a "[f]ailed trial of spinal cord stimulation 1/22/07."
R. 234.
On July 16, 2007, Hilderbrand returned to the Pain Center complaining of pain in his right lower leg and foot. R. 236. Dr. Swarm noted the same work restrictions as identified on April 18, 2007.
On January 9, 2008, Hilderbrand saw Dr. Jacques VanRyn of Premier Care Orthopedics for a consultation. R. 238. Dr. VanRyn found that Hilderbrand was at maximum medical improvement for his condition — complex regional pain syndrome. R. 240. Dr. VanRyn also found that Hilderbrand "should have permanent restrictions consistent with the recommendation of Dr. Swarm":
R. 240.
On March 29, 2004, Hilderbrand filed an application for disability benefits with the Social Security Administration alleging disability beginning October 9, 2002. R. 97. On April 18, 2007, Administrative Law Judge Alice Jordan found Hilderbrand "disabled" within the meaning of the Social Security Act from October 9, 2002 through December 8, 2004. R. 91-111. ALJ Jordan found that medical improvement occurred as of December 9, 2004, following Hilderbrand's recovery from a surgical procedure to release the peroneal nerve. R. 104.
ALJ Jordan concluded that, beginning December 9, 2004, Hilderbrand had the residual functional capacity to perform work that: required the ability to lift or carry up to 10 pounds occasionally or frequently and that accommodated the use of a hand-held device (a cane) for assistance with ambulation; allowed sitting for 6 to 8 hours with the accommodation to elevate the leg as needed; required no more than 2 hours of standing or walking with the use of a hand-held device; required no climbing or crawling, and only occasional balancing, crouching, or kneeling; and required no exposure to hazards. R. 105. In making the residual functional capacity determination, ALJ Jordan considered medical records as recent as November 27, 2006
On July 30, 2007, Hilderbrand filed a second application for disability benefits with the Social Security Administration. R. 177; 181. On December 2, 2008, ALJ John Dodson found Hilderbrand disabled under sections 216(i) and 223(d) of the Social Security Act since October 21, 2008. R. 177-81. ALJ Dodson found no basis for reopening Hilderbrand's prior application. R. 177. Moreover, ALJ Dodson observed that Hilderbrand had amended the alleged onset date of disability to October 21, 2008 (the day before Hilderbrand's 50th birthday). R. 177.
ALJ Dodson found that Hilderbrand had the residual functional capacity to perform sedentary work except that he was limited to work that accommodated the use of a hand-held device for assistance with ambulation. R. 179. In addition, the work should: allow sitting for 6 to 8 hours with accommodation to elevate the leg as needed
Taking into account the two Social Security decisions, Hilderbrand received Social Security benefits beginning April 2003 and ending March 2005 (R. 12) and again beginning November 2008 (R. 31).
In January 2012, Hilderbrand completed an NEBF Participant Pension Benefit Application seeking disability benefits. R. 1. The Plan is self-administered by its Trustees. R. 399.
The Plan defines disability as follows:
R. 334. This is the same definition used by the Social Security Administration.
R. 334.
In March 2012, the NEBF approved Hilderbrand's application for disability benefits in part. R. 53. The NEBF awarded Hilderbrand benefits of $640 per month (minus tax withholding) beginning in March 2012. The NEBF also found Hilderbrand was entitled to a retroactive payment for November 2002 through February 2012. However, the years 2005 and 2008 remained under review.
In July 2012, counsel for Hilderbrand treated the March 2012 determination as a denial of benefits for the period of March 2005 through October 2008 and asked for a review of that decision.
R. 127.
Hilderbrand appealed and submitted additional information.
In the "Opinions/Recommendations" section of the report, Hammond noted Hilderbrand's current age (54), which was considered a "person closely approaching advanced age." R. 268. Hammond also noted that Hilderbrand had not previously held any positions that provided skills for a sedentary level of work. R. 268. Hammond stated that the Social Security vocational rules for persons of Hilderbrand's age require direct transferability of skills for lower level jobs. R. 268. Hilderbrand did not have transferrable skills.
Hammond also concluded that Hilderbrand would be unable to work even in a sedentary position. R. 268. Hammond noted that Hilderbrand had to be in a seated position and elevate his right leg as needed. Hammond stated:
R. 268-69. Hammond concluded that Hilderbrand had less than sedentary ability, which would eliminate all positions in the general labor market. R. 269.
On February 8, 2013, the NEBF Trustees denied the appeal. R. 281-82. The NEBF Trustees noted that Hilderbrand must demonstrate total disability under the NEBF's definition of disability, which was the same as the Social Security Administration's definition of disability. R. 281. The Trustees held:
R. 281-82.
The Trustees referenced several physician findings cited by Hilderbrand in his appeal. The Trustees noted that while Hilderbrand's physicians restricted Hilderbrand to light duty, sedentary work that allowed for the elevation of his right leg, none of the physicians stated Hilderbrand was unable to work. R. 282. In addition, the Trustees noted that the Social Security Administration's December 2, 2008 decision did not find Hilderbrand totally disabled prior to October 21, 2008.
On June 7, 2013, Hilderbrand filed his Complaint seeking benefits pursuant to ERISA (29 U.S.C. § 1132(a)(1)(B)). Hilderbrand alleged the NEBF arbitrarily and capriciously denied him benefits and a full and fair review of his claim. Compl., ¶ 18 (d/e 1). The parties filed cross-motions for summary judgment.
On December 30, 2014, this Court reversed the denial of benefits and remanded the claim for benefits to the NEBF Trustees for a
On February 23, 2015, the NEBF Trustees
The NEBF Trustees specifically considered the two Social Security Administration decisions, the medical records, Hammond's report, and other documents in the administrative record. The NEBF Trustees considered whether Hilderbrand demonstrated "the inability to engage in substantial gainful employment as a result of his medical condition."
The Trustees found that this evidence outweighed Hammond's opinion.
Summary judgment is proper if the movant shows that no genuine dispute exists as to any material fact and that the movant is entitled to judgment as a matter of law. Fed. R. Civ. P. 56(a). When ruling on a motion for summary judgment, the court must consider the facts in the light most favorable to the nonmoving party, drawing all reasonable inferences in the nonmoving party's favor.
Summary judgment is proper if no reasonable factfinder could return a verdict for the non-moving party.
A district court reviews an ERISA administrator's benefit determination
In this case, the Plan gives the Trustees discretionary authority to interpret the Plan's provisions and review claims:
R. 353. Therefore, the arbitrary and capricious standard applies.
Hilderbrand argues, however, that the standard of review should be
Section 2001.3 of the Illinois Administrative Code prohibits provisions that purport to reserve discretion to insurers to interpret health and disability policies:
50 Ill. Admin. Code § 2001.3. In
The
In contrast here, no insurance company is involved at all. NEBF does not offer the benefits through an insurance company and has not granted an insurance company the authority to make benefit determinations. Moreover, Section 1144(b)(2)(B) of ERISA specifically provides that employee benefit plans described in section 1003(a) (which is the type of plan at issue here) shall not be deemed to be an insurance company or deemed to be engaged in the business of insurance. 29 U.S.C. § 1144(b)(2)(B);
Therefore, the arbitrary and capricious standard applies in this case. Under the arbitrary and capricious standard, the district court will not overturn an administrator's decision unless the decision is "downright unreasonable."
On summary judgment, this Court must determine, taking the evidence in the light most favorable to the nonmoving party, whether NEBF's decision denying Hilderbrand benefits for the period of March 2005 through October 2008 was arbitrary and capricious.
Hilderbrand argues that the Court should reverse the decision of NEBF and award benefits and fees to Hilderbrand. NEBF argues that, on remand, the Trustees conducted a
Even taking the evidence in the light most favorable to Hilderbrand, NEBF's decision was not arbitrary and capricious as the decision has support in the record. The NEBF Trustees considered the medical evidence, the Social Security decisions, and Hammond's vocational report. The Trustees offered a reasonable explanation, based on the evidence, for the determination that Hilderbrand did not meet the Plan's definition of disability between March 2005 and October 2008.
Hilderbrand argues that NEBF had an obligation to conduct a good faith investigation of Hilderbrand's functional ability to work and should have hired a vocational expert.
The Seventh Circuit has not expressed an opinion "as to whether ERISA plan administrators as a rule must hire vocational experts or perform a transferrable skills analysis."
Regardless, in this case, the NEBF Trustees took the vocational considerations into account. The Trustees expressly considered Hammond's report, as well as the Social Security Administration decisions and Hilderbrand's treating physicians' medical reports. In addition, the first Social Security decision contained evidence that a vocational expert concluded that jobs existed in the national economy for an individual with Hilderbrand's age, education, work experience, and residual functional capacity as of December 9, 2004. The NEBF Trustees considered this evidence when they made their decision.
Hilderbrand next argues that NEBF improperly disregarded Hammond's report, which was, according to Hilderbrand, unrebutted.
The NEBF Trustees clearly considered the Hammond report. The NEBF Trustees concluded that Hammond's report was entitled to little weight, however, because Hammond did not observe Hilderbrand until 2012. Decision at 5. In addition, although Hammond cited Hilderbrand's medical records and past relevant history, he did not specifically opine on Hilderbrand's ability to engage in substantial gainful employment from March 2005 to October 2008. Decision at 5. This was a reasonable interpretation of Hammond's report.
In the Opinion section of the report, Hammond noted Hilderbrand's current age (54) and the fact that Hilderbrand is closely approaching advanced age. R. 268;
In addition, Hilderbrand's assertion that Hammond's report was unrebutted is incorrect. The Social Security decisions contained vocational evidence that supports the NEBF Trustees' conclusion that Hilderbrand could engage in substantial gainful employment between March 2005 and October 2008.
The first Social Security Award found that Hilderbrand was disabled beginning October 9, 2002 and ending on December 9, 2004, when medical improvement occurred. R. 172. ALJ Jordan determined that, as of December 9, 2004, Hilderbrand had the residual functional capacity to perform work:
R. 166. In making this determination, ALJ Jordan considered numerous medical records, including the November 27, 2006 medical report by Dr. Swarm "that identified permanent work restrictions of: light duty, sedentary work with allowances for elevation of the right lower extremity; able to stand for a maximum of 15 minutes total every two hours; walking limited to a maximum of 40 yards on a rare basis and the need to use a cane." R. 170. This limitation by Dr. Swarm is the same limitation he proposed in April 2007 and July 2007, and Dr. VanRyn proposed in January 2008.
ALJ Jordan specifically noted that Hilderbrand's ability to perform the full range of sedentary work was impeded by his limitations. R. 171. The ALJ asked the vocational expert whether jobs existed in the national economy for an individual with Hilderbrand's age, education, work experience, and residual functional capacity. R. 171. The vocational expert testified that such an individual would be able to perform the requirements of representative occupations such as general office clerk, cashier, and dispatcher. R. 171. This vocational evidence is contrary to Hammond's conclusion.
The second Social Security decision also referenced vocational evidence. ALJ Dodson found Hilderbrand disabled as of October 21, 2008, but this determination was not based on any change in Hilderbrand's physical condition. In fact, ALJ Dodson's residual functional capacity finding was almost identical to ALJ Jordan's residual functional capacity finding (only failing to contain any mention of lifting limitations).
Under the Grid, claimants are designated as "disabled" or "not disabled" depending upon their exertional limitations (sedentary, light, medium, heavy, and very heavy), age, education, and work experience.
Therefore, the Trustees had vocational evidence that contradicted Hammond's findings. The Trustees had evidence that a person under the age of 50 with Hilderbrand's education, work experience, and residual functional capacity was not considered disabled by the Social Security Administration. Hilderbrand has not pointed to any evidence before the Trustees that anything changed — other than Hilderbrand's age — between the first decision and the second decision.
Hilderbrand next argues that the NEBF Trustees misstated Dr. Swarm and Dr. VanRyn's findings, improperly concluding that Dr. Swarm and Dr. VanRyn contradicted Hammond's report, and mischaracterized Dr. Swarm and VanRyn as stating that Hilderbrand could perform light duty or sedentary work.
Hilderbrand's complaint appears to be that the NEBF Trustees noted Dr. Swarm's opinion that Hilderbrand had permanent work restrictions but was capable of light duty, sedentary work that allowed for elevation of the right lower extremity and Dr. VanRyn's concurrence with Dr. Swarm's opinion that Hilderbrand could perform sedentary work, but that the Trustees failed to note that the physicians also found additional limitations. The additional limitations included standing for a maximum of 15 minutes total every two hours, walking limited to 40 yards on a rare basis, and the use of a cane.
A plan administrator cannot selectively consider evidence and pick out the statements that support the decision to deny benefits while ignoring the evidence that supports the individual's claim that he is disabled.
Hilderbrand also claims that NEBF gave improper weight to the medical providers, who are untrained in vocational analysis. However, there is nothing improper about considering physician's opinions about a claimant's ability to work.
Hilderbrand relies on a Social Security regulation (20 C.F.R. § 404.1527(d)(1)) and Social Security Ruling 96-5p to support his assertion that a medical doctor does not have the ability or training to determine whether a claimant can perform work. Reply at 6 (d/e 27). Social Security regulations and rulings are not applicable under ERISA, although the guiding principles developed in social security cases may be instructive.
Hilderbrand next argues that while the two Social Security decisions are relevant, they do not contain all of the medical evidence considered by the ALJs. Hilderbrand also argues that "statements made by ALJ Dodson that a physician[] whose medical records are not part of the administrative record" are hearsay and should be given little if any weight. Reply at 7. Although Hilderbrand's argument is not entirely clear, the Court notes that the Federal Rules of Evidence do not apply in ERISA cases and this court "reviews the entire administrative record, including hearsay evidence relied upon by the administrator."
Hilderbrand also argues that the Social Security Administration did not determine that Hilderbrand was not disabled between March 2005 and October 21, 2008. Although the Social Security Administration did not make that explicit finding, ALJ Jordan found that Hilderbrand was no longer disabled after December 9, 2004. In December 2008, ALJ Dodson refused to reopen the earlier application and found Hilderbrand was disabled again on October 21, 2008, the day before Hilderbrand reached age 50. As noted above, ALJ Dodson found Hilderbrand disabled under the Grid based on Hilderbrand achieving the age of 50. Consequently, the Court finds the NEBF did not misstate the Social Security Administration's holdings.
Hilderbrand also argues that the NEBF's position on Hilderbrand's disability is contradictory. According to Hilderbrand, the NEBF fails to explain why NEBF claim benefits are payable only if the Social Security Administration found a person disabled but then paid benefits to Hilderbrand from December 2004 to March 2005 despite ALJ Jordan's finding that Hilderbrand was no longer disabled after December 9, 2004.
When the NEBF denied Hilderbrand's appeal of its determination that Hilderbrand was not eligible for benefits during the period of March 2005 through October 2008, NEBF explained that Hilderbrand stopped receiving a Social Security award in March 2005.
Hilderbrand argues that NEBF failed to consider the psychological evidence presented by Hilderbrand at Exhibit O. Exhibit O is the Psychological Evaluation conducted by Beverly Field, PhD, on March 1, 2005. R. 216-219. Hilderbrand does not explain why NEBF's failure to consider this document is relevant. Moreover, the denial of Hilderbrand's claim shows that NEBF did consider Exhibit O but found that it did not address Hilderbrand's actual or expected ability to engage in substantial activity. NEBF also noted that the evaluator recommended:
Decision at 4 (d/e 25-1).
Finally, Hilderbrand argues that NEBF failed to consider Dr. Munir's medical report indicating that Hilderbrand had a markedly antalgic gait, used a cane, had to avoid bearing weight on his right leg. Hilderbrand asserts that this evidence is important because it contradicts NEBF implicit presumption that Hilderbrand medically improved from March 2005 until October 2008.
The medical report to which Hilderbrand refers was dated January 25, 2005. NEBF specifically stated that this record, and others dated from August 2004 to March 2005, were given little weight because those records did not address the issue of Hilderbrand's actual or expected ability to engage in substantial gainful activity from "March 2005 to November 2008." Decision at 4. The determination to give such records little weight was reasonable and did not render NEBF's decision arbitrary and capricious.
In sum, the undisputed facts, even taken in the light most favorable to Hilderbrand, demonstrate that NEBF's decision was not arbitrary and capricious.
In his Motion for Summary Judgment, Hilderbrand also sought sanctions. However, Hilderbrand did not include any legal basis or argument to support his request for sanctions. Hilderbrand addressed sanctions in his Reply (d/e 28), but arguments raised for the first time in a reply brief are forfeited.
For the reasons stated, the NEBF's Motion for Summary Judgment (d/e 26) is GRANTED and Hilderbrand's Motion for Summary Judgment Following Remand and Motion for Sanctions (d/e 22) is DENIED. THIS CASE IS CLOSED.