GORDON J. QUIST, District Judge.
Plaintiff, Kandise Schnoor, sued Defendant, Walgreen Income Protection Plan for Pharmacists and Registered Nurses, under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001 et seq., alleging that Defendant improperly denied her short-term and long-term disability benefits. The parties have filed cross motions for judgment on the administrative record (docket nos. 18 & 19).
Walgreen Co. (Walgreens) sponsors a self-funded employee benefit plan — the Walgreen Income Protection Plan for Pharmacists and Registered Nurses (Plan) — for eligible employees. (Docket no. 1, Page ID 46.) The Plan provides short-term and long-term disability benefits. (Id. at 44.) Benefits available during the first 180 days of a disability are defined as short-term benefits, and benefits available after 180 days are long-term benefits. (Id. at 47.) For purposes of short-term benefits:
(Id.) For long-term disability benefits,
(Docket no. 10, Page ID 47.) The Plan grants to Sedgwick, as claim administrator, the authority to construe and interpret the Plan and make benefit determinations, including claims and appeals determinations as Sedgwick deems "appropriate" in its "sole discretion." (See id. at 58.) The parties agree that the Plan is governed by ERISA.
Beginning on August 2, 2001, Schnoor worked as a pharmacist for Walgreens. (Id. at 130.) On April 22, 2011, Schnoor submitted a short-term disability claim. (Id.) Sedgwick approved one week of short-term disability benefits for April 29, 2011 to May 5, 5011. (Id. at 75.) Thereafter, Sedgwick denied Schnoor's claim on the basis that Schnoor did not qualify for continuing benefits because she failed to provide "objective medical documentation of clinical findings ... which would [have] prevent[ed] [her] from performing [her] job functions as of May 6, 2011." (Id. at 1337.) On October 19, 2011, the Social Security Administration awarded Schnoor Social Security Disability benefits. (Id. at 171-74.)
On November 16, 2011, Schnoor appealed Sedgwick's denial of short-term disability benefits and submitted a written document supporting her appeal and attached supporting medical records. (Id. at 207-56.) Sedgwick retained Insurance Appeals, Ltd. to conduct two "peer reviews" of Schnoor's medical records. (See id. at 1204.) Dr. Siva Ayyar, M.D., conducted the first review. (Id. at 1204-10.) Dr. Ayyar is a board certified specialist in occupational medicine. (Id. at 1210.) Dr. Penny Chow, M.D., a board certified psychiatrist, conducted the second review. (Id. at 1211-23.) On or about December 22, 2011, Sedgwick notified Schnoor that it had affirmed the denial of short-term benefits on appeal because Schnoor did not meet the Plan's definition of disability. (Id. at 1224-27.) The denial letter stated that if Schnoor wished to request a second formal appeal, Schnoor could do so by written request for review within 90 days of receipt of the letter. (Id. at 1226.)
On March 14, 2012, Schnoor submitted a second appeal of Sedgwick's denial of her short-term benefits claim and attached additional, updated medical records. (Docket no. 10, Page ID 178-92.) Sedgwick retained Reliable Review Services to conduct two additional "peer reviews" of Schnoor's medical records. (Docket no. 15, Page ID 1678-96.) Dr. Leonard Sonne, M.D., a board certified internist and pulmonary specialist, conducted the first review. (Id.
The threshold issue is the applicable standard of review.
In this case, Schnoor argues that Defendant failed to conduct a deliberate and principled review of Schnoor's claim, and the medical evidence "strongly preponderates in her favor." (Pl.'s Br. for J. on Merits, Docket no. 18, Page ID 2484.) She argues that because Defendant's only stated reason for denying her disability claims is that she lacked objective medical evidence to corroborate her subjective claims of cognitive dysfunction — in addition
In support of her first appeal, Schnoor produced evidence from Dr. Charles Lapp, M.D., a board certified internist, who has treated Schnoor regularly since 1997. (Docket no. 15, Page ID 1830.) Dr. Lapp stated in a letter, and supported with medical treatment notes, that Schnoor has been diagnosed with Chronic Fatigue Syndrome (CFS) since 1997. Since 1997, he has documented in detail her physical decline, including body pain, fatigue from normal daily activities, postexertional malaise, cognitive dysfunction, and a sleep disorder. He has also diagnosed and documented her fibromyalgia "for many years." (Id.; see also Docket no. 10 at 207-52.) He also stated that "exclusionary laboratory studies ... have confirmed [Schnoor's] CFS and FM, with no other plausible explanations for her symptoms." (Id.) He explained the results of those laboratory studies in the record. (Id. at 1831.) On the basis of his treatment notes from 1997 to 2011, physical examinations, personal interviews, and laboratory studies, Dr. Lapp concluded that Schnoor was,
(Id. at 1831.)
Schnoor also introduced evidence from Dr. Martin Wunsch, Ph.D., a licensed psychologist, to corroborate Schnoor's subjective complaints of cognitive dysfunction.
(Id. at 1053-67.)
The Diagnostic and Statistical Manual of Mental Disorders IV, which was in effect when Schnoor's examination occurred, defines "Cognitive Disorder Not Otherwise Specified" (DSM-IV 294.9) as a disorder characterized by cognitive dysfunction presumed to be due to the direct physiological effect of a general medical condition that does not meet criteria for any of the specific deliriums, dementias, or amnestic disorders defined in the DSM-IV. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed. Text Revision, 2000). The definition cross-references as an example "Mild Neurocognitive Disorder," which is defined by cognitive deficits that "must be corroborated by the results of neuropsychological testing or bedside standardized cognitive assessment techniques." Id. at Appendix B, 762. The cognitive deficits cause marked distress or interfere with the individual's social, occupational, or other important areas of functioning and represent
In support of her appeal, Schnoor also submitted a pharmacist assessment card dated April 19, 2011. (Docket no. 10, Page ID 170.) According to the card, it is a quality assurance tracking document for pharmacists. (Id.) The card indicates that Schnoor had made at least 14 errors during the review period of 6-9 months, (id. at 1118), including three events involving incorrect strength of medication, six events involving the incorrect drug, four events involving the incorrect patient, and one involving incorrect directions. (Id.)
Sedgwick denied Schnoor's first appeal on the grounds that Schnoor did not satisfy the Plan's definition of disability for her short-term disability claim. Sedgwick's determination relied on the record reviews conducted by Doctors Ayyar and Chow. According to the December 22, 2011 denial letter, Dr. Ayyar concluded that there was "no medical basis for disability from an Occupational Medicine perspective" because Schnoor's "subjective complaints of chronic fatigue and difficulty concentrating were not the result of a specific diagnosis or medical issue." (Docket no. 12, Page ID 1226; see also Ayyar Report, Docket no. 13, Page ID 1189.) Dr. Ayyar also observed that Schnoor lacked "objectively verifiable, reproducible, bona fide neurological deficits." (Docket no. 13, Page ID 1189.) Dr. Chow similarly concluded that "[f]rom a psychiatric perspective, the clinical findings provided for review do not support Ms. Schnoor's inability to perform her regular unrestricted job." (Id. at 1225; see also Chow Report, id. at 1203.) While noting that Dr. Wunsch diagnosed Schnoor with a cognitive disorder, Chow nonetheless concluded that the "only in-depth psychological evaluation provided for review was from 10/22/11, and did not report any significant objective cognitive deficits that would support the claimant's subjective symptoms of poor attention and concentration, poor recent and remote memory, impaired math skills, disruption of sense of direction and disorganization." (Id. at 1203.) Thus, Chow concluded that Schnoor was not disabled. (Id.)
Sedgwick's denial of Schnoor's first appeal fails under even an arbitrary and capricious review standard because Sedgwick has failed to support its decision with substantial evidence when viewed in light of the quantity and quality of medical evidence on each side. See Schwalm, 626 F.3d at 308. In this case, it cannot be said that Sedgwick's decision resulted from "a deliberate principled reasoning process." Id. (quoting Baker, 929 F.2d at 1144).
First, Dr. Ayyar's conclusion that Schnoor is not disabled is not supported by substantial evidence. Dr. Ayyar's review dismisses Schnoor's cognitive and other physical ailments in the matter of a
Regarding Dr. Ayyar's evaluation of Schnoor's CFS and FM, Dr. Ayyar similarly and summarily dismisses her symptoms in the course of two sentences. He states that a cardiologist, Dr. Castillo, administered a stress test and Holter monitor study with normal results. However, this analysis fails to account for the central medical disability complained of by Schnoor — CFS and FM. As described by Dr. Lapp in a follow-up letter submitted for a second appeal, Schnoor's impairments are
(Id. at 806.) Combined, Dr. Lapp opined that those documented low levels of functioning made Schnoor "a danger to others" in her role as a pharmacist. (See, e.g., id. at 806.) Dr. Ayyar does not refute this or otherwise address Dr. Lapp's extensive office notes or treatment notes documenting Schnoor's physical symptoms.
That Dr. Ayyar did not interview or examine Schnoor weighs in Schnoor's favor. "Whether a doctor has physically examined the claimant is indeed one factor that we may consider in determining whether a plan administrator acted arbitrarily
Second, Dr. Chow's conclusion that Schnoor is not disabled is not supported by substantial evidence. Dr. Chow's review was limited to Schnoor's purported cognitive dysfunction, not her CFS or FM. (See id. at 1203.) Dr. Chow's proffered rationale for concluding that Schnoor was not disabled is stated in one sentence: "The only in-depth psychological evaluation provided for review was from 10/22/11, and did not report any significant objective cognitive deficits that would support the claimant's subjective symptoms of poor attention and concentration, poor recent and remote memory, impaired math skills, disruption of sense of direction and disorganization." (Id.) Dr. Chow then concluded that because there "are no other in-depth psychological evaluations," Schnoor was not disabled. Dr. Chow does not comment on Schnoor's CFS or FM.
Similar to Dr. Ayyar's review, Dr. Chow dismisses Schnoor's subjective reports on the basis that there is no objective, corroborating evidence. Unlike Dr. Ayyar, Dr. Chow acknowledges Dr. Wunsch's "in-depth psychological evaluation." (Id.) Nonetheless, Dr. Chow dismisses the evaluation because it did not document what she calls "significant" cognitive deficits. (Id.) However, Dr. Chow does not offer any explanation for her interpretation of the results as insignificant. She does not attempt to refute, discredit, or otherwise explain her difference of opinion from Dr. Wunsch, who documented "a notable" drop in Schnoor's working memory, executive function and processing speed, which, combined with the demands of work as a pharmacist, corroborate Schnoor's self-reporting and Schnoor's children's CAARS results. Dr. Chow does not offer any alternative explanation for Schnoor's reported deficits, nor the objectively documented errors on Schnoor's performance assessment card. Because Dr. Chow does not offer an explanation for her difference of opinion from Dr. Wunsch, and absent an in-person interview or examination from which to refute Dr. Wunsch's assessment of Schnoor's self-reports and those of her children, neither Dr. Chow's conclusions nor Sedgwick's disability determination is supported by substantial evidence.
That the Social Security Administration awarded Schnoor Social Security Disability benefits also weighs in favor of
Schnoor submitted a second appeal of Sedgwick's denial of short-term disability benefits. In support of her second appeal, Schnoor submitted updated medical records. For purposes of this case, the evidence is largely the same. Sedgwick retained Reliable Review Services to conduct reviews of Schnoor's medical records. (Id. at 1678-96.) Dr. Sonne, an internist and pulmonary specialist, conducted the first review. Dr. Goldman, a psychiatrist, conducted the second review. (Id. at 1686-96.) Citing these reviews, Sedgwick again denied Schnoor's claim on the basis that Schnoor did not satisfy the definition of disabled for purposes of short-term disability benefits. (Id. at 1700.)
Dr. Sonne's review was conducted "from an internal medicine perspective," and cross-referenced Dr. Goldman's report for purposes of psychiatric review. (Id. at 1683.) Dr. Sonne acknowledged Dr. Lapp's conclusion that Schnoor had "impaired work capacity" on the basis of CFS and FM that could "not be explained by deconditioning alone." (Id. at 1682.) Dr. Sonne then stated that he disagreed with Dr. Lapp's conclusion because Schnoor's decreased work capacity was "completely" due to poor fitness ("deconditioning"). Dr. Sonne based this conclusion on the fact that Dr. Lapp had not performed a cardiopulmonary stress test, which is a method by which doctors can test malingering in disability cases. (Id.) Dr. Sonne also noted that Schnoor had had the same complaints of pain, cognitive disability and fatigue since 1997 but continued to work. (Id.) He also observed that her weight was stable, she was alert, her chest was clear, her heart sounds were normal, she ambulated without an assisted device, and there was no documentation of heart disease or lung disease. (Id.) On this basis, he concluded that Schnoor was not precluded, from an internal medicine perspective, from doing full-time work as a pharmacist. (Id. at 1683.)
Dr. Sonne's review of Schnoor's physical limitations — which does not address Schnoor's cognitive dysfunction — suffers from the same omissions as Dr. Ayyar. Dr. Sonne states that he disagrees with Dr. Lapp's conclusion that Schnoor's condition cannot be explained by deconditioning alone by stating that Schnoor's condition is caused by deconditioning alone. In support of his conclusion, he cites that Schnoor had normal vital signs (presumably on the basis of the record, as Dr. Sonne did not examine Schnoor) and Dr. Lapp never administered a cardiopulmonary stress test which would have better assisted Dr. Sonne in determining whether Schnoor was malingering. Like Dr. Ayyar's conclusions on the basis of Schnoor's cardiovascular health, Dr. Sonne's focus on Schnoor's cardiovascular health is a red
Finally, Dr. Goldman reviewed Schnoor's medical records "from a psychiatric perspective." (Id. at 1689.) Dr. Goldman began his "assessment" section by stating:
(Id. at 1692.) With that caveat, Goldman goes on to opine that Schnoor did not have a "functionally impairing mental condition" and was therefore not disabled as a result of a mental illness. The basis of Goldman's conclusion is the lack of "comprehensive diagnostic clinical Mental Health Assessments," mental health treatment notes, therapy notes, aggressive pharmacology or other evidence that Schnoor had been treated at "more intense levels of care such as a day program for a major mental condition." (Id.)
The basis of Schnoor's short-term disability claim is that she has a debilitating combination of symptoms resulting from CFS, FM, cognitive dysfunction, and other conditions. Specifically, Schnoor claims that she commits serious cognitive errors at work as a result of her cognitive dysfunction that make her dangerous to pharmacy patients. (Id. at 186.) Doctors Lapp and Wunsch have opined that there is a close relationship between Schnoor's intense fatigue, related pain, and resulting cognitive dysfunction, and she is a danger to patients. (Id. at 1046, 66.) However, Dr. Goldman's review only addresses the limited question of whether Schnoor has a global mental illness, such as a "DSM affective or anxiety condition." (Id. at 1692.) Dr. Goldman does not purport to assess the accuracy of Dr. Wunsch's neuropsychology opinion that Schnoor is disabled from her pharmacist job. As such, Dr. Wunsch's report is the only relevant medical evidence on the pertinent question — whether Schnoor's cognitive dysfunction renders Schnoor disabled. Even if Dr. Goldman had purported to offer an opinion about Schnoor's cognitive dysfunction, it would not follow from his reasoning (that Schnoor lacks a diagnosis of, or history of treatment for, a global affective or anxiety condition) that Schnoor was not disabled by cognitive dysfunction. Thus, Sedgwick's denial of Schnoor's appeal solely on record reviews by Doctors Sonne and Goldman was not supported by substantial evidence.
Defendant argues that if the Court finds Sedgwick's denial of Schnoor's short-term disability benefits to be arbitrary
ERISA prescribes that a civil action may be brought by a plan participant or beneficiary "to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan." 29 U.S.C. § 1132(a)(1)(B). In her Complaint, Schnoor alleges that Defendant wrongly denied her short-term disability benefits claim but also damaged her by effectively terminating her claim for long-term benefits. (Docket no. 1, Page ID 9.) In her prayer for relief, Schnoor requests a declaratory judgment declaring that she is entitled to the group employee benefits as set forth in the Plan in effect at the time benefits became payable. Thus, Schnoor requests both the short-term and long-term benefits "due to [her] under the terms of the plan," 29 U.S.C. § 1132(a)(1)(B).
Defendant responds that Schnoor has failed to exhaust her remedies for long-term benefits because she failed to accumulate 180 days of short-term disability benefits, a requisite for long-term disability benefit eligibility. Thus, Defendant argues that Schnoor is ineligible for long-term disability benefits. (Docket no. 21, Page ID 2533.)
The Sixth Circuit has "repeatedly held that exhaustion may be excused if the claimant establishes futility." Welsh v. Wachovia Corp., 191 Fed.Appx. 345, 356 (6th Cir.2006) (citing, e.g., Hill v. Blue Cross & Blue Shield of Mich., 409 F.3d 710, 718-19 (6th Cir.2005); Weiner v. Klais & Co., 108 F.3d 86, 90-91 (6th Cir. 1997)). A district court is "obliged to exercise its discretion to excuse nonexhaustion where resorting to the plan's administrative procedure would simply be futile or the remedy inadequate." Id. (quoting Fallick v. Nationwide Mut. Ins. Co., 162 F.3d 410, 419 (6th Cir.1998)). In assessing futility, the court must decide "whether a clear and positive indication of futility can be made." Fallick, 162 F.3d at 419. To meet this standard, a plaintiff "must show that it is certain that his claim will be denied on appeal, not merely that he doubts that an appeal will result in a different decision." Id. (quoting Lindemann v. Mobil Oil Corp., 79 F.3d 647, 650 (7th Cir.1996)). "The futility doctrine is more easily applied in situations when the claimant has properly filed an application for benefits and initially been denied, but then fails to
In Welsh v. Wachovia, the Sixth Circuit vacated and remanded a district court order awarding long-term disability benefits on the basis that the parties agreed that the district court lacked a sufficient administrative record from which to review the plan administrator's determination regarding long-term benefits. Id. Thus, the Sixth Circuit vacated and remanded with instructions that the plaintiff be afforded an opportunity to file a long-term benefits claim and pursue his administrative remedies prior to court review. Id. In remanding, the Sixth Circuit rejected the defendant's argument that the district court lacked jurisdiction to award long-term benefits, specifically noting that the Sixth Circuit, unlike the Second Circuit, "does not characterize the exhaustion requirement as `jurisdictional' but instead holds the application of the doctrine is `committed to the sound discretion of the district court.'" Id. at 358 n. 5 (quoting Fallick, 162 F.3d at 418) (emphasis added).
In this case, Schnoor's efforts to apply for long-term benefits would have been futile: as shown above, Sedgwick certainly would have denied Schnoor's application on the ground that she had not "accumulated a total of 180 disability days during any consecutive 365 day period." (Id. at 47.) Thus, Schnoor is not barred from applying for long-term benefits.
Defendant also argues that the Court should remand the determination of long-term benefits on the merits. "[R]emand to the plan administrator is appropriate `where the problem is with the integrity of the plan's decision-making process, rather than that a claimant was denied benefits to which he was clearly entitled.'" Cooper v. Life Ins. Co. of N. Am., 486 F.3d 157, 171 (6th Cir.2007) (quoting Elliott v. Metro. Life Ins. Co., 473 F.3d 613, 622 (6th Cir.2006)). However, in Cooper v. Life Insurance Company of North America, the Sixth Circuit held that where a claimant has "clearly established" that she is disabled under the applicable plan, remand is unnecessary. Id. Specifically, the Sixth Circuit noted that the plaintiff had introduced objective medical evidence of a disability from three treating physicians sufficient to support awarding long-term disability benefits. The court observed "[p]lan administrators should not be given two bites at the proverbial apple where the claimant is clearly entitled to disability benefits. They need to properly and fairly evaluate the claim the first time around; otherwise they take the risk of not getting a second chance, except in cases where the adequacy of claimant's proof is reasonable debatable."
Here, Schnoor has introduced sufficient evidence to establish long-term disability. First, unlike in Welsh, Schnoor has submitted substantially more than 180 days of medical records evidencing an ongoing disability. For instance, Dr. Lapp opined on August 30, 2011 that "it is medically certain that Ms. Schnoor will not improve significantly in 12 months and possibly never." (Docket no. 13, Page ID 1082.) Thus, there is a sufficient administrative record on which to determine whether Schnoor is entitled to long-term
For the foregoing reasons, the Court will enter judgment on the administrative record in favor of Schnoor for purposes of both short-term and long-term disability benefits.
An order consistent with this Opinion will be entered.