Case Name: Rebecca Filthaut v. AT & T Midwest Disability Benefit Plan and At & T Umbrella Benefit Plan No. 3.
Court: United States District Court Eastern District of Michigan Southern Division.
Type of Claim: Short Term Disability.
Insurance Company: AT & T Midwest Disability Benefit Plan.
Claimant’s Employer: Michigan Bell Telephone Company.
Claimant’s Occupation / Job Position: Service Representative.
Definition of Disability: The Plan provides short-term disability benefits if participants meet the following definition of disabled:
“[i]f the Claims Administrator determines that you are Disabled by reason of sickness, pregnancy, or an off-the job illness or injury that prevents you from performing the duties of your job (or any other job assigned by the Company for which you are qualified) with or without reasonable accommodation. Your Disability must be supported by objective Medical Evidence.”
The Plan defines objective Medical Evidence as:
“Objective medical information sufficient to show that the Participant is Disabled, as determined at the sole discretion of the Claims Administrator. Objective medical information includes, but is not limited to, results from diagnostic tools and examinations performed in accordance with the generally accepted principles of the health care profession. In general, a diagnosis that is based largely or entirely on self-reported symptoms will not be considered sufficient to support a finding of Disability.”
Benefits Paid? Plaintiff applied for and received benefits from December 2013 to early January 2014.
Procedural history: Plaintiff was approved for benefits from December 2013 to early January 2014. Plaintiff subsequently made three additional claims for short-term disability benefits: (1) January 13 to February 23, 2014; (2) March 3 to April 14, 2014; and (3) April 16 to May 7, 2014. Plaintiff was denied disability on all three claims. Plaintiff filed for Motion for Summary Judgment on the denial of all three claims.
Key Physician Opinions: By the time Sedgwick and AT & T ( “the Plan”) denied Plaintiff’s short-term disability claim, numerous medical records and physician opinions had been provided to assist with the decision-making process.
Plaintiff submitted medical records from her three treating physicians: Drs. Al Nouri, Kovar and Carley. Dr. Al Nouri diagnosed Plaintiff with lumbar degenerative disc disease. Dr. Kovar, Plaintiff’s neurologist, concluded that Plaintiff suffered from “myofascial strain near her ribs and multiple segmental somatic dysfunction throughout [her] thoracic region.”
On March 5, 2014, Dr. Carley, Plaintiff’s primary care physician, opined that Plaintiff was “unable to ambulate,” and placed a function restriction of “no work” on Plaintiff. On March 11, 2014, Dr. Carley determined that if Plaintiff returned to work, the following restrictions were required: (1) breaks every five minutes; (2) no sitting or standing for more than five minutes; (3) no lifting over two pounds; (4) no reaching over-head; and (5) no bending, twisting, kneeling or stooping.
Dr. Moshe Lewis, a reviewing physician, assessed the following restrictions for Plaintiff: (1) breaks every 5 minutes are required; (2) no sitting or standing more than 5-10 minutes; (3) no heavy lifting over 2 pounds; and (4) no reaching overhead, bending or twisting. However, despite the previous restrictions, Dr. Lewis concluded that “from a [physical medicine and rehabilitation perspective,] [the Plaintiff] is capable of any work and can complete her sedentary job without restriction.”
Dr. Friedman, a reviewing physician, concluded that: “Ms. Filthaut has no functional impairment from the nephrology standpoint so it can be stated administratively that there is no disability from the nephrology standpoint. Notably, her attending physician, Dr. Carley agreed that there are no issues from the nephrology standpoint affecting her functional capacity/ability to work.”
Issues: The Court addressed several issues within the Plan’s determination that the Court found did meet the required arbitrary and capricious standard. (1) Whether the Plan ignored favorable evidence from Plaintiff’s treating physicians. (2) Whether the Plan engaged in a selective review of the evidence from Plaintiff’s treating physicians. (3) Whether the Plan failed to conduct its own physical evaluation of Plaintiff. (4) Whether the Plan relied too heavily on non-treating physician consultants.
Holdings: The Court reviewed the administrator’s decision under a “arbitrary-and-capricious standard.”
In regards to the Plan’s denial of Plaintiff’s second claim for short-term disability benefits, it reasoned that “there was no evidence in the medical record of a functional impairment and no measureable objective findings to support disability.” The Court disagreed, stating that Plaintiff’s medical records did in fact contain such information. Specifically, the Court held that: “by stating that the Plaintiff lacked evidence of functional impairment or finding to support disability, the Plan made factually incorrect assertions about the evidence that Plaintiff submitted from Dr. Carley.”
Additionally, the Court held that the Plan wrongfully contradicted a treating physician’s opinions and diagnoses without issuing accompanying reasoning for doing so. Plaintiff’s own treating physicians, particularly Dr. Carley, had assessed various restrictions on Plaintiff’s ability to work. However, the Plan rejected the opinions of Plaintiff’s treating physicians and failed to give any reason for doing so. Dr. Lewis, one of the Plan’s reviewing physicians, acknowledged that the treating physicians had placed restrictions on Plaintiff, however, concluded that “[h]owever, from a [physical medicine and rehabilitation perspective], [the Plaintiff] is capable of any work and can complete her sedentary job without restriction.” The Plan chose to credit Dr. Lewis’s opinion over Plaintiff’s own treating physician Dr. Carley’s opinion, and completely failed to issue any explanation for doing so. The Court concluded that such action “failed to demonstrate deliberate and principled reasoning.”
The Court also determined that the Plan acted incorrectly by “failing to make a reasonable effort” to speak with Plaintiff’s treating physicians. The Plan’s peer review physicians gave Plaintiff’s treating physicians a mere 24 hours to respond to their telephone requests. The Court concluded that “because the Plan again failed to make a reasonable effort to speak with the treating physicians, its behavior raises questions about its reasoning process.”
In regards to Plaintiff’s challenge that the Plan engaged in a selective review of the evidence provided by Plaintiff’s treating physicians, the Court agreed. Specifically, the Court cited Dr. Friedman, one of the Plan’s reviewing physicians, for engaging in a selective review of the Plaintiff’s claim. Specifically: “Dr. Friedman noted that after ‘extensive evaluation,’ each of Plaintiff’s treating physicians determined “her back pain to be of musculoskeletal origin.’ Nevertheless, Dr. Friedman concluded ‘Ms. Filthaut has no functional impairment from the nephrology standpoint so it can be stated administratively that there is no disability from the nephrology standpoint. Notably, her attending physician, Dr. Carley, agreed that there are no issues from the nephrology standpoint affecting her functional capacity/ability to work.’”
Not only did the Court admonish the Plan for engaging in selective review of the evidence, but also for overgeneralizing and misinterpreting the conversation between Dr. Friedman and Dr. Carley. Dr. Friedman and Dr. Carley’s conversation was strictly limited to nephrology, citing multiple times within his opinion that he was opining “from the nephrology standpoint.” Ignoring this limitation of opinion, the Plan characterized Dr. Friedman’s opinion as stating that Plaintiff was not “disabled from any medical standpoint.” Thus, the Court concluded that both Dr. Friedman’s selective review of the medical evidence and the Plan’s misinterpretation of Dr. Friedman’s report “suggest arbitrary and capricious decision making.”
The Court held that the Plan’s failure to conduct its own physical evaluation of Plaintiff was error, and supports a finding that the decision-making was “arbitrary and capricious.” By crediting its peer review physicians’ opinions over Plaintiff’s treating physicians’ opinions, the Plan made an incorrect “credibility determination.” The Court concluded that, without conducting a physical examination of Plaintiff, the Plan “should not have made a credibility determination about [Plaintiff’s] continuous reports of pain.”
Lastly, the Court held that the Plan relied heavily on Dr. Lewis, a non-treating physician, whose “conclusions have been questioned in numerous federal cases, all of which he was hired by Sedgwick.” As a result, the Court assessed the Plan’s heavy reliance on Dr. Lewis’s skeptic conclusions as evidence that the Plan did not engage in a “deliberate, principled reasoning process.”
Summary: The Court granted Plaintiff’s Motion for Summary Judgment as to Claim Number 2 and 3. The Court denied Plaintiff’s Motion for Summary Judgment with respect to claim Number 1, and granted Defendant’s Motion for Judgment on the Administrative Record as to claim Number 1. “On this record, the Court concluded that the Plan’s reasoning with regard to Dr. Carley’s March 2014 reports was neither deliberate, nor principled. The Plan ignored Dr. Carley’s favorable evidence by making factually incorrect statements, contradicting his assessment without reason, and by failing to make a reasonable effort to speak with him. Furthermore, when a reviewing doctor (Dr. Friedman) actually made contact with Dr. Carley, the reviewing doctor engaged in a selective review of Dr. Carley’s evidence. Despite ignoring, selectively reviewing, or second guessing Dr. Carley’s reports, the Plan never exercised its right to conduct its own evaluation of the Plaintiff.”
Therefore, the Court held that the Plan’s denial of benefits in Claim No. 2 and Claim No. 3 met the “arbitrary and capricious” standard. However, although the Court cited some of the Plan’s decision-making process with respect to Claim No. 1 as “questionable,” the acts were not so flagrant that they met the required “arbitrary and capricious” standard. In sum, the denial of benefits with respect to Claim No. 2 and 3 was error, whereas the denial of benefits with respect to Claim No. 1 was correct.