Case Name: Graham v. Life Insurance Company of North America
Court: U.S. District Court for the Northern District of Georgia.
Date of Decision: November 28, 2016.
Type of Claim: Long Term Disability under the Employee Retirement Income Security Act of 1974 (“ERISA”).
Insurance Company: Life Insurance Company of North America (LINA).
Claimant’s Employer: DeKalb Regional Health System.
Claimant’s Occupation / Job Position: Registered Nurse.
Disabilities: After a total abdominal hysterectomy, Graham began to suffer severe pain, causing her, she claims, to be totally disabled. She also experienced significant back pain due to lumbar radiculopathy and suspected lumbar spondylosis and lumbar degenerative disease. Another physician’s, Dr. Oskouei’s, impression was left SI joint dysfunction versus lumbar radiculopathy, lumbar facet syndrome, and cervical strain. Yet another physician diagnosed “Lumbar disc
Definition of Disability: The Group Policy defines “disability” as follows:
“The Employee is considered Disabled if, solely because of Injury or Sickness, he or she is:
1. unable to perform the material duties of his or her Regular Occupation and
2. unable to earn 80% or more of his or her Indexed Earnings from working in his or her Regular Occupation.
After Disability Benefits have been payable for 24 months, the Employee is considered Disabled if, solely because of Injury or Sickness, he or she is:
1. unable to perform the material duties of any occupation for which he or she is, or may reasonably become, qualified based on education, training or experience; and
2. unable to earn 60% or more of his or her Indexed Earnings.”
Benefits Paid? No.
Basis For Denial / Termination of Benefits: Defendant informed Plaintiff that her claim for LTD benefits was denied because the medical information provided did not support restrictions and limitations, and did not demonstrate a functional loss.
Procedural history: The claimant appealed the denial. LINA upheld the denial. The claimant filed a lawsuit. Defendant Life Insurance Company of North America filed a motion for summary judgment.
Plaintiff filed her Response. Plaintiff argued that she was not required to submit objective medical evidence to prove disability. Plaintiff argued that, to the extent objective medical evidence is required, Defendant ignored the opinion of Dr. Chappuis, who opined that Plaintiff’s MRI showed herniations. Plaintiff argued that Defendant’s LTD benefits denial decision was unreasonable because the proper inquiry is not whether Plaintiff presented objective evidence of pain, but whether there are consistent diagnoses of chronic pain and consistent observations of physical manifestations of pain by the claimant’s doctors.
Other important factors:
Key Physician Opinions: On July 1, 2013, Plaintiff’s chiropractor submitted a Physical Ability Assessment (PAA) limiting Plaintiff to exerting ten pounds of force 0 – 1/3 of the day.
On July 8, 2013, Dr. Chappuis submitted a PAA limiting Plaintiff to, at most, lifting, pushing, and pulling 20 pounds occasionally, in addition to other limitations. Dr. Chappius’s diagnosis on the PAA was “Lumbar disc herniation L2-S1.”
On July 9, 2013, Dr. Stewart submitted a PAA limiting Plaintiff to pushing and pulling a maximum of 20 pounds. (R. 268-69). Dr. Stewart’s PAA did not include a diagnosis. Dr. Stewart also submitted an “All Systems Form,” which noted some restricted range of motion, weakness in the left leg, and which described Plaintiff’s gait and station as “left leg pain weakness.”
The Plaintiff’s own original treating orthopedist, Dr. Koch, circled “NO” to the question “Are you certifying disability” for Plaintiff.
On April 17, 2013, Defendant’s Associate Medical Director, Dr. Donald Minteer, reviewed Plaintiff’s records and found that “[t]here are no quantifiable, objective clinical exam, clinical testing or imaging documentations to support a significant ongoing physical functional impairment which would preclude [Plaintiff] from resuming her own occupational duties into or beyond LTD BSD [benefit start date] of 3/16/13.”
On August 27, 2013, Defendant’s Associate Medical Director Dr. Nick Ghaphery reviewed Plaintiff’s records and opined that the limitations placed on Plaintiff by her treating physicians were not supported by clinical findings. Dr. Ghaphery’s notes reference “med occ” and “medium occ,” which Defendant interprets as “medium occupation.”
The Denial Letter erroneously stated Plaintiff’s occupation required “Sedentary demand activities according to the Dictionary of Occupational Titles.” The letter defined Sedentary as follows:
Exerting up to 10 pounds of force occasionally or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are Sedentary if walking and standing are required only occasionally and all other Sedentary criteria are met.
Plaintiff’s occupation is a medium level occupation that requires exerting up to 20 to 50 pounds of force occasionally, or 10 to 25 pounds of force frequently, or greater than negligible up to 10 pounds of force constantly to move objects.
Issues: The crux of the parties’ dispute is (1) whether Plaintiff submitted “satisfactory proof” that she was disabled, (2) that is, that she was unable to perform the material duties of her regular occupation.
Holdings: The Court first conducts its de novo review to determine whether Defendant’s decision to deny benefits was wrong. The de novo review requires the Court to apply the terms of the plan to determine whether the administrator was “wrong” in denying benefits to the claimant.
(1) The Court noted that The Eleventh Circuit also has recognized that “pain-related disabilities, such as fibromyalgia or chronic pain syndrome . . . [may not be] subject to diagnosis by ‘objective’ laboratory tests.” …
“Plaintiff’s treating physicians did not agree upon or conclusively identify a cause, or etiology, of Plaintiff’s pain except ordinary age-related physical conditions and pain associated with age-related physical changes routinely experienced by people. In the case of Dr. Koch, on June 13, 2013, he circled “NO” to the question “Are you certifying disability” for Plaintiff. (R. 345). Dr. Koch listed 10/30/12 – 12/10/12 as the dates for which he declined to certify disability. (R. 345). One district court has noted that “[a] physician’s ability to make the correct diagnosis or properly isolate and classify an ailment, though important among medical practitioners and vital to proper treatment, has no real bearing on whether someone is in fact injured or disabled.” Meinke v. Comput. Sci. Corp., No. 302CV286, 2004 WL 5345274, at *11 (S.D. Ohio Sept. 20, 2004). “Rightly or wrongly diagnosed, a patient’s condition is what it is, and if it is disabling, it matters little for purposes of ERISA LTD benefits what the medical term for it is.” Id. While this observation is a bit hyperbolic, it is based on the reality in pain-based disabilities that it is the combination of all the objective and subjective evidence, the findings of physicians and the reports of claimants, upon which a plan administrator must determine, based on the record, if there exists a disability covered by a plan. That is the question here.
(2) In this case, the Dictionary of Occupational Titles requires Plaintiff to be able to perform medium duties. There are a variety of administrative record entries that support that the disability determination made by Defendant was based on this medium duty standard. (See R. 45-46). The Denial Letter, however, supports that the lesser “sedentary” duty standard was applied. Based on this contradiction, this matter must, at least, be remanded for Defendant to evaluate the evidence provided and apply the medium duty standard that the parties agree must be applied here.
Conclusion: “IT IS FURTHER ORDERED that this case is REMANDED to review Plaintiff’s claim under the “medium occupation” standard, and, if necessary, the “any occupation” standard in the definition of disability under the Plan.”