Case Name: Curtis Slaton v. Standard Insurance Company
Court: U.S. District Court for the Southern District of Ohio.
Date of Decision: January 26, 2016.
Type of Claim: Long Term Disability.
Insurance Company: Standard Insurance Company.
Claimant’s Employer: A law firm.
Claimant’s Occupation / Job Position: An attorney.
Disability: Multiple sclerosis, which was diagnosed in January of 2012. Listed symptoms included “chronic fatigue, weakness in legs, dizziness, balance problems, problems concentrating .”
On November 30, 2011, Dr. Valle ordered an MRI. Test results showed “[s]cattered white matter signal alterations most compatible with demyelinating process such as multiple sclerosis,” but there were “[n]o enhancing lesions to suggest active demyelination.”
Definition of Disability in the Plan/Policy: The long-term disability (“LTD”) portion of the Plan provides as follows:
Until LTD Benefits have been paid for 24 months, you are Disabled if, as a result of Sickness, Accidental Bodily Injury, or Pregnancy, you are either:
a. Unable to perform with reasonable continuity the material duties of your own occupation; or
b. Unable to earn more than 80% of your Indexed Predisability Earnings while working in your own occupation.
Basis For Denial / Termination of Benefits: On March 14, 2013, Standard denied Slaton ‘s claim for long-term disability benefits, concluding that he did not meet the Plan’s definition of “disabled .” Standard recounted, at length, Slaton’s medical history as recorded by Dr. Valle, Dr. Reiling, and Dr. Pensak. It then discussed Dr. Mass’s review of Slaton’s medical records , and her conclusion that, despite the fact that Slaton had been diagnosed with multiple sclerosis, his medical records did not adequately support his stated level of impairment. Standard noted that Dr. Valle had found no “significant progression of neurologic dysfunction” and had not yet recommended any specific treatment.
Based on its review of Slaton’s medical records, Standard concluded that at no point did the medical documentation support limitations or restrictions that prevented him from performing with reasonable continuity the material duties of his own occupation.
Procedural history: Slaton timely appealed the denial of his claim for long-term disability benefits. In his appeal letter, he stated that his claim was based, not on his problems with lack of balance, but on “chronic fatigue and inability to concentrate and focus on complex matters for any duration of time.”
On November 27, 2013, following receipt of Dr. Loaiza ‘s report (described more fully below), Standard upheld its denial of Slaton’s claim.
Key Physician Opinions: In support of his claim, Slaton submitted a statement from his neurologist, Dr. Michael Valle, dated December 12, 2012. Dr. Valle verified that Slaton had been diagnosed with multiple sclerosis, had “excessive fatigue, gait instability, dizziness, difficulty with concentration .”… When asked to describe Slaton’s “physical, mental and cognitive limitations and work activity limitations,” Dr. Valle stated, ” Fatigues and tires easily, unable to sit or stand for long periods of time. Decreased concentration.”
In support of his appeal, Slaton offered a letter from Dr. Valle. In response to the question raised in Dr. Mass’s report, Dr. Valle first clarified that Slaton had more than five oligoclonal bands in his spinal fluid; zero to one is normal. Dr. Valle also indicated that the concerns raised by Standard in its denial letter appeared “to reflect a lack of knowledge of the actual disease process.” He explained that 70 percent of individuals with multiple sclerosis start with “intermittent flare ups of neurologic symptoms, usually in the form of physical deficits,” but that cognitive impairment “occurs in up to half of all multiple sclerosis patients early in the disease,” impacting their “ability to function on a day-to-day basis.” He indicated that there can be a “slow accumulation of neurological dysfunction.”
Dr. Valle stated that Slaton’s complaints of cognitive impairment were consistent with these statistics, and that such symptoms “have interfered with his ability to function effectively in his capacity as an attorney.” Id. Dr. Valle explained that debilitating fatigue among patients with multiple sclerosis is also common and “very difficult to quantify.” He explained that there is no correlation between the degree of fatigue and the severity of the motor disabilities. He opined that fatigue had ” limited Mr. Slaton in his ability to function in the workplace . .. and in combination with cognitive impairment has greatly diminished his capacity to function as an attorney.”
IME Physician Opinions: In February of 2013, Dr. Michele Mass, a Board-certified neurologist, reviewed Slaton’s medical records on behalf of Standard, in connection with the long-term disability claim. She noted that Slaton had been treated for disequilibrium since he was nineteen years old , likely due to multiple head injuries . He had also been treated for end stage Meniere’s disease, an inner ear condition. She agreed that the MRI and the presence of oligoclonal bands in the spinal fluid supported a diagnosis of multiple sclerosis, but noted that the report failed to indicate how many oligoclonal bands were found.
Dr. Mass noted that, although Slaton had numerous subjective complaints, no objective abnormalities had been found. Her report states that Dr. Valle acknowledged Slaton ‘s complaints of fatigue, decreased concentration, and inability to sit or stand for long periods of time, but “Dr. Valle did not comment on having recommended that the claimant cease work.” Slaton ‘s neurologic examinations were largely normal. Although Slaton complained of weakness in his legs, all examinations revealed normal motor strength and, although his gait was mildly unsteady, he was able to ambulate independently. Dr. Mass noted Slaton ‘s other subjective complaints, but stated that she was unable to identify any “specific limitations or restrictions” from the medical records .
In connection with the appeal, Standard submitted Slaton’s claim file to Dr. Sergio Loaiza, another board-certified neurologist. In his report, Dr. Loaiza summarized Slaton’s medical records from Dr. Reiling, Dr. Valle, Dr. Pensak, and Dr. Seiden. He noted that the diagnosis of multiple sclerosis was based solely on the MRI and the lumbar puncture; the disease had not yet become “clinically manifest.” He noted that neurological examinations were consistently normal, with the exception of a later mild Romberg test and some decreased pin sensation to the left upper extremity. Dr. Loaiza’s report states: “No significant abnormalities to support neurological impairment. There is no documentation in support of a cognitive disorder. The claimant’s multiple sclerosis is felt to be stable without evidence of active demyelination in follow[-)up MRI studies. No disease modifying agents are being used. ” He stated that Slaton’s balance issues “have been attributed to end stage Meniere’s disease. ”
With respect to Slaton ‘s claims of fatigue , Dr. Loaiza stated that “[f]atigue in this clinical setting is really a nonspecific symptom,” and “no restrictions and/or limitations are supported from a neurological perspective.” Based on his review of the medical records “and from a neurological perspective[,] impairment resulting from fatigue/cognitive difficulties is not supported as of December 30, 2011.”
Dr. Loaiza noted that Dr. Valle’s suggestion of cognitive impairment “has not been supported by physical examination or a more formal neuropsychological evaluation. ” Dr. Loaiza also spoke to Dr. Valle, who admitted that, despite Slaton ‘s complaints, he had not personally observed any significant cognitive deficit.
In short, Dr. Mass and Dr. Loaiza, board-certified neurologists, found no clinical medical evidence to support a finding that Slaton was functionally disabled due to fatigue, cognitive impairment, or any other symptom of multiple sclerosis.
Issues: Standard maintains that its decision to deny long-term disability benefits resulted from a deliberate principled reasoning process, and is supported by substantial evidence .
Slaton, however, urges the Court to find that the decision was arbitrary and capricious for several reasons.
(1) First, he argues that Standard was operating under a conflict of interest. Where, as here, the insurer is charged with determining eligibility and paying benefits, an inherent conflict of interest exists, because the insurer has a financial incentive to deny claims.
(2) Second, Slaton argues that Standard failed to give adequate weight to the opinion of his treating physician, Dr. Valle. In Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003) , the Supreme Court held that, although plan administrators cannot arbitrarily reject the opinions of treating physicians, they are not required to give them any special deference.
(3) Third, Slaton argues that Standard failed to give adequate weight to his subjective complaints of fatigue and decreased concentration. He notes that his diagnosis of multiple sclerosis is clinically supported by the results of his MRls and his lumbar puncture and that, as Dr. Valle said, his self-reported symptoms of fatigue and cognitive impairment are common manifestations of this disease. Slaton maintains that, under the circumstances presented here, Standard acted in an arbitrary and capricious manner when it denied his claim based on a lack of objective medical evidence to support his claimed limitations.
(1) Given that Slaton has presented no evidence that the financial conflict of interest may have improperly influenced Standard’s decision, the Court accords little weight to this factor.
(2) Here, Standard has given a reasonable explanation for rejecting Dr. Valle’s opinion that Slaton is disabled as a result of the multiple sclerosis. In its November 27, 2013, letter upholding the denial of benefits, Standard noted that it had carefully considered the information submitted by Dr. Valle, but did not “find evidence to support that your multiple sclerosis was clinically active, or that there were limitations and restrictions associated with this condition that would have limited you to part time work as of January 1, 2012.”
Standard notes that the mere diagnosis of multiple sclerosis does not equate to a finding that Slaton was limited from performing the material duties of his job as an attorney on a full-time basis as of January 1, 2012. Slaton’s MRls show no evidence of active demyelination, and Dr. Loaiza noted that Slaton’s neurological examinations were consistently normal until June of 2012, when Dr. Valle documented a mild Romberg test and some decreased pin sensation in the left upper extremity. Moreover, Dr. Valle’s records do not support a finding that Slaton was suffering from fatigue or decreased concentration as of January 1, 2012.
(3) The Sixth Circuit has held that it is not unreasonable or irrational for an administrator to require objective medical evidence to support a claim of disability. Cooper, 486 F.3d at 166. Accordingly, when a disability plan specifically requires that claims be supported by objective medical documentation, that requirement is generally upheld. Nevertheless, it may be arbitrary and capricious for the plan administrator to impose an “objective medical evidence” requirement when the plan itself does not.
In the Court’s view, Slaton’s reliance on these cases is misplaced. He claims that Standard should have given more weight to his subjective complaints of fatigue and decreased cognitive ability, particularly since these symptoms are difficult to quantify with objective medical evidence . He further claims that, if the administrator did not find his subjective complaints to be credible, it should have ordered an independent medical examination instead of relying on a file-only review .
The problem is this. Slaton needed to submit satisfactory written proof that, as of January 1, 20 12- the date he claims that he became unable to work full-time – he was “disabled” as that term is defined in the Plan. Although he claims that chronic fatigue and decreased ability to concentrate rendered him unable to work full-time as of that date, there is absolutely no evidence in his medical records that he ever complained about any fatigue or decreased ability to concentrate before March 16, 2012, more than two months later. Therefore, this is not a question of whether his subjective complaints were credible. As Standard points out, as of January 1, 2012, he had never even made such complaints. This fact distinguishes Slaton’s case from the cases cited above. Without any documentation of such subjective complaints in the record as of the claimed date of disability, it cannot be said that Standard acted in an arbitrary and capricious manner in failing to give those complaints more weight, or in failing to order an independent medical examination to better assess Slaton’s credibility.
If there were any evidence that Slaton actually experienced fatigue or decreased cognitive ability prior to January 1, 2012, perhaps the outcome of this case would be different. However, under the circumstances presented here, the Court finds that Standard’s decision to deny long-term disability benefits was not arbitrary or capricious.
Although Slaton was diagnosed with multiple sclerosis early in January of 2012, that disease was not yet “clinically active” on January 1, 2012. Moreover, there is no evidence that Slaton was experiencing fatigue or decreased cognitive ability as of that date. As previously noted, Dr. Valle’s notes from the January 19, 2012, office visit actually indicate that Slaton has “[g]ood attention span and concentration” and his “neurological assessment is quite normal at this time.” On that date, there were no “objective findings that would suggest a chronic progressive condition.”
In upholding its decision to deny Slaton ‘s claim for long-term disability benefits, Standard indicated that it had considered all of the information submitted, but found no “evidence to support that your multiple sclerosis was clinically active, or that there were limitations and restrictions associated with this condition that would have limited you to part time work as of January 1, 2012.” The Court finds that Standard has offered a reasoned explanation for rejecting Dr. Valle’s opinion, and for denying Slaton ‘s claim for long-term disability benefits. Standard’s determination resulted from “a deliberate principled reasoning process, and is supported by substantial evidence .” McClain, 740 F.3d at 1065 (quotation omitted). Accordingly, the Court must uphold it .
Summary: For the reasons set forth above, the Court concludes that Defendant did not act in an arbitrary and capricious manner in denying Plaintiff’s claim for long-term disability benefits. Accordingly, the Court OVERRULES Plaintiff’s Motion for Judgment on the Administrative Record, Doc. #24, and SUSTAINS Defendant’s Motion for Entry of Judgment on the Administrative Record.