Case Name: Patti Okuno v. Reliance Standard Life Insurance Company
Date of Decision: September 1, 2015
Court: United States District Court for the Southern District of Ohio, Eastern Division
Type of Claim: Long Term Disability
Claimant’s Employer: Limited Service Corporation
Insurance Company / Plan Administrator: The long term disability plan (“the Plan”) was issued by Reliance Standard Life Insurance Company (“Reliance Standard”). Reliance Standard also serves as the claims review fiduciary for the Plan.
Claimant’s Occupation / Job Position: Art Director
Disabilities: At the beginning of the claim, fibromyalgia and cervical and lumbar spinal pain. On appeal, the Plaintiff added Crohn’s disease, narcolepsy, and fibromuscular dysplasia. In a second appeal, the Plaintiff added Sjogren’s syndrome, an autoimmune disorder. There was also evidence of depression and a generalized anxiety disorder.
Definition of Disability: The Insuring Clause of this disability plan provides for payment of a monthly benefit if an insured such as Okuno “(1) is Totally Disabled as the result of a Sickness or Injury covered by this Policy; (2) is under the regular care of a Physician; (3) has completed the Elimination Period; and (4) submits satisfactory proof of Total Disability to us,” with “us” meaning Reliance.
Under the Plan definition, “Totally Disabled” means that an injury or sickness has produced the following results:
“(1) during the Elimination period and for the first 12 months for which a Benefit is payable, an Insured cannot perform the material duties of his/her Regular Occupation; … and
(2) after a Benefit has been paid for 12 months, an Insured cannot perform the material duties of any occupation. Any occupation is one that the Insured’s education, training or experience will reasonably allow. We consider the Insured Totally Disabled if due to an Injury of Sickness he or she is capable of only performing the material duties on a part-time basis or part of the material duties on a Full-time basis.”
The Plan also contains a number of limitations. One such limitation is for mental or nervous disorders. That provision provides in relevant part:
“Monthly Benefits for Total Disability caused by or contributed to by mental or nervous disorders will not be payable beyond an aggregate lifetime maximum duration of twelve (12) months unless the Insured is in a Hospital or Institution at the end of the twelve (12) month period. The Monthly Benefit will be payable while so confined, but not beyond the Maximum Duration of Benefits.”
The policy then defines “Mental or Nervous Disorders” as including “disorders which are diagnosed to include a condition such as . . . depressive disorders; . . . anxiety disorders; [and] . . . somatoform disorders (psychosomatic illness).”
Another limitation provision targets pre-existing conditions. This provision provides:
“Benefits will not be paid for a Total Disability:
(1) caused by;
(2) contributed to by; or
(3) resulting from;
a Pre-existing Condition unless the Insured has been Actively at Work for one (1) full day following the end of twelve (12) consecutive months from the date he/she became an Insured.”
The policy also states that “ ‘Pre-existing Condition’ means any Sickness or Injury for which the Insured received medical treatment, consultation, care or services, including diagnostic procedures, or took prescribed drugs or medicines, during the twelve (12) months immediately prior to the Insured’s effective date of insurance.”
Benefits Paid? Benefits were paid for 12 months.
Procedural history: Reliance Standard denied the claim on the basis that the fibromyalgia was a pre-existing condition.
On appeal, Okuno asserted that she had not claimed that she was disabled due to fibromyalgia, but rather “due to a constellation of problems separate and distinct from fibromyalgia.” Specifically, Okuno cited as her disabling medical conditions Crohn’s disease, narcolepsy, and fibromuscular dysplasia. To support her appeal, Okuno submitted additional material, including medical records that she had not submitted as part of her original claim application. After having the claim reviewed by an “independent physician”, Reliance denied the appeal on the already discussed pre-existing condition grounds and on the grounds that the specific conditions for which Okuno sought disability benefits–Crohn’s disease, narcolepsy, and fibromuscular dysplasia–were not considered disabling under the Plan terms. In a second appeal, Okuno submitted additional medical information and asserted that she was disabled as a result of narcolepsy and Sjogren’s syndrome, an autoimmune disorder.
In an October 18, 2013 letter to Okuno’s long term disability attorney, Reliance disposed of the second appeal. Based on the Plan’s Mental or Nervous Disorders language, Reliance reversed a portion of its prior denial and awarded Okuno benefits for 12 months, explaining that “[i]t has been determined that Ms. Okuno was disabled due to her depression and generalized anxiety disorder.” Reliance again denied benefits for Crohn’s disease, narcolepsy, and fibromuscular dysplasia, however, stating that “although it appears Ms. Okuno is in fact impaired, said impairments are due to her cervical and lumbar conditions, as well as fibromyalgia.” Reliance also explained that even if these conditions were not pre-existing and outside the scope of the Plan’s coverage, Dr. Karetzky had opined that Okuno could engage in sedentary work – and that Okuno’s Art Director job qualified as a sedentary occupation.
Okuno subsequently filed a third appeal. In a letter to Okuno’s counsel, Reliance upheld its decision to terminate benefits.
After receiving this last denial letter, Okuno filed a lawsuit.
Issues: ”The parties’ core dispute instead involves whether Reliance acted reasonably in declining to pay long-term disability benefits for Okuno’s Crohn’s disease, narcolepsy, and Sjogren’s syndrome. [fn.3: This list of ailments omits fibromuscular dysplasia. Okuno explains in her briefing that, “[e]arly on, [her] physicians considered fibromuscular dysplasia as a potential diagnosis, so there is some discussion of that condition in the administrative record. Ultimately, however, Okuno’s physicians rejected that diagnosis.”] Okuno argues that Reliance used the wrong standard for its analysis, deciding whether she was able to perform the essential functions of her occupation as opposed to any occupation, the standard for total disability under the plan. She asserts that this led her into submitting medical and vocational evidence targeting her own occupation as opposed to any occupation.” (2) Okuno also asserts Reliance acted arbitrarily and capriciously in multiple ways, including its reliance on the opinions of Karetzky. She protests that because the doctor opined on matters far outside his area of expertise, Reliance could not have reasonably relied on his opinions. Similarly, Okuno contends that Reliance unreasonably relied upon the opinions of Parillo because he lacked the appropriate training and experience to opine on the issues he did. Additionally, Okuno argues that Parillo’s opinions are ultimately of little value because he did not have the benefit of subsequently submitted medical evidence before him when he formed his opinions.”
Holdings: (1) “But the Court disagrees with Okuno that this means that Reliance did not come to the correct ultimate conclusion regarding her entitlement to total disability benefits. Okuno’s specific sedentary occupation is a subset of “any occupation.” If, as it did, Reliance concluded that Okuno could perform her occupation, then it of course recognized that she could perform a job fitting within the plan definition of “any occupation,” which means that Reliance implicitly determined that Okuno did not meet the plan definition of “totally disabled” so as to entitle her to the benefits she seeks.” (2) In evaluating the opinions of the various doctors, the Court held:
“Although an independent medical examination might have been more reassuring, especially in regard to the mental or nervous disorders determinations, the Court is cognizant that there is “nothing inherently objectionable about a file review by a qualified physician in the context of a benefits determination.” Calvert v. Firstar Finance, Inc., 409 F.3d 286, 296 (6th Cir. 2005). It is the sufficiency of such a review that matters. Here, the file reviews conducted include the review of Karetzky, who opined that Okuno was disabled due to cervical and lumbosacral spinal pain and fibromyalgia and, notably, severe depression and generalized anxiety disorders. This latter conclusion is important because it is the contextual depth or sufficiency of the file review that matters, and Karetzky’s file review resulted in Reliance crediting its reviewer’s opinion, reversing part of its prior denial of benefits, and awarding 12 months of benefits.
Okuno devotes considerable time in her briefing to argue that Karetzky is not competent, derisively dismissing him as “a geriatric pulmonologist.” (ECF No. 12, at page ID # 30.) But other file reviewers reached similar conclusions throughout the claim process. Earlier in the claims process, Parillo opined (after reviewing less than all the records that were eventually submitted) that there was no clinical documentation substantiating that Okuno’s conditions were physically impairing to the point of requiring restrictions, limitations, or absence from work and no supportive evidence verifying that the conditions ever caused functional impairment. Subsequent to Karetzky in the appeals process (and after all of the evidence had been submitted), Walder agreed with the same core conclusions.
But what is perhaps more significant is the second point arising from Pelfrey’s December 29, 2013 letter: regardless of the credentials or lack thereof of Reliance’s consultants, Okuno own doctor stated that she has depression and anxiety and that at least one of these mental or nervous disorders have been disabling for her. Okuno cannot rely on Pelfrey’s opinions when they support her claim and then ignore him when his conclusions mirror in whole or in part the conclusions of Reliance’s consultants. Thus, even if this Court were to accept Okuno’s arguments that some of the file reviewers exceeded their expertise, her own doctor reached the same conclusions on key points that counter her benefits claim. Other doctors, such as Jones with his often compelling analysis, may disagree, but the end result is the same. There was record evidence, some of it even submitted by Okuno, that reasonably argued against an entitlement to benefits.”
Also Noteworthy: The Court stated “The remaining question is whether Okuno’s physical issues presented total disability. These conditions are Crohn’s disease, narcolepsy, fibromuscular dysplasia, and Sjogren’s syndrome. The mere diagnosis of any of these conditions alone is insufficient to render Okuno disabled within the meaning of the Plan. This is because, as the Sixth Circuit has explained,
“[i]t is insufficient for individuals attempting to prove disability status under this test to merely submit evidence of a medical diagnosis of an impairment.” [Toyota Motor Mfg., Ky., Inc. v. Williams, 122 S.Ct. 681, 691 (2002)]. An individualized case-by-case assessment of the effect of that impairment on the plaintiff’s life is required, including the extent of its limitation on a major life activity and the effect of any corrective or mitigating measures taken by the plaintiff. Id. at 691-92 (citing Sutton v. United Air Lines, Inc., 527 U.S. 471, 483-84, 119 S.Ct. 2139, 144 L.Ed.2d 450 (1999)); see also Albertson’s, Inc. v. Kirkingburg, 527 U.S. 555, 566, 119 S.Ct. 2162, 144 L.Ed.2d 518 (1999) (disability not based on the diagnosis, but on the effect of that impairment on the life of the individual).
Cartwright v. Lockheed Martin Utility Servs., Inc., 40 F. App’x 147, 153 (6th Cir. 2002). What is required, then, is examination of whether Okuno produced record evidence of the effect of those impairments on her life to qualify for long-term benefits.”
Also telling is this comment: “All of this leads to the conclusion that Reliance has acted within its rights, even if its benefits decision is not necessarily one at which others would have arrived. There is no doubt that Okuno has unfortunately experienced numerous conditions that present serious difficulties. But the law does not require Reliance or this Court to accept this misfortune as totally disabling. Rather, the law permits Reliance to rely on the opinions of its consultants (and Okuno’s own doctors) in evaluating Okuno’s claim for benefits, even where those opinions might disagree with other medical professionals.”
Summary: ”Here, Okuno has not established that she satisfied the requisite conditions to obtain disability benefits beyond what Reliance has already paid. Reliance’s denial of continued long-term disability benefits appears to have been the result of a principled and deliberative reasoning process. … Accordingly, Reliance is entitled to judgment on the administrative record.”