Ayer v. Liberty Life Assur. Co. of Boston

Citations: 382 F. Supp. 2d 162; 2005 U.S. Dist. LEXIS 15748; 2005 WL 1804428Docket: CIV. 04-213-B-W

Court: District Court, D. Maine; August 1, 2005; Federal District Court

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Linda E. Ayer filed a lawsuit against Liberty Life Assurance Company of Boston for wrongful denial of long-term disability benefits under an ERISA policy linked to her employer, FleetBoston Financial Corporation. Ayer suffers from myasthenia gravis (MG), an autoimmune disorder causing fluctuating muscle weakness, which impacted her ability to work; her last day was October 28, 2002, after her neurologist recommended she refrain from working due to speech difficulties. The court evaluated the case based on a stipulated record, allowing it to ascertain significant material facts. Ayer's symptoms began in 1997, characterized by a drooping eyelid and progressive issues with speech and swallowing. She reported these symptoms consistently to her healthcare providers, leading to her referral to a neurologist. The court found that Liberty’s denial of benefits was supported by substantial evidence, leading to the granting of Liberty’s motion for judgment.

Ms. Ayer first consulted Dr. Lash on April 3, 1998, presenting no current symptoms but recounting previous issues such as eyelid drooping and difficulty speaking or swallowing. Dr. Lash recognized these symptoms as indicative of a "mild myasthenic process" and ordered a blood test, which confirmed elevated acetylcholine receptor antibodies at 3.1. By her next visit on April 23, 1998, Ms. Ayer reported no new symptoms, leading Dr. Lash to diagnose her with "mild [MG]" that did not require medication at that time. On July 8, 1998, despite Ms. Ayer's complaints of twitching, Dr. Lash found no significant muscle contractions and stated that muscle twitching is not typically associated with myasthenia gravis (MG). She advised that if symptoms worsened, Mestinon could be considered.

After starting Mestinon, Ms. Ayer reported blurred vision and tension headaches during an August 24, 1998, visit, where Dr. Lash noted muscle twitches but no evidence of fatigue or ptosis. Since Mestinon was ineffective, Dr. Lash recommended tapering off the medication. In the fall of 1998, at the Myasthenia Gravis Center, tests indicated a "post-synaptic neuromuscular junction disorder" without sensorimotor polyneuropathy, and muscles were normal. By January 1999, Ms. Ayer reported improvement with only occasional twitching. Dr. Lash found no signs of fatigable ptosis and concluded that medication was unnecessary.

In October 2000, Ms. Ayer presented with increasing difficulty in daily tasks. Dr. Lash noted her strength was slightly reduced but still adequate, suggesting that her previously mild myasthenia might be becoming more active. To clarify her condition, additional antibody and pulmonary function tests were ordered. On November 3, 2000, Ms. Ayer had no significant new symptoms, although she still experienced some end-of-day difficulties with tasks. Despite elevated acetylcholine receptor antibodies, levels were lower than previously recorded.

Dr. Lash evaluated Ms. Ayer, noting her mild myasthenia gravis (MG) diagnosis and recommending no medication initially. On September 10, 2001, Ms. Ayer reported increased weakness and shortness of breath but had stable vision and occasional swallowing difficulties. Examination revealed fluent speech, full eye movements, normal strength in upper extremities, and intact sensation, with atypical symptoms for MG prompting further tests. A subsequent MG Panel D study indicated high levels of antibodies. In an October 2002 visit, Ms. Ayer expressed worsening swallowing issues and work-related stress. Dr. Lash observed her stable condition but ordered additional tests to clarify her symptoms before prescribing medication. A barium swallow test showed normal mechanics, leading to a prescription of Mestinon.

On December 2, 2002, Liberty approved Ms. Ayer's short-term disability benefits due to her MG symptoms impacting her ability to communicate. Dr. Lash confirmed her need for time off until December 4, recommending she assess her capacity to manage work demands. After a follow-up on December 4, Ms. Ayer reported improvement, but Dr. Lash acknowledged the unpredictability of her condition. Liberty later extended her disability benefits through January 17, 2003, recognizing the impact of her condition on her job as an operations manager, which required verbal interaction. A Liberty nurse corroborated that Ms. Ayer's symptoms rendered her unable to fulfill her work responsibilities.

The nurse indicated Ms. Ayer could return to work if a position without public interaction was available. Liberty emphasized the need for updated medical information before her next doctor's appointment on April 4, 2003. On January 8, 2003, Ms. Ayer reported to Dr. Lash difficulties with swallowing and speech but expressed a desire to return to work part-time. Dr. Lash noted her speech was normal and her strength was intact, recommending part-time work and starting her on azathioprine. Liberty extended her short-term disability benefits to January 31, 2003. On January 27, Dr. Lash provided a Physical Capacities Form detailing Ms. Ayer's work restrictions, including limitations on standing, walking, and speaking. Liberty continued to assess her situation and extended benefits through February 28, 2003.

On February 13, 2003, Fleet confirmed they could accommodate Ms. Ayer’s return part-time starting February 18, 2003, with a modified schedule limiting customer interaction and a reassessment after thirty days. Fleet outlined her duties in a memorandum, allowing a twenty-hour work week consisting of four-hour days. The plan involved working primarily as a teller but included desk time for paperwork. Fleet proposed informing staff of her condition and designating a co-worker as a "buddy" to assist her during potential distress situations.

However, on February 17, 2003, Ms. Ayer expressed concerns to Liberty about returning to what she perceived as a stressful environment, feeling that Fleet was uncooperative and that the proposed schedule set her up for failure.

A Liberty representative noted that Ms. Ayer experienced increasing difficulty with speech, including signs of a swollen tongue and trouble enunciating during a conversation. Ms. Ayer decided not to return to work, leading Liberty to extend her short-term disability benefits until March 28, 2003. On March 18, 2003, Ms. Ayer reported to Dr. Lash ongoing issues with swallowing and chewing, difficulty lifting heavy objects, stress-related exacerbation of symptoms, occasional knee instability, and blurred vision. Despite these complaints, Dr. Lash found her speech to be fluent and physical examinations normal, indicating a complex situation where Ms. Ayer reported significant disability despite good office evaluations. He increased her medication dosage and completed a Physical Capacities Form reiterating her limitations, resulting in another extension of her short-term disability benefits until April 11, 2003.

On April 2, 2003, Liberty assessed Ms. Ayer's medical records, with a nurse noting that while the diagnosis of myasthenia gravis (MG) was supported, there was insufficient evidence for her claimed speaking limitations. Consequently, Liberty terminated her short-term disability benefits effective April 12, 2003, citing a lack of medical documentation to justify her inability to work full-time, despite Dr. Lash's indications of her considering long-term disability. Following the termination, Ms. Ayer visited Dr. Lash on May 8, 2003, reporting overall improvement, reduced medication usage, and less severe slurred speech and swallowing issues, although she still felt unable to return to work. She expressed hope for future improvement that could enable her to resume work.

Dr. Lash evaluated Ms. Ayer and noted her speech was generally fluent but occasionally exhibited subtle dysarthria. She demonstrated full extraocular motion with no ptosis. Diagnosed with myasthenia gravis (MG), her symptoms were mild, without significant pulmonary issues, allowing her to manage her activities of daily living (ADLs). Key concerns included her fatigue and variable difficulties with speech and swallowing. Dr. Lash cautioned against reducing her Imuran medication due to potential symptom rebound, but acknowledged Ms. Ayer's commitment to this decision, emphasizing her responsibility to monitor her condition.

Discussions regarding her return to work highlighted the unpredictable nature of her symptoms, with Dr. Lash stating that working would not directly harm her, leaving activity limitations to her discretion. A follow-up appointment was scheduled for two months later, with plans to hold off on further neurodiagnostic testing unless symptoms worsened.

On August 1, 2003, Ms. Ayer reported significant improvement, including resolution of eye twitching and enhanced swallowing and speech abilities, with Dr. Lash confirming these improvements and noting she was off Mestinon. He cleared her to return to work, advising her to avoid sustained speaking engagements that might strain her voice.

On August 11, 2003, Ms. Ayer appealed the termination of her short-term disability benefits, providing a letter from her employer confirming the communicative demands of her job. She described her work's physical requirements and noted her ability to speak without incident during limited interactions. Her appeal was reviewed independently by Dr. Joseph Jares on October 3, 2003, who concluded that Ms. Ayer had mild neurological impairment but could work full-time in a sedentary role, albeit with expected absences during exacerbations and the need to limit speaking.

Ms. Ayer appears to be experiencing a period of relative remission, as evidenced by her ability to reduce her Mestinon dosage and discontinue Imuran. Her physician's restrictions align with her symptoms, though her self-reported limitations seem excessive given her capability to travel and perform daily activities, including grocery shopping. Concerns about her speech suggest a need for a speech therapy assessment. On October 6, 2003, Liberty denied continued short-term disability benefits, relying on Dr. Lash's visit notes and an independent review by Dr. Jares. Following this, Ms. Ayer appealed the denial to Fleet on October 31, 2003, emphasizing the need for objective medical documentation to support her claim. In her December 4, 2003 correspondence, Ms. Ayer expressed concerns about her manager's actions regarding her position and her difficulties with slurred speech during stress. She noted a doctor's recommendation for part-time work, but Fleet's response on December 30, 2003, confirmed short-term disability benefits for a limited period. After her short-term benefits expired on April 27, 2003, her claim transitioned to long-term disability. Liberty's review of her long-term claim referenced Dr. Lash's February 20, 2004, note indicating mild symptoms but ongoing issues with speech and swallowing. Dr. Lash advised stopping Mestinon but did not prescribe alternative medication due to toxicity concerns, while supporting her desire to return to part-time work.

On March 12, 2004, Liberty's MDS Unit reviewed Ms. Ayer's medical records and concluded that her work restrictions had not changed since a peer review by Dr. Jares in October 2003. The review indicated that her reported impairments were not addressed by any medical providers and were minimal given her ability to work during that time. Claims of work-related stress were deemed unsubstantiated, and Dr. Lash's classification of her mental impairment as class 3 lacked objective medical support. Liberty noted Ms. Ayer's capacity to communicate effectively despite her reported issues.

On March 16, 2004, Liberty's case manager recommended denying Ms. Ayer's long-term disability claim due to the absence of new medical evidence indicating a change in her condition or total disability. Consequently, Liberty sent a denial letter on March 22, 2004, explaining that she did not meet the disability definition under the FleetBoston LTD policy.

On September 13, 2004, Ms. Ayer, through her attorney, appealed the denial. Additional medical notes from Dr. Lash, dated August 25 and September 29, 2004, highlighted ongoing speech difficulties and stressors related to personal events. Despite some speech issues, Dr. Lash noted her overall status was atypical for her diagnosis and recommended further evaluation.

Liberty referred Ms. Ayer's case to a second neurologist, Dr. Lawrence R. Huntoon, for a comprehensive review of her medical history and related documents, including records from multiple sources and an audiotape submitted by Ms. Ayer.

On October 6, 2004, Dr. Huntoon evaluated the claimant's medical condition, primarily diagnosed with myasthenia gravis (MG), which has been documented since 1997. Initial symptoms included drooping of the eyelid and speech difficulties, with a diagnosis confirmed in April 1998. Dr. Huntoon noted that while MG can cause speech issues, the claimant’s speech problems also have a significant psychological component related to stress, complicating the differentiation between physical and psychological symptoms. 

Dr. Huntoon summarized that the treating neurologist classified the claimant's MG as "mild," and despite some speech variability, the neurologist reported that the claimant was functioning well as of August 25, 2004, with no specific limitations noted. The claimant's self-reported restrictions varied widely, with some being compatible with the ability to work as a bank branch manager. 

A review of the claimant's self-reported limitations revealed a disconnect from objective medical findings, indicating possible symptom magnification. An assessment of an audiotape provided on appeal showed the speaker's voice was well-maintained, contradicting claims of significant speech impairment. While MG can lead to fatigue in speech, the findings did not support that the claimant's speech issues were solely attributable to MG. The audiotape did not demonstrate evidence of speech impairment consistent with MG, as the speech’s quality and articulation were poor and unintelligible. Dr. Huntoon concluded that the audiotape should not be considered reliable evidence of speech impairment due to the lack of clinical corroboration in the medical records.

A neurologist can evaluate the claimant's speech issue using a Tensilon test with a saline control while the symptoms are evident, potentially at the end of a day of extensive talking or through a prolonged talking session during the visit. Improvement in speech after Tensilon administration, but not after saline, could document an objective basis for the claimant’s problem, potentially justifying a reconsideration of disability status. Conversely, improvement after saline would suggest a non-organic cause. Notably, not all myasthenia gravis (MG) patients respond to Tensilon. Dr. Huntoon reviewed audiotapes of the claimant's speech, noting a lack of speech disturbance in neurologic examinations. The first segment showed poor articulation, while subsequent segments displayed improved volume and prosody, albeit with slight articulation impairment. The audiotapes alone were deemed insufficient evidence of impaired speech. On October 20, 2004, Liberty denied Ms. Ayer's appeal for long-term disability. Ms. Ayer’s attorney subsequently requested Dr. Huntoon’s qualifications and notified Liberty of her recent hospitalization for MG exacerbation, offering to obtain relevant medical records if the appeal were reopened. Liberty later provided the claim file but could not supply evaluators' resumes. Following a lack of response to her appeal reconsideration request, Ms. Ayer filed a complaint. Courts review plan administrators' benefits decisions de novo unless discretion is granted, in which case decisions are upheld unless arbitrary, capricious, or an abuse of discretion. Liberty's decision will be upheld if reasonable and supported by substantial evidence.

The arbitrary and capricious standard evaluates whether a factfinder's decision is plausible based on the entire record. "Substantial evidence" refers to evidence that reasonably supports a conclusion, with the existence of contrary evidence not invalidating the administrator's decision. The plan administrator is tasked with weighing conflicting evidence. For a claimant to succeed, they must show that the administrative record at the time of the decision contained evidence proving their inability to perform their essential job duties.

In the case of Ms. Ayer, she contends that the insurer, Liberty, relied on an incorrect Department of Labor job definition for a bank manager that does not align with her specific job duties at Fleet. She highlights a discrepancy regarding her job's physical requirements, arguing that the DOT describes her position as sedentary, whereas Fleet's evaluation indicates a mix of sitting and standing requirements. Liberty concluded that Ms. Ayer could perform her own occupation based on medical records, which led to the denial of her claim. The policy does not define "own occupation," and courts typically defer to the DOT definition when the term is undefined, as insurers cannot foresee every job variation.

Reliance on the Dictionary of Occupational Titles (DOT) is deemed "objectively reasonable" in ERISA actions, with courts affirming that a general job description must reflect comparable duties, though not every specific duty. The DOT is recognized for its widespread use in defining occupations within the U.S. economy, supporting the rationale for plan administrators and courts to utilize it in disability determinations. Courts evaluate "own occupation" based on typical duties rather than the specific requirements of an employer. For instance, Sun Life's interpretation of "own occupation" as it is performed in the labor market aligns with this approach, as seen in various cases where courts upheld decisions based on national economic standards rather than individual job peculiarities.

In a specific case involving Ms. Ayer, the court concluded that Liberty appropriately relied on the DOT definition of branch bank manager instead of Fleet's job description to assess her disability claim. Under an arbitrary and capricious standard, the court focuses on whether Liberty's conclusion is supported by "substantial evidence" rather than agreeing with its interpretation of medical opinions. Liberty cited multiple medical reports indicating that Ms. Ayer could perform her job's essential duties. Dr. Lash, her primary physician, characterized her condition as mild, with no disabling symptoms, and although he imposed certain physical work restrictions, they largely aligned with both the DOT and Fleet's job descriptions. Dr. Lash consistently noted that Ms. Ayer's speech was normal and indicated her capability to return to work, which undermines claims of total disability.

On May 8, 2004, Dr. Lash stated that Ms. Ayer's work would not directly harm her and that she could not impose specific restrictions on her activities. Liberty's reliance on Dr. Lash's medical opinion to deny Ms. Ayer's claim was deemed appropriate by the Court. Supporting cases reaffirmed that an administrator can rely on a treating physician's opinion regarding a claimant's work capacity. Dr. Jares, after reviewing Ms. Ayer's medical records, noted she had a mild impairment and recommended temporary limitations, specifically advising her to limit speaking but concluding she could perform full-time sedentary work. Dr. Huntoon, upon reviewing the same records, found no objective medical evidence to support any restrictions or limitations related to her speech impairment and identified a discrepancy between Ms. Ayer's reported limitations and the medical findings. He also noted that an audiotape of Ms. Ayer's speech showed normal characteristics without signs of increased fatigue. The Court upheld Liberty's decision to rely on the independent reviews of Dr. Jares and Dr. Huntoon, as none of the medical experts concluded that Ms. Ayer's condition prevented her from fulfilling her job duties, indicating that her myasthenia gravis (MG) was mild and not totally disabling according to the policy. Although there were some contradictory medical notes, the overall evidence supported the conclusion that Ms. Ayer was capable of working.

Liberty's decision to deny Ms. Ayer long-term disability benefits is upheld as it is supported by substantial evidence, not deemed arbitrary or capricious. The court references relevant case law to affirm that Ms. Ayer should have provided documentation from a mental health professional to substantiate her claim related to stress from her job at Fleet; however, no such evidence was submitted. Despite the potential stress of her former position, Liberty's conclusion that she could perform the duties of a branch operations supervisor is not considered unreasonable based on the evidence presented. 

Ms. Ayer's claims regarding bias by Dr. Huntoon, based on his past affiliations and writings, are dismissed as irrelevant since these materials were not part of the administrative record reviewed by Liberty. The court emphasizes the importance of finality in ERISA administrative procedures, stating that new evidence cannot be introduced post-denial to challenge the administrative decision. The court grants the Defendant's Motion for Judgment on the Stipulated Record, concluding that Ms. Ayer had ample opportunity to present her evidence during the administrative process. Additionally, a note indicates that Ms. Ayer seeks attorney fees under 29 U.S.C. § 1132(g)(1). The court also includes definitions and information related to specific medical tests and treatments relevant to Ms. Ayer's condition but does not expand on these details in the ruling.

Repetitive nerve stimulation tests are utilized to diagnose Myasthenia Gravis (MG) by assessing the muscle response to nerve stimulation. Dr. Lash noted Ms. Ayer's sister has limb girdle muscular dystrophy and requested additional medical information. A Certification of Health Care Provider indicated Ms. Ayer was advised to remain out of work indefinitely due to her condition affecting her ability to engage in conversations. Imuran, an immunosuppressive drug, was mentioned in relation to her treatment.

Liberty's Managed Disability Services Unit offers consultation for case managers. Liberty denied Ms. Ayer's long-term disability claim on the grounds that the elimination period had not been satisfied, with the earliest possible benefit start date being April 27, 2003. Dr. Lash's November 26, 2003, Attending Physician's Statement indicated Ms. Ayer could return to work with restrictions on voice demand, categorizing her physical impairment as class 4 and mental/nervous impairment as class 3.

There is a dispute regarding Fleet's decision on Ms. Ayer's employment due to a lack of available positions accommodating her restrictions. Although Fleet awarded her benefits, the current issue pertains to long-term disability claims. The insurance contract grants Liberty the authority to interpret policy terms and determine eligibility for benefits, a point Ms. Ayer concedes. She also contends Liberty improperly terminated her short-term disability benefits, but this does not impact the long-term claim analysis. The Dictionary of Occupational Titles (DOT) categorizes jobs into occupations, which are defined by shared characteristics; it is a standard reference for defining occupations in the U.S. Ms. Ayer claims Liberty denied her long-term disability benefits based on her failure to meet the policy’s elimination period.

Liberty clarified that Fleet's decision to pay Ms. Ayer her remaining short-term disability benefits resolved any issues related to the elimination period, which Liberty did not cite as a reason for denying her claim. Since Fleet, not Liberty, awarded these benefits, Fleet's determination was not a definitive measure for assessing Ms. Ayer's disability status without evidence of improved conditions. Ms. Ayer contended that the question of her ability to work full-time was not a medical matter but failed to provide legal authority for this claim. Case law supports that disability determinations rely on medical opinions. Dr. Simone observed that Ms. Ayer exhibited somewhat thickened speech on two occasions. Liberty did not base its denial of Ms. Ayer's long-term disability claim solely on Dr. Huntoon's medical evaluation. Consequently, the Court declined to address Ms. Ayer's requests for future benefits and attorney fees given the case's resolution.