Court: District Court, M.D. Florida; March 27, 2019; Federal District Court
Plaintiff, covered under a Long-Term Disability Insurance Policy, filed a claim for benefits on August 10, 2015, citing debilitating pain from injuries sustained in a motor vehicle accident on April 20, 2012. Both the claim and subsequent appeal were denied, leading to the current litigation. To qualify for benefits, Plaintiff needed to prove total disability, defined as inability to perform the substantial duties of his occupation as a dentist.
Following the accident, Plaintiff was diagnosed with cervicalgia, and MRI results revealed a herniated disc and bulging discs in his cervical spine. He sought treatment from chiropractor Dr. Chet Barton and later consulted orthopedist Dr. Richard Smith, who noted significant physical limitations and recommended physical therapy and epidural steroid injections. Despite some relief from treatments, Plaintiff continued to experience pain and neurological symptoms, prompting consultations with neurologist Dr. Marc Sharfman. By May 2013, Dr. Sharfman indicated that Plaintiff had reached maximum medical improvement but had a permanent partial impairment, reiterating this assessment in July 2013 while recommending ongoing care. Throughout treatment, Plaintiff expressed concerns about how his condition affected his work capabilities.
The court has granted Plaintiff’s motion for summary judgment and denied the Defendant’s motion.
In September 2013, Dr. Smith determined that the Plaintiff had reached maximum medical improvement unless he opted for surgery, which the Plaintiff declined due to uncertainty of its benefits. There were no recorded treatments from September 2013 until June 2015. On June 19, 2015, the Plaintiff reported severe pain (10/10) to Dr. Smith, leading to a new MRI that revealed bulging discs at C4-C5 and C5-C6, consistent with a previous MRI, but also identified a new herniated disc at C6-C7. Notably, the herniated disc at C3-C4 from the 2012 MRI was no longer present. During a follow-up on June 30, 2015, the Plaintiff again reported severe pain and exhibited diminished reflexes in the biceps, although overall motor strength was mostly normal. Dr. Smith suggested that the Plaintiff may benefit from a career change. On July 10, 2015, the Plaintiff resigned from his dental position due to medical issues, effective in thirty days as per his employment agreement. Following his resignation, he filed a claim with the Defendant, accompanied by a physician's statement indicating he could not continue in his occupation.
In response, the Defendant commissioned an occupational analysis, which classified dentistry as a light occupation requiring high dexterity. An independent medical examination by Dr. Dan Gerstenblitt revealed that the Plaintiff had normal strength and grip but a significantly reduced neck range of motion. Dr. Gerstenblitt found no objective evidence to support the Plaintiff's pain claims, suggesting that his limited range of motion was likely self-imposed. He characterized the Plaintiff's MRI findings as typical for someone of his age and indicated that the MRI did not explain the Plaintiff's symptoms. Ultimately, Dr. Gerstenblitt concluded that the Plaintiff could continue working, barring his subjective pain complaints, but acknowledged potential safety concerns if the Plaintiff experienced weakness and numbness in his hands.
On March 10, 2016, Defendant denied Plaintiff's claim, primarily relying on Dr. Gerstenblitt's opinions. Key reasons for the denial included Plaintiff's three years of employment post-collision, the lack of objective evidence for his sudden inability to work in 2015, and the absence of treatment or complaints between September 2013 and June 2015. Plaintiff appealed this decision and submitted additional evidence, including a Functional Capacity Evaluation (FCE) conducted in May 2016 by occupational therapist Michael Yarvi. The FCE indicated Plaintiff demonstrated consistent effort but had an overall work ability classified as sedentary, with significant limitations in his right upper extremity, making him unable to safely perform the essential duties of a dentist. Yarvi recommended against Plaintiff returning to his dental practice without accommodations.
Additionally, Plaintiff sought a Neurophysiologic Pain Profile from Dr. David Ross, who conducted tests involving physical stimulation related to Plaintiff's pain. Dr. Ross's findings suggested a multidimensional pain syndrome, exacerbated by neck flexion, and indicated that prolonged or repeated positions would likely increase neurological symptoms. He diagnosed Plaintiff with Chronic Pain Syndrome, concluding that Plaintiff was permanently work-disabled from performing the duties of a dentist. Dr. Sharfman also examined Plaintiff, noting tenderness and muscle spasm in the cervical spine, further reinforcing concerns about Plaintiff's headaches and overall condition.
Dr. Sharfman concluded that Plaintiff was not malingering and deemed it unsafe for him to practice dentistry due to his headaches, which impair concentration, mental focus, and memory, potentially exacerbated by the stress and posture associated with dental work. He expressed that Plaintiff would not recover from these headaches. Non-treating physician Dr. Stephen Wender, after reviewing Plaintiff's medical history, asserted that Plaintiff was unequivocally unable to practice dentistry, noting concerns about numbness and weakness in his right arm, which increased the risk of patient injury. Wender disagreed with Dr. Gerstenblitt's analysis, citing supportive MRIs and a valid Functional Capacity Evaluation (FCE) that Gerstenblitt ignored. Plaintiff also submitted statements from dental assistants Madeline Rivera and Joan Olivar, who observed a decline in his ability to perform dental tasks post-accident, including shaking hands due to pain and dropping instruments. In contrast, Defendant's physician, Dr. James Butler, did not examine Plaintiff, dismissed the FCE as invalid, and downplayed evidence of pain by asserting that such symptoms should not persist four years after the accident. Following this review, Defendant denied Plaintiff's claim, citing a lack of objective evidence and relying on the opinions of Dr. Gerstenblitt and Dr. Butler. Plaintiff is now appealing this denial.
The Eleventh Circuit's six-step test for reviewing an ERISA plan administrator's benefits decision begins with a de novo determination of whether the decision was 'wrong.' If the decision is deemed 'de novo wrong' and the administrator lacked discretion in claims review, the decision is reversed. If discretion existed, the court assesses whether the administrator had reasonable grounds for their decision under the arbitrary and capricious standard. A lack of reasonable grounds leads to a reversal, while a finding of reasonable grounds requires an examination of any conflict of interest. If a conflict is present, it is considered as a factor in evaluating the decision's reasonableness.
In this case, the Defendant, as the claims review fiduciary with discretionary authority, allows for a focus on the third step of the analysis concerning whether the denial of the Plaintiff's claim was arbitrary and capricious. There is an acknowledged conflict of interest as the Defendant both made the eligibility decisions and would be responsible for paying any awarded benefits.
The analysis reveals that the Defendant's claim that the Plaintiff did not provide sufficient objective medical evidence of disability is unreasonable and amounts to an unsupported conclusion of dishonesty. Despite presenting substantial objective evidence of debilitating pain, the Defendant undermines the Plaintiff’s credibility, suggesting he is malingering. The Defendant incorrectly asserts that a sudden onset of disability must precede the claim, while the policy only requires that the claimant be disabled at the time of the claim. The Plaintiff's progressive pain, exacerbated by work-related stress and exertion, supports his claim for disability, countering the Defendant's position regarding the absence of recent treatment before the claim was filed.
Dr. Smith and Dr. Sharfman informed the Plaintiff that he had reached maximum medical improvement, with surgery being the only remaining treatment option, which was not guaranteed to alleviate his condition. The Plaintiff's delay in returning to work until his pain became intolerable is deemed reasonable given the doctors' assessments. The Defendant argues that the Plaintiff's three years of work post-collision and his thirty-day resignation notice indicate he is not disabled. However, precedent suggests that ongoing work does not negate claims of disability, as individuals may continue working despite severe illness. There is objective medical evidence supporting the Plaintiff's experience of debilitating pain. The law does not penalize individuals for attempting to work while disabled, as demonstrated in case law.
Furthermore, the Defendant's dismissal of evidence from the Plaintiff’s dental assistants, which indicated a decline in his condition, is countered by specific observations from Ms. Rivera, who noted that the Plaintiff's pain worsened over time. The Plaintiff's emotional attachment to his job and reluctance to resign further support his claims of disability. The Defendant's arguments fail to undermine the objective evidence presented.
Regarding the timing of evidence, the Defendant contends that additional evidence submitted during the internal appeal, including Dr. Ross's testing and functional capacity evaluations (FCE), should be disregarded because they were not conducted during the elimination period. This argument is flawed as the Defendant considered this evidence on appeal, and it corroborates earlier subjective evidence of the Plaintiff’s pain, making it relevant to his disability claim. Lastly, the Defendant asserts that the Plaintiff's claim was denied due to insufficient objective evidence of disability.
Defendant based its decision primarily on the opinions of its physicians, Drs. Gerstenblitt and Butler, who concluded that Plaintiff was not disabled, relying mainly on MRIs that they claimed did not objectively support Plaintiff's pain complaints. In contrast, Plaintiff's physicians, Dr. Smith and Dr. Wender, disagreed with this assessment. Despite acknowledging that the MRIs alone might not substantiate Plaintiff's claims, Plaintiff presented additional objective evidence, including tests conducted by Dr. Ross that confirmed Plaintiff was indeed experiencing severe pain. Dr. Butler recognized Dr. Ross's findings but dismissed both the test results and a comprehensive functional capacity evaluation (FCE) without proper justification, stating only that "pain is a perception." He also incorrectly claimed the FCE was invalid, despite validation from both Dr. Wender and Dr. Ross. Furthermore, Dr. Sharfman's examination revealed tenderness and muscle spasms possibly causing Plaintiff's headaches, but again, Dr. Butler did not adequately address this evidence, suggesting it was abnormal for Plaintiff to still experience muscle pain four years post-collision. Defendant's reliance on a single office visit where Plaintiff did not report a headache was criticized as unreasonable, given the numerous instances where he did complain. Records consistently showed decreased cervical range of motion, and multiple doctors, including Dr. Gerstenblitt, found no evidence of malingering. Despite this, Defendant favored Dr. Gerstenblitt's unsupported claim of Plaintiff being "self-limiting" without considering subsequent evidence of pain and effort. The Defendant's approach appeared to selectively use evidence, overlooking substantial unfavorable medical findings, which is not permissible under the standard of relying on conflicting, reliable evidence.
Defendant's denial of Plaintiff's disability claim was based on Dr. Butler's flawed peer review, which ignored unfavorable evidence, rendering the decision arbitrary and capricious. Central to the issue was the opinion that pain could not constitute a basis for disability, despite evidence indicating that Plaintiff's pain worsened with work-related physical demands. Record evidence showed that Plaintiff suffered from pain, numbness, and tingling that impaired his ability to perform dental tasks safely, leading to dropped instruments and the need to stop procedures. Dr. Sharfman corroborated that Plaintiff's headaches hindered his concentration and memory, further supporting his inability to practice safely. Drs. Gerstenblitt and Butler failed to counter this evidence and instead made unsupported claims regarding the irrelevance of pain. The Defendant's selective use of evidence and reliance on Dr. Butler's opinions indicated a bias aimed at denying the claim, influenced by financial incentives. Consequently, the court granted Plaintiff's motion for summary judgment, denied Defendant's motion, and ordered the parties to confer on damages by April 10, 2019, with further instructions if an agreement could not be reached. The court did not consider additional evidence related to the conflict of interest, as it deemed the existing evidence sufficient for its determination. The court noted that Defendant’s decision was delayed beyond the elimination period, potentially complicating Plaintiff's situation. Even disregarding the headaches, evidence supported that Plaintiff could not perform his duties due to neck pain and associated symptoms.
