Court: District Court, W.D. New York; May 3, 2019; Federal District Court
Farooq Khan, M.D., initiated a legal action under the Employee Retirement Income Security Act (ERISA) against Provident Life and Accident Insurance Company, seeking long-term disability benefits from an employer-sponsored individual disability insurance policy. The matter was reviewed by United States Magistrate Judge Leslie G. Foschio, who recommended denying both the Defendant’s Motion for Judgment on the Administrative Record and the Plaintiff’s Motion for Summary Judgment, suggesting a plenary bench trial instead. The case was reassigned to Judge Michael A. Telesca on October 24, 2018, and an Order was issued on April 5, 2019, confirming that the parties consented to a bench trial based on their submissions. The Court ultimately granted the Plaintiff’s Motion for Summary Judgment, denied the Defendant’s motion, and awarded long-term benefits to the Plaintiff under specific provisions of the Disability Policy.
The court's findings of fact, derived from the Administrative Record, indicate that the Plaintiff, a board-certified neurologist, has faced medical issues since at least 2005, with ongoing evidence submitted through mid-2014. During this period, he was treated by numerous physicians, including seven rheumatology specialists, none of whom determined that he was fit to work as a neurologist. The Court's approach to factual findings adheres to the standards set by Federal Rules of Civil Procedure, emphasizing the need to state findings of fact and conclusions of law clearly.
On January 17, 2005, Plaintiff consulted nephrologist Dr. George Wu due to proteinuria, experiencing significant fatigue and right knee pain without inflammation. Dr. Wu ordered repeat serology tests for renal function and complement levels. On August 24, 2005, Plaintiff underwent a whole body bone scan requested by rheumatologist Dr. Frank Lipson, which indicated unusual bone uptake in the proximal tibiae and significant tracer accumulation in multiple joints, suggesting a potential polyarthropathy. Although an MRI was recommended, it was never performed. When Plaintiff returned to Dr. Wu on August 26, 2005, regarding his proteinuria, no definitive rheumatological diagnosis was made, leading Dr. Wu to order further renal tests.
In 2006, during a February 8 visit, Plaintiff again reported knee arthralgia; Dr. Wu noted no active joint issues and requested additional tests for proteinuria. By October 16, 2006, Plaintiff's symptoms had progressed to include fatigue, malaise, paresthesia, and polyarthralgia, alongside active scleritis, which Dr. Wu linked to several possible conditions. A total body bone scan on November 24, 2006, showed mild arthritic changes, though no definitive diagnosis was made, and lab tests revealed negative results for anti-nuclear antibodies and rheumatoid factor.
In follow-up visits throughout 2007, Dr. Wu noted ongoing fatigue and joint pain. He recommended a nerve conduction study and repeated renal and serological tests. Referrals to rheumatologist Dr. Yan Liu led to an assessment of increasing polyarticular pain and abnormal bone scan findings. Despite negative rheumatoid factor results, Dr. Liu kept rheumatoid arthritis in the differential diagnosis. On November 26, 2007, Dr. Liu suggested the possibility of small vessel vasculitis, possibly Wegener's granulomatosis, linked to red cell casts, scleritis, and joint pain, with unremarkable repeat serology results. In January 2008, Dr. Wu followed up on the diagnoses of proteinuria and possible microscopic polyangiitis, noting occasional elbow and knee discomfort but no signs of inflammation or active joints.
On October 5, 2006, Dr. Calvin Breslin treated the Plaintiff for left eye episcleritis and limbic keratitis, prescribing an initial dosage of 60 mg prednisone, tapering to 40 mg. On March 18, 2009, rheumatologist Dr. Simon Carette assessed the Plaintiff for possible vasculitis, noting progressive symptoms including sub-costal fullness, anorexia, decreased energy, burning sensations in extremities, and right Achilles tendon enthesitis, all improving with prednisone. Examination revealed severe scleritis and corneal thinning. Dr. Carette requested an emergency consult with Dr. Breslin and further bloodwork due to diagnostic difficulties. Following Dr. Carette's referral on March 19, Dr. Breslin increased the prednisone dosage to 60 mg and prescribed Imuran (azathioprine) pending improvement of eye symptoms. Dr. Wu assessed the Plaintiff on March 20, suggesting potential microscopic polyangiitis or Wegener's granulomatosis, noting significant improvement of symptoms with prednisone but awaiting further treatment guidance from Dr. Carette.
Records from 2010-2011 are absent in the Administrative Record, although Plaintiff saw Dr. Larry Moreland in May 2011. In 2012, the Plaintiff visited Dr. Todd Orszulak, with initial negative reviews for fatigue, which later became positive by September. On January 24, 2013, Dr. Orszulak noted no joint or muscle pain, but on March 27, he addressed worsening fatigue related to possible Polychondritis, with prednisone not alleviating symptoms. A rheumatology evaluation by Dr. Ernesto Levy on April 30, 2013, highlighted extreme fatigue with dizziness when off prednisone, and symptoms worsening with dosage reduction, including severe joint pain, eye issues, and muscle spasms.
Dr. Levy noted that the patient’s illness remains undiagnosed but suggests features indicative of an inflammatory rheumatologic condition, such as scleritis and abnormal urine, alongside nonspecific symptoms like fatigue and dizziness. The patient experiences extreme fatigue, headaches, dizziness to the point of collapse, ear tingling, excessive thirst, anxiety, and foot swelling, with symptoms worsening when off prednisone. Moderate joint pain persists even at a low prednisone dosage. Examination revealed no synovitis and full range of motion in all joints, leading Dr. Levy to classify the case as 'high-complexity' due to lack of clear manifestations, although significant symptoms like arthralgia and scleritis were noted. Dr. Levy recommended new blood tests, a steroid-sparing agent (e.g., Imuran), and a slow prednisone taper under endocrinologist supervision.
On May 3, 2013, rheumatologist Dr. Moreland evaluated the patient, who reported ongoing issues with functioning and working as a neurologist due to fatigue and intermittent pain. Dr. Moreland documented the patient's ongoing medical problems, including relapsing polychondritis, and advised the patient to cease work based on his medical condition, offering to complete disability paperwork. No medication changes were noted.
During a follow-up on May 30, 2013, primary care physician Dr. Orszulak found normal joint motion and no signs of joint issues, though fatigue persisted. Dr. Rajarathna saw the patient in August and September 2013, diagnosing relapsing polychondritis, and noted plans for disability. On September 13, 2013, Dr. Moreland observed slight tenderness in the left ear but no active synovitis during a follow-up visit. The patient continued on low-dose prednisone with a recommendation for a return visit in six months.
In 2014, after filing a disability claim, the Plaintiff consulted two rheumatologists, Dr. Joseph M. Grisanti and Dr. John H. Stone, both of whom determined he was totally disabled. The details of their evaluations are further elaborated in Section V.A. The Plaintiff secured a neurologist position at Mount St. Mary's Hospital (now Ascension Health) on October 24, 2011. As part of his employment application, he completed a medical history questionnaire, indicating conditions such as high blood pressure, arthritis, and diabetes, as well as musculoskeletal pain. The questionnaire did not provide an option for reporting additional medical conditions.
On June 15, 2012, the Plaintiff applied for an individual disability benefit policy through Ascension Health, which resulted in the issuance of Disability Income Policy No. 06-6297809, effective July 1, 2012. Governed by ERISA, this policy offers a monthly benefit of $6,249 for insured individuals under 64 until they reach age 67. Key definitions in the policy include:
- "Disability" or "Disabled": Requires total disability to begin while the policy is active, starting with an elimination period and having a maximum benefit period.
- "Total Disability" for the first year means the insured cannot perform the substantial duties of their occupation and must be under physician care, with a waiver possible if further care is deemed non-beneficial.
- After 12 months, "Total Disability" requires the inability to perform any occupation in addition to the initial criteria.
- "Sickness" refers to conditions manifesting after the policy's effective date.
- "Your Occupation" is defined as the insured's current occupation at the disability onset, while "Any Occupation" encompasses jobs suitable based on education, training, or experience.
The policy mandates that "Written Proof of Loss" must be submitted within 90 days after each claimed monthly benefit period, allowing the insurer to require any necessary proof to assess claims.
Medical information, personal and business tax returns, financial statements, and other acceptable proof may be required. The insurer reserves the right to mandate medical, functional capacity, psychiatric, and psychological examinations at their expense, selecting the examiner as needed. A rider to the policy expands the definition of 'Disability' to include 'Residual Disability,' defined as the inability to perform one or more substantial duties of one's occupation or to perform them for the usual duration, while under a physician's care. This requirement may be waived if acceptable proof indicates further care would be unbeneficial.
The plaintiff ceased work at the Hospital on June 9, 2013, and applied for disability benefits the following day, citing relapsing polychondritis and polyarthralgias diagnosed by Dr. Moreland. Supporting documents included an Attending Physician Statement indicating severe joint pain and fatigue as current restrictions. Dr. Moreland noted that clinical evaluation supported these restrictions. A letter from Dr. Orszulak confirmed the plaintiff should stop work as advised by his rheumatologist.
The defendant requested additional documentation from the plaintiff, including an Individual Statement and Occupational Description. In his Individual Statement, the plaintiff identified polychondritis as the cause of his disability, noting symptoms began in 2006-07. He described limitations in performing his occupational duties due to fatigue and joint pain. His Occupational Statement indicated he was a physician (neurologist), spending 40 hours per week evaluating and treating patients.
Plaintiff reported in a workday activity form that he frequently sits, stands, walks, balances, and reaches (34-66% of the day) and occasionally climbs, bends, kneels, squats, crawls, uses foot controls, twists, carries, pushes/pulls, and lifts (1-33% of the day). During an initial phone interview on July 18, 2013, Plaintiff disclosed a disabling medical condition that began in 2006 and has progressively worsened. He is currently on prednisone, which helps his eye and arthritis issues but leads to increased fatigue and dizziness. He experiences severe difficulty standing and walking, often needing to find chairs or support himself on patients' beds to avoid falling. Despite his pain and fatigue, he continued working, sharing his condition with only a few due to the competitive nature of his medical field.
On October 20, 2013, Dr. Moreland completed an Attending Physician Statement (APS) indicating that Plaintiff could perform various activities, including sitting, standing, and walking, only occasionally (1-33% of the time) and could lift up to 10 pounds occasionally but never more than that. Dr. Moreland concluded that Plaintiff was unable to work and anticipated no improvement in his limitations.
Defendant's Senior Vocational Resource Consultant, David Gaughan, reviewed Plaintiff's case and noted low billing production from January to June 2013, which was unexpected for a neurologist. Gaughan defined the physical demands of Plaintiff's occupation as requiring light exertion, which involves lifting up to 20 pounds occasionally, or up to 10 pounds frequently, exceeding sedentary work requirements. Light work could also involve significant walking or standing, or sitting with the need to push or pull controls, even if the weight is negligible.
Cognitive considerations for the Plaintiff's job included attention, adherence to medical protocols, independent judgment, and clear communication. Benefits Specialist Robinson requested a review from Dr. Norman H. Bress, a board-certified internal medicine and rheumatology consultant, due to unclear restrictions assessed by Dr. Moreland, particularly regarding the Plaintiff's inability to work. Dr. Bress, after reviewing the medical file, acknowledged minimal physical findings consistent with relapsing polychondritis (RP) but deemed it mild or well-controlled, not justifying restrictions. His rationale included minimal symptoms, low-dose prednisone treatment, normal lab results, and the lack of frequent follow-ups indicating active disease. Regarding polyarthritis, Dr. Bress found no abnormal joint findings to suggest its presence and concluded that if it existed, it was mild and did not warrant limitations. He also noted that the Plaintiff's co-morbid conditions were not claimed as impairing. Dr. Bress maintained that no physical restrictions or limitations were supported by the overall assessment. Following a phone conversation with Dr. Moreland, which confirmed normal exam findings and lab results, Dr. Bress reiterated his opinion that the Plaintiff's claimed fatigue lacked supporting evidence. Dr. Moreland, while not imposing work restrictions, acknowledged the Plaintiff's reported fatigue and supported his disability claim, citing the subjective nature of fatigue in autoimmune disease patients.
Dr. Bress maintained his opinion on the Plaintiff's condition as 'unchanged' after reviewing Dr. Moreland's response, citing a lack of supporting evidence for the Plaintiff's alleged fatigue and chronic illness. Dr. Bress attempted to consult with the Plaintiff’s primary care provider, Dr. Rajarathna, but resorted to sending questions regarding the Plaintiff's restrictions and limitations when a phone call was unsuccessful. Dr. Rajarathna's letter on November 29, 2013, indicated that the Plaintiff's mental health was severely impacted by his disability, noting a lack of physical strength and an inability to sustain any position without pain, ultimately concluding that the Plaintiff could not continue his career as a neurologist.
On November 8, 2013, Plaintiff's attorney, Michael Quiat, informed Benefits Specialist Robinson that Dr. Moreland may not fully understand the concepts of Restrictions and Limitations, indicating a need for clarification. Dr. Moreland subsequently sent a follow-up letter on November 18, 2013, asserting that while some symptoms of the Plaintiff's autoimmune diseases may not be objectively verifiable, they are nonetheless debilitating. He listed several symptoms and physical findings, stating that these conditions prevent the Plaintiff from fulfilling his professional duties.
Despite Dr. Moreland's clarifications, Dr. Bress's opinion remained unchanged, as he found Dr. Rajarathna's letter lacking in physical findings to support her claims. He noted that while there were physical findings available, the dispute lay in their interpretation regarding the Plaintiff's functionality. Consequently, he recommended that a Designated Medical Officer (DMO) review the case rather than an Independent Medical Examination (IME). Dr. John G. Paty, Jr., a board-certified internist and rheumatologist, conducted a paper review as the DMO and concurred with Dr. Bress's assessment.
Dr. Paty's report from December 5, 2013, primarily reiterates the medical records and concludes that there is no support for Dr. Moreland’s claim of impairment. He cites physical findings, laboratory data, the claimant's activities, stable medication dosages, and a recent visit with Dr. Moreland as evidence against the existence of impairment related to Relapsing Polychondritis or polyarthralgia. Dr. Paty lists the claimant's daily activities—such as reading, computer use, light household chores, working until the date of disability, and grocery shopping—as inconsistent with reported impairment. He believes no further medical investigation is warranted.
On December 11, 2013, Benefits Specialist Robinson communicated to Attorney Quiat that the Defendant was denying the Plaintiff's claim for Total Disability benefits, Residual Disability benefits, Recovery benefits, and Waiver of Premium. The denial was grounded in the assertion that the medical information did not indicate an impairment preventing the claimant from performing occupational duties. The denial letter reiterated the inconsistency between the claimant's reported difficulties and the medical findings from Dr. Moreland and Dr. Orszulak, emphasizing that the claimant's reported activities contradicted the claim of impairment. Robinson noted that examinations found no abnormal joint signs to support the polyarthritis diagnosis.
Following the denial, Attorney Quiat requested the claim file on April 21, 2014, and submitted a formal appeal on June 9, 2014, which included a supporting certification from the Plaintiff and additional medical records. A new opinion from rheumatologist Dr. Joseph M. Grisanti was presented, noting the Plaintiff’s history of conditions and recommending early retirement or disability due to significant fatigue linked to these diagnoses. Dr. Grisanti expressed skepticism regarding the resolution of the Plaintiff’s symptoms. The appeal also included a Notice of Award from the Social Security Administration confirming the Plaintiff's eligibility for monthly disability benefits starting December 2013.
On July 24, 2014, Attorney Quiat provided a supplemental report from Dr. John H. Stone, a rheumatologist. Dr. Stone confirmed the diagnosis of relapsing polychondritis based on clinical evaluation and test results, noting that Plaintiff's severe fatigue and pain are typical symptoms of the condition. He asserted that Plaintiff is totally disabled from his previous occupation due to the physical demands of hospital-based medicine and his diagnosis. This opinion stemmed from Dr. Stone's clinical experience and evaluation of Plaintiff's medical history.
Subsequently, with Plaintiff's consent, Appeals Specialist Enberg obtained the Social Security Disability Insurance (SSDI) file, which was received by the Defendant between August 15, 2014, and October 17, 2014. Plaintiff's SSDI application was completed online and processed via phone, with a representative describing him as polite yet fatigued. A final decision was rendered on November 18, 2013, recognizing Plaintiff's disability claim based on relapsing polychondritis, fatigue, and arthralgia.
The SSDI review included medical records from Drs. Orszulak and Moreland from 2012 onwards, and detailed Plaintiff's typical workday activities. The Social Security Administration (SSA) determined that no consultative examination was necessary, classifying Plaintiff's impairment as "severe" for "other disorders of the nervous system" and "non-severe" for "diabetes mellitus." The SSA found that Plaintiff's subjective complaints were supported by objective medical evidence and concluded that he had the residual functional capacity (RFC) to stand/walk for less than 2 hours and sit for about 6 hours in an 8-hour workday. Due to extreme fatigue, he was deemed unable to maintain a 40-hour workweek. The SSA referenced past bone scans and other medical issues to substantiate these limitations and determined that Plaintiff could not perform his previous role as a neurologist, given the severity of his impairment.
Medical-Vocational Rule 204.00 indicated a finding of disability. Dr. Beth Schnars, an in-house medical consultant, conducted a review of the Plaintiff's claim and confirmed that the Plaintiff suffers from relapsing polychondritis, a rare autoimmune disorder linked to cartilage inflammation. However, Dr. Schnars pointed out that while some symptoms align with this diagnosis, the medical records lacked evidence of severe symptoms, aggressive treatment, or significant exam findings indicative of underlying pathology. Serial joint examinations since 2005 have shown normal results without significant tenderness or synovitis, and there is no documented cartilage inflammation in the ears, nose, or trachea.
Dr. Schnars referenced a rheumatologist's notes indicating minor findings, but these had persisted since 2006 and were not indicative of polychondritis or functional impairment. Additionally, all connective tissue panels and inflammatory markers have been negative since 2005. Despite early bone scans showing mild joint uptake, no recent imaging was recommended, and the Plaintiff has been self-prescribing prednisone since 2009 without any adjustments for joint pain.
In May 2013, a physician recommended work cessation due to fatigue and joint pain, but a subsequent primary care visit reported no pain and a normal exam. Dr. Schnars concluded that the Plaintiff's various medical conditions, both individually and collectively, do not constitute an impairment since the date of disability. She noted that supporting opinions from other medical experts were based on self-reported fatigue without corroborating clinical or laboratory evidence and a lack of aggressive medical management. An addendum from Dr. Schnars maintained her original assessment despite reviewing additional notes from another rheumatologist, Dr. Stone. Subsequently, an external medical expert, Appeals Specialist Enberg, sought a "no deference" review by a credentialed rheumatologist after conferring with Dr. Schnars.
Dr. Schnars posed several questions to an outside rheumatologist regarding the plaintiff's medical records, specifically focusing on the diagnosis of polychondritis, any restrictions or limitations since June 10, 2013, and the consistency of treatment intensity and diagnostic findings with the severity of the disease. On August 15, 2014, rheumatologist Dr. Alfonso Bello received these questions along with the plaintiff's medical records and prior reviews by the defendant's medical consultants, though the SSDI file was not included as it had not been received. Dr. Bello submitted his report on September 17, 2014, confirming the diagnosis of relapsing polychondritis based on clinical evaluations by two board-certified rheumatologists. However, he found no objective clinical evidence to support physical limitations or restrictions, determining that the activity level required to practice medicine was consistent with sedentary to light-duty work. He noted that while the evaluations and diagnostic testing aligned with the plaintiff's diagnosis, there were no established treatment guidelines for relapsing polychondritis, and there was no indication of a significant change in the plaintiff's condition around the alleged disability date, aside from scleritis. Dr. Bello emphasized a lack of specific musculoskeletal findings during clinical evaluations, making it challenging to determine any major changes in the plaintiff's condition over the reviewed period. Subsequently, on October 17, 2014, the defendant denied the plaintiff's appeal, citing Dr. Bello's review and distinguishing it from the SSDI decision by arguing that the SSA did not include a physician's review and overlooked additional evidence post-October 31, 2013, which did not support disability claims. On November 19, 2014, further unspecified records were submitted to Dr. Bello, who reaffirmed his previous opinion in a brief addendum on December 5, 2014.
On December 22, 2014, Appeals Specialist Enberg informed Attorney Quiat that additional records had been sent to Dr. Bello, who maintained his previous opinion after reviewing them. The determination of Plaintiff's long-term disability claim hinged on the credibility of his subjective complaints, as assessed by Defendant and its medical consultants. A district court's evaluation of the credibility of such complaints is a factual determination reviewed for clear error, while the legal sufficiency of the complaints as evidence of disability is subject to de novo review.
The Court's analysis follows a two-step credibility assessment used in Social Security Disability Insurance (SSDI) cases. It concluded that Plaintiff demonstrated, by a preponderance of the evidence, a medically determinable impairment capable of causing the reported pain and fatigue. Medical reviewers for Defendant did not contest the validity of Plaintiff's diagnoses, and Dr. Bello confirmed the diagnosis of relapsing polychondritis based on medical records. The Social Security Administration (SSA) corroborated the severity of Plaintiff's symptoms through his application statements and medical documentation from Drs. Moreland and Orszulak.
None of the examining physicians accused Plaintiff of malingering or exaggerating symptoms. The Court criticized Defendant's efforts to undermine Plaintiff's credibility, particularly citing Dr. Schnars’ observations regarding the absence of documented fatigue during a 2014 evaluation by Dr. Stone. However, the Court found consistent complaints of fatigue and joint pain in Plaintiff's medical history. Moreover, the reliance of Plaintiff's physicians on his subjective complaints did not weaken their assessments of his functional limitations, as such reports are crucial for diagnosis. Finally, concerns raised by Defendant's consultants regarding the lack of aggressive treatment were deemed insufficient to question the credibility of Plaintiff's symptomatology.
The Court's analysis of the medical records indicates that a recommendation was primarily aimed at alleviating the Plaintiff's serious side effects from prednisone, including steroid-induced diabetes and mental health issues. Despite Dr. Schnars claiming that the Plaintiff was not on medication for chronic pain, nephrologist Dr. Wu's notes reveal occasional use of Celebrex, prescribed by rheumatologist Dr. Liu, who noted ongoing joint pain but chose not to increase the Celebrex dosage due to blood pressure concerns. Dr. Schnars and Dr. Bress questioned the severity of the Plaintiff's symptoms based on his low prednisone dosage; however, higher doses have been linked to severe side effects like depression and psychosis. The Plaintiff reported ongoing breakthrough pain while on prednisone.
The appeals process involved scrutiny of the Plaintiff's continued work after Dr. Moreland's completion of disability documentation, which was interpreted as evidence of non-disability. Dr. Schnars referenced a comment from a Hospital representative indicating that the disability onset was shortly after the Plaintiff's termination, which the Hospital attributed to billing performance issues. This aligns with the Plaintiff's claims of worsening pain and fatigue, prompting his decision to seek disability. The Plaintiff acknowledged understanding the Hospital's non-renewal of his contract and declined an independent contractor offer due to his inability to maintain practice.
Importantly, the Court noted that the Plaintiff's ongoing work despite chronic fatigue and pain should not be held against him. Legal precedents cited emphasize that disability claimants should not be penalized for attempting to live normally despite their limitations, and that continued work does not automatically negate a disability claim, as seen in various court rulings regarding disability evaluations under ERISA.
The presence of a disability claimant on the payroll after the alleged onset of disability does not determine their actual disability status during that period. Medical consultants for the defendant noted that the claimant's limited daily activities contradicted the level of pain and fatigue claimed, as well as opinions from Dr. Moreland. Specifically, Dr. Paty highlighted that the claimant's ability to engage in activities such as reading, using a computer, performing light household chores, and grocery shopping does not demonstrate the capacity to meet the demands of a hospital neurologist's job, especially under full-time and on-call conditions. Courts in this Circuit have established that daily living activities do not negate claims of pain or impairment unless they are sustained for periods comparable to full-time employment. Examples cited include cases where the Secretary could not prove that claimants could engage in sedentary work based solely on their occasional activities. The Court finds the claimant credible regarding the debilitating nature of his reported symptoms, particularly fatigue and pain. Under the de novo standard of review, as agreed by the parties, the claimant must prove, by a preponderance of evidence, that he meets the definition of disability under the applicable policy to qualify for benefits. The Court also notes that any objection to a magistrate judge's report would prompt a de novo review of those specific portions of the report by the presiding judge.
The district court is not obligated to follow a magistrate's recommendations, even if neither party objects, as clarified in Grassia v. Scully. A judge may accept, reject, or modify the magistrate's findings and can also consider additional evidence or send the matter back to the magistrate with instructions. The defendant raised several objections, including: 1) improper admission of evidence outside the administrative record without good cause; 2) errors in considering facts from other insurers' decisions not in the record for a future bench trial; 3) reliance on a claims manual not part of the administrative record; 4) the recommendation for a bench trial being unnecessary; and 5) the erroneous conclusion that Unum Group is the plan administrator.
Specifically regarding the admission of evidence, on January 5, 2016, Dr. Carette diagnosed the plaintiff with granulomatosis with polyangiitis. During a subsequent status conference, the plaintiff's counsel stated that no discovery beyond the Administrative Record was needed. However, in support of a summary judgment motion, the plaintiff sought to introduce Dr. Carette's Reassessment Summary, arguing it was relevant to proving total disability. The defendant contended that this summary was not part of the Administrative Record and that the plaintiff failed to demonstrate good cause for its inclusion. The R. R. stated that while the admission of additional evidence is discretionary, it should not occur without good cause, referencing DeFelice v. American Int'l Life Assurance Co. The R. R. concluded that good cause was established due to the objective nature of Dr. Carette's diagnosis. However, the plaintiff's counsel paradoxically acknowledged that the summary was not material to the issue of disability, indicating that the probative value of extra-record evidence does not determine good cause for augmenting the administrative record.
The Court does not consider Tritt v. Automatic Data Processing, Inc. controlling in this case, as Tritt addressed the weight of a retrospective diagnosis in an ERISA context. Similarly, Paese is distinguishable; in Paese, the district court admitted a report due to its high probative value and the disinterested nature of the author, who had examined Paese, with no fault on Paese's part for the report's absence. In contrast, the record in this case was created after the Administrative Record closed, although Plaintiff may not be at fault for the missing report. Dr. Carette's notes indicate that relevant information potentially leading to an earlier diagnosis of Granulomatosis with Polyangiitis (GPA) was overlooked by the treatment providers. Dr. Carette's diagnosis, based on a repeated ANCA test in June 2015, followed observations of previous positive results and the Plaintiff's medical history. However, as of June 30, 2015, Dr. Carette noted a lack of a clear diagnosis, and while Wegener's granulomatosis had been considered previously, the retrospective nature of Dr. Carette's diagnosis complicates its probative value regarding Plaintiff's disability status at the time of his benefits application. The Court concludes that Dr. Carette's Reassessment Summary does not meet the criteria for admissibility under Paese, as it lacks high probative value and was not included in the Administrative Record through no fault of the Plaintiff.
Regarding the admissibility of decisions from other insurers, the Court agrees with the R. R. that favorable claims decisions from The Hartford and MetLife are not binding in this case. While these decisions may be considered at trial, the Court finds Frischman inapplicable to this ERISA matter for several reasons.
Frischman establishes that a physician's medical reports regarding a claimant's disability can be considered by the Social Security Administration (SSA) but are not binding. In this case, the decisions from other insurers are absent from the Administrative Record, and the only evidence presented is the Plaintiff's claim of being quickly awarded benefits by The Hartford and MetLife. The Court determines it is unreasonable to interpret Frischman as implying that the decisions from these other insurers, which are based on different policies and definitions of disability, would influence the current determination of the claimant's disability under his specific policy.
The argument regarding the relevance of the Defendant's claims manual, which allegedly states that SSA decisions should be given significant weight, is also rejected. The Defendant objects to this argument, noting that the claims manual was not included in the Administrative Record and was mentioned for the first time in the Plaintiff's reply brief. The Court finds that the Disability Policy itself does not require significant weight be given to SSA decisions, contrary to the suggestion in the R. R. However, evidence exists in the Administrative Record from two employees indicating that the claims manual does mandate significant weight be given to SSA decisions.
The Court acknowledges that Appeals Specialist Enberg communicated the necessity of considering the SSA's decision if the rheumatologist's opinion did not support disability, further emphasizing the importance of the SSA's findings. Ultimately, the Court finds no error in the R. R.'s assessment regarding the SSA's decision and the corresponding weight it should be accorded under the claims manual relevant to the Plaintiff's Disability Policy, despite the Defendant's claim that the record lacks the information supporting the SSA's decision.
The Administrative Record contains the full SSA file, and the SSA's decision specifies which medical records were requested and considered. The recommendation for a plenary bench trial is moot as the parties have agreed to a trial "on the papers." The defendant contests the R. R's assertion regarding the identity of the claims administrator, stating that it misinterpreted facts by claiming all claims under the Disability Policy are managed by Unum Group without citation. The defendant clarifies that while Unum Group's employees administered the claim, it is unclear how this impacts the case's outcome given the undisputed standard of review. The court finds the objection moot.
Plaintiff objects to the R. R's finding that their doctors' opinions conflict with those of the defendant's medical professionals, arguing that the latter's opinions are irrelevant, do not counter their doctors' conclusions, and lack necessary objective medical evidence, which the policy does not require. Plaintiff emphasizes that their condition of fatigue cannot be proven objectively. The defendant, however, contends that the R. R correctly concluded that Plaintiff has not met the burden of proving disability under the policy, as the opinions from Plaintiff's doctors primarily reflect subjective complaints without objective testing to substantiate the extent of limitations.
Defendant contests Plaintiff's claim that objective medical evidence is unnecessary, citing the Policy's provision allowing for any proof deemed necessary to assess claims. However, the Court finds that Plaintiff has demonstrated entitlement to long-term disability benefits under the "Your Occupation" clause of the Disability Policy. The Court observes that Defendant imposed a requirement for objective proof not specified in the Policy. Under de novo review, the Court interprets plan provisions without deference to the claims administrator, applying the doctrine of contra proferentem to ambiguous language in ERISA contracts. The Court notes that Defendant, as the drafter, could have included an exception for claims based on self-reported symptoms but did not, thereby assuming the risk of covering claims for difficult-to-diagnose conditions. The Disability Policy's vague requirement for "any evidence" allows Defendant to interpret it as necessitating only objective proof, effectively excluding claimants with conditions primarily characterized by subjective symptoms. The Court rejects this interpretation, emphasizing ERISA’s intent to protect employee benefits.
Additionally, the Court points out that Defendant and its medical consultants arbitrarily overlooked Plaintiff's subjective complaints, underscoring that the subjective experience of pain is crucial in assessing disability. It references established case law affirming the importance of considering subjective symptoms, such as fatigue, which cannot be objectively quantified, and clarifies that such subjective experiences must not be dismissed in disability determinations.
Claimant alleged chronic fatigue syndrome (CFS), which lacks a known etiology, arguing that requiring clinical evidence as a condition for long-term disability (LTD) benefits undermines participant expectations. The district court, upon de novo review of an ERISA plan administrator's decision, is not obliged to accept subjective complaints as credible but cannot dismiss them as legally insufficient evidence of disability. The court previously found the plaintiff's subjective complaints credible and will assess the legal sufficiency of this evidence. In the Second Circuit, a claimant's subjective complaints, if believed, can establish disability. Prior case law supports that such complaints, along with testimony and medical reports, can constitute substantial evidence of pain and disability. The court noted that many medical conditions rely on patient-reported symptoms for diagnosis and cannot always be objectively verified.
The defendant, however, required objective proof, such as laboratory data, which is inappropriate given the nature of CFS. Medical reviewers for the defendant dismissed the plaintiff's complaints based on the absence of objective clinical findings, overlooking abnormal bone scans suggestive of polyarthralgia. They failed to specify the types of laboratory results expected for the plaintiff’s condition and did not provide authority supporting that expected clinical signs must always be present. The court highlighted that assessments based on a patient’s appearance are subjective and pointed out that no definitive tests measure fatigue. The defendant's medical reviewers' opinions were found to undermine the plaintiff's credibility without direct examination, and although plan administrators are not required to give special deference to treating physicians, they cannot arbitrarily disregard their opinions.
In Decker Disability Plan v. Nord, the court addressed the challenges in assessing a plaintiff's disability due to subjective symptoms like fatigue and pain, emphasizing that credibility determinations are crucial. The case highlighted a significant issue where the defendant, despite having the option for an in-person medical examination, relied solely on paper reviews, raising concerns about the thoroughness of their benefits determination. This aligns with previous rulings indicating that reliance on non-treating physicians for credibility assessments can result in arbitrary denials of benefits.
Furthermore, the defendant ignored critical evidence regarding the plaintiff's vocational capabilities. Although Dr. Moreland provided a form indicating the plaintiff's exertional limitations, the defendant's reviewers overlooked this information and focused instead on generalized critiques of Dr. Moreland's assessments. The vocational expert, VRC Gaughan, classified the plaintiff’s job as requiring "light" exertion, which conflicted with the defendant's assessment that did not adequately consider this classification. The Social Security Administration (SSA) had also determined the strength level of the plaintiff's previous position as "light," yet the defendant failed to acknowledge this decision, despite internal guidelines indicating that SSA determinations should carry significant weight. The defendant's justification for dismissing the SSA's findings was deemed unconvincing, revealing that the opinions of the defendant's medical reviewers did not constitute sufficient grounds to overlook the SSA's conclusions.
The Court determined that the Plaintiff has demonstrated, by a preponderance of the evidence, an inability to perform the essential duties of his role as a hospital neurologist due to sickness, qualifying him as disabled under the "Your Occupation" provision of the Disability Policy. The Court found that remanding the case for consideration of the "Any Occupation" claim was unnecessary, as the Plaintiff's failure to exhaust administrative remedies was not a jurisdictional issue but an affirmative defense, which the Defendant had waived. The recommendation was to dismiss the "Any Occupation" claim without prejudice, adhering to ERISA's preference for exhaustion. The Court, applying a de novo standard, noted that the existing Administrative Record had sufficient evidence, including an SSA disability finding, to support the Plaintiff’s claims, concluding that no new evidence could justify a denial. Therefore, the Court ruled that the Plaintiff is entitled to long-term disability benefits under both the "Your Occupation" and "Any Occupation" provisions of the Disability Policy, but it could not specify the benefit amount at this time. The parties are instructed to discuss the proposed judgment wording, attorney's fees under 29 U.S.C. § 1132(g)(1), and the applicable pre-judgment interest rate and start date.
The Court mandates that the parties must make reasonable efforts to resolve all remaining issues regarding a proposed judgment. If they cannot agree after a good faith attempt, each party may submit their proposed judgment along with a memorandum detailing their positions on the benefits, attorney's fees, and pre-judgment interest. The Court has partially accepted and partially rejected the R. R (Docket No. 33); granted Plaintiff's Motion for Summary Judgment (Docket No. 25); and denied Defendant's Motion for Judgment on the Administrative Record (Docket No. 23). Plaintiff is awarded long-term disability benefits under both "Your Occupation" and "Any Occupation" provisions of Disability Policy No. 06-6297809 from June 10, 2013, until his 67th birthday. The parties must report in writing within 20 days on their progress in agreeing on the amount of past-due benefits, entitlement to attorney's fees under 29 U.S.C. 1132(g)(1), and the amount and rate of pre-judgment interest. The Administrative Record, filed under seal, includes six PDF files with Bates number identifiers, some containing illegible notes from Dr. Toma. A letter from Dr. Toma indicates he ceased treating Plaintiff on December 4, 2008, due to conflicts. The Hospital terminated Plaintiff's employment on June 30, 2013, citing insufficient patient billing. There is a dispute regarding the timing of Dr. Moreland's diagnosis of Plaintiff's condition, but this is not material to the disability claim. Several treatment providers suggested immunosuppressants, and tests indicated inflammation associated with relapsing polychondritis.
Plaintiff informed Senior Disability Specialist Robinson that he avoids grocery shopping due to store size and prefers to shop at a gas station, relying heavily on his car to minimize walking. Under the SSA's Single Decision Maker (SDM) model, disability examiners can make initial determinations without a medical consultant's signature. There are no medical records from 2004 indicating that Plaintiff had an infection treated with prednisone; however, the reference may relate to his left eye episcleritis, which was treated with prednisone. In the Dictionary of Occupational Titles (DOT), a neurologist is classified under light exertional level jobs. In evaluating disability claims, the adjudicator must first determine if the claimant has a medically determinable impairment that could explain the alleged symptoms, then assess the intensity and persistence of these symptoms based on available evidence. If the claimant's pain claims lack objective medical support, the Administrative Law Judge (ALJ) must conduct a credibility inquiry. Celebrex (celecoxib) is identified as a non-steroidal anti-inflammatory medication used for managing pain and inflammation associated with osteoarthritis and rheumatoid arthritis.
