Opinion
Civil Action No. SA-04-CA-0883-XR.
December 14, 2005
ORDER
On this date, the Court considered Defendant SBC Disability Income Plan's ("the Plan") Motion for Summary Judgment, filed September 30, 2005. Plaintiff contends she was wrongly denied disability benefits by the Plan. Plaintiff argues it was an abuse of discretion to deny her benefits. The Plan argues Plaintiff failed to timely submit required medical records and the medical records ultimately submitted did not support a finding of total disability. After reviewing the record and the determination by the Plan, the Court finds there was no abuse of discretion. The Plan's motion for summary judgment (docket no. 28) is GRANTED.
I. Factual and Procedural Background
SBC Communications Inc. provides its employees with a disability income plan administered under the provisions of the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132. At all times relevant to this lawsuit, SBC Communications Inc. contracted with CORE, Inc., an independent third party administrator, to administer disability claims under the Plan. Because the Plan is self-insured, CORE played no role in funding the payment of disability claims. CORE was responsible for processing disability claims, reviewing medical records, and ultimately recommending acceptance or denial of disability benefits claims. The Plan had no authority to override CORE's disability determinations.
Although initially a party defendant in this suit, CORE was dismissed by this Court's order dated September 8, 2005. See docket no. 26.
Plaintiff worked as an operator for Southwestern Bell Telephone Company for approximately nineteen (19) years before applying for disability benefits. On an unspecified date in August/September 1998, Plaintiff applied for short-term disability ("STD") benefits, claiming that she could no longer perform her essential job functions because of depression. Plaintiff's last day of work appears to have been August 15, 1998. Although the Plan authorized the commencement of benefits to automatically begin eight days after Plaintiff's last day of work, Plaintiff began to receive STD benefits as of September 15, 1998. Based on her years of service, Plaintiff was eligible to receive STD benefits at full pay for twenty-six (26) weeks and at sixty percent (60%) pay for twenty-six (26) weeks as long as her application was approved under the Plan. Plaintiff was initially authorized to receive STD benefits from September 15, 1998 through October 12, 1998. The Plan conditioned continued payment of STD benefits on, among other things, Plaintiff providing timely medical information regarding her condition.
Plaintiff was evaluated by various psychiatrists/psychologists in late 1998. At least one doctor diagnosed Plaintiff with major depression and generalized anxiety disorder. Plaintiff's treatment regime consisted of weekly therapy sessions and medication. It was initially expected that her condition would keep Plaintiff out of work for three months. Based on the medical information Plaintiff submitted, CORE recertified her STD benefits for October 13 through November 7, 1998 and November 8 through December 8, 1998.
On December 9, 1998, Plaintiff contacted CORE requesting an extension in her STD benefits. Plaintiff informed CORE that on December 1, 1998 she had an appointment with Dr. Brad Burdin, a chiropractor. Plaintiff stated Dr. Burdin was the doctor that was taking her out of work at this time. In a narrative report dated December 1, 1998, Dr. Burdin diagnosed Plaintiff with cervical strain, cubital tunnel, carpal tunnel, pronator syndrome, myofascitis, migraine headaches and a depressed state. Dr. Burdin indicated Plaintiff was unable to work as a result of tissue damage that is causally related to her work activities. CORE estimated Plaintiff's length of disability would be three to six months.
Although Plaintiff's last day of work was August 15, 1998, with STD benefits beginning as of September 15, 1998 for her depression, the record indicates Plaintiff agreed in February, 2001 that the only compensable worker's compensation injury she suffered occurred on December 1, 1998. See Mot., at Ex. F (SBC 334-35) ("Parties agree that the date of injury is 12/1/98. . . . Parties also agree there was no compensable injury on 8/15/98."). Plaintiff's depression was apparently not a compensable injury for purposes of worker's compensation.
Based upon Plaintiff's chiropractic and psychological treatment, CORE extended Plaintiff's eligibility for STD benefits through April 16, 1999. On April 27, 1999, Dr. Burdin informed CORE that he expected Plaintiff to remain off work another thirty to sixty days based on a pain management specialist recommending her for trigger point epidural injections. Dr. Burdin, however, failed to provide medical documentation supporting an extension of Plaintiff's case. CORE attempted to contact Dr. Burdin on three separate occasions to obtain the necessary medical documentation.
The record is not entirely clear regarding the length of Plaintiff's treatment for depression. It appears she attended her last therapy session on February 24, 1999. The record also included an undated report by Dr. Lin Sutton reflecting Plaintiff suffered from a moderate to severe level of depression. Dr. Burdin's notes during 2000 indicate he believed Plaintiff need to be psychologically evaluated.
A May 3, 1999 notepad entry provides: "MD — 40 [year old employee] with depression, cervical disc, carpal tunnel syndrome for ongoing disability — [left message] with Leah for [Dr. Burdin to call back]. Mot., at Ex. D (SBC 101). Dr. Burdin did not contact CORE. On May 17, 1999, Plaintiff was denied STD benefits, effective April 17, 1999, for lack of clinical information. CORE mailed a STD benefits denial letter to Plaintiff on April 18, 1999.
On June 29, 1999, Plaintiff contacted CORE requesting an explanation for why her STD benefits were denied. On the next day, Dr. Burdin contacted CORE and explained Plaintiff's condition. Dr. Burdin felt Plaintiff was totally disabled from any occupation until at least August 1, 1999. Based upon Dr. Burdin's diagnosis, Plaintiff's STD benefits were re-certified from April 17, 1999 through July 31, 1999. Plaintiff was scheduled to return to work on August 1, 1999.
Plaintiff did not return to work on August 1. On August 6, 1999, CORE contacted Dr. Burdin regarding Plaintiff's status. CORE learned Plaintiff's last office visit had been July 15, 1999. Subsequently, Plaintiff informed CORE that she had an appointment with Dr. Burdin on August 9, 1999. Between August 16 and 18, CORE contacted Dr. Burdin's office on three separate occasions to obtain additional medical information necessary to extend Plaintiff's STD benefits and evaluate her potential long-term disability ("LTD") benefits. Dr. Burdin was not forthcoming with the medical information.
Despite not receiving the medical information necessary to extend Plaintiff's STD benefits, CORE began the process of evaluating her for LTD benefits. See Mot., at Ex. C (2-A-O) ("New episode opened for potential LTD. . . . Will need [follow up] when additional days approved on STD claim."). On August 25, 1999, CORE advisor #448 conducted a vocational review and noted Plaintiff's permanent work restrictions were pending. "Upon receipt of permanent restrictions, I will initiate the internal job search [at] SBC. Will also address the A/O employability issue for LTD determination." On August 26, 1999, the SBC Pension Plan mailed Plaintiff a letter regarding her "upcoming disability retirement." The letter informed Plaintiff that her disability benefit commencement date was September 15, 1999, i.e. the day after her 52-week period of STD benefits would have expired.
"An employee who meets the eligibility requirements for LTD benefits under the SBC Disability Income Plan may also be entitled to a pension benefit under the SBC Pension Benefit Plan. . . . As a practical matter, the Pension plan administrators rely upon the determination by the Disability Plan Administrator in determining whether a participant is disabled." Christine Holland Aff., at ¶ 4.
After not receiving the medical information from Dr. Burdin, CORE attempted to contact Plaintiff. Similar to Dr. Burdin, Plaintiff did not respond. On September 20, 1999, CORE denied Plaintiff's claim for STD benefits due to lack of clinical information, effective August 1, 1999. On September 21, 1999, the Claims Manager mailed a STD benefits denial letter to Plaintiff. Because Plaintiff received STD benefits for a period less than 52 weeks (September 15, 1998 — August 1, 1999), she was not eligible to receive LTD benefits. The Plan provided a sixty-day deadline for appealing an adverse benefit determination. Plaintiff did not file a timely appeal.
Plaintiff claims she never received the September 21, 1999 denial letter. She also asserts CORE's failure to mail the letter is evidenced by a backdated notepad entry from April, 2000 regarding mailing the letter. A separate notepad entry dated September 21, 1999 provides "mailed a denial [letter] #1 to [employee]." Mot., at Ex. C.
Plaintiff contacted CORE on January 5, 2000 requesting information regarding her disability benefits. She was advised that she was not eligible for benefits because CORE never received the necessary medical information to extend her STD benefits. Plaintiff was also told to have Dr. Burdin contact CORE if it was his intention to extend her disability. CORE did not receive any information from Dr. Burdin.
On April 5, 2000, Plaintiff again contacted CORE requesting an explanation for why her STD benefits had been denied. Although Plaintiff initially claimed she did not receive the September 21, 1999 denial letter, she also asserted that she did not file a timely appeal because "she was trying to get well."
On July 17, 2000, Plaintiff requested CORE reconsider the denial of her benefits claim. She was again advised that Dr. Burdin had failed to respond with the necessary clinical information to extend her case. CORE finally received medical documentation from Dr. Burdin on August 17, 2000. These medical reports and records, included Dr. Burdin's typed notes from various treatment sessions, an August, 1999 letter from Dr. Burdin indicating Plaintiff had reached maximum medical improvement with a 9% impairment rating, reports by Dr. Anjali Jain, a chronic pain specialist, and a July 25, 2000 cervical spine MRI report. Dr. Jain's reports included a nerve conduction study (EMG) dated June 23, 2000, which revealed that despite Plaintiff's subjective complaints of pain the EMG revealed no specific radicular findings. The MRI report indicated Plaintiff suffered from a C5-6 disc herniation with mild cord compression. A CORE nurse reviewed the information on August 22 and noted "the appeal time frame has expired, clinical was dated from a different time period and does not apply, this case remains in denial." The record is not entirely clear at this point, but it appears Plaintiff learned of CORE's decision to uphold her denial of STD benefits by telephone.
It is unclear when CORE received notification of Dr. Burdin's determination that Plaintiff reached maximum medical improvement in August, 1999. In the entire administrative record, Dr. Burdin's August, 1999 impairment rating letter is the only medical information related to the relevant time period for which Plaintiff was requesting her STD benefits be extended, i.e. August 1, 1999 through September 14, 1999.
On October 3, 2000, Plaintiff filed identical, simultaneous written appeals with CORE and the SBC Pension Plan. The only new medical information Plaintiff attached to her appeals was an undated report by Dr. Lin Sutton that indicated she suffered from moderate to severe depression and was a candidate for chronic pain management therapy. By letter dated October 18, 2000, CORE again upheld the denial of disability benefits. Plaintiff was informed her time for appeal had expired and the decision was final. The SBC Pension Plan subsequently denied Plaintiff's appeal on January 17, 2001 because CORE had determined her to not be totally disabled.
On March 14, 2001, Plaintiff appealed the SBC Pension Plan's denial of her claim. Plaintiff requested her case be reviewed by the SBC Benefit Plan Committee. Plaintiff attached hundreds of pages of medical reports and records, however, the only new medical information was an October 19, 2000 report by Dr. Dennis Vollmer, which further described Plaintiff's July 25, 2000 cervical spine MRI. Prior to reviewing her case, the Benefit Plan Committee requested an explanation Plaintiff's one-year delay in appealing CORE's September 21, 1999 denial. Plaintiff responded that no supporting information for her cervical injury was available until the July 25, 2000 MRI was taken. Because the SBC Pension Plan's disability benefits are dependent on the Plan administrator finding the employee to be totally disabled, the information Plaintiff submitted was forwarded to CORE for further consideration.
Plaintiff also claimed the SBC Pension Plan's August 26, 1999 letter regarding her disability retirement led her to believe she did not need to appeal the September 21, 1999 denial. Contrary to her previous assertions, Plaintiff did not claim she never received the September 21 denial letter.
Following receipt of Plaintiff's medical documentation, CORE submitted her claim to CORE PA/MD #501 for independent review. CORE PA/MD #501 noted that SBC received additional medical reports and records from Plaintiff on March 14, 2001. Though no report of PA/MD #501 had been furnished to the Court, CORE's July 2, 2001 notepad entry provides #501 concluded that Plaintiff's medical documentation did not warrant overturning the September 21, 1999 denial of STD benefits. #501 also determined Plaintiff's medical information failed to establish that she was "unable to perform her essential job functions of the job of operator at SBC." Plaintiff's appeal was denied by CORE on August 22, 2001. Subsequent to CORE's denial, the SBC Pension Plan denied Plaintiff's appeal on September 20, 2001.
CORE's July 2, 2001 notepad entry indicates Plaintiff submitted the information on June 14, 2001. The Court assumes this is a typographical error and #501 was actually referring to the information Plaintiff attached to her March 14, 2001 appeal letter. The record includes no other indication that Plaintiff submitted medical reports and records on June 14, 2001.
Plaintiff filed the current federal action under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132, on September 30, 2004. The Plan now moves for summary judgment arguing there is sufficient evidence in the record to hold that it did not abuse its discretion and Plaintiff is not entitled to STD or LTD benefits.
The Plan also asserts Plaintiff's claims are barred by the statute of limitations. As previously discussed in footnote 5, Plaintiff disputes when she received CORE's September 21, 1999 denial letter. As such, genuine issues of material fact exist as to when Plaintiff received notice of CORE's denial.
II. Standard of Review
Summary judgment is proper "if the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to material fact and that the moving party is entitled to judgment as a matter of law." FED. R. CIV. P. 56(c). The moving party has the burden of showing that there is no genuine issue as to a material fact and that the moving party is entitled to judgment as a matter of law. Willis v. Roche Biomedical Lab., Inc., 61 F.3d 313, 315 (5th Cir. 1995). Once the movant carries its initial burden, the burden shifts to the nonmovant to show that summary judgment is inappropriate. Fields v. City of S. Houston, 922 F.2d 1183, 1187 (5th Cir. 1991). All justifiable inferences to be drawn from the underlying facts must be viewed in the light most favorable to the party opposing the motion. Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 587 (1986). In making this determination, the court will review the evidence in the record and disregard the evidence favorable to the moving party that the jury is not required to believe. Reeves v. Sanderson Plumbing Prods., Inc., 530 U.S. 133, 135 (2000). In order for a court to conclude that there are no genuine issues of material fact, the court must be satisfied that no reasonable trier of fact could have found for the nonmovant, or, in other words, that the evidence favoring the nonmovant is insufficient to enable a reasonable jury to return a verdict for the nonmovant. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 250 n. 4 (1986). If the record, viewed in this light, could not lead a rational trier of fact to find for the party opposing the motion, summary judgment is proper."[F]or factual determinations under ERISA plans, the abuse of discretion standard of review is the appropriate standard," even if the Plan does not expressly give the administrator discretionary authority. Vercher v. Alexander Alexander, Inc., 379 F.3d 222, 226 (5th Cir. 2004). "In applying the abuse of discretion standard, the Court analyzes whether the plan administrator acted arbitrarily or capriciously." Meditrust Fin. Servs. Corp. v. Sterling Chems., Inc., 168 F.3d 211, 214 (5th Cir. 1999) (quotation omitted). If the administrator's decision is supported by substantial evidence, the Court must affirm the decision. Id. at 215; Vega v. Nat'l Life Ins. Servs., Inc., 188 F.3d 287, 299 (5th Cir. 1999) ("[T]he administrator's decision [must] be based on evidence, even if disputable, that clearly supports the basis for its denial."). A decision is arbitrary only if "made without a rational connection between the known facts and the decision or between the found fact and the evidence." Meditrust, 168 F.3d at 215 (quotation omitted).
Plaintiff attempts to argue that a less deferential abuse of discretion standard should be applied to the Plan administrator's decision. Plaintiff's contention that because SBC Communications, Inc. funds the SBC Disability Income Plan there is an inherent conflict of interest is in error. CORE, Inc., is an independent administrator hired as a third-party vendor. A conflict arises in this context only, however, where the party making the benefit determination also insures or funds the program. Vega v. Nat'l Life Ins. Servs., 188 F.3d 287, 295 (5th Cir. 1999). Because SBC Communications, Inc. has no role in CORE's benefit determination analysis, there is no evidence supporting the contention of a conflict of interest. As such, the typical abuse of discretion standard applies to the determination of Plaintiff's claim.
The Court is constrained to the evidence before the Plan administrator. Vega, 188 F.3d at 299 (citations omitted). The record must contain all information submitted to the administrator prior to the filing of the instant lawsuit which was provided in a manner that gave the administrator a fair opportunity to consider it. Id. at 300.
Plaintiff's counsel submitted additional medical evidence to CORE's successor and the SBC Pension Plan in July and August, 2004, respectively. Each entity returned the records after refusing to review them. Waiting three years to provide medical information did not provide the administrator with a fair opportunity to consider it. See Vega, 188 F.3d at 300. The administrator's refusal to review the submitted records was not an abuse of discretion.
III. Objections to Summary Judgment Evidence
Both Plaintiff and Defendant objected to certain evidence submitted in connection with the motion for summary judgment and response thereto. Defendant's numerous objections to evidence attached to Plaintiff's response are overruled. The evidence Plaintiff attached, while outside the administrative record, is relevant to her claims and will be considered by the Court.
Plaintiff's objection to Defendant's summary judgment evidence is more substantive. CORE's July 2, 2001 notepad entry by #448 includes a review of Plaintiff's medical evidence by PA/MD #501. Plaintiff objects to #501's review as hearsay. All of CORE's notepad entries are offered under a business record affidavit of Donna L. Karkos, a CORE Senior Paralegal. See Fed.R.Evid. 803(6) 902(11). Plaintiff does not object to the business record affidavit. As such, CORE's notepad entries, including the July 2, 2001 entry, are admissible as CORE's business records. See id.
To the extent Plaintiff is making a "hearsay within hearsay" objection pursuant to Federal Rule of Evidence 805, that objection is also overruled. "Double hearsay in the context of a business record exists when the record is prepared by an employee with information supplied by another person. If both the source and the recorder of the information, as well as every other participant in the chain producing the record, are acting in the regular course of business, the multiple hearsay is excused by [Federal Rule of Evidence] 803(6)." Wilson v. Zapata Off-Shore Co., 939 F.2d 260, 271 (5th Cir. 1991). Here, the statements at issue are made by CORE PA/MD #501 to CORE #448. Because the source (PA/MD #501) and the recorder (CORE #448) are both CORE employees and were acting within the regular course of business, CORE PA/MD #501's review is admissible under Rule 803(6). Plaintiff's hearsay objection is overruled.
Because the Court has found #501's statements are admissible under the hearsay exception of Rule 803(6), the applicability of Pierre v. Connecticut General Life Insurance Co., 932 F.2d 1552 (5th Cir. 1991), need not be addressed. In Pierre, the Fifth Circuit discussed the weight to be given to hearsay statements for which no exception applied. 932 F.2d at 1562 ("On review, however, we can require that the hearsay meet certain indicia of reliability; if it does not, the abuse of discretion standard permits the court to reject the finding.").
IV. Analysis
Under the highly deferential abuse of discretion standard, the Court finds that the Plan administrator did not abuse its discretion in denying Plaintiff's claim for STD benefits. Glaringly absent from Plaintiff's thirty page response, however, is any reference to reports and records from her treating physicians substantiating her claim of total disability. Rather, Plaintiff spends an inordinate amount of time attacking CORE's procedures for reviewing disability claims.Though Plaintiff clearly has evidence (although she fails to direct it to the Court's attention) that indicates some level of disability, there is strong evidence in the record supporting the administrator's decision. As of September 21, 1999, Plaintiff had failed to submit medical information necessary to extend her STD benefits claim beyond July 31, 1999. Plaintiff's failure to comply with the Plan's terms entitled the administrator to deny her claim. It cannot be said that there was no rationale connection between the facts and determination.
As Plaintiff's claim progressed through its first appeal process, the administrator received medical records purportedly in support of the disability claim. The information supplied by Dr. Burdin in August, 2000 and Plaintiff in October, 2000 was collected by the administrator and reviewed by a nurse. The nurse noted that the information was submitted outside the sixty-day appeal deadline and was dated from a time period not relevant for determining whether Plaintiff's STD benefits should be extended beyond July 31, 1999. The administrator's October 18, 2000 denial was not an abuse of discretion.
Plaintiff, unsatisfied with the administrator's decision, filed a second appeal with the SBC Pension Plan in March, 2001. She supported her appeal with hundreds of pages of medical records and reports. Because the pension plan's disability benefits were dependent upon the administrator's determination of total disability, Plaintiff's medical information was eventually forwarded to CORE for another review. The administrator collected the information and had it reviewed by CORE PA/MD #501.
Plaintiff vehemently takes issue with the legitimacy of #501's review. Plaintiff claims #501 was nothing more than a "physician's assistant," whose opinion should be discredited. While the record initially describes #501 as "PA/MD #501," the July 18, 2001 notepad entry provides that Plaintiff's case was reviewed by " CORE MD #501." The Court is satisfied that reading the record as a whole, and resolving all reasonable inferences in favor of Plaintiff, reveals #501 was a medical doctor.
Plaintiff further argues that #501's review cannot be credited because he/she is not identified as a specialist in the fields of chronic pain, neck injuries, or carpal tunnel syndrome, unlike Plaintiff's treating physicians. Although Plaintiff fails to provide authority for her position, the Court assumes she is referring to 29 C.F.R. § 2560.503-1(h)(3)(iii) which requires that in an appeal of an adverse benefit determination based upon a medical judgment, the administrator is required to consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical treatment. This regulation is not so hyper-technical, however, that it requires a medical diagnosis by a chronic pain, neck injury, or carpal tunnel specialist to be reviewed by another equally credentialed specialist. The review by #501 was sufficient to base the denial of benefits upon. In any event, procedural violations of ERISA do not entitle the plan beneficiary to a substantive remedy of an award of benefits. See Duncan v. Assisted Living Concepts, Inc., No. 03-1931N, 2005 WL 331116, at *4 (N.D. Tex. Feb.10, 2002).
Similarly, Plaintiff's argument that the administrator's practice of identifying its reviewers by numbers and acronyms was an abuse of discretion fails. The administrator's failure to identify reviewers by name is at most a procedural violation of ERISA which does not entitle Plaintiff to an award of benefits. See id.
Even if the Court were to accept Plaintiff's argument that #501 is a "physician's assistant", the administrator's denial was not an abuse of discretion. Plaintiff fails to recognize that this is not a case involving an administrator's denial of disability benefits by discrediting or ignoring the findings of the claimant's treating physicians. #501's findings exactly track (and, in fact, quote from) those of the doctors who performed and/or interpreted Plaintiff's nerve conduction study and cervical spine MRI. Anjali Jain, MD, noted that the "[p]atient continues to have pain in the neck as well as the upper extremity; however, I did not find any specific radicular findings in the EMG." #501 also noted the cervical spine MRI, dated July 25, 2000, as interpreted by E. Dennis Harris, M.D., indicated "[a] large C5-6 posterior disc herniation causing mild central compression of the cord." #501 proceeded to heavily rely on Dr. Dennis Vollmer's detailed interpretation of the MRI report, which noted that "[t]he cord had no signal change within it, and the remainder of the cervical spinal canal appears normal. . . . She does not at this time have evidence of myelopathy or frank radiculapathy," and "surgery was probably not indicated. . . ." Dr. Vollmer also indicated Plaintiff was benefitting from her current non-surgical treatment regime. In sum, #501 reviewed all of the medical information that was before the administrator and came to the objective conclusion that Plaintiff was not disabled so that she could not perform the functions of her job as an operator. The administrator was permitted to rely on this determination, especially in light of Plaintiff's treating physicians never providing a disability determination or work restrictions after the denial of benefits in July, 1999. See Black Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003) ("[C]ourts have no warrant to require administrators automatically to accord special weight to the opinions of a claimant's physician; nor may courts impose on plan administrators a discrete burden of explanation when they credit reliable evidence that conflicts with a treating physician's evaluation."); Sweatman v. Commercial Union Ins. Co., 39 F.3d 594, 601-02 (5th Cir. 1994) (upholding denial of benefits based on an independent review of the claimants' medical records); Donato v. Metropolitan Life Ins. Co., 19 F.3d 375, 380 (7th Cir. 1994) (holding that MetLife's denial of benefits was not an abuse of discretion when the "decision simply came down to a permissible choice between the position of UMAC, MetLife's independent medical consultant, and the position of [the claimant's physicians]."). Nothing in the record indicates that any of Plaintiff's evidence, including the opinions of her treating physicians, has been ignored. Nord, 538 U.S. at 834. The fact remains that Plaintiff's treating physicians simply failed to bring to the attention of the administrator that Plaintiff was totally disabled. The evidence before the administrator is sufficient to find that there was no abuse of discretion in denying Plaintiff's claim in 1999.
In Gellerman v. Jefferson Pilot Financial Insurance Co., the court determined that "the level of deference due nurses should generally be less than that extended to doctors whose professions concentrate in the relevant field. That is not to say that an administrator automatically abuses its discretion if it relies on a nurse, but rather that when an administrator relies on nurses to override highly trained physicians, the court should decrease the level of deference afforded the administrator." 376 F. Supp. 2d 724 (S.D. Tex. 2005). As such, the administrator's reliance on #501's review, whether he/she was a medical doctor or physician's assistant, is not determinative because #501 did not overrule the disability determinations of Plaintiff's treating physicians.
Plaintiff's argument that the administrator ignored her physical injuries and only considered her depression in evaluating her claim for STD benefits is without merit. The administrative record is replete with medical records and reports focusing solely on Plaintiff's physical injuries. #501's review of Plaintiff's medical documentation clearly demonstrates that the administrator fully considered her physical injuries.
Plaintiff's final argument centers on the administrative record not containing a description of Plaintiff's job duties as an operator. Plaintiff claims that without having such a description the administrator necessarily abused its discretion in denying benefits because it could not determine whether Plaintiff was unable to perform her job functions. While the lack of a job description raises questions, the record does describe plaintiff's job as a sedentary position and the fact remains that Plaintiff failed to submit medical evidence demonstrating total disability after July 31, 1999. Under the facts of this case, the Court concludes the failure to include Plaintiff's job description was not an abuse of discretion.
Even if the Court concluded that the lack of a job description was an abuse of discretion, an award of LTD benefits would not be warranted. Whether a claimant can perform her specific job functions is a determination relevant solely to STD benefits. After the 52-week STD benefits period expires, the claimant must produce medical evidence demonstrating she is totally disabled from any occupation to qualify for LTD benefits. Because Plaintiff did not produce such evidence, the lack of Plaintiff's job description is inapposite.
Contrary to Plaintiff's assertions, the Court finds Gambino v. Liberty Life Assurance Company of Boston, 2005 U.S. Dist. LEXIS 28116 (D.N.J. Nov. 16, 2005) to be factually distinguishable. In Gambino, the court found an administrator could not conclude that the plaintiff was unable to perform his job duties as a sales account manager without obtaining a job duty description. Id. at *22-3. The administrator acknowledged that it had no knowledge of a sales account manager's duties at the time it denied the plaintiff's STD benefits. Id, at *23. Here, the administrator's August 25, 1999 vocational review of Plaintiff's case clearly indicates the administrator was aware that Plaintiff's job as an operator was a light duty, sedentary clerical position. Mot., at Ex. C (2-A-O) ("Assessment: This [employee's] job is sedentary. [Employee] has transferable skills suitable for other clerical sedentary [occupations]. . . . Upon receipt of permanent restrictions, I will initiate the internal job search [at] SBC."). Therefore, Plaintiff's argument that it was an abuse of discretion for the administrator to denial her STD benefits without a job description is without merit.
Plaintiff's motion for leave to file a sur-reply to Defendant's reply to Plaintiff's response to Defendant's motion for summary judgment is GRANTED (docket no. 37). The Court ORDERS the Clerk of Court to file Plaintiff's sur-reply as of the date it was received by this Court on December 14, 2005.
Thus, the decision to deny Plaintiff's STD benefits claim was not an abuse of discretion.
V. Conclusion
There was clear evidence in the record to support the administrator's decision to deny Plaintiff's claim for STD benefits. Though evidence in the administrative record supports the fact that Plaintiff suffers from some level of disability, there is no evidence to support a finding that the denial of STD benefits under the Plan was an abuse of discretion. The analysis does not focus on the Plaintiff's, or the Court's, subjective beliefs. The focus is solely on whether the decision of the administrator was arbitrary and capricious, that is whether there was a rational connection between the known facts and the decision. The Court finds that there was such a rational connection. The medical documents, including the reports of Drs. Burdin, Jain, Harris, and Vollmer were noted and credited throughout the process. These reports were noted by #501 in his/her findings. In fact, #501 apparently relied almost solely on these reports, as #501 did not examine Plaintiff and did not independently examine the MRIs of Plaintiff's cervical spine. The administrator was acting within its discretion to credit #501's reports over Plaintiff's complaints in denying Plaintiff's claim on August 21, 2001. The Court finds that the decision to deny STD benefits to Plaintiff was not an abuse of discretion. Because entitlement to LTD benefits is dependent upon entitlement to STD benefits, Plaintiff's claim for LTD benefits is disposed of by the adverse determination. The Plan's motion for summary judgment is GRANTED (docket no. 28).
The Clerk of the Court is directed to enter judgment in favor of Defendant.