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Creech v. Deroyal Industries

August 20, 2008


The opinion of the court was delivered by: Leon Jordan United States District Judge


This civil action is brought pursuant to the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001, et seq. It is now before the court for consideration of plaintiff's motion for judgment [doc. 13] and the motion for judgment [doc. 11] filed by defendants DeRoyal Industries, Inc. ("DeRoyal") and the Prudential Insurance Company of America ("Prudential"). The parties have filed responses [docs. 15, 16], and the motions are ripe for the court's consideration. For the reasons stated herein, plaintiff's motion will be denied, defendants' motion will be granted, and this civil action will be dismissed.

I. Procedural Background

Prudential issued to DeRoyal an insurance plan (the "Plan" or "Policy") that provides short term ("STD") and long term ("LTD") disability benefits. [A.R. 004-017].*fn1 DeRoyal is the Plan administrator. [A.R. 071]. Prudential is the claims administrator. [A.R. 072]. In its initial phase, the Plan defines "disability" as: You are disabled when Prudential determines that: you are unable to perform the material and substantial duties of your regular occupation due to your sickness or injury; and you have a 20% or more loss in weekly earnings due to the same sickness or injury.

[A.R. 031] (emphasis in original).

Plaintiff worked at DeRoyal as a material handler from 1996 through 2004. He filed a claim for STD benefits on November 8, 2004, alleging that he could no longer work due to "hypogammaglobulinemia, inflammatory arthritis, recurrent pnuemonia [sic], asthma, [and] bronchitis." [A.R. 110-11].*fn2

After being diagnosed with hypogammaglobulinemia, plaintiff began receiving monthly gamma globulin infusions ("IVIG") in 2002. He contends that "[a]lthough [he] suffers from a number of maladies and injuries . . ., variable immune deficiency syndrome is the primary cause of his disability." [Doc. 14, p. 5]. Apparently, side effects of IVIG therapy include headaches and joint pain, and pain is a principal reason why plaintiff is purportedly unable to work. In addition, plaintiff claims to be "highly vulnerable to any exposure, however small, to a large number of environmental hazards." [Doc. 14, p. 4]. For example, he ultimately stopped working shortly after allegedly being "overcome by dust and bird droppings from material that was being cleaned by a fellow worker." [Doc. 14, p. 4].

Plaintiff received benefits from November through December 2004. [A.R. 076, 084]. By letter dated December 1, 2004, Prudential notified him that his STD payments would be discontinued. [A.R. 076].

Plaintiff submitted additional information, but Prudential denied his claim a second time by letter dated January 26, 2005. [A.R. 084]. Prudential again restated its decision via letter dated August 3, 2006. [A.R. 091]. Plaintiff filed an appeal with Prudential the following month. [A.R. 124]. Prudential then sought review of the medical record by "a physician who specializes in Allergy and Immunology . . . ." [A.R. 094]. Prudential informed plaintiff by letter dated December 12, 2006, that it was denying his appeal. [A.R. 096]. In sum, the letter advised,

Since Mr. Creech does not have a proven immune deficiency and has only mild asthma/Chronic Obstructive Pulmonary Disorder (COPD) in part due to cigarette smoking, there is no basis for any limitation from an allergy/immunology standpoint. Due to the lack of any proven allergic/immunology disorder, there is no evidence of functional impairment from an allergic/immunologic standpoint.

[A.R. 098].

Plaintiff submitted a second appeal to Prudential on December 28, 2006. [A.R. 129]. In part, plaintiff's counsel advised that he was enclosing "a notice of decision fully favorable from the Social Security Administration ["SSA"], wherein the Administrative Law Judge . . . found that because Mr. Creech's immune system is so severe, he is unable to perform any work existing in significant numbers in the national economy." [A.R. 129]. By letter dated February 16, 2007, Prudential informed plaintiff's counsel,

We are unable to make an appeal determination on Mr. Creech's claim at this time because you have not yet provided important information concerning his claim. As of the date of this letter, we have not received the detailed letter regarding the Social Security Disability Benefits (SSDB) determination from the Social Security Administration, specifically from the Administrative Law Judge (ALJ). In addition, please provide any documentation supporting the ALJ decision. [A.R. 103]. Plaintiff's counsel responded by letter on February 27, 2007, again enclosing the abbreviated SSA "notice of decision," which counsel termed "a detailed letter regarding the social security disability benefits determination . . . ." [A.R. 131]. By follow-up letter dated March 14, 2007, plaintiff's counsel wrote,

The enclosed decision from the Social Security Administration, which is the short form decision, is the only decision that is available. However, in further support of Mr. Creech's claim, we are enclosing for your information and review a copy of the entire Social Security Administration file . . . . [A.R. 133] (emphasis added).

Following review by in-house Medical Director Dr. John LoCascio, Prudential again affirmed its decision by letter dated April 30, 2007. [A.R. 104]. Plaintiff then filed the present lawsuit on June 8, 2007.

II. Standard of Review

In Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989), the United States Supreme Court held that "a denial of benefits challenged under ยง 1132(a)(1)(B) is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Id. at 115. If a plan grants the administrator or fiduciary the appropriate discretionary authority, this court must instead review the decision at issue under the "highly deferential arbitrary and capricious standard of review . . . ." Yeager v. Reliance Standard Life Ins. Co., 88 F.3d 376, 380 (6th ...

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