United States District Court, E.D. Tennessee, Chattanooga Division
CURTIS L. COLLIER, District Judge.
Before the Court is Plaintiff Brenda Holt's ("Holt") motion for judgment on the record in this case brought under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. §§ 1001 et seq. (Court File No. 15). Defendant Life Insurance Company of North America ("LINA") responded (Court File No. 17) and Holt replied (Court File No. 19). Related to the motion for judgment on the record, LINA moved to strike the Social Security Disability Insurance decision offered by Holt and any references to it (Court File No. 16). Holt responded in opposition (Court File No. 20) and LINA replied (Court File No. 21). The Court heard oral arguments from the parties. For the following reasons, the Court will GRANT IN PART and DENY IN PART Holt's motion and will REMAND this matter to LINA for reconsideration of Holt's disability claim.
Holt, a 64-year-old former project administrator for Bechtel Corporation, was covered by that company's long-term disability plan (the "Plan"). Holt claims she is disabled under the Plan because of fibromyalgia and related symptoms. She stopped working in January 2011 because of these problems and filed for short-term disability ("STD"), complaining of joint pain and problems thinking and sleeping (Court File No. 17-1, Administrative Record ("AR"), p. 153). LINA denied the STD claim in February 2011, noting that available medical information did not show she was unable to perform her regular occupation because of fibromyalgia symptoms (AR, p. 255). In June 2011 LINA upheld the decision on appeal (AR, p. 246).
Holt then applied for long-term disability ("LTD"), which LINA granted (AR, p. 217). The nurse case manager noted that it would be reasonable to allow additional time for treatment and recovery ( id. ). LINA continued to review Holt's claim and later terminated her LTD benefits beyond July 12, 2012, for lack of an impairment that prohibited her from performing her occupation (AR, p. 187). LINA affirmed the denial, after which Holt filed the instant suit for wrongful denial of LTD benefits.
Under the Plan, a claimant is initially considered disabled if solely because of injury or sickness she is (1) "[u]nable to perform all the material duties of his or her Regular Occupation or a Qualified Alternative" or (2) "[u]nable to earn 80% or more of his or her Indexed Covered Earnings" (AR 789). After receiving benefits for 24 months, a claimant is consider disabled if solely because of injury or sickness she is "[u]nable to perform all the material duties of any occupation for which he or she is, or may reasonably become, qualified based on education, training or experience, " or (2) "[u]nable to earn 80% or more of his or her Indexed Covered Earnings." Id. The policy gives LINA the right to obtain a physical examination by an independent physician or a functional capacity evaluation "as often as it may reasonably require" (AR, p. 807). It also allows LINA to require a claimant to pursue Social Security Disability Insurance benefits. The parties agree that, pursuant to the Plan, the arbitrary and capricious standard applies to LINA's decision to terminate Holt's benefits.
B. Medical History and Disability Determinations
Before her STD claim was denied, Holt's primary care physician, Dr. Cecil Breetzke ("Breetzke"), provided her with a note excusing her from work from January 26, 2011, to April 25, 2011, based on her general tenderness to touch; sleep and memory problems; and irritability (AR, p. 381). Rheumatologist Indra Shah saw Holt a number of times in early 2011 and concluded she suffered from (1) "polyarthralgia/fibromyalgia, " (2) "[a]dhesive capsulitis of both shoulders, " (3) "somewhat limited movement along the hips, " (4) "[o]steoarthritis of the hands and the feet, " and (5) "[h]istory of carpal tunnel syndrome" (AR, p. 453).
After LINA denied her STD claim, Dr. Breetzke indicated that Holt could return to work on June 16, 2011, but Holt maintains that she never returned to work and notes that there is no evidence in the record that she did (AR, pp. 370, 631). In May 2011 Holt saw a Mayo Clinic rheumatologist, Dr. Andy Abril ("Abril"), who conducted tests and ruled out numerous disorders, concluding that "[s]he has classic presentation for fibromyalgia, with an otherwise unremarkable joint examination" (AR, p. 441). Dr. Breetzke agreed with the fibromyalgia diagnosis and stated that she could return to work, with restrictions, on August 7, 2011 (AR, p. 607). The record does not show she did return to work.
In July 2011, at the behest of LINA, rheumatologist Penny Chong reviewed Holt's file and concluded that she could return to work while being treated, noting that "[p]hysical impairment that precluded Ms. Holt from doing her work was not demonstrated, " and that "[t]here was no significant weakness, muscle wasting, limitation of movement, deformity, synovitis or overt sensory deficit. Myofascial tenderness or tender points should not be construed as a disability" (AR, p. 594). Dr. Breetzke gave Holt permission to return to work part time in August 2011 and noted that "[p]atient is really doing quite well as far as pain is concerned" (AR, pp. 343, 337). The record does not indicate she did return to work.
Holt applied for LTD benefits in October 2011. In November 2011, Dr. Breetzke completed a form noting several limitations and restrictions and opined that Holt could not return to work because she had to take frequent naps because of her medication (AR, p. 552). In December 2011 LINA granted STD and LTD starting from July 25, 2011, based on a nurse case manager's report noting the diagnosis of fibromyalgia and neuropathy pain and concluding that "given [claimant's] age and multiple issues [with] most severe of the shoulder it would be reasonable to allow additional time for treatment and recovery" (AR, p. 63).
A clinical note from Dr. Breetzke in February 2012 showed some positive signs, stating that "patient is really doing quite well. The pain is minimal but right now she has some elbow pain. Her energy level is improved. Her disease management is doing quite well as far as diabetes is concerned and the fibromyalgia is concerned. The issue that is still bothering her is that she continues to increase in her weight" (AR, p. 742). And in April of that year he noted that Holt "really is doing quite well. She certainly has not been cured of fibromyalgia but the therapy program that we are going through right now is keeping her fairly well-controlled. She does have bouts of depression that come now and then but they are short lived" (AR, p. 741).
Pursuant to a June 2012 request for additional information on Holt's health, Dr. Breetzke completed a Physical Ability Assessment, in which he stated that Holt could only "occasionally" ("0-2.5 Hrs/Day [or] 1/3 of the Day") do each activity listed, except for seeing and hearing, which he said she could frequently do (AR, p. 752). The activities she could do only occasionally included ...