United States District Court, M.D. Tennessee, Nashville Division
WILLIAM J. HAYNES, Jr., Senior District Judge.
Plaintiff, Christopher Strickland, filed this action under the Employees Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132, against the Defendants, Merck & Co., Inc., his former employer, and Merck & Co., Inc., Medical, Dental, and Long Term Disability Program for Non-Union Employees (collectively, "Merck"), the Administrator of Plaintiff s employee benefit plan. Plaintiff seeks judicial review of the Defendant's denial of continuation of long term disability benefits under insurance policies issued to Plaintiffs former employer. The Defendant filed the Administrative Record of its reviews of Plaintiff s disability claims. (Docket Entry No. 13).
Both parties have moved for judgment in their favor. In his motion for judgment on the pleadings (Docket Entry No. 17), Plaintiff contends, in sum: (1) that Plaintiff is totally disabled under the terms of the policy; (2) that Defendant's reliance upon the opinions of non-examining file reviewers is inadequate to provide a reasoned explanation for its decision to deny disability benefits; and (3) that Defendant's failure to consider the impact of pain and pain medications on Plaintiffs ability to work is arbitrary. In its motion for judgment on the administrative record (Docket Entry No. 15), the Defendant contends, in essence, that its decision denying benefits was rational in light of the plan provisions and was supported by substantial evidence.
For the reasons set forth below, the Court concludes that Defendant's decision to deny continuation of long term disability benefits under the Plan was based upon Plaintiffs medical records, the diagnoses of Plaintiff s treating physician, and records reviews by two consultants. Thus, the Defendant's decisions were not arbitrary and capricious.
A. Review of the Record
1. Procedural History
Merck & Co., Inc. ("Merck") is the plan sponsor and plan administrator of the Merck & Co., Inc., Medical, Dental and Long-Term Disability Program for Non-Union Employees. (Docket Entry No. 5, Complaint at 5). Merck's Plan is an employee benefit plan covered by ERISA. Id. at 7. Plaintiff worked for Defendant as a pharmaceutical salesman. Id. at 8. In the course of his employment, Plaintiff injured his back and shoulder while lifting a box. Plaintiff applied for long term disability (LTD) benefits from Merck's Plan, and began receiving benefits on October 2, 2008. Id. at 13.
According to the terms of the Plan, after 24 consecutive months of benefits, the terms change to require the employee to be "unable to engage in any Gainful Employment for which [employee is] or may become reasonably qualified by education, training, or experience." (Docket No. 13, Administrative Record at 758). Under this definition, Plaintiffs benefits were terminated on October 2, 2010. (Docket Entry No. 5, Complaint at 14). Plaintiff appealed the termination administratively, then sought judicial review. Id. at 15-16. The parties reached a settlement, in which Plaintiff was paid accrued benefits through February 28, 2011 and the proceeding was remanded to the Plan to consider benefits after February 28, 2011. Id. at 17. The Plan denied benefits after February 28, 2011, and Plaintiff has pursued administrative remedies, and then this action. Id. at 17, 20-22.
2. Medical History
The definition of total disability under which Plaintiffs application was considered reads:
Totally Disabled (or "Total Disability"). Totally Disabled means you are unable to perform all material aspects of your occupation during the Eligibility Period and during the first 24 consecutive months that benefits are paid under the Long-Term Disability Plan. After the first 24 consecutive months of disability, you must be unable to engage in any Gainful Employment for which you are or may become reasonably qualified by education, training or experience.
"Gainful Employment" is defined as:
Gainful Employment means compensation (either wages, commissions, earnings, profits or otherwise) for services that would replace at least 60% of your Base Pay prior to your disability in a job that is reasonably available, within up to 75 miles. (The area may be less, depending upon the facts surrounding your disability and the location of your residence when you became disabled.) A job is reasonably available if an opening exists or the job is being performed within that geographic area, even if there is no current opening.
(Docket No. 13, Administrative Record at 758).
Plaintiffs treating physician is Dr. T. Scott Baker, a pain management specialist. Id. at 227, 513. Dr. Baker has been treating Plaintiff since at least March 2010. Id. at 3. Plaintiff underwent surgery for his shoulder injury in December 2010. In Dr. Baker's February 15, 2011 report, he indicated that Plaintiffs pain rated 7/10, and that "he is on COBRA Insurance and requesting to decrease meds." Id. at 376. In March 2011, Plaintiff reported that "4 out of 7 days [he] wakes up with a stabbing pain that he can not walk off." Id. at 371. Dr. Baker also noted that Plaintiff had been referred to a rheumatologist. Id . In May 2011, Dr. Baker noted that "[Plaintiff] reports that his pain is inadequately controlled. He reports that his condition is unchanged." Id. at 353. On November 2, 2011, the rheumatologist reported "diffuse pains are still overall better presently mostly low back, shoulders and, and neck (sic). Most pains are areas of trauma." Id. at 454.
In June 2012, Dr. Baker noted that Plaintiff "reports that his condition is unchanged, " but also that "overall he is doing well." Id. at 295-96. Still, on that visit Dr. Baker prescribed six medications, including two opioids. Id . In July 2012, Plaintiff reported a pain level of 5/10, and 5/5 performance in his shoulder and hip joints to Curry Dudley, a Certified Family Nurse Practitioner. Id. at 293. On August 28, 2012, Plaintiff "returned scripts for Celebrex and Zanaflex stating he did not need them this month." Id. at 279. Celebrex a non-steroid antiinflammatory medication that Plaintiff had been prescribed, and Zanaflex is a muscle relaxer. On September 18, 2012, Plaintiff again reported a pain level of 5/10, but also that "he has pain 90 percent of the time that he is awake." Id. at 270. Dr. Baker's note also states, "the treatments which are effective include: none." Id.
On January 15, 2013 and February 12, 2013, Dr. Baker noted that Plaintiff reported pain levels of 7/10, pain 90% of the time he is awake, and an unchanged condition. Id. at 240, 468. On February 14, 2013, Plaintiff was examined by Dr. Lonergan, at the Pain Center. Id. at 201. Dr. Lonergan's report states: "The pain score today is 8. The average pain score for the last 3 months is said to be 6. During a 24 hour period, the patient needs to take medication for pain 7 times." Id.
3. LTD Eligibility Reports
On September 28, 2012, Dr. Baker completed a Medical Opinion Form at Merck's request. Id. at 451. Dr. Baker indicated that Plaintiff could sit for 6 hours a day, 30 minutes at a time, and stand for 2 hours a day, 30 minutes at a time. Id . Dr. Baker also stated that Plaintiff would not require more than one 30 minute and two 15 minute breaks in a workday. Id . These constraints do not produce a full workday.
On January 31, 2013, Merck sent a letter to Dr. Baker's office, stating, "[w]e are reviewing the Long Term Disability (LTD) claim for your patient Christopher Strickland... In order to review your patient's eligibility for LTD benefits, we will need the following dating from September 1, 2012 through present." Id. at 474. The letter then included a list of questions, one of which was "[a]re you currently keeping this patient out of work?" Id . Dr. Baker answered this question "NO, " but Dr. Baker did not sign this response. Id . Merck's letter requested a return of the response by February 7, 2013, but the response is dated February 21, 2013. Id.
On February 8, 2013 - the day after Merck requested a response from Dr. Baker - Merck sent another copy of the letter. Id. at 218. In this response, the question "[a]re you currently keeping this patient out of work?" is answered "yes." Id . Dr. Baker also answered "yes" to "[a]re you restricting your patient from performing full time sedentary work at this time?" and [a]re you restricting your patient from performing full time light work at this time?" Id . Dr. Baker then signed this response, dated March 8, 2013.
4. Peer Review
On March 11, 2013, Dr. Donald Minteer, a Merck consultant, reviewed Plaintiffs file. Id. at 222-23. Dr. Minteer's report is two pages long, and was "reviewed in accordance with the DMS Expert Resource Professional Conduct Statement. All available medical and/or vocational evidence bearing on Disability and/or functional capacity and its impact on the whole person has been considered in order to provide an accurate representation of the medical and/or vocational facts of the claim file, " including Dr. Baker's notes from the February 13, 2013 visit. Id . Dr. Minteer concluded that "[w]ithin a reasonable degree of medical certainty, it is my professional opinion that there are no objective clinical exam, clinical testing or imaging documentation to support a significant physical functional impairment which would preclude at least a sedentary level occupation." Id . The bases for Dr. Minteer's conclusion were as follows:
1. The clinical exam notes of Dr. Baker show consistent findings of normal motor strength, heel and toe walking and squatting. The findings are inconsistent for SLR testing which are intermittently noted as positive and can very (sic) from normal to positive on the left side to positive bilaterally. No abnormal sensory changes are noted.
2. Per the 2/13/13 office note of Dr. Baker, there is notation of new complaints of knee, wrist, and elbow discomfort. Other than subjective tenderness on palpation of these areas as well as the paraspinal areas of the neck, thoracic spine area and the lumbar area, no other abnormalities such as synovitis, swelling or erythma are noted. No rheumatological studies are ordered.
3. There are no abnormal electrodiagnostic studies to support either a cervical or lumbar radiculopathy.
In a March 19, 2013 letter, Merck denied Plaintiffs application for continuation of his LTD benefits after February 28, 2011. Id. at 113-115. Merck's letter stated, "following review of your claim, it was determined you are able to perform the duties of a sedentary level occupation and no longer meet the definition of disability beyond March 1, 2011." This letter notes Plaintiffs February 12, 2013 office visit to Dr. Baker, but does not mention Dr. Minteer's review on March 11, 2013.
Plaintiff administratively appealed this denial, and on September 11, 2013, received a second denial letter. Id. at 116-119. Merck's second letter stated, "[a]fter completing our review of Mr. Strickland's claim, we are unable to continue paying benefits beyond February 28, 2011." Id . This denial was based upon the information cited in the original March 19, 2013 denial, as well as February 2013 progress notes from Dr. Baker and the initial consultation at the Pain Center. This appeal included the report of Dr. Siva Ayyar, an "independent peer reviewer." Id. at 175-179.
Dr. Ayyar's report was dated September 5, 2013; in it, he references an initial review conducted on August 8, 2013. Id . Dr. Ayyar concluded that Plaintiff would be "functionally limited, " but that he would not be unable to work in any capacity. Id . Dr. Ayyar's report lists the question, "[d]oes review of the additional information alter your previous opinion? Please explain" to which Dr. Ayyar answered, "[t]he previous opinion is unaltered." Id . After listing limitations for Plaintiff, Dr. Ayyar concluded: "I feel that these limitations are more an accurate characterization of the clinical picture than the proclamation of the total inability to work put forth by Dr. Baker." Id.
B. Conclusions of Law
Under ERISA, review of denial of benefits is subject to 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." Firestone Tire Rubber Co. v. Bruck 489 U.S. 101, 115 (1989) . Here, the Plan grants the Plan Administrator discretion to determine eligibility for benefits in accordance with the Plan Documents. Plan Administrator/Claims Administrator
The Plan Administrator has the exclusive discretion to construe and interpret the terms of the LTD Plan as follows:
To make factual determinations, interpret and construe the Plan, correct defects, supply omissions and reconcile inconsistencies to the extent necessary to effectuate the Plan, resolve all questions arising in the administration, interpretation and application of the Plan, and such action will be conclusive upon ...