SCOTT v. RELIANCE STANDARD LIFE INSURANCE COMPANY (2020)

ORDER

This matter is before the Court on Defendant Reliance Standard Life Insurance Company's (“Reliance”) Motion for Summary Judgement [Doc. 12]. After consideration of the pleadings, arguments of counsel, applicable law, and all appropriate matters of record, the Court hereby GRANTS the Motion based of the following findings of fact and conclusions of law.¹

I. FACTUAL FINDINGS

Reliance issued a group, long-term disability insurance policy to GEODIS Logistics, LLC (“GEODIS”). [Doc. 12-1 at ¶ 1]. The policy provides coverage to active, full-time employees of GEODIS who meet the eligibility requirements detailed within the policy. [Id. at ¶ 2]. The policy includes an Insuring Clause which provides for the payment of a monthly benefit if an insured employee:

(1) is Totally Disabled as the result of a Sickness or Injury covered by this Policy;

(2) is under the regular care of a Physician;

(3) has completed the Elimination Period;

(4) submits satisfactory proof of Total Disability to [Reliance]. [Doc. 13-1 at p. 21 (AR p. 21) ].

The policy also includes the following limitation on benefits:

PRE-EXISTING CONDITIONS: Benefits will not be paid for a Total Disability:

(1) caused by;

(2) contributed to by; or

(3) resulting from;

a Pre-existing Condition unless the Insured has been Actively at Work for one (1) full day following the end of twelve (12) consecutive months from the date he/she became an Insured.

“Pre-Existing Condition” means any Sickness or Injury for which the Insured received medical Treatment, consultation, care or services, including diagnostic procedures, or took prescribed drugs or medicines, during the three (3) months immediately prior to the Insured's effective date of insurance. [Doc. 13-1 at pp. 25-26 (AR pp. 25-26) ].

Finally, the policy provides that the term “Total Disability” means that “an Insured cannot perform the material duties of his/her Regular Occupation” after a period of 90 consecutive days of disability or the expiration of short-term disability benefits. [Doc. 13-1 at pp. 7, 13 (AR pp. 7, 13) ].

Plaintiff became a full-time GEODIS employee on January 9, 2017. [Doc. 12-1 ¶ 3]. After a thirty-day waiting period, Plaintiff's coverage under the Reliance policy was effective on February 8, 2017. [Doc. 12-1 ¶ 4]. Plaintiff stopped working on April 25, 2017, and submitted a claim to Reliance for long-term disability benefits. [Doc. 12-1 ¶ 5]. In her application for disability benefits, Plaintiff identified her symptoms as “weakness in legs, burning and tingling – abdominal pain – chest pain.” [Doc. 12-1 ¶ 10]. Bruce Wood, D.O., Plaintiff's family medicine doctor, completed the Attending Physician's Statement portion of the claim. Dr. Wood identified Plaintiff's primary diagnoses as: “peripheral neuropathy, [right] pelvic mass, GERD, and constipation.” [Doc. 12-1 ¶ 9].

Plaintiff went to the emergency room on April 27, 2017, complaining of headaches and chest pain. [Doc. 12-1 ¶ 16]. Then, on May 1, 2017, Plaintiff was again seen by Dr. Wood, who noted that those symptoms might be related to stress. [Doc. 12-1 ¶ 20]. On May 4, 2017, Plaintiff underwent an MRI of the brain and cervical spine. The results did not explain her claimed symptoms. [Doc. 13-8 at pp. 50-64 (AR 959-973) ].

According to the policy, Plaintiff would be excluded from coverage if she had received “medical [t]reatment, consultation, care or services, including diagnostic procedures, or [taken] prescribed drugs or medicines” during the three-month period immediately preceding Plaintiff's effective date of insurance for any condition on which she based her disability claim. [Doc. 13-1 at pp. 25-26] (AR pp. 25-26). This three-month period ran from November 8, 2016, through February 8, 2017 (the “look-back period”). [Doc. 12-1 ¶ 7].

During the look-back period, Plaintiff was prescribed Venlafaxine, a medication for depression, anxiety and panic disorders, and on December 16, 2016, Plaintiff re-filled her prescription for Venlafaxine. [Doc. 12-1 ¶¶ 21-23]. Plaintiff was also prescribed and re-filled a prescription for Lyrica to treat neuropathy during the look-back period. [Doc. 12-1 ¶¶ 13-14].

Not only was Plaintiff prescribed medication during the look-back period, but also Emory Clinic medical records show that Plaintiff had the following “Active” conditions during the look-back period: anxiety, asthma, chronic constipation, ovarian cyst, peripheral neuropathy, endometriosis, headaches, hyperreflexia, dyspepsia, lumbar spondylosis, nausea and vomiting, neuropathic pain, cervical radicular pain, lumbar foraminal stenosis, and throat pain. [Doc. 12-1 ¶ 24; Doc. 13-6 at p. 67 (AR p. 731) ]. Other medical records indicate that Plaintiff received treatment for a knee injury during the look-back period. [Doc. 13-1 at p. 110 (AR p. 110) ].

On September 24, 2018, Reliance denied Plaintiff's claim for long term disability benefits, explaining:

Our investigation has revealed that you received medical treatment, consultation, care or services or took prescribed drug of medicine during the period (11/8/16-2/8/17). Accordingly, your Sickness or Injury is considered to be Pre-existing and your claim for LTD benefits must be denied. [Doc. 13-1 at pp. 95-97 (AR pp. 95-97) ].

Plaintiff then sent an email to Reliance on September 26, 2018, appealing the denial of benefits. [Doc. 13-10 at p. 296 (AR p. 2021) ].

During the appeal process, David Hoenig, M.D., reviewed Plaintiff's medical records and provided a report to Reliance. [Doc. 13-11 at pp. 16-21 (AR pp. 2073-2078) ]. In his report, Dr. Hoenig concluded that:

[b]ased on the documentation provided, and from a neurological perspective only, there is no clear neurological condition in which the claimant is alleging impairment as of 04/26/2017. There is documentation that the claimant had headaches. There is documentation the claimant saw a neurologist, but that data was not submitted for review. There is no documentation of any neurological deficits on exam from a neurologist. MRI of the brain is negative. It appears that pain management demonstrated right leg weakness and abnormal sensation, but it is not clear what the basis is for their findings, and there is no explanation why the weakness improved and the sensory changes became patchy. Without clinical information from neurology, impairment is not clearly identified. [Doc. 13-11 at p. 20 (AR p. 2077) ].

Plaintiff retained counsel to assist her in the process of appealing the denial of long-term benefits. Plaintiff's counsel wrote a letter to Reliance asserting, inter alia, that Reliance's review of Plaintiff's medical records did not appreciate the severity of the Plaintiff's headaches, and skipped or omitted portions of the medical records relating to her chronic back pain and other conditions. [Doc. 13-11 at pp. 113-114 (AR pp. 2170-71) ]. In response to the letter from Plaintiff's counsel, Reliance conducted an independent medical examination of Plaintiff, which was performed by Mark Hinrichs, M.D. [Doc. 12-1 ¶ 46; Doc. 13-11 at pp. 115-125 (AR pp. 2172-2182) ]. With respect to the back pain, Dr. Hinrichs reported that a May 24, 2017, MRI of Plaintiff's lumbar spine showed “facet joint arthropathy, mild in nature.” [Doc. 13-11 at p. 117 (AR p. 2174) ]. Dr. Hinrichs further stated that:

[a]s of April 26, 2017, ongoing, there is evidence that she had facet joint arthropathy, as she improved with medial branch blocks as well as radiofrequency ablation in October 2017. She did have an adnexal mass and is status post oophorectomy. She does appear to have well-controlled asthma. She has not had an arthroscopy, and there is no objective evidence of impairment due to her knee at this time. [Doc. 13-11 at p. 121 (AR p. 2178) ].

Dr. Hinrichs concluded that “[a]s of April 26, 2017, and ongoing, the [Plaintiff] may work full-time within the lifting restrictions detailed in the Physical Capacities Questionnaire.” [Doc. 13-11 at p. 123 (AR p. 2180) ]. In the Physical Capacities Questionnaire, Dr. Hinrichs indicated that Plaintiff is capable of various forms of bodily movement on a continuous basis (67% – 100%) and is capable of working at a “Medium Lift” exertion level. [Doc. 13-11 at pp. 124-125 (AR pp. 2181-82) ]. Plaintiff's Regular Occupation as a Warehouse Supervisor only required a light level of exertion. [Doc. 13-1 at p. 113 (AR p. 113) ].

On December 23, 2018, Reliance notified Plaintiff that it was upholding its decision that she was not eligible to receive long term disability benefits under the policy. [Doc. 13-1 at pp. 109-117 (AR pp. 109-117) ]. Addressing the denial based on the pre-existing conditions limitation, Reliance explained:

Information contained with Ms. Scott's claim file indicates that during the Pre-Existing Condition period, she filled prescriptions for Linzess on November 21, 2016 to treat irritable bowel syndrome, Lyrica on December 9, 2016 and January 6, 2017 for nerve and muscle pain, Venlafaxine, an antidepressant, on December 16, 2016, Diclofenac on December 21, 2016, which is a non-steroidal anti-inflammatory also used to treat pain and migraines, Flexeril, a muscle relaxant, on December 27, 2016, and Hydrocodone, an opioid pain medication, on December 27, 2016. [Doc. 13-1 at p. 110 (AR p. 110) ].

Reliance further stated that:

An Urgent Care visit on December 21, 2016 noted a left knee injury that occurred at home. Ms. Scott also reported a history of peripheral neuropathy. Her examination revealed tenderness to the left knee and antalgic gait with intact neurovascular status. The assessment was left knee injury. Decadron and Toradol injections were given and a knee brace was prescribed. Ms. Scott followed up with Belinda Gibson, NP, on December 27, 2016 due to continued left knee pain. She also followed up with Susan Snouse, PA, on January 24, 2017 and was diagnosed with knee effusion and knee meniscus pain. A Magnetic Resonance Imaging (“MRI”) of the left knee on January 26, 2017 revealed Grade 1 patellar chondrosis and Grade 3 lateral trochlear chondrosis. [Doc. 13-1 at p. 110 (AR p. 110) ].

Reliance ultimately concluded that “Ms. Scott is capable of performing the material duties of her Regular Occupation, a Warehouse Supervisor, as of April 26, 2017 and ongoing” and, thus, “is not entitled to LTD benefits in connection with this claim.” [Doc. 13-1 at p. 116 (AR p. 116) ].

II. LEGAL STANDARD

Under Federal Rule of Civil Procedure 56, the Court should grant summary judgement “if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a). The moving party bears “the initial responsibility of informing the ․ court of the basis for its motion, and identifying those portions of the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, which it believes demonstrate the absence of a genuine issue of material fact.” Hickson Corp. v. N. Crossarm Co., 357 F.3d 1256, 1259 (11th Cir. 2004) (quoting Celotex Corp. v. Catrett, 477 U.S. 317, 323, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986) (internal quotations omitted)).

“When that burden has been met, the burden shifts to the nonmovant to demonstrate that there is a genuine issue of material fact, which precludes summary judgment.” Lamar v. Wells Fargo Bank, 597 Fed. App'x. 555, 557 (11th Cir. 2014) (citing Clark v. Coats & Clark, Inc., 929 F.2d 604, 608 (11th Cir. 1991)). “The applicable substantive law identifies which facts are material.” Stephens v. Trust for Pub. Land, 475 F. Supp. 2d 1299, 1307 (N.D. Ga. 2007) (citing Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 258, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986)).

III. ANALYSIS

ERISA allows an individual who has been denied benefits under an employee benefit plan to bring a lawsuit in federal court challenging the benefits denial. See 29 U.S.C. § 1132(a)(1)(B). “[I]n an ERISA benefit denial case ․ in a very real sense, the district court sits more as an appellate tribunal than as a trial court. It does not take evidence, but, rather, evaluates the reasonableness of an administrative determination in light of the record compiled before the plan fiduciary.” Curran v. Kemper Nat'l Serv., Inc., 2005 WL 894840, at *7 (11th Cir. Mar. 16, 2005) (quoting Leahy v. Raytheon Co., 315 F.3d 11, 17-18 (1st Cir. 2002)).

The Eleventh Circuit has established a multi-step test for review of ERISA benefits decisions as follows:

(1) Apply the de novo standard to determine whether the claim administrator's benefits-denial decision is ‘wrong’ (i.e., the court disagrees with the administrator's decision); if it is not, then end the inquiry and affirm the decision.

(2) If the administrator's decision in fact is ‘de novo wrong,’ then determine whether he was vested with discretion in reviewing claims; if not, end judicial inquiry and reverse the decision.

(3) If the administrator's decision is ‘de novo wrong’ and he was vested with discretion in reviewing claims, then determine whether ‘reasonable’ grounds supported it (hence, review his decision under the more deferential arbitrary and capricious standard).

(4) If no reasonable grounds exist, then end the inquiry and reverse the administrator's decision; if reasonable grounds do exist, then determine if he operated under a conflict of interest.

(5) If there is no conflict, then end the inquiry and affirm the decision.

(6) If there is a conflict, the conflict should merely be a factor for the court to take into account when determining whether an administrator's decision was arbitrary and capricious.

Blankenship v. Metro. Life Ins. Co., 644 F.3d 1350, 1355 (11th Cir. 2011).

Accordingly, “[a] denial of benefits under an ERISA plan must be reviewed de novo ‘unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan.’ ” Lee v. Blue Cross Blue Shield of Ala., 10 F.3d 1547, 1549 (11th Cir. 1994) (quoting Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989)). Where the plan does provide such discretion to the claims administrator, the court's review the denial of benefits under an arbitrary and capricious standard. Id. at 1549-50.

In applying the de novo standard pursuant to first step of the 11th Circuit's test, this Court finds that Reliance's decision in denying Plaintiff's long-term benefits was not wrong. The evidence shows that Plaintiff received medical treatment, consultation, care or services, and/or took prescribed drugs during the look-back period which are related to Plaintiff's condition for which she claims disability. Thus, Plaintiff was not allowed to recover the long-term benefits she requested under the Pre-Existing Conditions Limitation of the policy, and Reliance's decision to deny Plaintiff's request for long-term benefits was correct.

Even if the Court disagreed with Reliance's decision, this disagreement would not be controlling. Here, the Reliance policy states that a Monthly Benefit is payable if a claimant “submits satisfactory proof of Total Disability to [Reliance].” This language confers discretionary authority on Reliance. Tippitt v. Reliance Standard Life Ins. Co., 457 F.3d 1227, 1233-34 (11th Cir. 2006). Because Reliance has discretionary authority in denying benefits, the more deferential arbitrary and capricious standard applies.

Under the arbitrary and capricious standard, if reasonable grounds for the decision exist, the Court must defer to the claim administrator and uphold the decision “even if there is evidence that would support a contrary decision.” Blankenship, 644 F.3d at 1355-56 (quoting Jett v. Blue Cross and Blue Shield of Alabama, Inc., 890 F.2d 1137, 1140 (11th Cir. 1989)); Townsend v. Delta Family-Care Disability and Survivorship Plan, 295 F. App'x. 971, 976 (11th Cir. 2008) (“So long as [the decision] was supported by evidence in the administrative record, the [administrator]’s decision to deny ․ benefits was not improper; it is irrelevant whether this court or anyone else might have reached a different conclusion”).

Here, to qualify for long term disability benefits, Plaintiff's medical conditions could not be subject to the policy's Pre-existing Conditions Limitation. The Court finds that there is ample evidence in the record that Plaintiff received medical treatment, consultation, care or services, including diagnostic procedures, and/or took prescribed drugs or medicines, during the three (3) months immediately prior to her effective date of insurance for the conditions on which she bases her long-term disability claim.

In particular, records from the Emory Clinic during the look-back period identify as Plaintiff's “Confirmed” and “Active” conditions: Anxiety, Asthma, Chronic constipation, Ovarian cyst, Peripheral neuropathy, Endometriosis, Headaches, Hyperreflexia, Dyspepsia, Lumbar spondylosis, nausea and vomiting, neuropathic pain, cervical radicular pain, lumbar foraminal stenosis, and throat pain. [Doc. 13-6 at pp. 67, 86, 92, 95 (AR pp. 731, 750, 756, 759) ]. Thus, the Court concludes that substantial evidence supports Reliance's conclusion that Plaintiff's application for long-term benefits be denied based on her pre-existing conditions. Therefore, the denial was reasonable and not arbitrary and capricious.

Not only does the Court find that the denial based on Plaintiff's pre-existing medical conditions was not arbitrary and capricious, but also that Reliance's denial of long-term benefits based on Plaintiff's inability to prove total disability was not arbitrary and capricious. Plaintiff bears the burden of proving entitlement to benefits under the policy. Horton v. Reliance Standard Life Ins. Co., 141 F.3d 1038, 1040 (11th Cir. 1998). “[D]isability under the terms of a disability plan is not established simply because there has been a medical diagnosis or because a claimant suffers pain, even severe pain.” Stiltz v. Metro. Life Ins. Co., No. 1:05-cv-3052-TWT, 2006 WL 2534406 at *10 (N.D. Ga., Aug. 30, 2006). “[W]here the plan puts the burden on the claimant to prove that she is disabled, it is implicit in the requirement of proof that the evidence be objective.” Watts v. BellSouth Telecomms., Inc., 218 F. App'x. 854, 856-57 (11th Cir. 2007) (citing Brucks v. Coca-Cola, Co., 391 F. Supp. 2d 1193, 1205 (N.D. Ga. 2005)).

Based on the evidence in the administrative record, the Court concludes that Reliance's decision that Plaintiff failed to prove that she was totally disabled in accordance with the terms of the policy was reasonable and not arbitrary and capricious.

Because reasonable grounds existed for Reliance's denial of Plaintiff's long-term benefits, the Court must also consider whether Reliance operated under a conflict of interest. In Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 128 S. Ct. 2343, 171 L.Ed.2d 299 (2008), the Supreme Court held it was not “necessary or desirable for courts to create special burden-of-proof rules, or other special procedural or evidentiary rules, focused narrowly upon the evaluator/payor conflict.” Id. 554 U.S. 105, 128 S.Ct. at 2351. Rather, “conflicts are but one factor among many that a reviewing judge must take into account.” Id. “[T]he burden remains on the plaintiff to show the decision was arbitrary; it is not the defendant's burden to prove its decision was not tainted by self-interest.” Doyle v. Liberty Life Assurance Co. of Boston, 542 F.3d 1352, 1360 (11th Cir. 2008). Furthermore, even where a conflict of interest exists, district courts still owe deference to the plan administrator's discretionary decision-making as a whole and, thus, the basic analysis still centers on assessing whether a reasonable basis existed for the administrator's decision. Blankenship, 644 F.3d at 1355.

Based on the administrative record in this case, the Court concludes that Reliance had a reasonable basis for its benefits decisions and that it's conflict of interest did not render those decisions arbitrary and capricious.

For the reasons stated above, the Court concludes that Reliance's decision to deny Plaintiff long-term benefits should be affirmed.

IV. CONCLUSION

Accordingly, IT IS HEREBY ORDERED that Defendant's Motion for Summary Judgment [Doc. 12] is GRANTED. The Clerk of Court is directed to close this file.

IT IS SO ORDERED, this 15th day of July, 2020.

FOOTNOTES

1.   The Court notes that counsel for Defendant submitted a proposed order, which the Court reviewed and edited, as appropriate.

WILLIAM M. RAY, II, UNITED STATES DISTRICT JUDGE