When Laurie Cooper walked into the U.S. Court of Appeals, 5th Circuit, in New Orleans, she had to demonstrate before the court that she had been denied a full and fair review of her claim and that the denial of her benefits abused the discretion given the benefit provider, Hewlett Packard Company Disability Plan. Two out of three judges found that she had failed to do this. In a two-to-one decision, the ruling from the U.S. District Court for the Southern District of Texas was affirmed.
The end result? Ms. Cooper will not receive long-term disability benefits. Let’s look at this case and see how the circuit judges reached their conclusions.
Cooper had been a content manager at Hewlett Packard (HP) for 16 years when she stopped working on March 24, 2004. The main duty of her job involved writing technical documentation, which entailed long hours in front of the computer. Cooper participated in HP’s short-term and long-term disability plans which HP funded and VPA, Inc. (VPA) administered. The 43 year old applied for short term disability benefits based on the neck and back pain she had been experiencing.
The policy language
The policy stated that during the first 26 weeks following the onset of her injury or illness, Cooper had to be unable to perform the material and essential functions of her usual occupation, content manager. Cooper submitted medical evidence from her psychiatrist and another treating physician that documented her chronic back pain, depression, bipolar disorder and generalized anxiety. Based on this evidence, VPA approved Cooper’s short-term disability benefits on April 20, 2004.
When the 26 weeks ended, Cooper applied for long-term disability benefits under the “Totally Disabled” provision of the plan. Under this provision her qualifications for long-term benefits were contingent up to the 24th month on her still being unable to fulfill the duties of her usual occupation as a content manager. Cooper’s medical evidence supported this extension of benefits, and she was approved for long-term disability coverage on September 23, 2004.
VPA contacted Cooper on September 19, 2005 to confirm her continued eligibility for disability benefits. On March 25, 2006, Cooper’s eligibility would come under stricter requirements, the inability to perform any occupation for which she was or could become qualified for based on her education, training or experience. She also would not be able to use a nervous or mental disorder to support her extension of benefits.
To support her claim, Cooper submitted medical records from several treating physicians. These records suggested that the neck and hand surgeries Cooper had undergone had produced an improvement in her condition. Some records indicated that her pain levels were in an acceptable range. One doctor stated that she was in “no acute distress”.
VPA ordered an independent medical evaluation (IME) by a neurologist. His April 19, 2006 findings suggested that Cooper could stand, walk, sit, and drive for up to four hours each day as long as these activities didn’t last long than one hour at a time. He also felt that she would be able to lift up to 10 pounds, bend, squat, crawl, reach above her shoulders, and perform activities with her hands that included fine manipulation and pushing/pulling and grasping.
VPA then referred Cooper’s file to a vocational specialist. The specialist reviewed Cooper’s medical history along with the most recent IME and identified three potential jobs that would accommodate Cooper’s limitations, including her need to change positions frequently. The vocational specialist noted that all three positions would allow Cooper to work at modified workstations.
Denial of benefits
Based on this information, VPA denied Cooper’s claim for long-term disability benefits on July 19, 2006. The claim denial letter acknowledged Cooper’s inability to return to her former job, but that the basis for the denial was on the fact that Cooper could work in another job for which she was qualified or could become qualified to perform. VPA listed the jobs recommended: program manager, computer operations manager and department manager. VPA cited her improving condition as well.
On February 13, 2007, Cooper appealed VPA’s decision. She submitted documentation from a November 12, 2006 doctor’s visit that noted that while she was healing well from her fusion surgeries at C5-C6 and C6-C7, he found evidence that she had degenerative disk disease above and below the fusion which was giving Cooper enough pain to disable her from her work. He noted that she was having difficulty doing any meaningful work, but especially found working at a computer increased her pain to an unbearable level.
She also submitted the March 21, 2006 notes from another treating physician that indicated that she was going to be starting work at a jewelry store because her long-term benefits were going to end soon. The same physician noted on April 21, 2006 that she was working part time, experiencing pain and tolerating her medications. He saw her again on June 28 and again noted that she was working 25 hours a week, but this time made no mention of Cooper complaining of pain.
She also provided the records from a visit with her pain management provider on September 18, 2006. During this visit the physician noted that she had increased pain. During an October 30, 2006 visit, the doctor noted that Cooper ranked her pain at a 4/10 level, with 10 being the least tolerable level. He scheduled her for a caudal epidural steroid injection the following day.
During a follow-up visit on January 18, 2007, Cooper noted that the effects of the steroid injection had not lasted very long. She reported that her pain level had changed to a 4-5/10 level. By her next visit on February 12, her pain level was at 5/10. Her doctor noted that she was still working as a jewelry store sales clerk and that she was abiding by her doctor recommended restrictions, which stipulated that she not stand or sit for more than 20-30 minutes at a time. He noted disc bulges in her thoracic and lumbar spine. He “strongly doubted” she could work full-time.
VPA asked for copies of Cooper’s pay stubs, which were provided. The pay stubs indicated that from the time her disability coverage ended on April 1, 2006, Cooper had worked from 28.44 to 92.61 hours in any two-week period. Cooper applied for Social Security Benefits but was denied on July 11, 2006 because she was working and made too much. VPA took this decision into consideration, and on May 16, 2007 denied Cooper’s appeal.
In the denial, VPA pointed to documents in the record that indicated her symptoms had improved. They noted their unsuccessful attempts to contact one of her primary care providers. They also noted that the fact that she was working supported their conclusion that she was able to work in another occupation, which disqualified her from continuing benefits under the provisions of the plan.
On May 23, VPA received a letter from her primary care provider stating that her primary diagnosis impaired her ability to work and that she should be considered, based on her medical pathology, totally disabled and unable to be gainfully employed. When this letter failed to reverse VPA’s denial, she filed action against the HP Plan on September 6, 2007. On January 14, 2009, the District Court sided with VPA’s decision and granted summary judgment to HP.
Court of Appeals
When the case came before the Court of Appeals, it was reviewed de novo, afresh, using the same standard as the district court did. The Appeals Court reviewed the VPA’s decision from the same perspective as the district court did. They also looked explicitly for any evidence of abuse of discretion as Cooper alleged.
The Court found that VPA’s decision was supported by substantial evidence, and thus could not be found arbitrary or capricious. Two of the justices also found that Cooper’s claim that VPA changed the basis upon which they denied her claim could not be substantiated.
One justice found that using Cooper’s employment as substantiating evidence that she was ineligible for long-term disability under the terms of the plan’s “any employment” clause, denied her right to a full and fair hearing. The other two justices disagreed. Citing the fact that VPA had based its denial on the fact that her medical records did not substantiate her inability to work, they found VPA’s mention of her employment a mere technical noncompliance, not a changing the basis for their decision which was the failure of her medical records to support her inability to work at any job.
The court found it illogical to expect Cooper to contend that she was unable to perform “any occupation” while she was holding down a job. They found her dependence on a brief, four sentence letter from her treating physician did not negate his earlier assessment which found her able to work under certain conditions. Her other physicians also failed to produce evidence the made it clear why she would be unable to work.
The Court found that the administrative record contained considerable evidence to support VPA’s denial of benefits and that Cooper failed to produce controlling evidence that she could not perform the duties of “any occupation.” The only decent to this decision revolved around the use of Cooper’s employment against her. Under the terms of the long-term disability policy, VPA’s denial was reasonable and was thus affirmed again in Appeals Court.