A Federal Court determined that Prudential was wrong to terminate a man’s disability insurance benefits by relying on a vocational expert who was not given enough information and a doctor who failed to explain why he disagreed with the claimant’s treating physicians. Let’s take a detailed look at the Court’s opinion to understand its ruling.
David Givens was a pharmacy technician at Medco. As a Medco employee he participated in the Medco-sponsored long-term disability insurance plan governed by ERISA and insured by Prudential. In early 2004, Givens was involved in a motor vehicle accident which resulted in chronic back pain. After receiving Short Term Disability benefits, he unsuccessfully attempted to return to work. Givens then applied for Long Term Disability benefits in August 2006. After two appeals, Social Security Disability benefits approval, and an Independent Medical Evaluation by Dr. Joann Mace, he was approved for long-term disability benefits in October 2007, with an effective date of August 2006.
Givens’ policy contained the common language of most disability policies. His policy stated that for the first 24 months a person is considered disabled if they cannot perform the material and substantial duties of their regular occupation. After that 24 month period, a person is then only considered disabled when Prudential determines that they are unable to perform any gainful occupation. These periods are commonly referred to as the “own occupation” period and the “any occupation” period.
After the 24 month own occupation period expired in August 2008, Prudential canceled Givens’ benefits. In the cancelation letter, Prudential indicated that it based its decision partially on the results of Dr. Joann Mace, the same doctor it used to approve LTD benefits during the “own occupation” period. Givens appealed, sent more doctor notes and as well as a report from a rehabilitation consultant. Prudential denied the appeal.
Prudential’s denial of disability benefits decision was based on the report of a vocational expert, Laurie Martin, and an independent review of the medical records by Dr. Phillip Marion. It turns out that vocational expert Laurie Martin reviewed the notes of only one of the many doctors, physician assistants and chiropractors that had treated Givens. Martin only reviewed the notes of Dr. Joann Mace (who determined that Givens did not suffer from any functional impairment) and determined that Givens was capable of performing sedentary and light work with restrictions. It must be noted that Martin did not ignore the notes of the remaining 16 doctors, physician assistants or chiropractors that treated Givens. Martin had in fact never been given those additional reports from Prudential who had only given him the reports/notes of Dr. Mace (it must be noted that the majority of other practitioners, but not all, agreed with Dr. Mace’s assessment of Givens).
Dr. Phillip Marion, a specialist in physical medicine and rehabilitation, conducted the independent review of Givens’ medical records dated November 2004 through March 2009. Dr. Marion concluded that Givens was functionally independent and capable of performing the activities of daily living because he was fully ambulatory and not restricted from driving. Dr. Marion also found that the records did not support Givens’ complaints of adverse side effects due to pain medications.
The ERISA Lawsuit
Due to his denial for long term disability benefits, David Givens filed an ERISA lawsuit in the Federal District Court of Missouri. At issue in the lawsuit is whether Prudential abused its discretion when it determined that Givens was not disabled under the “any occupation” definition of disability.
ERISA Standard of Review
Givens’ long-term disability plan stated that “a person is disabled when Prudential determines that”¦ you are unable to perform the duties of any gainful occupation.” The Court noted that prior cases have held that where a plan gives the administrator discretionary authority to grant or deny benefits (such as the language in Givens’ policy) the Court reviews the administrator’s determination for an abuse of discretion. Under this standard, the “administrator’s decision to deny benefits will stand if a reasonable person could have reached a similar decision.” Ratlift v. Jefferson Pilot Fin. Ins. Co. Also, the Court noted, that under ERISA, plan administrators do not have to give greater weight to the opinions of a claimant’s treating physicians. The Court continued that where “medical records conflict, a plan administrator does not abuse its discretion by finding the employee is not disabled.” Rutledge v. Liberty Life Assurance Co. of Boston. Under these circumstances, the Court stated, it cannot substitute its own decision if substantial evidence existed to support Prudential’s decision.
The Court’s Analysis
The Court found that it was arbitrary and capricious for Prudential to have only sent one doctor’s report to the vocational expert Laurie Martin when there were other physicians’ reports indicating limitations on Givens’ abilities. For example, the doctor’s report that was sent to Martin indicated that Givens could lift up to thirty pounds while two other doctors’ reports that weren’t shared with the rehab counselor stated he was limited to five or ten. The Court found that Martin’s report was an incomplete and inaccurate representation of Givens’ ability to work because Prudential did not provide Martin with all of the relevant records regarding Givens’ capacity to work. The Court found that Prudential abused its discretion by sending a “cherry picked” file to Martin that consisted of only one physician’s recommended restrictions.
The Court also took issue with Prudential’s reliance on the independent review of the medical reports by Dr. Phillip Marion. The Court found that Dr. Marion’s opinion failed to explain why he departed from the other doctors’ findings regarding Givens’ physical limitations when he concluded that Givens was functionally independent and fully ambulatory. Additionally, Prudential did not explain why it believed Dr. Marion’s decision over the other physicians who had examined Givens, including Dr. Mace who concluded that Givens is under permanent limitations, including no prolonged sitting or standing, no repetitive twisting, turning or bending, and no lifting greater than thirty pounds. Because Prudential relied upon Dr. Mace’s report to support both a prior award of disability benefits under the “own occupation” standard as well as its initial denial of Givens’ claim under the “any occupation” standard, it was arbitrary and capricious for Prudential to fail to explain why it now relied upon Dr. Marion’s seemingly contrary opinion instead of Dr. Mace’s of which it had previously relied.
Finally, the Court found that Prudential’s reliance on Dr. Marion’s view of the cognitive effects of pain medication on Givens was also arbitrary and capricious. The court noted that while Dr. Marion concluded that “the medical records do not support significant adverse side effects from any medication,” he failed to explain his reasoning. In reality, only one doctor was able to examine Givens after he began to use morphine and that doctor noted that morphine’s effect on Givens included inability to focus and stay alert, and caused Givens to make mistakes often. Dr. Marion failed to point to any evidence to support his conclusion and ignored that other doctor’s report. The Court found that Prudential’s reliance on Dr. Marion’s statement did not satisfy ERISA’s notice requirements.
In the end, the Court found that Prudential abused its discretion in terminating Givens benefits by relying on a vocational expert who was not given enough information and a doctor who failed to explain why he disagreed with the examining physicians. Although the Court ruled for Givens and he will be paid the back benefits owed, the Court’s ruling does not prevent Prudential from terminating Givens’ future benefits if they rely on a vocational expert who has access to all the medical reports and a doctor who explains why he is departing from the other physicians’ opinions.