Statia Scott v. Eaton Corporation Long Term Di, No. 10-2124 (4th Cir. 2011)
Annotate this CaseCourt Description: Unpublished opinion after argument: Reversed
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UNPUBLISHED UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT No. 10-2124 STATIA SCOTT, Plaintiff - Appellee, v. EATON CORPORATION LONG TERM DISABILITY PLAN, Defendant - Appellant. Appeal from the United States District Court for the District of South Carolina, at Anderson. Henry M. Herlong, Jr., Senior District Judge. (8:09-cv-02572-HMH) Argued: October 27, 2011 Decided: November 21, 2011 Before MOTZ, KING, and DUNCAN, Circuit Judges. Reversed by unpublished per curiam opinion. ARGUED: Anna K. Raske, BENESCH, FRIEDLANDER, COPLAN & ARONOFF, LLP, Cleveland, Ohio, for Appellant. Robert Edward Hoskins, FOSTER LAW FIRM, LLP, Greenville, South Carolina, for Appellee. ON BRIEF: Jeffrey D. Zimon, BENESCH, FRIEDLANDER, COPLAN & ARONOFF, LLP, Cleveland, Ohio, for Appellant. Unpublished opinions are not binding precedent in this circuit. PER CURIAM: This case arises from the revocation by appellant Eaton Corporation Long Term Disability Plan ( Eaton ) of long-term disability ( LTD ) benefits provided to appellee Statia Scott. The district court reversed Eaton s decision and awarded LTD benefits to Scott. Because we find that Eaton s decision was not an abuse of discretion, we reverse. I. A. Eaton is the administrator of a LTD benefit plan for the employees of Eaton Corporation, a manufacturer of, inter alia, electrical components. Benefits are funded by premiums paid by the contributions employees general assets. and by from Eaton Corporation s This LTD plan is a welfare plan governed by the Employee Retirement Income Security Act ( ERISA ). 3(1). ERISA ยง Eaton is the plan administrator and has discretion to interpret and apply its provisions. Eaton has delegated claims administration Management to Sedgwick Claims Service, Inc. ( Sedgwick ). To be eligible for benefits under the plan, a beneficiary must have a covered disability and must be under the continuous care of a physician who verifies the beneficiary s disability to the satisfaction of the claims administrator. 2 As relevant to this appeal, a covered disability is an injury that renders the beneficiary totally and continuously unable to engage in any occupation or perform any work . . . for which [she is], or may become, reasonably well fit by reason of education, training, or experience. eligibility, J.A. the 67. After claims an initial administrator evaluations to revalidate eligibility. determination performs of periodic The burden is on the beneficiary to show at the initial determination stage and at subsequent revalidations that she is disabled. LTD benefits end on [t]he first day for which [the beneficiary is] unable to provide satisfactory evidence of a covered disability. 71. J.A. The disability must be shown at all times by objective findings, i.e., those that can be observed by [a] physician through objective means, not description of the symptoms. from J.A. 73. [the beneficiary s] In addition, for those claiming to be disabled due to mental illness, they must be under the continuous care of a psychologist or psychiatrist. B. Because our review is very fact-dependent, we lay out the history of Scott s disability and treatment in some detail. Eaton Corporation employed Scott for approximately 17 months. In 1998, Scott stopped working because of chronic pain in her right wrist and arm. of a childhood The chronic pain appears to be the result injury that healed 3 improperly and that was aggravated by an injury at work. Eaton initially granted Scott benefits in 1998 based on this right arm pain. In August 2003, Scott had surgery to address her right arm pain. Two months after surgery, her orthopedist, Dr. Timms, noted no wrist misalignment, and although Scott complained of crepitus 1 in her wrist, Dr. Timms saw no real signs of anything going wrong and opined, overall things look good. J.A. 437. Three months after surgery, Dr. Timms noted that Scott s wrist had loosened up nicely; that she was not experiencing a lot of pain or swelling; and that her range of motion was quite improved. J.A. 442. Five months after surgery, however, Scott complained that the pain in her wrist had returned and that she was experiencing decreased sensation and shooting pains. 443. J.A. Dr. Timms could not pinpoint the cause of the symptoms, noting that, she is just having generalized pain. is no swelling. full. Incisions are clean. Again, there Motion appears to be J.A. 444. Scott s LTD benefits were terminated in 2004 based upon insufficient documentation of a functional impairment that would preclude [Scott] from the job duties of any occupation. J.A. 119. Scott appealed this termination and Eaton reinstated 1 Crepitus is a palpable or audible grinding. The Merck Manual of Diagnosis and Therapy 285 (Robert S. Porter et al. eds., 19th ed. 2011). 4 her benefits after an independent medical evaluation. This independent medical evaluation noted that Scott s symptoms were possibly caused by Reflex Sympathetic ( RSD ) 2 Dystrophy secondary to her 2003 surgery. In 2005, benefits. Scott The applied Social for Security Social Security Administration disability denied Scott benefits because it concluded that she was not disabled. 3 Also in 2005, Scott presented to Dr. Riley--her primary physician-with swelling in her feet and ankles. Later, a blood test showed elevated levels of Rheumatoid Factor ( RF ). 4 Based upon these Rheumatoid symptoms Arthritis and ( RA ), rheumatologist. Scott s Dr. Scott family Riley history suggested declined. that of Scott Nevertheless, see Dr. a Riley eventually diagnosed Scott with RA. In 2006, as part of a periodic revalidation of her eligibility for benefits, Eaton required Scott to undergo an 2 RSD, also known as complex regional pain syndrome, is a neurological condition that typically follows an injury, and is characterized by various degrees of burning pain, excessive sweating, swelling, and sensitivity to touch. The Merck Manual of Diagnosis and Therapy, supra, at 1633-34. 3 This was Scott s second such denial. Scott was previously denied Social Security disability benefits because she had not yet paid enough into the system to become eligible. 4 RFs are antibodies that are present in about 70 percent of patients with RA. The Merck Manual of Diagnosis and Therapy, supra, at 333. 5 independent medical rheumatologist, evaluation Dr. Stephenson, by a rheumatologist. stated, Scott s The [p]revious diagnosis of RSD and as well as RA are not supported by my examination. . . . factor. J.A. I don t think the RA is currently a clinical 510. being overmedicated. Dr. Stephenson also believed Scott was He concluded that Scott s chronic pain was most likely caused by her depression and anxiety. 5 Nonetheless, Dr. Stephenson believed Scott was totally disabled based on her pain and mental illness. Revalidation of Scott s disability began again in 2007. part of this revalidation, Sedgwick asked Scott s As treating physicians to complete questionnaires and submit medical notes from recent examinations. In his medical notes from May 1, 2007, Dr. Riley indicated that Scott s RA symptoms were worsening. Dr. Riley indicated that Scott told him that she has not seen a rheumatologist. is unclear if Dr. Riley was aware of Dr. It Stephenson s examination of Scott in 2006 and his conclusion that Scott was 5 Dr. Stephenson did not discuss Scott s mental illness indepth. The first indication in the record that Scott suffers from mental illness is a 2004 letter from Dr. Riley noting that Scott suffers from anxiety and is taking Valium. It appears Dr. Riley first prescribed Scott an antidepressant, Lexapro, in January of 2007. 6 not suffering from RA. Dr. Riley also noted that Scott was on pain medication, which she tries to take sparingly. J.A. 532. 6 In a questionnaire from Sedgwick completed by Dr. Riley on September 22, 2007, Dr. Riley concluded that Scott was totally disabled due to her anxiety and depression and pain in her right arm. Dr. Riley made no mention of Scott s previous diagnoses of RSD and RA. Dr. Riley also indicated for the first time that the medication Scott was taking made it difficult for her to concentrate. In medical notes from October 4, 2007, Dr. Riley concluded that Scott is permanently disabled secondary to RA and RSD. J.A. 547. Dr. Riley also indicated that Scott had been seeing Dr. Sida, a neurologist, for treatment. The times. record In shows notes that from Dr. Dr. Sida Sida, examined dated Scott October 3, multiple 2007, he observed that Scott was alert and oriented and had normal language and attention. Scott could perform memory was normal. J.A. 545. serial seven Dr. Sida also noted that calculations 7 and that her X-rays ordered by Dr. Sida indicated that Scott was suffering from degenerative facet joint arthritis of 6 At the time of the most recent review of her eligibility, Scott was taking Mobic and Percocet. 7 A test for mental function, where a patient is asked to count down from 100 by sevens. 7 mild degree . . . and mild osteoarthritis. from his stated, November he could persistent pain. has been 7, told 2007, not find J.A. 255. she treating for this. examination has a J.A. 248. of In notes Scott, neuropathic Dr. cause Sida for her Dr. Sida also noted that Scott rheumatoid arthritis but no one is Id. Between December 13, 2007, and March 25, 2008, it appears from the record that Dr. Riley examined Scott three times. Dr. Riley s medical notes indicate that on December 13, 2007, Scott came [i]n for follow up on rheumatoid arthritis. Dr. Riley ordered a blood test, which showed J.A. 259. Scott had an Scott was examined by Dr. Riley again on March 7, 2008. On elevated RF level. an examination RSD. sheet J.A. 266. to work. Id. under Assessment:, Dr. Riley wrote, Under Plan:, Dr. Riley wrote, Still unable No mention is made of RA. In a Sedgwick questionnaire completed by Dr. Riley on March 17, 2008, he noted for the first time that side effects from Scott s pain medication interfere[] with her ability to work, J.A. 264, but he did not describe what this interference was or provide objective findings to substantiate such interference. After her next exam--on March 25, 2008--on an examination sheet under arthritis. Assessment:, J.A. 268. Dr. Riley wrote, Rheumatoid On the sheet, Dr. Riley also checked the 8 box next to edema and noted that Scott s hands and feet were puffy. Sedgwick also asked Dr. Riley to capacity evaluation ( PCE ) for Scott. fill out a physical On the PCE, Dr. Riley indicated that Scott was capable of sitting, standing, walking, speaking, and viewing a computer screen for 8 hours a day. Despite this, on the same PCE, Riley concluded that Scott could do zero hours of sedentary work per day. To address this apparent inconsistency, a Sedgwick representative contacted Dr. Riley by phone. The Sedgwick representative reported that Dr. Riley said that Scott was capable of sedentary work. To summarize, Scott had, at various times, been diagnosed with four potentially evidence as to each. a neurological disabling conditions, with conflicting Two doctors had diagnosed Scott with RSD-- condition--but Dr. Stephenson rejected this diagnosis and Scott s treating neurologist, Dr. Sida, could find no neurological cause for her pain. Scott with rejected RA; this however, Dr. diagnosis, rheumatologist for treatment. Dr. Riley had diagnosed Stephenson, and Scott had a rheumatologist, never seen a Two doctors also diagnosed Scott as suffering from mental illness; Scott, however, has never been under the continuous care of a psychologist or psychiatrist, as required by the plan. Dr. Riley also concluded that the side effects from Scott s pain medication would interfere with her 9 ability to work, but no objective findings exist in the record to substantiate such interference. Also, Dr. Riley previously noted that Scott tried to take her medication sparingly, and Dr. Sida concluded that Scott had normal cognitive functioning. Finally, as to the cumulative effect of Scott s ailments on her ability to work, Dr. Riley came to conflicting conclusions on the PCE and, when asked to clarify, stated that Scott could perform sedentary work. C. Sedgwick submitted the above information along with Scott s medical records to a specialist rheumatology, Dr. Lumpkins. report, concluded that in internal medicine and Dr. Lumpkins, in a July 23, 2008, Scott could perform sedentary work. First, Dr. Lumpkins noted that Scott s primary physician, Dr. Riley, had concluded that Scott could perform sedentary work. Regarding Scott s RSD, Dr. Lumpkins concluded that Scott could perform work so long as it did not entail repetitive fine motor manipulation. J.A. 575. As to concerns regarding potential side effects of Scott s pain medication, Lumpkin concluded that one medication Scott was taking, Mobic, would not be expected to influence [Scott s] functional ability in a sedentary . . . work environment. J.A. 578. As to another medication, Percocet, Lumpkin concluded that its side effects would limit Scott from working at unprotected heights, driving a company 10 vehicle, [and] working with heavy machinery or safety sensitive materials. Id. As to Dr. Riley s diagnosis of RA, Dr. Lumpkins noted that while there was some objective evidence that Scott has some sort of arthritis, conclude that Scott had RA. it was insufficient to Based on Dr. Lumpkins s report, on October 7, 2008, Sedgwick notified Scott that her LTD benefits would cease starting November 1, 2008. Scott procedure sought on review October 25, of this 2008. decision On pursuant November 7, to 2008, plan Scott provided Sedgwick with a letter from Dr. Riley, dated October 11, 2008, in which he again asserted that Scott was totally disabled and could perform no work. In the letter, Dr. Riley referred to the side effects of the chronic medication that [Scott] takes, J.A. 552, but did not indicate what those side effects were. The letter contained no objective findings and did not attempt to explain his previous inconsistent conclusions on the PCE or sedentary work. his later statement that Scott could perform Dr. Riley also submitted additional information to Sedgwick in December 2008 and early 2009. This information showed that Dr. Riley had not seen Scott in person from March of 2008 until after Eaton revoked her benefits in October of that year. The information also indicated that in March of 2009, Dr. Riley ordered a bone scan for Scott to check for RA. scan revealed no obvious signs of RA. 11 The bone On review, Sedgwick engaged three physicians (a physical medicine specialist, a psychiatry and neurology specialist, and an internal medicine and rheumatology specialist) to re-evaluate Scott s medical records and speak with Dr. Riley. All three physicians concluded that Scott was able to work. Based on these reports, Sedgwick reaffirmed its original decision. Scott appealed this decision to Eaton, pursuant to plan procedure. Upon her appeal, Eaton provided her records to three anonymous physicians (a specialist in neurology, a specialist in psychiatry, and a specialist in physical medicine). physicians all concluded that Scott could work. Scott s appeal on September 28, 2009. letter, Eaton noted that the only J.A. 86. physician conclude Scott was disabled was Dr. Riley. These Eaton denied In its denial since 2007 to Eaton discounted Dr. Riley s conclusions based on the various inconsistencies among his diagnoses concluded dearth of that and his the weakness supporting lack of of objective objective Dr. findings. Riley s evidence, Eaton conclusions, and the the unanimous contrary view of the seven reviewing physicians, noted above, was enough to support the original revocation of Scott s LTD benefits. D. On October 9, 2009, Scott sued Eaton, seeking reinstatement of her benefits. On February 12 11, 2010, the district court stayed the action to permit Eaton to review an affidavit by Dr. Riley. 8 this Eaton agreed to reconsider its revocation in light of affidavit. anonymous After reviewing review physicians of who the affidavit, previously could work again came to the same conclusion. Eaton sustained the revocation. the concluded same Scott Based on this, As to Dr. Riley s assertion that Scott s medication will prevent her from working, Eaton noted: [A]lthough Dr. Riley expresses concern with respect to Ms. Scott s ability to perform sedentary work, given the medications she uses, his office notes and records do not evidence the cognitive changes that he told the independent physician reviewer may impact her functional capacity. J.A. 97. The parties then moved for judgment pursuant to the district court s Specialized Case Management Order for ERISA benefits cases. J.A. 1249. The district court found Eaton had abused its discretion in two ways. First, the district court concluded that Eaton acted unreasonably when, on review of its initial determination, it failed to give adequate weight to Dr. Riley s letter of October, 17, 2008: Instead of meaningfully 8 The affidavit was undated and not notarized, but appears to be from sometime in 2009. Scott s subjective complaints were listed and Riley averred that Scott s subjective complaints and limitations are consistent with her objectively diagnosed medical conditions, J.A. 598, but the affidavit listed no objective findings. Scott s medical conditions were noted as RSD and RA. 13 discussing the impact that Dr. Riley s subsequent letter had on the conclusion that Scott could perform sedentary work, Eaton turned to hired peer reviewers in an attempt to reconcile its initial determination disability. J.A. that Scott 1257-58. no longer Second, the had a covered district court concluded that Eaton violated terms of the plan when it failed to adequately address the impact of Scott s medication regime on her ability to work. J.A. 1259. The district court stated: Eaton s reviewers collectively failed to evaluate and consider the disabling side effects of Scott s narcotic medication. By failing to consider the side effects of Scott s pain medication, the Plan Administrator and its reviewers have disregarded the terms of the Plan. J.A. 1261-62. The district court accordingly reversed Eaton s revocation and awarded Scott LTD benefits. Eaton appealed. II. On appeal, Eaton argues that the district court erred when it reversed because Eaton s Eaton s decision to decision-making end Scott s process was LTD sound benefits, and its ultimate decision was supported by substantial evidence. We agree. Because the LTD plan granted Eaton discretionary authority to determine eligibility for benefits, the exercise of assigned 14 discretion is reviewed for abuse of discretion. Evans v. Eaton Corp. LTD Plan, 514 F.3d 315, 321 (4th Cir. 2008). district court functions in this context as a [T]he deferential reviewing court with respect to the [administrator s] decision, and we review the district court s decision de novo, employing the same standards applied by the district court in reviewing the [administrator s] omitted). In decision. Evans, we Id. provided a (internal helpful quotations and in-depth discussion of the abuse of discretion standard in ERISA cases, beginning with the following principle: At its immovable core, the abuse of discretion standard requires a reviewing court to show enough deference to a primary decision-maker s judgment that the court does not reverse merely because it would have come to a different result in the first instance. It is also discretion important standard . to . keep . like in mind other that such Id. at 322. the abuse standards, of bites mainly in close cases, and in a close case, a court should . . . acknowledge[] the essential equipoise and stay[] its hand. Id. at 325. Particularly as to ERISA, we advised, a court should not disturb an ERISA administrator s discretionary decision if it is reasonable, and an administrator s decision is reasonable if it is the result of a deliberate, principled reasoning process and if it is supported by substantial evidence. 15 Id. at 322 (internal quotations omitted). In Donovan v. Eaton Corp. LTD Plan, 462 F.3d 321, 329 (4th Cir. 2006), this court held an administrator s reasoning process to be unprincipled when the administrator ignored pro-beneficiary evidence. As we have noted, what rightly offended the Donovan court was not [the administrator s] selectivity (which is part of a plan administrator's job), but its wholesale disregard of evidence in the claimant s favor. Evans, 514 F.3d at 326 (quoting Donovan, 462 F.3d at 329). Applying these principles to the facts of this case, we conclude that Eaton s decision was reasonable. First, the district court was incorrect that Eaton disregarded Dr. Riley s October 2008 letter. The record is clear thoughtfully considered the views of Dr. Riley. reviewers discussed Dr. Riley s views, but that Eaton Eaton and its gave them little weight because of their inconsistency and the fact that many of them were not based on objective evidence. Furthermore, Dr. Riley s conclusions--those of a well-meaning family doctor--were contradicted by several specialists, who gave no indication of unreliability. conclusions in It was not unreasonable to discount Dr. Riley s these circumstances. See Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003) ( [C]ourts [may not] impose on plan administrators a discrete burden of explanation when they credit reliable evidence that conflicts 16 with a treating physician s evaluation. ); see also id. at 832 (noting that a treating physician s conclusion may be questioned because a treating physician, in a close case, may favor a finding of disabled ). Second, the district court was incorrect that Eaton ignored potential side effects of Scott s medication in concluding that she was able to work. Dr. Lumpkins, in reviewing Scott s record for Sedgwick, noted that Scott can do sedentary work but that side effects of Percocet would keep Scott from working at unprotected heights, driving a company vehicle, [and] working with heavy machinery or safety sensitive materials. J.A. 573. Then, in the final cancellation letter, Eaton stated, We also note that although Dr. Riley expresses concern with respect to Ms. Scott's medications evidence ability she the uses, cognitive to his perform office changes sedentary notes that he work and told given records the do not independent physician reviewer may impact her functional capacity. 92. the J.A. This is sufficient consideration, especially considering the lack of objective evidence supporting the existence of such side effects. See Evans, 514 F.3d at 326 (noting approvingly that [t]he benefits cancellation letter . . . gave due regard to the evidence in [the beneficiary s] favor ). Finally, the district court erred in reversing Eaton s decision, which was based upon--at best--conflicting evidence. 17 In favor of a finding of disability were only Scott s subjective complaints, the inconsistent conclusions of physician, and some objective evidence of RA. Scott s primary Against a finding of disability were not only the unanimous assessments by peer reviewers, but also the following facts: (1) Dr. Riley s diagnosis of RA has never been substantiated by a rheumatologist and a bone scan revealed no obvious signs of RA; (2) Dr. Riley s diagnosis Scott s of RSD, treating a neurological neurologist, condition, Dr. Sida, was refuted by who found no neurological cause of her pain; and (3) there is no objective evidence Scott suffers side effects from her medication and Scott had been observed by Dr. Sida as alert and oriented. 9 Based on this evidence, Eaton s decision to end Scott s benefits was not unreasonable. See Elliot v. Sara Lee Corp., 190 F.3d 601, 606 (4th Cir. 1999) (noting that an administrator does not abuse its discretion by denying benefits if the record contains conflicting medical reports ). 9 Scott has not argued that her mental illness entitled her to LTD benefits. 18 III. For the foregoing reasons, the holding of the district court is REVERSED. 19
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