Mason v. Federal Express Corp.
Mason v. Federal Express Corp.
Opinion of the Court
ORDER AND OPINION
[Re: Motions at dockets 55 and 57]
I. MOTIONS PRESENTED
At docket 55 plaintiff Maurice K. Mason (“Mason”) moves for judgment after a trial on the record pursuant to Federal Rule of Civil Procedure (“Rule”) 52 or, alternatively, summary judgment pursuant to Rule 56. Defendants Federal Express Corporation, FedEx Trade Networks Transport & Brokerage, Inc., Aetna Life Insurance Company, Federal Express Corporation Short Term Disability Plan, and Federal Express Corporation Long Term Disability Plan (collectively, “Defendants”) oppose Mason’s motion at docket 58 and cross-move for summary judgment at docket 57. These two filings are supported by a memorandum at docket 59. Mason replies in support of his motion at docket 66 and opposes Defendants’ cross-motion at dock
Oral argument was not requested and would not assist the court.
II. BACKGROUND
While he was employed by defendant FedEx Trade Networks Transport & Brokerage, Inc. (“FedEx Trade”) Mason was diagnosed with a rare autoimmune disease known as Stiff Person Syndrome (“SPS”). SPS is “manifested clinically by the continuous isometric contraction of many of the somatic muscles; contractions are usually forceful and painful and most frequently involve the trunk musculature, although limb muscles may be involved.”
Mason argues that Aetna abused its discretion by ignoring objective medical evidence in the record that shows that his SPS and the side effects of his medications prevent him from performing the duties of his former job. The following is a summary of the evidence in the record.
A. Initial Treatment from Medical Park Family Care
Beginning in early 2008 Mason repeatedly complained about muscle spasms to his primary care physicians at Medical Park Family Care,
B. SPS Diagnosis from the VA
In February 2010 Mason saw neurologist Gregg Meekins, M.D. with the VA Medical Center. Dr. Meekins noted Mason’s lengthy history “of severe spasms affecting hands, feet, torso, etc.,” and the multiple medications that Mason was taking “without benefit or .intolerable side effects of excessive sedation.”
C. Consult with Neurologist Wayne Downs, M.D.
Mason met with neurologist Wayne Downs, M.D. in April 2010. Mason described his history of cramping, which he said had gotten gradually worse.
Dr. Downs assessed Mason as having “anti-GAD65 stiff person syndrome.” As to Mason’s 'lack of focus and memory loss, Dr. Downs stated that Mason’s encephalopathy
D.Follow-Up Treatment
Following his consult with Dr. Downs, Mason returned to Medical Park Family Care complaining about the side effects of his medications. On May 7, 2010 Dr. Lord ordered Mason to taper off baclofen but stated that he would still “likely need high
On July 8, 2010 Mason saw Dr. Lord again, complaining that his SPS was worsening and that the tapering of the dosage of his muscle relaxants was not helping.
On July 15, 2010, Mason was admitted to the emergency department of Providence Alaska Medical Center, complaining of cramps and muscle spasms with pain that he described as a 10 on a scale of 0 to 10.
The next morning Mason met with Dr. Lord, who noted in his physical exam that Mason was suffering from “moderate pain/distress.”
In the following months Mason sought medical treatment repeatedly for his SPS, including the following visits:
• Dr. Lord’s July 27, 2010 physical exam notes state that Mason was suffering from “mild pain/distress” and had a “depressed affect.”27 Dr. Lord concluded that Mason’s SPS had deteriorated.28
• The next day Mason met with Dr. Meekins, complaining of painful spasms and stiffness in his trunk and extremities. Dr. Meekins described Mason’s SPS as “progressive.”29
• On August 16, 2010, Dr. Lord again examined Mason, assessed Mason’s SPS had deteriorated, and noted that he w as suffering from “mild pain/distress” and “[cjontinued diffuse muscle spasms.”30
• Dr. Lord examined Mason again on August 25, 2010, and again noted that Mason was suffering from “mild pain/distress” and had a “depressed affect.”31
• On September 22, 2010, Mason was referred to VA internist Madeleine M. Grant, M.D., who addressed Mason’s reports that his medicine was causing him to be too sedated to drive or work.32 Dr. Grant listed Mason’s treatment goal as “find[ing] medication that worked and did not affect him cognitively.”33 She recommended tapering Mason’s baclofen usage and gradually increasing diazepam.
*839 • In Dr. Lord’s notes to Mason’s September 29, 2010 visit, Dr. Lord states that he discussed Mason’s SPS with the VA and they agreed to “maximize the dosing of Valium to try and treat his spasms” and “[s]lowly titrate down the baclofen.”34
• On October 6, 2010, Mason complained to Dr. Lord that his body cramps had “worsened especially the feet and arms since tapering off of the baclo-fen” but he noticed less sedation.35
• On October 28, 2010, Dr. Lord again noted that Mason’s SPS had deteriorated, he was suffering “moderate pain/distress,” and had a “depressed affect.”36
• On November 15, 2010, Mason complained to Dr. Lord about “pain and discomfort and depression” from SPS. Dr. Lord’s physical exam noted that Mason was suffering from “moderate pain/distress” and had a “depressed affect.”37
• On December 23, 2010, Mason told another Family Park Medical Care physician, Jeffrey Kim, M.D., that he was doing “okay” on Valium but it made him “very sleepy and very poor functioning.”38
• On January 9, 2011, Mason was admitted to the emergency department at the hospital complaining of severe abdominal pain, which he graded as a 9 on a scale of 0 to 10.39 The emergency department physician noted that Mason alleviated his pain by taking his medication at home, but within about 20 minutes of presenting himself at the hospital Mason had already fallen asleep.40
E. Neuropsychological Exam
Because Mason was complaining of memory decline, Dr. Meekins referred Mason to neuropsychologist Paul D. Dukarm, Ph.D. for testing in September 2010. In his summary of his findings Dr. Dukarm states that Mason was “exhibiting variable neurocognitive performance deficits in the areas of executive functioning. Specifically, he [was] demonstrating impaired performance in the area of visuospatial organization and planning during problem solving and impaired response flexibility under changing conditions.”
F. Psychotherapy
On September 1, 2010, Mason was seen by Camilla A. Madden, Ph.D., a psychologist at the VA, who diagnosed Mason with severe depression related to his struggles at work and with his family because of the side effects of his medications and the limitations of his disorder.
G. Mason Applies For Short-Term Disability Benefits
Mason applied for short-term disability benefits in December 2010, stating that he was no longer able to work due to his SPS and described his symptoms as follows: “Muscle spasms all over, cramps all over, dystonia
H.Mason’s Supervisor States that Mason is Unable to Work
Mason worked as a manager for FedEx Trade who oversaw a group of 26 employees.
Combs stated that Mason started “really declining in the fall of 2009,” when he had “spasms much, more frequently and more severely.”
Combs’ report is consistent with a December 13, 2010 entry in Aetna’s claim records which states that Mason’s “HR Advisor” called Aetna because she wanted to help Mason with his claim. The advisor stated that she would “make [Mason] understand” what Aetna needed and would “ask' [Mason’s] girlfriend to help him, because he is in a lot of pain and many times he is [on] pain medicine and cannot understand what he is being asked.”
I. Mason’s Treating Physicians Opine That He Is Unable to Work
In June 2010 Dr. Lord filled out a FedEx form indicating that Mason was unable to perform any of his job functions due to his SPS, and his condition w as permanent.
The physician responsible for Mason’s primary care shifted from Dr. Lord to Dr. Kim.
J. Aetna Denies Mason’s Claim
Aetna denied Mason’s claim on March 28, 2011. In the denial notice Aetna Nurse Consultant Patricia Earns (“Earns”) writes that she reviewed Mason’s file and presented his claim to “an independent peer physicians [sic] specializing in internal medicine, neurology, and neuropsychol-ogy.” She informs Mason that Aetna determined that “the clinical data received and reviewed fails to support a functional impairment from [Mason’s] sedentary occupation.”
Aetna did find that some unspecified “data indicates that [Mason was] unable to work related to side effects of [his] medications.”
Aetna’s notice states that Mason needed to submit, among other things, “medical documentation that clearly states the significant objective findings that substantiate a disability.”
K. Mason Submitted Additional Information
Between the date of Aetna’s denial and the date Mason filed his appeal, Mason was admitted to the emergency department three times related to SPS spasms: on April 27,
On May 23, 2011, the Social Security Administration determined that Mason was disabled under the rules of its disability insurance program (“SSDI”).
Mason also submitted to Aetna letters from three of his treating doctors: Dr. Grant, Dr. Downs, and Dr. Madden. Dr. Grant wrote a letter dated March 3, 2011, stating that it was her opinion that Mason was unable to work on account of his disability “both due to severe discomfort from his stiff man syndrome, and also from side effects of the medication, which affects him cognitively.”
Dr. Downs wrote a letter dated June 10, 2011, stating that Mason’s “symptoms are consistent with [SPS] and blood work has been positive for the relevant antibodies. The diagnosis is not in question.”
The disease is extremely rare and poorly understood. There seem to be several etiologies, but the final result is significant loss of inhibition of spinal motor neurons which results in extreme excessive firing of these motor neurons and contraction of the innervated muscles. This is similar to but very much more severe than what is seen in spasticity after a stroke, and the spasms can in fact be severe enough to break bones. Symptoms can sometimes be controlled by medications, but the medications are extremely sedating, and we have as of yet been unable to give [Mason] any significant relief.90
In addition, Dr. Downs provided Aetna with a copy of the section from Goetz Textbook of Clinical Neurolgy that discusses SPS and directed its attention to the final section, “Prognosis and Future Perspectives.” That section reads as follows: “Without treatment, SPS progresses to total disability related to generalized rigidity and secondary musculoskeletal deformities. The pathogenetic autoimmune mechanisms remain to be elucidated.”
Finally, Dr. Madden wrote a letter dated July 13, 2011, in which she describes how the side effects of Mason’s medications impair his ability to function. She notes that Mason’s medications make him “very tired to the point of not being able to stay awake while engaged in an appointment. There have been therapy sessions with me when Mr. Mason has fallen asleep despite a valiant effort to stay awake and to benefit from the therapeutic encounter.”
L. Aetna’s Appeals Committee Upholds the Denial of Mason’s Claim The Plan provides that if an “adverse benefit determination is appealed on the basis of medical judgment, the appeal committee shall consult with an independent health care professional who is qualified in the areas of dispute who shall not have been involved in the initial claim denial.”
1. Aetna’s Internal Medicine Peer Reviews
a.) Wendy Weinstein, M.D.
Dr. Weinstein, who is board-certified in internal medicine, submitted a February 11, 2011 Peer Physician Review that states she reviewed various medical reports and concludes that “none of the examination findings by multiple providers have documented abnormalities that would preclude the claimant from performing a sedentary occupation.”
With regard to the effects of Mason’s SPS, Dr. Weinstein’s February 11 report states that Mason was noted to “walk stiffly” at “one point,” “but there has been no documentation of abnormal muscle tone on specific muscle testing or other muscu-loskeletal or neurologic examination abnormalities.” She acknowledges that Dr. Meekins diagnosed Mason with SPS in February 2010, but adds that “there was no documentation of any change in the claimant’s physical examination and no documentation of specific functional im
With regard to the side effects of Mason’s medications, Dr. Weinstein discounts Dr. Dukarm’s neuropsychological test’s conclusion that Mason was likely suffering from a cognitive defect caused in part by the effects of his medications. Dr. Wein-stein writes that the test’s “findings were non-specific and it was noted they could be attributed to medication affects, pain, and sleep disturbance as well as depression.”
Dr. Weinstein’s second review indicates that she was provided with a copy of Dr. Dukram’s neuropsychological test and Combs’ email.
b.) Second Opinion From Dennis Mazal, M.D.
Dr. Mazal, who is board certified in pul-monology and internal medicine, submitted an August 8, 2011 Peer Physician Review that states that he cannot “discuss functionality” based on Mason’s SPS diagnosis because neurological diagnoses are “not within the scope of [his] specialty.”
With regard to the side effects of Mason’s medications, Dr. Mazal wrote without further explanation that “[tjhere is no documentation that any of those medications caused any clinically significant side effects or adverse reactions that impact the claimant’s ability to perform the duties of a sedentary demand occupation during the time period under consideration.”
2. Aetna’s Neuropsychology Peer Reviews
a.) Elana Mendelssohn, Phy.D.
Dr. Mendelssohn, who is board certified in clinical psychology and neuropsycholo-gy, submitted a February 24, 2011 Peer Physician Review. Dr. Mendelssohn prefaced her report by noting that most of the records she reviewed pertain to Mason’s “physical complaints” related to SPS, and therefore she deferred “to the appropriate medical specialists to determine the impact
With regard to the side effects of Mason’s medications, Dr. Mendelssohn noted that “various treating providers included sporadic reports of [Mason’s] emotional and cognitive difficulties,” but discounted this by concluding that none of those providers “included specific measurements of [Mason’s] cognition or a description of direct and observed behaviors to corroborate the presence of impairment in neuropsy-chological functioning.”
Dr. Mendelssohn noted that Dr. Du-karm’s neuropsychological exam diagnosed Mason with a cognitive disorder secondary, in part, to the side effects of his medications. But she then offered four reasons for why she discounted the results of this test: (1) Mason continued to work afterward; (2) “there was no indication that [Dr. Dukarm] utilized symptom validity measures to ensure adequate effort and motivation and valid test findings; (3) “office visits just prior to and after the neu-ropsychological examination noted that the claimant presented as alert and oriented with normal attention and concentration;” and (4) “none of [Mason’s] providers indicated that the claimant was unable to work in relation to his neuropsychological status.”
After reviewing Combs’ email that outlined Mason’s problems at work, Dr. Mendelssohn maintained that Mason had not shown that he is disabled because: (1) Combs’ report of Mason slurring words was not reflected in the documents that she reviewed previously; (2) although Combs reported that Mason was falling asleep at work, “there was no indication that [Mason] fell asleep during [Dr. Du-karm’s] evaluation;” (3) “[a]lthough [Dr. Dukarm] noted that [Mason] appeared lethargic, more specific description was not included;” and (4) there was no indication from Mason’s various office visit notes that he was “falling asleep during his office visits nor did the provided information include ... description of overt cognitive difficulties.”
b.) Second Opinion From Leonard Schnur, Phy.D.
Dr. Schnur, who is board certified in psychology, submitted an August 9, 2011 Peer Physician Review. He was provided with Dr. Madden’s July 13, 2011 letter. With regard to the side effects of Mason’s medications, Dr. Schnur’s report states
3. Aetna’s Neurology Peer Reviews a.) Vaughn Cohan, M.D.
Dr. Cohan, who is board certified in neurology, submitted a March 26, 2011 Peer Physician Review. After describing the records he reviewed, Dr. Cohan states that “[t]he neuropsychological and neuro-cognitive aspects of this case would fall outside the scope of general medical neurology” and therefore he deferred to Dr. Mendelssohn regarding those issues.
Dr. Cohan describes a “peer-to-peer consultation” he had with Dr. Kim, who is a family practitioner and not a neurologist, despite noting that Mason’s treating neurologists are Dr. Downs and Dr. Mee-kins.
Dr. Cohan relied heavily on Dr. Kim’s statements in his report. He states that “[although there are references to over-sedation in the medical record and as submitted by one of the claimant’s coworkers/managers, nevertheless, there is no independent medical verification or substantiation to that effect. When the claimant has been seen medically by medical providers, there has been no report of objective excess sedative or medication effect.”
b.) Second Opinion From Andrew J. Gordon, M.D.
Dr. Gordon, who is board certified in neurology, submitted an August 11, 2011 Peer Physician Review. Mason asserts that “Dr. Gordon was the only reviewer hired by Aetna that did not appear to be ‘in house.’ He apparently works for MES.”
The claimant is described by numerous doctors including two neurologists as having Stiff Man Syndrome. He tests positive twice (blood work). There are numerous notes indicating refractory spasms, cramping and poor work performance resulting from these symptoms. Evaluation and testing has excluded other diagnoses. The claimant is described as responding poorly to usual treatment and he is described as suffering from side effects with treatment which include lethargy and sleepiness. A supervisor at work documents his inability to properly perform his duties and gives numerous examples of his impairments that have occurred as a result of Stiff Man Syndrome. Finally, the treating neurologist notes that the claimant cannot work due to refractory symptoms and resultant functional impairment.127
In response to this report, Aetna sent Dr. Gordon the following message: “Dr. Gordon please clarify: You found the claimant to be impaired from 12/01/10 through current however; [sic] your report and findings were based on the medical data dated prior to the disability date under consideration of 12/01/10. Please review and comment on the medical data, physical exam findings that demonstrate'a functional impairment for the time period under review (12/01/10 through current).”
About one month later, Dr. Gordon submitted a second review in which he states that Aetna’s request for “clarification” changed his prior recommendation, and he now concludes that Mason has not shown that he is disabled. Dr. Gordon asserts that “records from earlier periods (early 2010 and before) document more significant difficulties with spasticity, gait impairment and altered mental status,” but “the more recent records from 12/1/10 onward do not demonstrate functional impairment from a neurologic perspective.”
III. STANDARD OF REVIEW
A. The Abuse of Discretion Standard Applies
To determine which standard of review applies in an ERISA benefits case, the court must determine whether the ERISA plan unambiguously grants discretion to the administrator.
Determining that the .abuse of discretion standard applies “is only the first step” in determining the standard by which courts review an administrator’s denial of benefits.
1. Conflict of Interest
“[T]he degree of skepticism with which [courts] regard a plan administrator’s decision when determining whether the administrator abused its discretion varies based upon the extent to which the decision appears to have been affected by a conflict of interest.”
Mason argues that Aetna 'operates under a conflict of interest -because its behavior is similar to the behavior of the administrators in Abatie,
But that is not the end of the story. Mason also argues that a conflict of interest exists here because “Aetna’s contract with FedEx depends on providing favorable financial results for FedEx.”
Defendants do not dispute that FedEx pays benefits claims out of its own undedi-cated funds. FedEx therefore has an obvious incentive to hire a Claims Paying Administrator that minimizes benefits awards. According to the Supreme Court in Glenn, an employer’s own conflict may “extend to its selection of an insurance company to administer its plan.”
It is apparent from the record that FedEx’s (and by extension, Aetna’s) conflict of interest significantly colored the decision-making process. Nowhere is this conflict more evident than with Aetna’s response to Dr. Gordon’s initial finding that Mason is disabled. Aetna’s treatment of Dr. Gordon’s disability finding suggests bias for at least five reasons. First, Aetna’s request for “clarification” misleadingly implies that Dr. Gordon’s initial report only considered medical data dated before December 1, 2010.
Second, Mason asserts and Aetna does not deny that the Plan does not forbid consideration of medical records that predate the date of the claim.
Third, Aetna asked Dr. Gordon to submit a new report, ostensibly because he relied on pre-December 2010 data, but it did not ask the same of its doctors who found that Mason was not disabled, even though they, too, relied on such data.
Fourth, the date restriction that Aetna imposed on Dr. Gordon is inconsistent with the scope of records upon which Aetna itself relied. For example, Aetna’s initial denial letter references Mason’s September 2010 neuropsychological exam, and its final denial letter relies on exam reports from July 16, 2010 and November 24, 2010.
Finally, Dr. Gordon’s supplemental report indicates that he was influenced by Aetna’s suggestive request for “clarification.” Dr. Gordon’s second report concludes that “[w]hile records from earlier periods (early 2010 and before) document more significant difficulties with spasticity, gait impairment and altered mental status; the more recent records from 12/1/10 onward do not demonstrate functional impairment from a neurologic perspective.”
2. Procedural Irregularities
“A procedural irregularity, like a conflict of interest, is a matter to be weighed in deciding whether an administrator’s decision was an abuse of discretion.”
Saffon is instructive. In Saffon the claimant was receiving disability benefits on account of degeneration of her cervical spine.
Although the claimant submitted additional evidence on appeal, Metlife’s second reviewing doctor reached the same conclusion as its first: there was “ ‘not enough objective medical findings and office notes’ ” showing that the claimant’s “ ‘self-reported headache and chronic pain syndrome has been enough to preclude her from’ working.”
The Ninth Circuit held that MetLife’s termination was riddled with procedural eiTors. It held that MetLife’s termination letter was insufficient for at least three reasons. First, although the letter notes that “ ‘[t]he medical information provided no longer provides evidence of disability that would prevent [the claimant] from performing [her] job or occupation,”’ it does not “explain why that is the case, and certainly does not engage [the claimant’s treating neurologist’s] contrary assertion.” Second, although the letter suggests that the claimant can “appeal by providing ‘objective medical information to support [her] inability to perform the duties of [her] occupation,’ ” it “does not explain why the information [she] has already provided is insufficient for that purpose.”
The procedures that Aetna followed in this case are even more flawed that those at issue in Saffon.
ERISA plan administrators “must follow certain practices when processing and deciding plan participants’ claims.”
Aetna’s March 28, 2011 denial notice analyzes hundreds of pages of Mason’s medical records in one paragraph containing a series of disjointed sentences.
The record is replete with similar examples. Aetna’s denial notice does not disclose to Mason that Dr. Mendelssohn discounted his doctors’ observations of his emotional and cognitive difficulties because those doctors did not include “specific measurements of [Mason’s] cognition or a description of direct and observed behaviors to corroborate the presence of impairment in neuropsychological functioning.”
Further, when Dr. Kim filled out Aet-na’s “Attending Physician Statement” form, he listed numerous diagnostic test results that, in his opinion, were “objective data” that document Mason’s disability, including the lab tests that confirmed Mason’s diagnosis.
b. Aetna Failed to Engage in a Good Faith Exchange of Information
In determining the degree of deference to which an administrator is entitled, courts must also consider its course of dealing with the claimant and her doctors.
Defendants argue that Mason had no right to review and rebut its peer review reports “generated during the appeal process.”
What is more, Aetna even failed to provide its own reviewers with pertinent records. As Mason observes, Aetna failed to provide Dr. Weinstein or Dr. Mendelssohn with any records from his treating psychologist, Dr. Madden.
This particular deficiency was likely significant to Dr. Weinstein’s and Dr. Mendelssohn’s findings. Dr. Mendelssohn concludes that none of the records that Aetna provided her show that Mason “was falling asleep during his office visits nor did the provided information include ... description [sic] of overt cognitive difficulties.”
Finally, Aetna’s physicians erred by not engaging in peer-to-peer consultations with Mason’s physicians to resolve perceived ambiguities in Mason’s records.
B. A Bench Trial on the Record Would be Improper
The parties dispute whether the proper vehicle for determining Mason’s benefit claim is a “bench trial on the record” followed by a judgment that complies with Rule 52 or summary judgment under Rule 56. Relying on Kearney v. Standard Insurance Company,
Mason is essentially seeking to transform this abuse-of-discretion case into one involving de novo review. But, because the cases upon which his argument relies involve de novo review, his argument misses the mark.
C. Summary Judgment Principles Have Limited Application
Because of the limited nature of review, “[t]raditional summary judgment principles have limited application in ERISA cases governed by the abuse of discretion standard.”
IV. DISCUSSION
A. FedEx Trade Is Not a Proper Party
Defendants argue that Mason’s employer, FedEx Trade, is not a proper party to this action because it is only a “Controlled Group Member” and “Sponsoring Employer,” and it does not exercise any control over the plan as an administrator or otherwise.
Mason responds by stating that he is not pursuing a § 1132(a) claim against FedEx Trade, but rather a claim that arises under § 1132(c) f or FedEx Trade’s violation of 29 U.S.C. § 1024(b)(4) and 29 C.F.R. § 2560.503 — l(h)(2)(iii).
B. Aetna Abused Its Discretion
The court finds that, based on the record that Aetna had before it, Aetna abused its discretion in denying Mason’s claim. The evidence in the record shows that Mason suffers from a permanent disability that prevents him from working. Aetna’s conclusion to the contrary is illogical, implausible, and not supported by the facts.
1. Evidence of Mason’s Medical Conditions
As noted above, the fundamental basis of Mason’s claim is his contention that he can no longer work because he suffers from a combination of (1) painful spasms and (2) the negative side effects from the medication he takes for those spasms,
a.) SPS Symptoms
There is ample objective evidence in the record showing that Mason suffers from painful spasms, including Mason’s blood tests that came back positive for SPS and exam notes that show Mason has been repeatedly observed suffering from symptoms typical of this disease: spasms, pain, and stiffness.
Inexplicably, both of Aetna’s denial notices fail to mention Mason’s positive lab results. Aetna’s final denial notice also does not connect his spasm s with his SPS diagnosis, stating only that the data show that Mason “had stiffness and muscle pain.”
b.) Medication Side Effects
Aetna does not dispute that Mason’s medications can potentially cause side effects of sedation and cognitive impairment; it .does dispute that Mason was in fact suffering from them.
Ample evidence in the record shows that Mason’s medication had a sedative effect, including all 14 visit notes from Dr. Madden, various visit notes from other doctors,
Dr. Dukram’s neuropsychological test is also objective evidence that Mason suffers from a cognitive disorder. Over the course of this four-hour exam, Dr. Dukram subjected Mason to a litany of tests,
As Defendants point out, just because someone has a medical condition does not by itself establish disability.
Dr. Lord, Dr. Kim, and Dr. Grant each concluded that Mason is unable to work on account of his medical conditions. Aetna’s denial notices do not consider these significant opinions, let alone explain why these three treating physicians got it wrong. Aetna also failed to consider Mason’s SSDI award as evidence of his disability. “Social Security disability awards do not bind plan administrators, but they are evidence of disability. Evidence of a Social Security award of disability benefits is of sufficient significance that failure to address it offers support that the plan administrator’s denial was arbitrary, an abuse of discretion. Weighty evidence may ultimately be unpersuasive, but it cannot be ignored.”
Finally, Aetna failed to consider the only evidence in the record regarding Mason’s actual performance at work: Combs’ email. In her email Combs states that Mason fell asleep on the job “many times,” had difficulties focusing and remembering things, and had become a “grave liability” for the company. Aetna’s two denial notices completely ignore this probative evidence.
Before receiving Combs’ email, Drs. Mendelssohn and Weinstein each concluded that the side effects of Mason’s medications must not have been so bad because he was still able to work.
V. CONCLUSION
For the reasons set forth above, Plaintiffs motion at docket 55 for judgment pursuant to Rule 52 is DENIED. Summary judgment is GRANTED in favor of FedEx Trade Networks Transport & Brokerage, Inc. In all other respects, Plaintiffs motion for partial summary judgment at docket 55 is GRANTED, and Defendants’ cross-motion for partial summary judgment at docket 57 is DENIED. Defendants are hereby ORDERED to grant' Plaintiffs claim for short-term disability benefits.
. Stedman’s Medical Dictionary (2014). See also doc. 32-2 at 9.
. 29U.S.C. §§ 1001-1461.
. Doc. 32-2 at 122. See also Mason’s November 26, 2008 chart note, id. at 126 ("This 44-year-old male is having unusual symptoms that continue, which include this type of cramping sensation of his extremities associated with some tremors.He is noting increased intensity and frequency recently.”); his April 21, 2009 chart note, id. at 127 ("[H]as had an increase in his muscle spasm. .... Primarily they are in the hands, forearms, lower legs and feet.”); his October 15, 2009 notes, id. at 130 ("This 45-year-old male presents with a long history of cramping in the extremities and neck as well. It has been going on for greater than a year.”); his November 11, 2009 notes, id. at 132 (“45-year-old male presents for a constant cramping pain in his neck for the past 3-4 days. Pain intermittently down both arms, tingling or burning and somewhat painful, associated w/ hand and finger spasms or locking up.”); his February 4, 2010 notes, id. at 136 (“Chief Complaint: Cramping in stomach, arms, and legs that will not stop, and along with headaches (since Monday).”); his February 12, 2010 notes, id. at 138; and his February 15, 2010 notes, id. at 140 ("This patient returns with continued spasms of the extremities and cramping with headaches of concern it may have been related to anxiety a full work up has been done with no etiology determined at this time.”).
.See, e.g., Masons’s November 26, 2008 chart note, id. at 126 ("Extremity cramping, tremors, and weakness. The etiology Is not clear.”); and his February 4, 2010 note, id. at 137 (“Unclear etiology of patent’s symptoms ....”).
. Id. at 129.
. Id.
. Id. at 57.
. Id.
. Id.
. Id. at 101.
. Id. at 108.
. Id. at 146.
. Id.
. Id.
. Encephalopathy is a disorder of the brain. Stedman’s Medical Dictionary (2014).
. Doc. 32-2 at 146.
. Id. at 148.
. Id. at 149.
. Id. at 153.
. Id. at 163.
. Id.
. Id. at 52.
. Id. at 53.
. Id. at 164.
. Id. at 55.
. Id.
.Id. at 168.
. Id.
. Id. at 61.
. Id. at 173.
. Id. at 175.
. Id. at 68.
. Id. at 69.
. Id. at 181.
. Id. at 183.
. Id. at 188.
. Id. at 190.
. Id. at 192.
. Id. at 48.
. Id. at 49.
. Id. at 77.
. Id.
. Id.
. Id.
. Id:
. Id. at 77-78.
. Id. at 64-65.
. See, e.g., id. at 66-67; 71-72; 79-82; 83-84; 88-89, 90-91; 94-85; 97-98.
. Dystonia is defined as "[a] syndrome of abnormal muscle contraction that produces repetitive involuntary • twisting movements and abnormal posturing of the neck, trunk, face, and extremities.” Stedman’s Medical Dictionary (2014).
. Doc. 32-3 at 32-33.
. See the Plan § 1.1 (s), doc. 32-6 at 50. See also Doc. 59 at 4.
. Doc. 32-2 at 235.
. Id. at 236.
. Id.
. Id.
.' Id.
. Id. at 237.
. Id.
. Id.
. Id.
. Id.
. Doc. 32-3 at 45.
. Doc. 32-2 at 159-62.
. Id. at 172.
. Id.
. Doc. 55 at 11.
. Doc. 32-2 at 194.
. Id. at 198.
. Id. at 196.
. Id. at 199.
. Id. at 4.
. Id.
. Id. (emphasis added).
. Id.
. Id. (emphasis added).
. Id.
. Id. at 5.
. Id.
. Id. at 4.
. Doc. 32-3 at 19.
. Doc. 32-2 at 32-39 (Mason was suffering from "still present,” severe, "whole body spasms” and listed his pain level at 10 on a scale of 0 to 10).
. Id. at 22-31 (Mason was taken to the emergency room in an ambulance complaining of
. Id. at 15-21 (Mason had fallen after suffering a spasm in his right leg, and was diagnosed with a left ankle sprain and right quadriceps strain).
. Id. at 11.
. Id. at 12.
. Cleveland v. Policy Mgmt. Sys. Corp., 526 U.S. 795, 797, 119 S.Ct. 1597, 143 L.Ed.2d 966 (1999) (citing § 223(a) of the Social Security Act, as set forth in 42 U.S.C. § 423(d)(2)(A)).
. Doc. 32-2 at 11.
. Id. at 121.
. Id. at 8.
. Id.
. Id. at 9.
. Id. at 13.
. Id.
. Id.
. Doc. 32-6 at 72.
. Doc. 32-1 at 1.
. Id. at 2.
. Doc. 32-2 at 260.
. Id. at 255, 260.
. Id. at 255.
. Id. at 260.
. Id. at 256.
. Id.
. Id. at 258.
. Id. at 260.
. Id. at 259.
. Doc. 32-3 at 1.
. Id.
. Doc. 32-2 at 242.
. Id. at 245.
. Id. at 245, 249.
. Id. at 245.
. Id.
. Id. at 249-50.
. Id. at 250.
. Doc. 32-3 at 6.
. Doc. 32-2 at 265.
. Id. at 245, 249.
. Id. at 265.
. Id.
. Id.
. Id. at 266.
. Id. at 264.
. Id. at 266.
. Doc. 55 at 23.
. Doc. 32-3 at 11.
. Id.
. Id. at 14-15.
. Id. at 15.
. Pac. Shores Hasp. v. United Behavioral Health, 764 F.3d 1030, 1039 (9th Cir. 2014).
. Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 673 (9th Cir. 2011).
. Doc. 55 at 28; Doc. 59 at 16.
. Abatie v. Alta Health & Life Ins. Co., 458
. Pac. Shores Hosp., 764 F.3d at 1042.
. Stephan v. Unum Life Ins. Co. of Am., 697 F.3d 917, 929 (9th Cir. 2012) (quoting Salo-maa, 642 F.3d at 676).
. Saffon v. Wells Fargo & Co. Long Term Disability Plan, 522 F.3d 863, 867 (9th Cir. 2008).
. Id. at 868.
. Abatie, 458 F.3d at 972,
. Stephan, 697 F.3d at 929.
. Abatie, 458 F.3d at 965 (quoting Firestone, 489 U.S. at 115, 109 S.Ct. 948).
. Montour v. Hartford Life & Acc. Ins. Co., 588 F.3d 623, 630 (9th Cir. 2009).
. Abatie, 458 F.3d at 967-68. See also Salo-maa, 642 F.3d at 681 (Hall, J., dissenting) ("Although this standard’s dualism between skepticism and deference may seem strange, it is the proper standard and must be applied carefully.”).
. Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 117, 128 S.Ct. 2343, 171 L.Ed.2d 299 (2008).
. Abatie, 458 F.3d at 959.
. Saffon, 522 F.3d at 866.
. Montour, 588 F.3d at 626-27.
. Salomaa, 642 F.3d at 674.
. Abatie, 458 F.3d at 965 n. 5 (citing Firestone, 489 U.S. at 105, 109 S.Ct. 948).
. Abatie, 458 F.3d at 966.
. Doc. 59 at 3 n 3-4.
. Doc. 32-6 at 1.
. Id. at 3.
. Doc. 55 at 37.
. Doc. 59 at 23.
. Glenn, 554 U.S. at 114, 128 S.Ct. 2343.
. Abatie, 458 F.3d at 977 (Kleinfeld, J., concurring).
. Id.
. Id.
. Doc. 32-3 at 15.
. See id. at 11 (noting that Mason tested "positive twice (blood work)” for SPS); id. at 10 ("Anti-GAD antibodies (diagnostic test for Stiff Man Syndrome) are positive (slightly elevated) on 12/7/10 and significantly elevated on 2/24/10 and negative from 7/28/10.”).
. Id. at 11 ([T]he treating neurologist notes that the claimant cannot work due to refractory symptoms and resultant functional impairment.”).
. Doc. 64 at 31.
. See Doc. 32-2 at 243-45, 252-256, 259-60.
. Doc. 32-3 at 15.
. Doc. 32-2 at 160 (“Probable duration of condition: life long”); id. at 161 ("[E]stimate the beginning and ending dates for the period of incapacity: permanent”); id. at 194 (stating that Mason’s SPS “has rendered him permanently disabled.”); id. at 198 ("I anticipate significant clinical improvement by (date): never.”). See also id. at 8-9. These prognoses are consistent with Dr. Meekins' assessment of Mason's SPS as progressive on July 28, 2010. Id. at 61. See also id. at 172 (Dr. Lord noted on July 29, 2010, that Mason’s symptoms have "progressively worsened and his symptoms are currently poorly controlled.”); id. at 173 (Dr. Lord noted on August 16, 2010, that Mason’s SPS had "deteriorated”); id. at 188 (Dr. Lord noted on October 28, 2010, that Mason’s SPS had “deteriorated”).
. Abatie, 458 F.3d at 972.
. Id. (quoting Jebian v. Hewlett-Packard Co. Employee Benefits Org. Income Prot. Plan, 349 F.3d 1098, 1107 (9th Cir. 2003)).
.Id. at 973.
. Pac. Shores Hosp., 764 F.3d at 1040. See also Abatie, 458 F.3d at 972.
. Saffon, 522 F.3d at 866.
. Id. at 869.
. Id.
. Id. at 869-70.
. Id. at 870.
. Id. at 871.
.Id. at 873.
. Abatie, 458 F.3d at 971.
. Booton v. Lockheed Med. Ben. Plan, 110 F.3d 1461, 1463 (9th Cir. 1997) (citing former 29 C.F.R. § 2560.503 — 1(£)). The pertinent language is now codified at 29 C.F.R. § 2560.503-l(g).
. Booton, 110 F.3d at 1463. See also 29 C.F.R. § 2560.503-l(g)(l) (requiring, among other things, that notices of adverse benefit determinations must set forth "in a manner calculated to be understood by the claimant:” (i) "[t]he specific reason or reasons for the adverse determination;” (ii) "[r]eference to the specific plan provisions on which the determination is based;” and (iii) "[a] description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary.").
. Doc. 32-2 at 4.
.Id. at 5.
. See Dr. Mendelssohn's first report, id. at 243-44 ("Dr. Dukarm noted that the claimant appeared lethargic, and the claimant reported having a headache and experiencing pain. There was no indication that formal measures of validity were utilized to ensure valid test results.”); id. at 245 (rejecting Dr. Dukarm’s cognitive disorder diagnosis in part because "there was no indication that the examiner utilized symptom validity measures to ensure adequate effort and motivation and valid test findings.”); Dr. Mendelssohn’s second report, id. at 249 ("[I]n my previous review I questioned the presence of whether the claimant’s test performance was reflective of valid test findings. However, validity could not be determined given that there was no indication that the examiner administered symptom validity measures to ensure optimal effort and motivation and validity of the neuropsycho-logical evaluation.”).
. 29 C.F.R. § 2560.503-1 (g)(1).
. Doc. 32-2 at 245.
. Id. at 255.
. Id. at 256.
. Id. 32-2 at 260.
. Cf.Abatie, 458 F.3d at 974.
. Doc. 32-2 at 198.
.. Id. at 4.
.Saffon, 522 F.3d at 873.
. Doc. 55 at 36.
. Doc. 32-2 at 4.
. Doc. 73 at 8 (citing Midgett v. Washington Grp. Int’l Long Term Disability Plan, 561 F.3d 887, 896 (8th Cir. 2009); Metzger v. UNUM Life Ins. Co. of Am., 476 F.3d 1161, 1166 (10th Cir. 2007); Warming v. Hartford Life & Acc. Ins. Co., 663 F.Supp.2d 10, 20 (D.Me. 2009); Winz-Byone v. Metro. Life Ins. Co., No. EDCV 07-238-VAP, 2008 WL 962867, at *8 (C.D.Cal. Mar. 26, 2008)).
. See Metzger, 476 F.3d at 1166 (holding that although plan administrators must release documents relied upon during the initial benefit determination, they need not release "documents generated during the appeal process itself.”); Midgett, 561 F.3d at 896 ("[T]he full and fair review to which a claimant is entitled under 29 U.S.C. § 1133(2) does not include reviewing and rebutting, prior to a determination on appeal, the opinions of peer reviewers solicited on that same level of appeal.") (emphasis added).
. Salomaa, 642 F.3d at 679 (citing 29 U.S.C. § 1133).
. Doc. 32-2 at 247-48.
. Doc. 73 at 7.
. Doc. 32-2 at 4.
. Id. at 241-42, 247-48.
. Id. at 241-46, 247-50.
. Id. at 249-50.
. Id. at 256.
. Id. at 63, 66, 72, 81, 83, 88, 91, 94, 97, 103, 106, 110, 113, and 117.
. Id. at 13. Although Defendants correctly note that Dr. Schnur was provided with Dr. Madden's records, he made no findings regarding the side effects of Mason's medications, stating that he lacked necessary expertise to do so. Doc. 32-3 at 6..
. The only Aetna physician that reached out to one of Mason’s treating physicians was
. Id. at 260.
. Id. at 172.
. Id. at 249.
. Booton, 110 F.3d at 1463.
. 175 F.3d 1084 (9th Cir. 1999) (en banc).
. Doc. 55 at 2.
. 228 F.3d 991, 996 (9th Cir. 2000) ("Kear-ney clarifies that participants and beneficiaries claiming benefits under ERISA are not entitled to ‘full trial[s] de novo' because such trials would undermine the policies behind . ERISA. Rather, Kearney created a 'novel form of trial,’ in which the district court, subject to its discretion to consider additional evidence under limited circumstances, is to conduct 'a bench trial on the record.’ ”) (citing Kearney, 175 F.3d at 1094, 1095 & n. 4).
. Doc. 64 at 2.
. See Kearney, 175 F.3d at 1095-96; Thomas, 228 F.3d at 994 ("As in Kearney, the district court should have reviewed Thomas’ claim de novo.”); O’Neal v. Life Ins. Co. of N. Am., 10 F.Supp.3d 1132, 1135 (D.Mont. 2014). But see Tapley v. Locals 302 & 612 of Int’l Union of Operating Engineers-Employers Const. Indus. Ret. Plan, 728 F.3d 1134, 1139 (9th Cir. 2013) (the district court conducted a trial on the record despite the fact that the abuse of discretion standard of review applied). Because the Ninth Circuit did not address the propriety of the district court’s procedural choice on appeal and, in any event, reversed the court's judgment, Tapley is not binding authority on this issue. Id. at 1139— 43.
. Kearney, 175 F.3d at 1095.
. 185 F.3d 939, 942-43 (9th Cir. 1999) (overruled on other grounds by Abatie, 458 F.3d at 965).
. Nolan v. Heald Coll., 551 F.3d 1148, 1154 (9th Cir. 2009).
. Bendixen v. Standard Ins. Co., 185 F.3d 939, 942 (9th Cir. 1999)
. Stephan, 697 F.3d at 929.
. Nolan, 551 F.3d at 1154.
. Doc. 59 at 16-17.
. 642 F.3d 1202, 1207 (9th Cir. 2011).
. 770 F.3d 1282, 1297 (9th Cir. 2014).
. Doc. 64 at 27.
. 29 U.S.C. § 1132(c) ("Any administrator ... who fails or refuses to comply with a request for any information which such administrator is required by this subchapter to furnish to a participant or beneficiary ... may in the court’s discretion be personally liable to such participant or beneficiary ....”) (emphasis added).
. See, e.g., Doc. 32-2 at 23, 49, 56, 163, 173.
. Id. at 36.
. Id. at 23.
. Doc. 32-1 at 1.
. Doc. 32-1 at 2.
. Id.
. See Glenn, 554 U.S. at 118, 128 S.Ct. 2343 (holding that selective consideration of evidence is a proper grounds for setting aside an administrator's decision); Holmstrom v. Metro. Life Ins. Co., 615 F.3d 758, 777 (7th Cir. 2010).
.See Dr. Cohan’s report, doc. 32-2 at 266 ("Although the claimant does take medications which have potential adverse side effects, including sedation, nevertheless there is no objective data in the medical records provided to substantiate that the claimant has
. See Dr. Dukarm’s report, doc. 32-2 at 75 (“His affect appeared obtunded .... The patient appeared lethargic .... ”); Dr. Downs’ April 29, 2010 note, id. at 148 ("His attention span and concentration are slightly reduced, and he appears somewhat somnolent.”); Dr. Lord's May 5, 2010 office note, id. at 150 (physical exam describes Mason as "fatigued”); Dr. Lord’s May 7, 2010 office note, id. at 152 (same); Providence Alaska Medical Center’s January 11, 2011 emergency report, id. at 48 ("He did take diazapam and Zanaflex that has improved his symptoms. When he initially checked in, his pain [was] 9/10. Currently, he has minimal pain and is sleeping.”); id. at 49 ("He is sleeping upon my arrival into the room, which was about 20 minutes after presentation.”).
. Doc. 32-2 at 196, 198.
. Id. at 13.
. Id. at 121.
. Id. at 94.
. Doc. 32-1 at 1 (noting only that Dr. Madden described Mason's mood as depressed, his thought process as normal and coherent, his language as intact, and his speech as spontaneous).
. Doc. 32-2 at 4.
. Id. at 13, 265.
. Id. at 75.
. Id. at 77.
. Although Aetna concludes that Dr. Du-karm did not note "significant sedation” during testing, Dr. Dukarm described Mason as "lethargic” and his affect "obtunded.” Aetna's interpretation of Dr. Dukarm's remarks is questionable.
. Jordan v. Northrop Grumman Corp. Welfare Benefit Plan, 370 F.3d 869, 880 (9th Cir. 2004).
. Id.
. Salomaa, 642 F.3d at 679. See also Bennett v. Kemper Nat. Servs., Inc., 514 F.3d 547, 555 (6th Cir. 2008).
. Doc. 32-2 at 245 (Dr. Mendelssohn’s first report states, "It was opined [on Dr. Du-karm’s report] that the claimant's cognitive difficulties were multifactorial in nature secondary to medications, pain, sleep disturbance, and depression. However, it is important to note that the claimant continued to work despite findings from this evaluation.”); id. at 255-56 (Dr. Weinstein's first report discounts Mason's SPS symptoms because he had been suffering from them "for over 15 years and this has not precluded him from working.” It also discounts Dr. Dukarm’s findings because, "[d]espite the fact that this study was done on 9/27/10, it appears the claimant was still able to perform his own occupation with the first date of absence being listed as 11/10/10.”).
. Id. at 250.
. Id.
. Id. at 260.
. Id.
Reference
- Full Case Name
- Maurice K. MASON v. FEDERAL EXPRESS CORPORATION
- Cited By
- 5 cases
- Status
- Published