Taylor v. The Prudential Insurance Co. of America

          MEMORANDUM OPINION AND ORDER

          Tom S. Lee UNITED STATES DISTRICT JUDGE.

         This cause is before the court on the motion of plaintiff Theresa A. Taylor for summary judgment and to vacate termination and denial of long term disability benefits and on the cross-motion of defendant The Prudential Insurance Company of America (Prudential) for summary judgment. Both motions have been fully briefed by the parties. The court, having considered the memoranda of authorities submitted by the parties and having carefully reviewed the administrative record, concludes that Prudential is entitled to summary judgment. Accordingly, Prudential's motion will be granted and plaintiff's motion will be denied.

         Facts

         Prior to February 2, 2011, when she stopped working due to symptoms associated with fibromyalgia, sleep apnea and worsening of spinal disease, Theresa Taylor was employed by the Wm. Wrigley Jr. Company as a Territorial Sales Manager. Through her employment, Taylor was a participant in an employee welfare benefit plan that provided disability coverage. The Plan was administered by Prudential. Under the terms of the Plan's short-term disability coverage, a claimant is entitled to receive benefits for a period of up to fifty-two weeks if she is “unable to perform the material and substantial duties of your regular occupation due to your sickness or injury....” The Plan's long-term disability coverage provides for continued payment of benefits for up to twelve months to a participant who remains unable to perform the material and substantial duties of her regular occupation. After twelve months, she is considered disabled and entitled to continued long-term disability benefits if she is unable to perform the duties of any “gainful occupation for which [she is] reasonably fitted by education, training or experience.” “Gainful occupation” is defined as “an occupation, including self-employment, that is or can be expected to provide you with an income equal to at least 60% of your indexed monthly earnings within 12 months of your return to work.”

         After she stopped work, Taylor submitted a claim for disability benefits to Prudential. Initially, on March 11, 2011, Prudential denied her claim, citing a lack of objective medical evidence to support a finding that she met the Plan definition of disabled. After Taylor appealed, Prudential found she was entitled to receive short-term disability benefits for a period of thirty days, through March 3, 2011, for diagnostic testing, treatment and evaluation by specialists, and for physical therapy due to an exacerbation of chronic low back pain. It denied her claim for additional benefits. Following unsuccessful administrative appeals of Prudential's decision, ^[1] Taylor filed this action on October 15, 2012, alleging she was wrongly denied short-term and long-term disability benefits under the Plan.

         By memorandum opinion and order entered July 1, 2013, the court found that Taylor had failed to exhaust the administrative process on her claim for long-term disability benefits and so stayed the case so she could pursue her claim for long-term disability benefits through the administrative process.

         In the meantime, on February 22, 2013, Taylor was awarded Social Security disability benefits, retroactive to February 11, 2011. Thereafter, on July 22, 2013, Taylor filed her formal claim for long-term disability benefits. As support for her claim that she was disabled from performing the duties of her job at Wrigley, Taylor noted her diagnoses of multiple illnesses and conditions which included fibromyalgia syndrome; shoulder pain and calcific tendinitis; history of C5-C6 anterior cervical discectomy and fusion and history of lumbar surgery times two at the L4-5 level on the left; low back pain with radiation to the left lower limb; irritable bowel syndrome; and sleep apnea. She cited medical records from her various medical providers, including her primary care provider, Dr. Massie Headley; her physical medicine and rehabilitation specialist, Dr. Rahul Vohra; and her rheumatologist, Dr. James Hensarling. In addition, she provided her award of Social Security disability benefits and a June 2011 Functional Capacity Evaluation (FCE) which indicated she was “capable of performing physical work at a Light level” but should not lift or carry weight greater than 25 pounds and 15 pounds overhead, and would do well to limit “sitting, twisting, kneeling, elevated work, and forward bending work to occasionally.”

         Upon receipt of Taylor's claim, Prudential had an in-house physician, Dr. Jonathan Mittelman, review her file. Based on his review, Dr. Mittelman agreed with the conclusions of the FCE that she could work in a light capacity. With regard to Taylor's back pain, Dr. Mittelman noted that she had a remote history of a cervical fusion in 2008 and a lumbar surgery in 2000 and 2007; and though she had complaints of pain, she had been able to work following those surgeries. He noted the limitations identified in the FCE were consistent with her past surgical history. He further acknowledged that the clinical data was consistent with her diagnosis of fibromyalgia. He explained that fibromyalgia is a chronic condition and is not progressive. “It does not cause damage to any joints, muscles, or organs and with multidisciplinary treatment, including life style management (good sleep habits, regular exercise and stretching, ensuring ergonomic work activity, attention to good nutrition) most people with this condition would be expected to maintain the ability to perform gainful work activity on a reliable basis.” He observed that Taylor had been “largely stable in her complaints over the course of 2013, ” and he found “no reason to alter the limitations determined in her 2011.”

         On February 5, 2014, Prudential notified Taylor that her claim for long-term disability benefits was denied. Prudential advised that based on the limitations identified in the FCE and Dr. Mittelman's report, Taylor had the capacity for light work; that her job at Wrigley was in the light category; and therefore, she did not meet the policy definition of disabled. Taylor appealed this decision, and on July 14, 2013, Prudential reversed its initial decision and awarded Taylor long-term disability benefits through February 13, 2011. Prudential found that Taylor's job at Wrigley was more accurately classified as medium rather than light, and that, given the findings of the FCE, she met the policy's “regular occupation” definition of disability applicable for the initial twelve months. Prudential denied further benefits from and after February 16, 2013, but advised that it was continuing its review of Taylor's claim to determine whether she was eligible for long-term disability benefits beyond the initial twelve-month period, i.e., under the “gainful occupation” standard.

         As part of that review, Prudential requested that Taylor submit to an Independent Medical Examination (IME). Taylor agreed, and on October 31, 2014, was examined by Dr. Philip J. Blount. Following the examination, and after spending approximately two hours reviewing Taylor's medical records, Dr. Blount issued his report detailing her medical history and diagnoses, the results of his examination and his findings and opinions. As part of the evaluation, Dr. Blount was asked to identify appropriate restrictions and/or limitations in view of her functional limitations. He responded,

Ms. Taylor's presentation is completely consistent with fibromyalgia syndrome. I would offer no formal restrictions and limitations based on this.

The examinee has been followed chronically for greater than ten years by appropriate treating physicians. Given the chronicity and complexity, two ... FCEs have been performed and limitations have been provided by outside treating physicians.

         Asked whether her “self-reported level of chronic pain” was “supported and/or consistent with the results of diagnostic testing, ” Dr. Blount responded that her examination was “completely consistent with a fibromyalgia syndrome” and that “[f]ibromyalgia syndrome cannot be objectively measured. Pain cannot be objectively measured.” He opined that while Taylor had a cervical spine procedure previously, this condition “was stable and not the cause of her chronic symptoms.” She also had a history of two prior lumbar procedures, “but her presentation today was not indicative of any active radicuolopathy, ” which, he noted, was “supported by her negative electrodiagnostic evaluation performed by her treating physician and her MRI findings of stability.” Thus, he considered that the primary condition causing her symptoms was fibromyalgia. Regarding that condition, he wrote:

Fibromyalgia syndrome, in my practice, does not have any formal limitations or restrictions, as tolerance for symptoms are the limiting factor.

I did spend over two hours reviewing chronic notes dating more than ten years that have included evaluations and appropriate conservative management from her primary care, surgery specialists, physical medicine and rehabilitation specialists, and rheumatologists. At the collective opinion of these providers, FCEs were recommended, and the result of this was light-duty status. ...

Although it is true that fibromyalgia syndrome is non-sinister, with age and chronicity, there is a normal physiologic decline in abilities. ...

I agree with the treating physician that the examinee should not be required to climb ladders, ropes, and scaffolds given her balance issues I observed today and her medications that she is currently taking. I do feel, however, that she should be able to work as indicated by her FCE.... Again, with her presentation today, primarily with fibromyalgia syndrome, the tolerance for symptoms would be her own limiting factor, and I would certainly allow her to do this.

In conclusion, I respect the treating physicians with their request of light-duty status, and this is based on two FCEs and my review of chronic records spanning over ten years by reputable and reliable physicians that I believe have provided good care.

         On November 24, 2014, after receiving Dr. Blount's report, Prudential requested a vocational assessment to identify alternative occupations which would provide earnings of at least $15.63 per hour^[2] for which Taylor would be qualified, given her education, training, and work experience and taking into consideration the restrictions identified in Dr. Blount's IME and the June 2011 FCE. A Prudential Vocational Specialist, Steve Lambert, undertook this assessment, and reported that, taking into account the various restrictions and limitations identified in Dr. Blount's IME and the FCE and Taylor's transferrable skills, he had identified three alternative sedentary occupations that would provide the required gainful wage: Inside Sales Representative (hourly wage of $21.33), E-Commerce Sales Representative (hourly wage of $21.51), and Customer Center Representative (hourly wage of $17.78). Accordingly, by letter dated December 19, 2014, Prudential denied Taylor's claim for long-term disability benefits beyond February 16, 2013. In doing so, it noted that it had taken into consideration the fact that she was approved for Social Security disability benefits but explained that whereas “the [SSA] must make their determinations based on the ...