United States District Court, S.D. Mississippi, Northern Division
THERESA A. TAYLOR PLAINTIFF
v.
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA DEFENDANT
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 ...