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Jones v. Mountaire Corp. Long Term Disability Plan

August 16, 2007

LARRY JONES PLAINTIFF
v.
MOUNTAIRE CORPORATION LONG TERM DISABILITY PLAN AND THE PRUDENTIAL INSURANCE COMPANY OF AMERICA DEFENDANTS



The opinion of the court was delivered by: Wm. R. Wilson, Jr. United States District Judge

ORDER

Pending are Defendants' and Plaintiff's Motions for Summary Judgment.*fn1

Responses were filed by each party.*fn2

This is an ERISA*fn3 claim for benefits under 29 U.S.C. § 1132(a)(1)(b). Plaintiff Larry Jones was an employee of Mountaire Corporation ("Mountaire"), and participated in its Disability Plan (the "Plan"), which was insured and administered by The Prudential Insurance Company of America ("Prudential").

Defendants contend that Prudential's decision to deny Plaintiff Long Term Disability ("LTD") benefits is reasonably based on substantial evidence and on the clear terms of the Plan, and, therefore, should be upheld. Plaintiff contends that Prudential's decision was arbitrary and should be reversed for ignoring the medical evidence presented by Plaintiff.

Plaintiff further contends that, because Prudential is the claims administrator and the insurer, a conflict of interest exists, and a de novo review should be applied.

I. Background

A. Procedural History

Plaintiff last worked for Mountaire selling agricultural supplies on September 20, 2005.*fn4 He filed a claim for LTD benefits on November 2, 2005, and attached a disability statement from his treating physician, Dr. C. E. Ransom.*fn5 Plaintiff stated that he was unable to work because he had emphysema,*fn6 and could no longer work around dust and chemicals.*fn7 Dr. Ransom stated that Plaintiff could preform sedentary work.*fn8

On December 20, 2005, Plaintiff's claim was denied based on the opinion of a nurse who reviewed the medical records and found that Plaintiff's claimed impairment lacked support.*fn9 Prudential explained that Plaintiff had worked in the past with the same chronic conditions, and there was no medical record of a sudden worsening of his condition at his date of disability."*fn10

Plaintiff appealed the decision by letter dated January 11, 2006.*fn11 Along with this letter, Plaintiff submitted more medical records and a report from his cardiovascular thoracic surgeon, Dr. Miguel Aguinaga. Dr. Aguinaga confirmed that Plaintiff's coronary heart disease and severe chronic emphysema was incapacitating.*fn12

Plaintiff submitted a job description from Mountaire that showed his job was not sedentary. The description explained that Plaintiff was required to assist dealers at trade shows by setting up product displays. This part of the job required lifting 20, 40, and 50 pound bags of sample feed and gallon jugs of health products.*fn13 In addition to this job description, a more detailed explanation was sent by Mountaire, which added that Plaintiff was required to visit farms, handle large animals, and to participate in the quarterly product inventory where he stood on his feet for long hours -- "stooping, lifting, and moving inventory in a dusty, dirty, environment."*fn14

Prudential consulted its own rehabilitation specialist, Michael Chretien. He did not talk to Plaintiff or Mountaire, but consulted vocational reference materials and concluded that Plaintiff's regular occupation was listed in the Dictionary of Occupational Titles ("DOT")*fn15 as "Sales Representative, Animal Feed Products." According to Mr. Chertien, the DOT classified the job as "light," not "sedentary," which included the ability to "push/pull/and carry 10 to 20 pounds occasionally, and 10 pounds frequently, with periods of walking and standing during work hours."*fn16

The DOT's definition of light work was sent to a reviewing physician, Dr. Kowalski, who concluded that emphysema did not prevent Plaintiff from working a light duty job.*fn17

After this, Prudential's claim manager prepared an exhaustive summary of Plaintiff's medical history and concluded that Dr. Kowalski was correct -- Plaintiff could perform light work.*fn18 On March 3, 2006, Plaintiff was told that, based on his employer's job description and the DOT's definition of light work, he did not meet the Plan's definition of disabled.*fn19

Plaintiff appealed again, requesting that Prudential take a second look at his actual job duties, and make sure that the chosen DOT job title accurately portrayed his work requirements.*fn20 Plaintiff also requested an independent review by a "third-party [s]pecialist."*fn21

Prudential complied with Plaintiff's first request, and another rehabilitation specialist reviewed the two different job descriptions. This specialist found that the chosen DOT job title was accurate, i.e., Plaintiff's regular occupation was: "Sales Representative, Animal-Feed Products," DOT number "272.357-010."*fn22

Dr. Robert Brown, an internal medicine physician specializing in pulmonology, was hired as the third-party specialist. Dr. Brown reviewed Plaintiff's Pulmonary Function Test ("PFT") and treadmill test, and opined that Plaintiff was mildly impaired as a result of his lung and heart conditions. Dr. Brown concluded that Plaintiff had the physical ability to perform his light duty job, i.e., he can stoop, kneel, crouch, and lift from 10 to as much as 50 pounds.*fn23 Prudential denied Plaintiff LTD benefits on April 19, 2006.*fn24

This was Prudential's final decision. Plaintiff attempted a third appeal, but Prudential notified Plaintiff that a third appeal was no longer allowed.*fn25 Plaintiff filed this action on October 31, 2006.*fn26

B. Medical History

In June 2005, Plaintiff saw his family doctor, Dr. Ransom, for right side chest pain, and was referred to radiologist for a chest x-ray.*fn27

Plaintiff's chest x-ray was abnormal, and the radiologist made the following observations: "[e]xtensive emphysematous changes are noted with bullous change in the upper lobes."*fn28 A bulla is a blister larger than one centimeter wide, that is filled with fluid.*fn29 Bullous emphysema occurs where bullae are compressing functional lung tissue.*fn30

A CT-Scan, performed on September 19, 2007, established extensive emphysematous changes throughout both lungs.*fn31 After all studies were completed, Plaintiff was sent to Dr. Aguinaga, because a "suspicious lesion" ...


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