United States District Court, W.D. Arkansas, Fayetteville Division
MEMORANDUM OPINION AND ORDER
TIMOTHY L. BROOKS, UNITED STATES DISTRICT JUDGE
Charles Pippin brings this action pursuant to the provisions
of the Employee Retirement Income Security Act of 1974
(“ERISA”), 29 U.S.C. § 1001 et
seq., alleging Defendant Rock-Tenn Company Group Benefit
Plan wrongly denied his claim for short-term disability
benefits. Before the Court are the Administrative Record
(Doc. 13) and applicable Group Benefit Plan (Doc. 16),
Plaintiff’s Brief (Doc. 14), and Defendant’s
Brief (Doc. 18). For the reasons stated herein, the Court
REVERSES the administrator’s denial of benefits and
ORDERS that Mr. Pippin’s claim for short-term
disability benefits be paid.
Charles Pippin is a 68-year old male who currently works as a
Maintenance Technician for Rock-Tenn Company. He has been
employed by this company, in this same position, for the past
48 years-since 1968. His job is classified as a “medium
work-level” position that requires Mr. Pippin to be on
his feet 100% of the work day, either standing or walking.
(Doc. 13-19, p. 88). He is expected to lift, carry, push, and
pull up to 50 pounds and occasionally climb, stoop, kneel,
and crouch. Id. at p. 89. His job description states
that his duties include dust mopping, pushing a four-wheel
ink cart and trash can, lifting five-gallon buckets of ink,
bundling flat boxes together, and maneuvering both wood and
plastic pallets for loading. Id. In order to do all
of these tasks, he is expected to have “normal
mobility, ” including the ability to maintain
“independence on steps without rails, ” and
“work in a manufacturing environment . . . around heavy
machinery with rotating parts on a constant basis.”
Id. at 91.
Pippin injured himself outside of work on February 27, 2014,
when he suffered a contusion and hematoma, i.e., bruising and
swelling, on his right leg, from his shin to his toes, after
jumping on a trailer hitch. He first missed work to seek
medical treatment a little more than a week after the
accident, on March 10, 2014, when the condition of his injury
worsened. He reported on March 10th to the Mercy Clinic in
Rogers, Arkansas, and was seen by Advanced Practice
Registered Nurse Kelly D. Pruett. (Doc. 13-2). Mr. Pippin was
diagnosed with an infection and abscess at the site of the
injury. (Doc. 13-19, p. 62). He underwent an ultrasound that
day to rule out the possibility of deep vein thrombosis.
Id. Nurse Pruett then wrote him a note, which she
intended that Mr. Pippin present to his employer, explaining
that he was not to report for work until March 12, 2014, the
date of a scheduled follow-up appointment. (Doc. 13-2).
Pippin’s follow-up appointment took place at Mercy
Clinic with Licensed Practical Nurse Amanda Meeker on March
12, 2014. Following the visit, Nurse Meeker wrote a note for
Mr. Pippin’s employer that simply stated: “Due to
medical reasons, Charles E. Pippin may not return to work
until further evaluation is done by his physician.”
(Doc. 13-3). No other doctor’s notes or medical records
are associated with the March 12th visit.
March 14, 2014, the Benefit Service Center for Rock-Tenn
Company Group Benefit Plan (“Rock-Tenn”) received
a claim filed by Mr. Pippin for short-term disability
benefits, related to his right-leg injury. (Doc. 13-4, p. 1).
Rock-Tenn advised Mr. Pippin in a letter dated March 17,
2014, about his rights under the Family Medical Leave Act
(“FMLA”) and requested that he submit a completed
Health Care Provider Certification form, which authorized
Rock-Tenn’s claims reviewers to speak to Mr.
Pippin’s doctors about his short-term disability claim.
The letter also stated that Mr. Pippin’s
“return-to-work date will be determined based on
information we receive from your health care provider,
” and he “will be expected to return to work on
the day, or the next scheduled work day, that [his] health
care provider certifies [he is] able to return.”
Id. at p. 2.
March 19, 2014, Mr. Pippin was examined by Dr. David C.
Garrett, who wrote a note that day directed to Mr.
Pippin’s employer to explain that Mr. Pippin had
developed a staph infection in his leg and was to be
“off work [the] rest of [the] week.” (Doc. 13-19,
p. 47). Soon after, Mr. Pippin was seen at the Mercy Wound
Care Center, which provided him yet another note,  dated March 21,
2014, ordering Mr. Pippin to remain “off work
3-21-3-31.” Id. at p. 48.
the Benefit Service Center for Rock-Tenn began conducting its
review of Mr. Pippin’s short-term disability claim. It
sent Mr. Pippin a status letter on March 24, 2014, explaining
that it was unable to make a decision about the claim
“due to the lack of supporting documentation.”
(Doc. 13-5). In particular, Rock-Tenn noted that its claims
agents had attempted to contact Mr. Pippin’s primary
care physician, Dr. Garrett, on March 18th, 20th, and 21st,
requesting medical records to support the claim, but no other
documentation had been provided. Rock-Tenn also contacted Mr.
Pippin on March 17th and his wife on March 24th, informing
them both that more medical paperwork was required to support
the claim. At the close of the March 24th letter, the company
informed Mr. Pippin that it could not approve his claim at
this time, “based on insufficient evidence to establish
the initial denial of his claim, Mr. Pippin visited Dr.
Garrett again on April 1, 2014. Dr. Garrett wrote a note to
Mr. Pippin’s employer ordering that “[d]ue to
medical reasons, Charles E. Pippin may not return to work
until seen by [an] orthopedic specialist.” (Doc. 13-19,
p. 49). Mr. Pippin then saw orthopedic specialist Dr. John D.
Mertz on April 10, 2014, one month after he first sought
treatment for his leg wound. Chart notes from the April 10th
visit indicate that Mr. Pippin still suffered from a
“[r]esolving hematoma” and “[s]taph
infection, ” with no obvious sepsis, but with minimal
warmth and mild pain. Id. at p. 59. Dr. Mertz noted
on the chart that Mr. Pippin had “[g]ood motion of the
knee and ankle, ” and the CT scan taken of his injured
leg was “unremarkable.” Id. Despite
these observations, Dr. Mertz documented that Mr. Pippin was
suffering “with enough pain to keep him off
work.” Id. The summary report of the visit
also listed a number of medications Mr. Pippin had been
prescribed for pain and infection, including: pregabalin
(Lyrica),  chlorhexidine gluconate (Hibiclens) 4%
liquid,  ciprofloxacin (Cipro) 500 mg tablet,
and etodolac SR 24 hr (Iodine XL) 600 mg. Id. at p.
54. In addition, Dr. Mertz ordered Mr. Pippin “to be
off work for one month due to leg injury” following
this April 10th visit. Id. at p. 50.
prior to the April 10th consultation with Dr. Mertz,
Rock-Tenn communicated with Mr. Pippin in a letter dated
April 2, 2014, to confirm once again that his claim had been
denied because the medical information he had provided to
date was insufficient to substantiate a short-term
disability. The letter stated: “We have tried to reach
you and your health care provider by telephone/fax on several
occasions but have not been successful in getting the
information.” (Doc. 13-6, p. 1). The letter further
advised Mr. Pippin that he had a right to appeal the
company’s decision within 180 calendar days and, in the
course of that appeals process, provide further documentation
to support his claim, including medical records.
April 18, 2014, Mr. Pippin filed an appeal of the initial
denial of his claim, which was acknowledged by Rock-Tenn in a
letter dated April 28, 2014. (Doc. 13-9, p. 1). The letter
reminded Mr. Pippin: “It is your responsibility to
provide us with medical information that you believe will
support your claim. The Benefit Service Center does not
request or pay for medical records during the appeal
appears that Mr. Pippin then made efforts to supplement his
medical file, as reflected in a fax received by Rock-Tenn on
April 29, 2014, from Mercy Clinic Orthopedics, containing Dr.
Mertz’s Attending Physician’s Statement of Work
Capacity and Impairment-a fill-in-the-blank and check-the-box
document prepared by Rock-Tenn for use by physicians, that
requested certain medical data, including the doctor’s
diagnosis of the claimant’s condition, the dates the
claimant visited the doctor’s office, the
doctor’s recommendations about the claimant’s
current ability to return to work, and the doctor’s
estimate on when the claimant could return to work. (Doc.
13-10, p. 1). In filling out this form, Dr. Mertz opined that
due to Mr. Pippin’s “hematoma, ” he should
“stay home from work” as of April 10,
2014. Id. In the blank where Dr.
Mertz was asked to state his reason for “recommending
disability leave, ” he only wrote: “No prolonged
standing or walking.” Id. He also noted under
the “Patient’s Complaints” section of the
form that Mr. Pippin suffered from “leg pain, bruising
and swelling from shin to toes.” Id. at p. 2.
Dr. Mertz checked “Yes” in response to the
question on the form that read, “Do you currently
consider your patient to be totally impaired from
working?” Id. Finally, Dr. Mertz noted that he
“anticipate[d] significant clinical improvement in my
patient’s functional capacity by the following date:
Garrett filled out the same Rock-Tenn-generated form that Dr.
Mertz did-the Attending Physician’s Statement of Work
Capacity and Impairment. On the form, dated May 22, 2014,
after Mr. Pippin had already returned to work full-time, Dr.
Garrett described Mr. Pippin’s injury as
“contusion lower leg-swelling-pain-heat” due to
“hematoma” and “infection.” (Doc.
13-19, p. 57). Like Dr. Mertz, Dr. Garrett also checked the
box on the form indicating that Mr. Pippin was “totally
impaired from working.” Id.
Pippin reported to Dr. Mertz for a follow-up examination, as
scheduled, approximately a month after his initial
consultation. Dr. Mertz’s chart notes from that visit
on May 13, 2014, acknowledge that Mr. Pippin was
“basically almost asymptomatic, ” though he still
had “a little bit of nodular feeling of the medial
aspect of his right leg along the medial gastrocnemius
muscle.” Id. at p. 65. The doctor noted that
Mr. Pippin had been “off work doing home range of
motion strengthening” and had at this point recovered
to the point of being “neurovascularly intact”
and with “good strength.” Id. Dr. Mertz
wrote a note releasing Mr. Pippin to work without
restrictions, beginning the very next day. Id. at p.
51. As his doctor ordered, Mr. Pippin did indeed report to
work at Rock-Tenn, full-time, the day after his appointment
with Dr. Mertz, May 14, 2014.
18, 2014, Rock-Tenn sent Mr. Pippin a letter informing him
that review of his appeal would take longer than usual-an
extra 45 days-in order to have a physician-consultant review
the file. (Doc. 13-12). The physician-consultant hired by
Rock-Tenn was Dr. Martin Mendelssohn, a board-certified
orthopedic surgeon who conducted a peer-review of Mr.
Pippin’s paper file, but never physically examined Mr.
Pippin. See Doc. 13-13. Dr. Mendelssohn noted in his
report, dated July 24, 2014, that Mr. Pippin’s job
involved 50% walking and 50% standing “with 0%
sitting” and frequent lifting, carrying, pushing and
pulling. Id. at p. 2. He also credited Dr.
Mertz’s diagnosis of Mr. Pippin’s right-leg
hematoma and resulting staph infection and observed that Dr.
Mertz believed Mr. Pippin had “enough pain to keep him
off work for one month.” Id. Dr. Mendelssohn
indicated in his report that he had spoken by telephone with
Dr. Garrett’s nurse, who relayed Dr. Garrett’s
recommendation that an orthopedic surgeon or wound care
physician should be assigned by Rock-Tenn to review Mr.
Pippin’s claim, “since the claimant had a
hematoma and cellulitis.” Id. at p. 4. Dr.
Mendelssohn also reported that, according to Dr.
Garrett’s nurse, Dr. Garrett expressed “no
opinion with respect to [Mr. Pippin’s] work
Mendelssohn also spoke by telephone with Dr. Mertz, Mr.
Pippin’s orthopaedist, prior to writing his report.
According to Dr. Mendelssohn, Dr. Mertz confirmed “that
the claimant had a cellulitis with hematoma in his leg and
was unable to work”; however, Dr. Mendelssohn opined
that Dr. Mertz “could not provide evidence of any
functional or neurological deficits.” Id. It
is clear from Dr. Mendelssohn’s report that he did not
dispute that Mr. Pippin actually suffered a hematoma on his
right leg, or that the leg became infected and was treated
with antibiotics. Id. He acknowledged that Mr.
Pippin did, in fact, suffer “bruising and swelling from
shin to talus.” Id. at p. 3. He noted,
however, that although Mr. Pippin’s injury caused
swelling, the paper file lacked “evidence of any
marked swelling.” Id. at p. 4
(emphasis added). Moreover, Dr. Mendelssohn observed
in his report that though Mr. Pippin’s doctors
recommended that he not return to his regular duties at work,
there was no specific mention in the file of him suffering
from an “abnormal gait” or “need for
ancillary aides for ambulation.” Id. Further,
there was no evidence of “deep vein thrombosis, ”
or “lymphangitis or lymphadenopathy.”
Id. at p. 5. Nor could Dr. Mendelssohn find evidence
“of drainage, lymphangitis, cellulitis, adenopathy,
quantified restricted motion of his knee or ankle, or motor
weakness of lower extremity muscles that would constitute a
functional impairment or that would require reasonable
accommodations or restrictions.” Id. at p. 6.
Dr. Mendelssohn therefore concluded that Mr. Pippin-despite
his injury-could have performed his job, “which is a
medium physical exertion level, ” throughout the entire
two-month period he claimed for disability leave.
Id. In particular, Dr. Mendelssohn
“disagree[d] with the total length of work incapacity
suggested by Dr. Mertz” because he found there was
“no evidence of any functional or neurological deficits
when the claimant was seen [by Dr. Mertz] on 4/10/14, ”
and “the findings do not support the need for a
functional impairment or accommodations and restrictions from
[Mr. Pippin’s] regular occupation . . . .”
solely on Dr. Mendelssohn’s review of the file and his
recommendations, Rock-Tenn prepared a document entitled
“Denial Uphold Recommendation, ” dated August 19,
2014, which stated that Mr. Pippin’s first appeal was
denied. (Doc. 13-14). That decision was memorialized in an
August 22, 2014, letter addressed to Mr. Pippin, which
reproduced Dr. Mendelssohn’s findings and conclusions
from his report and explained Mr. Pippin’s next level
of appeal rights. (Doc. 13-15).
September 11, 2014, Mr. Pippin wrote a letter requesting a
second appeal of the denial of his claim. (Doc. 13-17). That
appeal was acknowledged by the company by letter dated
September 16, 2014. (Doc. 13-18). Then, on September 22,
2014, Rock-Tenn commissioned a second review of Mr.
Pippin’s medical file. See Doc 13-20. An
unnamed doctor employed by Medical Review Institute of
America, Inc. (“MRIoA”) performed the second
peer-review. According to the record, this reviewer was
board-certified by the American Osteopathic Board of
Physicians, and he identified himself as having had
“experience with wound care treatment.”
Id. at p. 4.
MRIoA reviewer began his report by listing all the documents
in Mr. Pippin’s claim file and then summarizing his
treatment history. He observed that Mr. Pippin injured his
right leg and thereafter suffered a hematoma and cellulitis,
which his doctors indicated produced “enough pain to
keep him off work.” Id. at p. 2. The reviewer
then suggested two “Questions for Review” that
would help him determine whether to approve or deny the
claim. The first question was: “Was Charles Pippin able
to work 3/10/14 through 5/14/14?” Id. at p. 3.
To this he responded, “Yes, ” noting that
although Mr. Pippin had suffered an injury, he did not
qualify for short-term disability for the following reasons:
While there are notes in the records indicating the patient
was advised to stay off work, the office notes document no
functional deficits, motor weakness, sensory loss, or
physical exam findings that would support the need to be out
at work. Based on the records sent for ...