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Pippin v. Rock-Tenn Co. Group Benefit Plan

United States District Court, W.D. Arkansas, Fayetteville Division

June 20, 2016

CHARLES PIPPIN PLAINTIFF
v.
ROCK-TENN COMPANY GROUP BENEFIT PLAN DEFENDANT

          MEMORANDUM OPINION AND ORDER

          TIMOTHY L. BROOKS, UNITED STATES DISTRICT JUDGE

         Plaintiff 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.

         I. BACKGROUND

         Plaintiff 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.

         Mr. 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).

         Mr. 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.

         On 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.

         On 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, [1] dated March 21, 2014, ordering Mr. Pippin to remain “off work 3-21-3-31.” Id. at p. 48.

         Meanwhile, 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 disability.” Id.

         Following 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), [2] chlorhexidine gluconate (Hibiclens) 4% liquid, [3] ciprofloxacin (Cipro) 500 mg tablet, [4] and etodolac SR 24 hr (Iodine XL) 600 mg.[5] 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.

         Just 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.

         On 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 process.” Id.

         It 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.[6] 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: 5/19/14.”

         Dr. 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.[7]

         Mr. 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.

         On July 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 ability.” Id.

         Dr. 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 . . . .” Id.

         Based 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).

         On 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.

         The 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 ...

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