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Reyes v. USAble Life

United States District Court, W.D. Arkansas, Fort Smith Division

April 9, 2019

DINORA REYES PLAINTIFF
v.
USABLE LIFE; and POLICY NUMBER 50019936-LTD DEFENDANTS

          OPINION AND ORDER

          P.K. HOLMES, III U.S. DISTRICT JUDGE

         Before the Court is an action under the Employee Retirement Income Security Act of 1974 (“ERISA”), as set out in Plaintiff Dinora Reyes's (“Reyes”) complaint (Doc. 1). Defendant USAble Life (“USAble”) filed an answer (Doc. 7), and the parties submitted a stipulated administrative record under seal (Doc. 9). Reyes filed a motion (Doc. 11) for summary judgment, a statement of facts (Doc. 12), and a brief (Doc. 13) in support. USAble filed a response (Doc. 14). Having considered the parties' respective briefs, the Court finds that Reyes was deprived a full and fair review of her claim because at each stage of the review process, USAble failed to follow the definition of “disability” as written in the policy. The appropriate remedy for this ERISA violation is to remand the case to the plan administrator with instructions to reopen the administrative record.

         I. Background

         Dinora Reyes worked as a Mental Health Professional at Western Arkansas Counseling & Guidance Center, Inc. (“WACGC”). Reyes last worked at WACGC on April 20, 2015. On June 30, 2015, Reyes applied for long-term disability benefits. (Doc. 9-9, p. 593). WACGC sponsors a group policy for long-term disability benefits administered by USAble Life (the “Policy”). Reyes's application represents that she suffered from “severe neck, joint pain, headaches, infection, and fatigue.” (Doc. 9-9, p. 593). Reyes first received treatment for these injuries in February 2014 and had been treated by Dr. Donna Shipley, Dr. Robert Fisher, and Dr. Sheharyar Ali.

         In support of her application for long-term disability benefits, Reyes submitted three physician's statements by Dr. Shipley, Dr. Fisher, and Dr. Missy Clifton. Each document represented that the doctor had examined Reyes and each physician indicated that Reyes was “totally disabled.” Dr. Shipley, Reyes's primary care physician, identified, among other things, Reyes's spinal injury as the primary cause of her disability. Dr. Shipley noted that a fall the previous year had caused Reyes's cervical spine to worsen, and her injury would require additional treatment, including neurosurgery. (Doc. 9-1, p. 173; Doc. 9-9, p. 598). Dr. Shipley did not believe that Reyes's condition would ever improve.

         Dr. Clifton, Reyes's dermatologist, noted a skin infection and inflammation which could be treated with oral antibiotics. (Doc. 9-9, p. 597). However, Dr. Clifton determined Reyes was physically impaired due her neck injury and mentally impaired “due to pain.” Id. Dr. Clifton concluded that Ms. Reyes could not work until she underwent neck surgery. Id. Finally, Dr. Fisher, her pain management physician, diagnosed Reyes with a cervical radiculopathy, both physical and mental impairments, and concluded Reyes was totally disabled and could not perform her job duties. (Doc. 9-9, p. 595).

         USAble assigned Reyes's claim to Man Ho, a Managed Disability Analyst. (Doc. 9-9, pp. 546-48). Ho obtained medical records, payroll records, and interviewed Reyes over the phone. At the outset of the initial review, Ho obtained a vocational review from Nancy Wiley-Gilpatrick, a Vocational Rehabilitation Counselor. Gilpatrick was to determine “the physical demands of [Reyes's occupation] as it is performed in the national economy.” (Doc. 9-9, p. 338). Gilpatrick reviewed the job description for a Mental Health Professional, Reyes's position at the time of her alleged disability, and determined that Reyes's job was performed at a “sedentary level of physical demand.” Id.

         Ho then contacted Janet Thurston, a registered nurse and independent medical consultant, to evaluate the merits of Reyes's application for benefits.[1] (Doc. 9-9, pp. 355-59). Thurston obtained medical records from seven of Reyes's physicians, including Drs. Fisher, Clifton, and Shipley. (Doc. 9-9, p. 355). Thurston concluded that Reyes “has multiple and diffuse symptoms reports however there is no clear indication that any condition or combination of conditions result in impairment of function.” (Doc. 9-9, p. 358). Though Thurston acknowledged the treating physicians' conclusions that Reyes suffered physical and mental impairment, she suggested “[t]here is no medical support for the inability to physically complete prior level of activities on a sustained basis.” (Doc. 9-9, p. 359). Because her assessment differed from Reyes's physicians, Thurston intended to follow-up with the treating physicians to clarify the treating physicians' findings. Id.

         On September 14, 2015, Ho advised Reyes that additional information was necessary before USAble could render a decision. In response, Reyes provided her notice of award from the Social Security Administration (“SSA”) for USAble's consideration. (Doc. 9-9, pp. 332-36). Thurston reviewed the additional information provided by Reyes and other medical documents but again determined that there was no evidence of Reyes's disability.

         On December 7, 2015, Ho sent a letter authored by Thurston to Dr. Shipley. (Doc. 9-7, pp. 896-98). In the letter, Thurston acknowledged reviewing Dr. Shipley's physician statement “that advised [Reyes] is incapable of even sedentary activity; has severe mental/nervous impairment and there is never improvement expected.” (Doc. 9-7, p. 897). Thurston then outlined her conflicting assessment of Reyes's symptoms and condition. Id. Thurston indicated that she was “unable to identify any medical condition which would warrant a functional loss from the work setting on April 21, 2015.” (Doc. 9-7, p. 898). At the bottom of the letter, Thurston wrote:

Our vocational staff have identified her occupation is performed at a sedentary level of physical demand.
If you are in agreement that Ms. Reyes has the physical capacity for full time sedentary function as of April 21, 2015, please sign and date this letter in the space provided.
• Per the dictionary of occupational titles, sedentary level work is defined as exerting up to 10 pounds of force occasionally to lift, carry, push, pull, or move objects. It involves sitting most of the time, but may involve walking or standing for brief period of time.

Id. (emphasis in original). USAble required Dr. Shipley to respond to the letter by December 16, 2015. (Doc. 9-7, p. 899).

         On December 11, 2015, Reyes advised Ho that Dr. Shipley would not complete the paperwork until Dr. Shipley reexamined Reyes, so Reyes requested an extension until December 30, 2015. (Doc. 9-7, p. 899). Dr. Shipley was no longer Reyes's treating physician at this time because Reyes had moved to Texas. Ho declined to extend the response date. Id. Nonetheless, Dr. Shipley signed and returned the letter. (Doc. 9-7, p. 898).

         On December 17, 2015, USAble sent Reyes a letter denying her claim for disability benefits. (Doc. 9-7, pp. 883-86). The letter properly outlined the procedures that USAble used in evaluating her claim and detailed the factual basis for the decision as required by the policy. (Doc. 9-7, pp. 883-84; Doc. 9-9, p. 630). The letter noted that “Dr. Shipley confirmed on 12/4/2015 that you have the physical capacity to perform a full-time sedentary function as of 4/21/2105.” (Doc. 9-7, p. 884). USAble determined ...


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