United States District Court, W.D. Arkansas, Fort Smith Division
OPINION AND ORDER
HOLMES, III U.S. DISTRICT JUDGE
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.
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.
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.
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).
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.”
contacted Janet Thurston, a registered nurse and independent
medical consultant, to evaluate the merits of Reyes's
application for benefits. (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.
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.
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).
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).
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