United States District Court, W.D. Washington
For Dana Mirick, Plaintiff: Melton L Crawford, LEAD ATTORNEY, MACDONALD HOAGUE & BAYLESS, SEATTLE, WA.
For Prudential Insurance Company of America, Defendant: Amanda A. Sonneborn, Christopher M Busey, LEAD ATTORNEYS, PRO HAC VICE, SEYFARTH SHAW (IL), CHICAGO, IL; Thomas J Wybenga, LEAD ATTORNEY, SEYFARTH SHAW LLP, BELLEVUE, WA.
For The " Short Term Disability Coverage For All Employees" Employee Benefit Plan, The " Long Term Disability Coverage For All Employees" Employee Benefit Plan, Fred Hutchinson Cancer Research Center in its capacity as Plan Administrator for said employee benefit plans, Defendants: D Michael Reilly, LANE POWELL PC, SEATTLE, WA; Thomas J Wybenga, LEAD ATTORNEY, SEYFARTH SHAW LLP, BELLEVUE, WA.
ORDER GRANTING PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT
Robert S. Lasnik, United States District Judge.
This matter comes before the Court on " Plaintiff's Motion for Summary Judgment and/or for Entry of Judgment Under Fed.R.Civ.P. 52" (Dkt. # 24) and " Defendants' Cross-Motion for Summary Judgment or for Entry of Judgment Under Fed.R.Civ.P. 52" (Dkt. # 29). Plaintiff brought this action for disability insurance benefits against defendants pursuant to the Employee Retirement Income Security Act (" ERISA" ). 29 U.S.C. § 1132.
Plaintiff is employed at the Fred Hutchinson Cancer Research Center as a biostatistician investigating the role of disrupted circadian cycles as they relate to cancer risk. Plaintiff was diagnosed with unspecified connective tissue disease, a chronic autoimmune disease, in 2000. For approximately a decade, she successfully managed her condition with a combination of medicine, a gluten-free diet, and exercise. She was able to work full-time despite flare ups of her symptoms. In January 2013, however, she began experiencing near constant headaches and a marked increase in joint pain, fatigue, and sleep disturbance. By August 2013, she realized that she was experiencing a decline in her cognitive abilities: her work was taking longer to complete than it should have, she could not recall work that she had done in the past, and she was having to turn down projects because she could not focus or comprehend the problem. When she adjusted her work schedule to provide extended periods off, she noticed a slight improvement in her symptoms. Her rheumatologist, Dr. Brodie, put her on Prednisone, but a therapeutic dose caused severe headaches and dizziness: a lower dose was inadequate to provide pain relief.
In consultation with her doctor, plaintiff decided to take a medical leave of absence from work in the hopes that a reduction in stress and an increase in rest would alleviate her symptoms and so that she could see a neurologist and sleep specialist to help diagnose and treat her condition. Plaintiff applied for short-term disability (" STD" ) benefits under an ERISA plan offered by her employer. Prudential denied the claim in December 2013 on the ground that there were " no acute findings in the physical exam notes or lab results, the MRI completed on October 21, 2013 is within normal limits, and there are no restrictions provided by your medical provider. While we understand that you may be experiencing an increase in your symptoms the medical documentation does not indicate a severity of symptoms or intensity of treatment that would prevent you from performing the duties of your job." AR 946. Plaintiff provided additional medical records and a letter, part of which is quoted in footnote 1, describing her work, her medical history, the effects of her disease on her ability to perform her job, and why she needed a leave of absence. AR 866-67. Prudential was not impressed, sticking with its prior decision because " the physical exam reports currently available for review do not indicate abnormal findings or loss of cognitive or physical function that would result in an inability to perform the duties of your job." AR 943.
Plaintiff filed a formal appeal of the denial decision on February 12, 2014, and provided a declaration from Dr. Brodie, a declaration from her neurologist, Dr. Reif, and the results of a single photon emission computed tomography (" SPECT" ) study of her brain demonstrating moderate to severe perfusion abnormalities scattered throughout the tissue. Both doctors addressed the impact of plaintiff's condition on her ability to work, and plaintiff provided a copy of her curriculum vitae to show the nature of her work. Prudential obtained a medial record file review. The reviewer took issue with Dr. Brodie's description of plaintiff's diagnosis as " unspecified connective tissue disease, mostly likely systemic lupus erythematosus, often referred to as lupus" and opined that anyone who had central nervous system impacts from lupus would " have more than confusion, fatigue, memory loss, and difficulty expressing their thoughts. They usually become comatose and are at risk of death and require high-dose steroids. None of this has been noted in any of the reports or evaluations of Ms. Mirick." AR 562-63. Although the reviewer acknowledges the existence of the SPECT results and Dr. Reif's conclusion that the multiple perfusion abnormalities shown are consistent with the neurocognitive dysfunction deficits of which plaintiff complained, he does not address the findings or conclusions, instead rejecting Dr. Reif's opinions because she " is diagnosing lupus on the SPECT abnormalities rather than diagnosing lupus from the claimant and the claimant's symptoms . . . ." AR 563. Shortly after receiving this review, Prudential rejected plaintiff's appeal of the denial of STD benefits and sua sponte disallowed a claim under the long-term disability (" LTD" ) benefits plan. AR 930. Prudential relied heavily on the reviewer's analysis, concluding that there was no clinical evidence to support a diagnosis of lupus and that her reported limitations on her ability to work were not confirmed diagnostically. AR 935-36.
Plaintiff's second level appeal of the STD denial and her first level appeal of her LTD denial were also rejected. Prudential was unswayed by Dr. Brodie's response to the reviewer's findings, fourteen years' worth of medical records regarding plaintiff's unspecified connective tissue disease, statements and records from Dr. Reif and a neuropsychologist, examples of plaintiff's research papers, a copy of plaintiff's job description, or recent treatment records. Instead, it relied on further consultation with the medical reviewer, a file review conducted by a neurophychologist, and a vocational consultant's opinions regarding whether plaintiff's job duties would allow her to take breaks or required her to recall visual material. Prudential reiterated that there were no physical limitations that would preclude plaintiff from working and, while acknowledging " some minor cognitive weaknesses," concluded that they would not " impact Ms. Mirick in the performance of her regular occupation, on a full-time basis. In fact, it has been reported that Ms. Mirick has returned to work in June of 2014 with her employer, on a part-time basis." AR 915.
A. Standard of Review
Under ERISA, the proper standard of review of a plan administrator's benefits denial is de novo unless the plan grants discretionary authority to the administrator. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). Where the plan gives the administrator discretionary authority, the court reviews the decision for abuse of discretion. Saffon v. Wells Fargo & Co. Long Term Disability Plan, 522 F.3d 863, 866 (9th Cir. 2008). Defendants assert that, although the STD plan states only that Prudential has the authority to make benefits determinations (AR 407), the Summary Plan Description (" SPD" ) and its Administrative Services Agreement (" ASA" ) with the employer grant Prudential discretion in exercising that authority (AR 29 and 427).
This argument fails for one of two reasons. The SPD and the ASA are generally not considered part of the ERISA plan. Becker v. Williams,777 F.3d 1035, 1039 n.3 (9th Cir. 2015) (" The Supreme Court has specifically excluded the statutorily mandated summary plan description . . . as a source of the plan's governing terms." ); Fritcher v. Health Care Serv. Corp.,301 F.3d 811, 817 (7th Cir. 2002) (the service contract between the employer and the claims administrator is not a " 'plan document' for purposes of holding its terms against a plan participant or beneficiary." ). If these additional documents are not part of the plan, the terms of the plan itself -- which simply states that Prudential will make benefits determinations -- control. If, on the other hand, the SPD or the ASA are part of the plan, then Washington State law invalidates the attempt to grant deference to Prudential's claim decision. WAC 284-96-012 (" No disability insurance policy may contain a discretionary clause." ); Landree v. Prudential Ins. Co. of ...