United States District Court, M.D. North Carolina
MEMORANDUM OPINION AND ORDER
WILLIAM L. OSTEEN, Jr., District Judge.
Plaintiff Mary Hairston ("Plaintiff") initiated this action in Guilford County Superior Court, pursuant to section 502 of the Employee Retirement Income Security Act of 1974 ("ERISA"), codified as amended at 29 U.S.C. § 1132. Defendant Liberty Life Assurance Company of Boston ("Defendant") removed this action, pursuant to 28 U.S.C. § 1441. (See Notice of Removal (Doc. 1).)
Presently before this court is Defendant's Motion for Judgment on the Administrative Record. (Doc. 28.) Plaintiff has responded to Defendant's motion (Doc. 37), and Defendant has replied (Doc. 38). This motion is now ripe for ruling.
For the reasons set forth herein, this court will grant Defendant's Motion for Judgment on the Administrative Record and this case will be dismissed.
The facts in this case have been taken from the Administrative Record, submitted by Defendant. (See Notice of Filing Admin. Record, Ex. B, Administrative Record ("Admin. Record") (Doc. 27-3).)
Plaintiff was employed by Technimark, LLC, for 20 years, but last worked for Technimark in mid-November 2012. (See id. at 8 (Phone Note 1), 81-82.) During her employment, Plaintiff developed a variety of serious health problems and medical conditions, including degenerative disk disease. (See Pl.'s Resp. (Doc. 37) at 23.) By late 2012, Plaintiff's primary care provider, Dr. Jeffrey Hooper, opined that she was totally disabled. (See id. at 1-2.)
Defendant administers Technimark's Group Disability Income Policy (the "Policy"). A copy of the Policy has been filed with this court. (See Notice of Filing Admin. Record, Ex. A, Group Disability Income Policy ("Policy") (Doc. 27-2).) Plaintiff filed a claim for short-term disability benefits on November 21, 2012, claiming muscle spasms in her shoulders and neck along with weight loss. (Admin. Record (Doc. 27-3) at 8 (Claim Notes 1-2).) In the first conversation between Plaintiff and Defendant, Plaintiff's Disability Case Manager ("DCM") asked Plaintiff for medical evidence supporting her disability claim (id. at 8 (Phone Note 1), 73-74), and on November 27, 2012, the DCM requested treatment notes, diagnostic tests, and procedure reports from Dr. Hooper. (Id. at 77-80.) In a letter dated November 27, 2012, addressed to Plaintiff, the DCM explained that Plaintiff had until January 10, 2013, to complete her file but asked that Plaintiff submit the evidence by December 11, 2012, in order to expedite her file. (Id. at 73-74.)
After additional requests for medical records by Defendant (see id. at 6-7 (Phone Notes 3-5)), Dr. Hooper provided treatment notes from Plaintiff's appointments dated August 6, 2012, August 24, 2012, September 21, 2012, October 19, 2012, and November 16, 2012. (Id. at 55-59.) In a prescription note from the August 24 appointment, Dr. Hooper indicated that Plaintiff should not lift more than 15 pounds. (Pl.'s Resp., Ex. G (Doc. 37-7) at 2.) The appointment notes were reviewed by a Nurse Case Manager ("NCM"), and the NCM found that the medical information provided by Dr. Hooper did not support the restrictions and limitations reported by Plaintiff, as there were no exam findings, no indication that any testing had been performed, no indication of whether Plaintiff's range of motion was affected by her alleged impairments, and no information on where the spasms were located. (Admin. Record (Doc. 27-3) at 5 (MDS Note).)
Following the NCM's review, Defendant denied Plaintiff's short-term disability claim, finding there was insufficient medical evidence to prove that Plaintiff was unable to fulfill the requirements of her position. (Id. at 47.) Defendant notified Plaintiff by letter dated December 11, 2012 that it was denying her claim. (Id. at 46-48.) In its letter, Defendant explained that Plaintiff could provide additional medical evidence and Defendant gave examples of the documentation that could support her disability claim. (Id. at 47.)
Plaintiff then appealed the denial of short-term disability benefits. (Id. at 4 (Claim Note 25).) On December 15, 2012, her file was referred to Defendant's Appeals Review Unit. (Id. at 2 (Claim Note 29), 43.) Before that, on December 11, 2012, Dr. Hooper called Defendant to contest the denial of Plaintiff's benefits. (Id. at 4 (Phone Note 12).) During the conversation with Dr. Hooper, Defendant explained that it needed exam results in order to approve Plaintiff's claim. (Id.) The next day, Defendant received a letter from Dr. Hooper, explaining why he believed Plaintiff was disabled and entitled to short-term disability benefits. (Id. at 4 (Claim Note 24), 50.) Dr. Hooper drew a connection between Plaintiff's medical condition in 2012 - including neck and shoulder spasms, bi-lateral hand pain, weight loss, headaches, hair loss, fatigue, and insomnia - and her "status post cervical spine surgery in 2008 and cervical spine discectomy and cervical spine fusion in 2009." (Id. at 50.) Dr. Hooper also recited results from an undated neurological exam that showed some weakness in Plaintiff's upper extremities. (Id.) In a subsequent call, Plaintiff confirmed that there were no other diagnostic test results to be submitted on appeal. (Id. at 4 (Phone Note 14).)
Another NCM then reviewed the additional information provided by Dr. Hooper and concluded that "based on available records, " there was "no evidence of diagnostics to reflect acute pathology in neck/low back/shoulder or nerve related dysfunction." (Id. at 3 (MDS Note).) Specifically referencing the neurological exam results provided by Dr. Hooper, the NCM explained that the results of the exam did not explain how "mild strength abnormalities" in Plaintiff's upper extremities were "impacting functionality" or whether this was a change from Plaintiff's "baseline." (Id.) Moreover, the NCM explained that results from other office visits had not provided corroborating evidence of these limitations, and the NCM noted that Plaintiff had been taking pain medication for a long period of time due to Plaintiff's "long standing complaint of pain." (See id.) These findings were then incorporated into Defendant's decision-making process on Plaintiff's appeal. (See id. at 15.)
On January 9, 2013, Dr. Hooper provided additional medical records from Regional Physician's Neurosurgery. (See id. at 17-42.) These records pertained to Plaintiff's treatment and back surgery in 2008. (See id.) These medical records were added to the Administrative Record and were incorporated into Defendant's decision-making process on Plaintiff's appeal. (See id. at 15.)
Although Plaintiff does not dispute the foregoing facts, Plaintiff notes that there were other events throughout this time period, as reflected in the Administrative Record, which slowed the process of filing her claim and providing the required medical evidence. Plaintiff notes that she was transferred from one DCM to another soon after she filed her claim and that it took a week to effectuate this transition. (See id. at 7 (Claim Note 11) (noting transition to new DCM on November 29); id. at 6 (Phone Note 5) (advising Plaintiff of DCM transition on December 4).) Plaintiff also alleges that the DCM originally faxed its correspondence with Dr. Hooper to the wrong number, taking an additional two days to get in touch with Dr. Hooper. (See id. at 6 (Claim Notes 14, 17).) Furthermore, Plaintiff highlights that this process fell during the holiday season, making it difficult to schedule appointments with specialists.
Nonetheless, on January 17, 2013, the Appeals Review Unit informed Plaintiff that it was denying her appeal. (See id. at 2 (Claim Note 31), 14-16.) Defendant ultimately concluded, "[T]here is insufficient medical evidence including exam or diagnostic findings or an intensity of treatment to substantiate a condition resulting in restrictions ...