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Jones v. Charter Communications Short Term Disability Plan

United States District Court, M.D. North Carolina

March 28, 2019

ERIC JONES, Plaintiff,
v.
CHARTER COMMUNICATIONS SHORT TERM DISABILITY PLAN, Defendant.

          MEMORANDUM OPINION AND ORDER

          OSTEEN, JR., District Judge

         Plaintiff Eric Jones (“Jones”) brings this action pursuant to 29 U.S.C. § 1132(a)(1)(B) of the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1001 et seq., seeking this court's review of a denial of short-term disability benefits. (Complaint (“Compl.”) (Doc. 1) ¶ 10.) Presently before this court are cross-motions for summary judgment filed by Jones, (Doc. 22), [1] and Defendant Charter Communications Short Term Disability Plan (the “STD Plan”), (Doc. 23). Each party has filed a brief in support of its motion. (Doc. 22-1 (Jones);[2] Doc. 24 (STD Plan).) Defendant has responded to Plaintiff's motion, (Doc. 26), and the parties agree that this matter can be resolved on summary judgment, (see Doc. 10 at 2).[3] For the reasons that follow, Plaintiff's motion will be denied, and Defendant's motion will be granted.

         I. FACTUAL BACKGROUND AND PROCEDURAL HISTORY

         A. The STD Plan

         Jones is a former employee of Charter Communications, Inc. (together with Time Warner Cable (“TWC”), which Charter Communications acquired in 2016, “Charter”). Charter has an employee benefit program called the Charter/TWC Benefits Plan (the “Benefits Plan”). (See A.R. at 2459-91.)[4] The STD Plan is a self-funded component program of the Benefits Plan. (See A.R. at 2496-2501.)[5] As an employee, Jones was a beneficiary of the STD Plan.

         The STD Plan provides eligible employees up to twenty-six weeks of short-term disability benefits, which cover a percentage of an eligible employee's compensation when he is unable to perform his job duties. (A.R. at 2497.) To receive short-term disability benefits, claimants must be “totally” or “partially” disabled, as defined by the STD Plan. (A.R. at 2499.) An employee is “totally disabled” if he “cannot perform the Essential Duties of [his] own occupation” and is “earning less than 20% of [his] pre-disability Covered Compensation due to an injury or illness (including Mental Illness . . .).” (See A.R. at 2499.) An employee is “partially disabled” if he is “able to work part-time for any employer performing some, but not all, of the Essential Duties of [his] own occupation” and “cannot earn more than 80% of [his] pre-disability Covered Compensation.” (A.R. at 2499.) “Essential dut[ies]” are “the important tasks, functions and operations generally required by employers from those engaged in their usual occupation that cannot be reasonably omitted or modified.” (A.R. at 2505.) A grant of short-term disability benefits lasts until the earliest of the date a beneficiary is no longer disabled, his failure to furnish satisfactory proof of continued disability, or the exhaustion of his twenty-six weeks of short-term disability benefits. (See A.R. at 2498-99.)

         A third party may administer the Benefits or STD Plans. The Benefits Plan defines the “Administrator” as the “Committee” and, in turn, the “Committee” as at least three members appointed by Charter and receiving no compensation for such services. (A.R. at 2463, 2476.) Importantly, the Committee has:

[T]otal and exclusive responsibility to control, operate, manage, and administer the [Benefits] Plan in accordance with its terms. The Committee shall have the authority that may be necessary or helpful to enable it to discharge its responsibilities with respect to the [Benefits] Plan. Without limiting the generality of the preceding sentence, the Committee, or its delegate, if any, shall have the exclusive right to interpret the [Benefits] Plan, to determine eligibility for coverage under the [Benefits] Plan, to determine eligibility for benefits under the [Benefits] Plan, to construe any ambiguous provision of the [Benefits] Plan, to correct any default, to supply any omission, to reconcile any inconsistency, and to decide any and all questions arising in administration, interpretation, and application of the [Benefits] Plan.

(A.R. at 2476.) The Committee's decisions, as well as those by the Claims Administrator, are conclusive and binding. (A.R. at 2476, 2478.) And the Committee's authority does not extend to “any matter as to which a Claims Administrator or another designated party under any Component Program is empowered to make determinations.” (A.R. at 2477.)

         The Committee “delegated its authority to determine benefits under the [Benefits] Plan to the Claim Administrators.” (A.R. at 2476.) The STD Plan then provides that the Claims Administrator “is the claims fiduciary with sole authority to determine benefit claims under the terms of the [STD Plan].” (A.R. at 2501.) The STD Plan allows the Claims Administrator to request that an employee receiving short-term disability benefits be examined to verify continued disability and to request that a beneficiary provide it with “other satisfactory proof of [the beneficiary's] continued disability.” (A.R. at 2499; see also A.R. at 2502.)[6] Finally, the STD Plan provides that any appeal of a denied claim will be reviewed by the Claims Administrator and conducted by a person not involved in the initial determination. (See A.R. at 2503.)

         Charter partnered with Sedgwick Claims Management Services, Inc. (“Sedgwick”) to administer the STD Plan. (A.R. at 2508.)[7]

         B. Jones's Mental Illness and the Short-Term Disability Benefits at Issue

          Jones was a Customer Care Rep I (“CSP 1”) at Charter, (A.R. at 1900-01), providing “customer sales and service support by telephone for the high-speed data broadband product, digital phone and cable television[, ]” (A.R. at 1410). His job responsibilities included interacting with customers and coworkers positively and empathetically, performing mathematical calculations, providing expertise on products and services, problem solving, and other sedentary tasks. (A.R. At 2402-06.) Jones's job required concentration, stable mood, multitasking, and the ability to handle high call volume. (A.R. at 116-17.)

         Jones has a history of mental health issues, stemming in part from a traumatic burn he suffered as a child. (See A.R. at 1426, 1431.) He has received therapy since he was young and started taking medications in 1999. (A.R. at 117.) Jones was diagnosed with bipolar disorder in 2008. (A.R. at 117.)

         Jones first applied for short-term disability benefits under the STD Plan on or around May 18, 2015, due to psychiatric issues, including his bipolar disorder. (A.R. at 4, 9.) His treating physician at the time, Dr. M. Chan Badger, noted in a June 3, 2015 attending physician statement that Jones was “not stable to perform his current job functions.” (A.R. at 9-10.) In the attending physician statement, Dr. Badger noted a projected return to work date of August 18, 2015. (A.R. at 10.) Sedgwick ultimately approved Jones's claim for short-term disability benefits through August 9, 2015, and Jones returned to work on or around August 10, 2015. (See A.R. at 11, 36.)

         In late 2015, Jones switched medical providers and began seeing Dr. Chris Aiken and Nurse Practitioner Sara Robertson (“N.P. Robertson”) at the Mood Treatment Center. (A.R. at 1499.) Jones first visited the Mood Treatment Center on December 17, 2015, and N.P. Robertson diagnosed him with bipolar type II disorder, obsessive-compulsive disorder (“OCD”), attention-deficit/hyperactivity disorder (“ADHD”), remissive cocaine use, and also noted post-traumatic stress disorder (“PTSD”). (1499-1508.) Jones regularly received treatment at the Mood Treatment Center over the following months, including on December 30, 2015, (A.R. at 1498); January 14, 2016, (A.R. at 1495); February 19, 2016, (A.R. at 1492); March 10, 2016, (A.R. at 1489); March 24, 2016, (A.R. at 1486); and May 5, 2016, (A.R. at 1483).

         Jones's treatment continued through the summer of 2016. Jones saw N.P. Robertson on July 20, 2016. (A.R. at 1480-83.) N.P. Robertson's psychiatric progress notes from that visit, signed by Dr. Aiken, indicate that Jones endorsed high-to-moderate depressed mood, mild problems with concentration, anxiety, and no suicidal ideations. (A.R. at 1481.) Jones reported feeling well four of the previous seven days. (A.R. at 1482.) The notes also state that Jones was “[u]nhappy at his job - wants to do PR work.” (A.R. at 1481.) The notes do not indicate whether Jones was unable to perform any job functions, (see A.R. at 1480-83), but state that his “judgment may be impaired depending on the task/setting[, ]” (A.R. at 1483).

         On August 17, 2016, Jones applied for the short-term disability benefits relevant here. (A.R. at 1689-94.) On August 19, 2016, Jones saw N.P. Robertson. (A.R. at 1478-80.) Her psychiatric progress notes from that visit, signed by Dr. Aiken, indicate that Jones was depressed, anxious, and had developed mild insomnia since his last visit on July 20, 2016. (See A.R. at 1478-80.) Jones endorsed high-to-moderate depressed mood, anxiety, concentration problems, and he denied suicidal ideations; N.P Robertson again noted Jones's bipolar disorder, PTSD, OCD, ADHD, and remissive cocaine use. (A.R. at 1478-80.) Jones reported feeling well zero of the previous seven days and wanted to go on short-term disability. (A.R. at 1478-79.) The notes do not indicate that Jones was unable to perform any job functions and state that Jones had no functional impairment from his depression. (See A.R. at 1478-80.) N.P. Robertson continued Jones's current medications. (A.R. at 1480.)

         Shortly thereafter, on August 26, 2016, Dr. Aiken and N.P. Robertson indicated in a statement of incapacity/attending physician statement (“SOI”) that Jones was incapacitated until September 22, 2016, due to his bipolar type II disorder, PTSD, and ADHD. (A.R. at 1646.) The SOI also indicates that Jones had visited the emergency room at Novant Health. (A.R. at 1647.) The Mood Treatment Center appears to have faxed this SOI to Sedgwick on August 29, 2016 and September 8, 2016. (A.R. at 1645-46.) On September 6, 2016, Sedgwick approved Jones's short-term disability benefits from August 22, 2016 through September 6, 2016, effective after an elimination period of August 22, 2016 to August 28, 2016. (A.R. at 1662-63.)

         On September 6, 2016, Jones visited N.P. Robertson, who noted that Jones's mood had improved. (A.R. at 1474.) N.P. Robertson's notes state that Jones endorsed very mild symptoms of depressed mood, anxiety, and problems with concentration. (A.R. at 1474.) Jones reported feeling well five of the seven previous days and had no suicidal or impulsive thoughts. (A.R. at 1474-75.) N.P. Robertson did not indicate whether Jones was unable to perform his job functions. (See A.R. at 1474-75.)

         Thereafter, in an SOI dated September 26, 2016, Dr. Aiken indicated that Jones was unable to perform his job functions due to his condition. (A.R. at 1627.) Dr. Aiken recommended that Jones not return to work until October 25, 2016, because of his bipolar type II disorder, PTSD, ADHD, as well as four panic attacks in the prior month. (A.R. at 1627-28.) Attached to the SOI was a September 26, 2016 “summary of disability” form in which N.P. Robertson and Dr. Aiken specifically noted that they had advised Jones to stop working. (A.R. at 1630-31.) They noted Jones's full impairment in certain of his job functions, including the inability to: “maintain a work pace appropriate to a given workload”; “perform complex or varied tasks”; “make generalizations, evaluations or decisions”; and “relate to other people beyond giving and receiving instructions.” (A.R. at 1631-32.) The Mood Treatment Center faxed the SOI and disability summary to Sedgwick on September 26, 2016. (A.R. at 1624-32.)

         On September 29, 2016, a Sedgwick employee reviewed Jones's file and recommended extending Jones's short-term disability benefits until October 21, 2016, based on an expected return-to-work date of October 25, 2016. (A.R. at 1144-45.) Sedgwick's internal documentation summarizes the approval rationale and notes that Jones needed “additional time for symptoms to stabilize prior to [return to work] as a CSP 1.” (A.R. at 359.) On September 30, 2016, Sedgwick extended Jones's short-term disability benefits through October 21, 2016. (A.R. at 1620.)

         On October 12, 2016, Dr. Aiken and Jones spoke on the phone regarding Jones's treatment and response to his medications. (A.R. at 1472-73.) Dr. Aiken's notes of that call do not indicate whether Jones was unable to perform his job duties. (See A.R. at 1472-73.) On October 21, 2016, Jones visited N.P. Robertson. (A.R. at 1469-71.) Her notes, signed by Dr. Aiken, indicate that Jones's mood had improved, that he felt well six of the prior seven days, and suggest no functional impairment. (See A.R. at 1469-71.) Jones still exhibited mild symptoms of depressed mood, hypoactivity, concentration problems, and anxiety. (A.R. at 1469.) But he showed no signs of psychosis or suicidal thoughts. (A.R. at 1469-71.) The notes state that Jones “had 2 interviews - on STD - extended 1 more month.” (A.R. at 1469.) The notes also indicate that Jones would see a new therapist, Ms. Barbara Farran, ASCW, LCSW. (See A.R. at 1469.) N.P. Robertson did not indicate whether Jones was unable to perform his job duties. (See A.R at 1469-71.)

         Sedgwick attempted to call Jones on October 15, 2016 before his grant of short-term disability benefits expired on October 21, 2016. (A.R. at 340.) Sedgwick did not immediately cut Jones's benefits off on October 21st. Sedgwick attempted to contact Dr. Aiken's office to get an update on Jones's condition. On October 26, 2016, Sedgwick spoke with Jones and told him that no updated information had been received from the Mood Treatment Center. (A.R. at 352.) On October 27, 2016, Sedgwick faxed the Mood Treatment Center requesting updated medical information on Jones and again called Jones. (A.R. at 340, 350.) On October 28, 2016, the Mood Treatment Center faxed Sedgwick Jones's updated medical records, including a list of current medications and the notes from Jones's October 12, 2016 telephone conference and October 21, 2016 office visit. (See A.R. at 346-48; 1598-1608.) A Sedgwick form document requesting medical information was also filled out by someone at the Mood Treatment Center and indicates that Jones's next treatment was on November 18, 2016 and that his estimated return to work date was November 25, 2016. (A.R. at 1599.)

         Sedgwick spoke to Jones on November 1, 2016 and advised him that it was reviewing the additional information from the Mood Treatment Center. (See A.R. at 343-44.) On November 2, 2016, after reviewing the additional office visit notes, Sedgwick left a voicemail with the Mood Treatment Center seeking to clarify “what provider saw on exam that is preventing [employee] from working, examples how those symptoms were observed to be severe, and if [employee] could [return to work] with restrictions.” (A.R. at 1776.) Sedgwick left another voicemail with Dr. Aiken and N.P. Robertson on November 3, 2016. (A.R. at 1776.) The voicemails apparently went unreturned. Later that day, November 3, 2016, one of Sedgwick's registered nurses reviewed Jones's file, including Dr. Aiken's notes from his October 12, 2016 telephone conference with Jones, N.P. Robertson's psychiatric notes from Jones's October 21, 2016 treatment, and Jones's medication list. (See A.R. at 1775.) Sedgwick's nurse concluded that Jones's “[m]edical information does not support severity that [he] is disabled still because exam findings are minimal and do not indicate that [he] has a cognitive impairment.” (A.R. at 1776.) The nurse was unable to tell whether Dr. Aiken and N.P. Robertson had cleared Jones to return to work as there was “no visible indication that [he] need[ed] more time off of work[, ]” and it looked to the nurse as if Jones's symptoms were more in control and his mood had improved. (A.R. at 342, 1776.)

         For those reasons, on November 3, 2016, Sedgwick denied a continuation of Jones's short-term disability benefits, effective October 22, 2016, and notified Jones in writing. (A.R. at 315, 1463-65.) Sedgwick's denial letter states that it had “received medical information from Dr. [sic] Sara Robertson & Dr. Chris Aiken on 09/26/2016, which confirmed [Jones's] disability through 10/21/2016. The determination to deny an extension of benefits is based on a review of medical documentation provided by Amanda Kirby [sic] & Dr. Badger [sic] ¶ 10/28/2016.” (A.R. at 1464.)[8] The letter continues that those records did not “support severity of disability due to exam findings being minimal and do not indicate that the [employee] has a cognitive impairment. Attempts to gather additional information were unsuccessful.” (A.R. at 1464.)

         On November 4, 2016, Dr. Aiken faxed Jones's medical records to Sedgwick, with an “urgent” notation. (A.R. at 1587-88.) These documents included the October 12, 2016 and October 21, 2016 psychiatric progress notes, (A.R. at 1587-95), which Sedgwick had already reviewed after Dr. Aiken sent them on October 28th, (A.R. at 1598-1608). Jones also called Sedgwick several times between November 4, 2016 and November 9, 2016 to dispute the denial. (A.R. at 325-26, 332-36.)

         C. The Administrative Appeal

         On November 10, 2016, Jones appealed Sedgwick's denial through a faxed letter dated November 9, 2016, from Dr. Aiken to Sedgwick's National Appeals Unit. (A.R. at 1461-62, 1466 (STD Appeal Form signed by Jones on November 7, 2016).) Dr. Aiken requested that Sedgwick reconsider its denial because Jones's medical condition “impair[ed] his ability to work in any capacity.” (A.R. at 1462.) In his cover letter, Dr. Aiken reiterated that Dr. Badger and Ms. Kirby were “not affiliated with Mood Treatment Center” in any way. (A.R. at 1462.) Dr. Aiken provided Jones's psychiatric progress notes from December 17, 2015 through October 21, 2016. (A.R. at 1461-1508.)

         On November 15, 2016, Sedgwick's Appeals Unit notified Jones of its receipt of his appeal, which Sedgwick assigned to Appeals Specialist Tricia Pike. (A.R. at 1457-58.) On November 17, 2016, Sedgwick contacted Jones to explain the appeal process and told him that an independent physician would review Jones's file and contact N.P. Robertson and Ms. Farran to discuss Jones's medical issues. (A.R. at 309-12.) Jones stated that no other providers needed to be contacted. (See A.R. at 310.) Sedgwick told Jones which medical documents it currently had for review, including the Mood Treatment Center's notes from August 19, 2016 and September 16, 2016, as well as the associated SOI from September 26, 2016, and notes from Jones's October 12, 2016 telephone conference with Dr. Aiken and his October 21, 2016 office visit. (A.R. at 310.) Jones told Sedgwick that there would be additional information submitted from a forthcoming treatment on November 18, 2016, and possibly information from Ms. Farran. (See A.R. at 310-11.) On November 17, 2016, Sedgwick tolled Jones's appeal through November 30, 2016, to allow Jones time to perfect his appeal. (A.R. at 309-11, 1434).

         On November 18, 2016, Jones saw N.P. Robertson. (A.R. at 1432.) Her psychiatric progress notes from that visit, signed by Dr. Aiken, state that Jones's short-term disability benefits were denied and that Jones was now extremely depressed, “[t]earful, not sleeping, [and] hopeless.” (A.R. at 1430-32.) Jones reported feeling well zero of the prior seven days, and N.P. Robertson noted “passive suicidal thoughts without plan/intent (low-moderate).” (A.R. at 1430-31.) The notes describe Jones's mental status as “[m]arkedly ill, with functional impairment from symptoms, ” and judgment impairment depending on the task or setting. (A.R. at 1431-32.) The notes do not specifically indicate that Jones was unable to perform his job functions. (See A.R. at 1431-32.) N.P. Robertson increased Jones's dosage of Klonopin due to his anxiety. (A.R. at 1432.)

         On or around November 28, 2016, Sedgwick received N.P. Robertson's notes from the November 18, 2016 visit and Jones's updated prescription list. (A.R. at 299-04, 1427-32.) On November 30, 2016, Ms. Pike left a voicemail with the Mood Treatment Center, asking if more time was needed to submit additional information. (A.R. at 299.) Thereafter, Sedgwick tolled Jones's appeal through December 18, 2016. (A.R. at 1423.)[9]

         On December 5, 2016, Ms. Farran faxed Sedgwick a letter stating that she had been seeing Jones since October 27, 2016. (A.R. at 1424-26.) Ms. Farran's diagnosis was for PTSD “based on [Jones's] trauma of being a burn victim, a former Marine, and the subsequent bullying he ...


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