ERISA Long Term Disability Case Citations and references

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Claimant wins when Disability Plan does not consider ALL ailments

Guthrie v. Nat'l Rural Elec. Coop. Ass'n Long-Term Disability Plan, 509 F.3d 644 (4th Cir. 2007)

UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT

CALLIE D. GUTHRIE,
Plaintiff-Appellant,
v.
NATIONAL RURAL ELECTRIC COOPERATIVE
ASSOCIATION LONG-TERM DISABILITY PLAN;
COOPERATIVE BENEFIT ADMINISTRATORS, INCORPORATED,
Defendants-Appellees.

GREGORY, Circuit Judge:

Callie D. Guthrie ("Guthrie") was denied long-term disability benefits ("LTD benefits") by her employee benefit plan. She brought suit against Cooperative Benefit Administrators, Inc. ("CBA") under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132(a)(1)(B). CBA moved for summary judgment. The District Court granted CBA's motion for summary judgment and denied Guthrie's motion for summary judgment, holding that no genuine issue of fact supported Guthrie's disability claim.

Because we find that CBA failed to consider all of Guthrie's medical ailments in denying her claim for disability benefits, we reverse and remand.

Put simply, CBA denied Guthrie's claim because she was physically and mentally capable of working a sedentary job. The crux of Guthrie's appeal is that CBA denied her a "full and fair review" by [Slip. Op. 651] ignoring compelling evidence that she was limited by a number of physical and mental ailments in addition to occupational asthma.

She claims that CBA improperly relied on pulmonologists who did not adequately address her other health conditions, in violation of ERISA provisions, which require an administrator to "consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment." 29 C.F.R. § 2560.503-1(h)(3)(iii). Guthrie also argues there is ample evidence supporting her disability claim based on other conditions that CBA never considered. CBA contends that Guthrie's primary complaint was occupational asthma, and therefore it was not inappropriate to refer her claims to pulmonary specialists. More significantly, CBA asserts that Guthrie's other ailments were not the basis for her claim for LTD benefits. The district court found that all of Guthrie's arguments lacked merit and held that there was substantial evidence to deny her disability claim.

ERISA requires that plan administrators give plan participant appeals a "full and fair review" so that an administrator's decision is "the result of a deliberate, principled reasoning process" and "supported by substantial evidence." 29 U.S.C. § 1332(a); Weaver v. Phoenix Home Life Mut. Ins. Co., 99 F.2d 154, 157 (4th Cir. 1993); Stup v. Unum Life Ins. Co., 390 F.3d 301, 307 (4th Cir. 2004).

Employing this standard, we find CBA's denial of benefits was unreasonable. Although initially CBA had substantial evidence that Guthrie could perform sedentary work, by 2003 CBA was on notice that Guthrie's other ailments were causing her health to deteriorate. On May 12, 2003, Dr. Goodman noted that Guthrie's medical problems were very significant and that she was suffering from "very prominent anxiety," depression, "is frequently tearful," and that "in some ways [Guthrie's] dermatological lesions were making her unemployable." (J.A. 77.) By the time CBA commenced its investigation on January 22, 2004, into whether Guthrie's LTD benefits would continue, she was already diagnosed by a clinical social worker, albeit not a psychologist, as suffering from major depression and anxiety. In response to the investigation, Dr. Goodman completed an attending physician statement on January 28, 2004. In the statement, he indicated that Guthrie's asthma, nerves, skin lesions, and arthritis all placed her in a Class 5 physical impairment category; that is, Guthrie's functional capacity was severely limited and she was incapable of minimal sedentary activity. Dr. Goodman also noted that she had developed very prominent anxiety symptoms. On February 27, 2004, Dr. Goodman reported that Guthrie's skin rash was so terrible that she had small infected boils in some areas. [Slip. Op. 652] Despite these reports, CBA denied Guthrie LTD benefits on May 24, 2004.

And even after Dr. Goodman, in support of Guthrie's appeal, stated that her osteoarthritis, severe dermatitis, asthma with an occupational component, esophageal disease, hyperlipidemia, and hypertension rendered her disabled from any occupation, CBA claimed that her medical condition did not prevent her from returning to other gainful employment. In so deciding, CBA relied on Drs. Sonne's and Pearl's reports. Both pulmonologists found that Guthrie was not disabled based on her occupational asthma. Although Dr. Pearl noted that Guthrie had "multiple other problems," neither doctor addressed her other ailments.

Given that CBA was aware of the extent to which Guthrie's other ailments were disabling, we cannot conclude that CBA's reliance on the opinions of pulmonologists was reasonable. Under the circumstances, CBA should have referred Guthrie's appeal to an internist or primary care physician to assess her other ailments. Without question, CBA honed in on Guthrie's pulmonary issues, which effectively resulted in denying her claim based on occupational asthma alone. The record makes clear that on appeal the basis for Guthrie's claim for LTD benefits included far more than her occupational asthma. Moreover, the record is bereft of any evidence demonstrating that Guthrie's other ailments were not disabling. Thus, CBA's failure to consider Guthrie's constellation of medical issues denied her a full and fair review and, consequently, its decision to deny benefits was not based on substantial evidence.

Awarded: Claimant Wins