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Johnson v. AT&T, Inc.

United States District Court, N.D. Alabama, Southern Division

January 9, 2018

D'ANZA JOHNSON, Plaintiff
v.
AT&T UMBRELLA BENEFIT PLAN No. 3, Defendant,

          MEMORANDUM OPINION

          HERMAN N. JHONSON, JR., UNITED STATES MAGISTRATE JUDGE.

         This action proceeds before the court on defendant's Motion for Summary Judgment. (Doc. 29). Plaintiff filed this action pursuant to the Employee Retirement Income Security Act, 29 U.S.C. § 1001 et seq. (ERISA), seeking short term disability and long term disability benefits under an employee welfare benefit plan provided by her employer, AT&T, Inc., through its AT&T Umbrella Benefit Plan No. 3. Plaintiff asks the court to reverse defendant's adverse decision denying short term disability benefits. In addition, plaintiff asks the court to find her entitled to long term disability benefits, or in the alternative, remand the case for a further determination whether plaintiff is entitled to long term disability benefits. For the reasons discussed herein, the court GRANTS defendant's motion.

         Standard of Review

         The general principle of Rule 56, Federal Rules of Civil Procedure, that summary judgment is proper “if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law, ” has limited application in an ERISA case because the district court “sits more as an appellate tribunal than as a trial court” and “evaluates the reasonableness of an administrative determination in light of the record compiled before the plan fiduciary.” Curran v. Kemper Nat'l Servs., Inc., 2005 WL 894840, *7 (11th Cir. Mar. 16, 2005) (unpublished per curiam opinion) (quoting Leahy v. Raytheon Co., 315 F.3d 11, 18 (1st Cir. 2002)). To that end, the Eleventh Circuit's six-step sequential framework for reviewing ERISA benefit denials guides the court:

(1) Apply the de novo standard to determine whether the claim administrator's benefits-denial decision was “wrong” (i.e., the court disagrees with the administrator's decision); if it is not, then end the inquiry and affirm the decision.
(2) If the administrator's decision in fact is “de novo wrong, ” then determine whether he was vested with discretion in reviewing claims; if not, end judicial inquiry and reverse the decision.
(3) If the administrator's decision is “de novo wrong” and he was vested with discretion in reviewing claims, then determine whether “reasonable” grounds supported it (hence, review his decision under the more deferential arbitrary and capricious standard).
(4) If no reasonable grounds exist, then end the inquiry and reverse the administrator's decision; if reasonable grounds do exist, then determine if he operated under a conflict of interest.
(5) If there is no conflict, then end the inquiry and affirm the decision.
(6) If there is a conflict, the conflict should merely be a factor for the court to take into account when determining whether an administrator's decision was arbitrary and capricious.

Blankenship v. Metro. Life Ins. Co., 644 F.3d 1350, 1355 (11th Cir. 2011). The court undertakes the review by considering “the material available to the administrator at the time it made its decision.” Id. Moreover, the claimant sustains the burden of proving entitlement to ERISA benefits. Glazer v. Reliance Std. Life Ins. Co., 524 F.3d 1241, 1248 (11th Cir. 2008).

         Factual Background

         A. The Benefits Plan

         The AT&T Umbrella Benefit Plan No. 3 constitutes an employee welfare benefit plan regulated by ERISA, and the AT&T Southeast Disability Benefits Program functions as a component program of the Plan. (Doc. 15-2, Siegel Decl., ¶ 2). AT&T Services, Inc., serves as the Plan Administrator. (Id., ¶ 3). Sedgwick Claims Management Services, Inc., (Sedgwick) serves as the third party Claims Administrator for the AT&T Southeast Disability Benefits Program. (Id.). As the Claims Administrator, Sedgwick operates the AT&T Integrated Disability Service Center, and Sedgwick employees review and adjudicate all benefit claims submitted by Plan participants. (Id.).

         The Plan provides as follows regarding the funding and contributions for the Southeast Disability Benefits Program:

The Program is funded by a trust. Program costs are funded by periodic, nonreversionary Company contributions determined by the Program's actuaries for the purpose of funding Program benefits and maintaining appropriate reserves. Contributions are transferred to the Trust, which is established exclusively for approved Plan purposes. Benefits under the Program are paid or reimbursed by the Trust. Benefits paid in excess of IRS limits are funded by the general assets of your Participating Company. No benefits provided under the Program are provided by insurance.

(Doc. 15-3 at 36).

         The Plan documents confer complete and exclusive discretionary authority to Sedgwick to finally and conclusively interpret and administer the terms of the AT&T Southeast Disability Benefits Program.[1] (Doc. 15-2, Siegel Decl., ¶ 4). Sedgwick renders initial decisions on claims for benefits, as well as decisions on the appeals of benefit denials. (Id.). Neither the employees of AT&T nor any of its companies instruct Sedgwick to grant or deny benefits, nor do they provide any recommendations to grant or deny benefits in specific cases. (Id.). AT&T Services, Inc., the Plan Administrator, possesses no authority to reverse or alter Sedgwick's benefits determinations. (Id.).

         The Plan defines “disability” as follows:

You are considered Disabled for purposes of Short-Term Disability Benefits if the Claims Administrator, at its sole discretion, determines that you are Partially or Totally Disabled. You are considered Totally Disabled when, because of illness or injury, you are unable to perform all the essential functions of your job or another available job assigned by your Participating Company with the same full-time or part-time classification for which you are qualified. You are considered Partially Disabled when, because of illness or injury, you are unable to perform all of the essential functions of your job or another available job assigned by your Participating Company within the same full-time or part-time classification for which you are qualified, for the same number of hours that you were regularly scheduled to work before your Partial Disability.
You are considered Disabled for purposes of Long-Term Disability Benefits when you have a continuous physical or mental illness or injury, whether work-related or non-work-related, that renders you unable to perform any type of work other than work for which the rate of pay is less than 50% of your Pay on the day immediately before your Short-Term Disability Benefits began. You may be eligible for Long-Term Disability Benefits payable if you are only capable of performing a job which pays less than 50 percent of your Pay before your Short-Term Disability Benefits started.
You are considered Disabled for purposes of Short-Term Disability Benefits if the Claims Administrator determines, at its sole discretion, that you are Totally or Partially Disabled. Disabled means that you have a medical condition supported by objective Medical Evidence.
You are considered Disabled for purposes of Long-Term Disability Benefits under this Program when you have a continuous physical or mental illness or injury, whether work-related or nonwork-related, that renders you unable to perform any type of work other than work for which the rate of pay is less than 50 percent of your Pay on the day immediately before your Short-Term Disability Benefits began.

Doc. 15-3 at 6, 7, 11, 21).

         With regard to “Medical Evidence, ” the Plan defines this term as follows:

Objective medical information sufficient to show that the Participant is Disabled, as determined at the sole discretion of the Claims Administrator. Objective medical information includes, but is not limited to, results from diagnostic tools and examinations performed in accordance with the generally accepted principles of the health care profession. In general, a diagnosis that is based largely or entirely on self-reported symptoms will not be considered sufficient to support a finding of Disability. For example, reports of intense pain, standing alone, will be unlikely to support a finding of Disability, but reports of intense pain associated with an observable medical condition that typically produces intense pain could be sufficient.

(Id. at 33).

         B. Plaintiff's Claim

         Plaintiff worked for AT&T as an accounting specialist. Her duties consisted of conducting complex accounting and financial assignments, examining and analyzing data, and preparing reports, and the job comprised sedentary work. (AR 58, 61, 215). Plaintiff participated in the AT&T Southeast Disability Benefits Program. (Doc. 15-2, Siegel Decl., ¶ 3).

         Plaintiff sought short term disability (STD) benefits for an absence beginning February 27, 2014. (AR 001).[2] Plaintiff alleged she was disabled due to chronic pelvic pain, pelvic floor myalgia, major depression, post-traumatic stress syndrome, psoriatic arthritis, fibromyalgia, kidney proteinuria, and interstitial cystitis. (AR 59). Sedgwick approved plaintiff's STD benefit claim, and after the seven-day waiting period, commenced paying STD benefits for the period from March 6, 2014, through May 15, 2014. (AR 001, 201). STD benefit payments ceased as of May 16, 2014. (AR 201). Plaintiff appealed the cessation of benefits on May 29, 2014. (AR 207).

         As part of the first-level appeal, Sedgwick effected review of plaintiff's medical records by Dr. William Mazzella, board-certified in internal medicine (AR 246-49), Dr. Dennis Payne, board-certified in rheumatology and internal medicine (AR 256-59), and Dr. Tahir Tellioglu, a board-certified psychiatrist (AR 250-55). Plaintiff submitted additional medical records, and Sedgwick effected review of these records by Dr. Lyle Mitzner, board-certified in internal medicine and endocrinology (AR 306-09), as well as Drs. Mazzella (AR 311-14), Payne (AR 321-24), and Tellioglu (AR 316-20).

         After consideration of the evidence from plaintiff's medical care providers, as well as the opinions of the independent medical consultants, the Plan Administrator upheld the denial of further benefits on December 5, 2014, finding no objective medical evidence to support a conclusion that plaintiff remained disabled beyond May 16, 2014. (AR 334).

         On January 28, 2015, plaintiff appealed to the second level of review, based on the diagnoses of the afore-mentioned conditions. (AR 57-58, 340). As part of the second-level review, Sedgwick effected review of plaintiff's medical records by Dr. Robert J. Cooper, board-certified in endocrinology and internal medicine (AR 353-56); Dr. David Knapp, board-certified in rheumatology and endocrinology (AR 357-62; 371-76); Dr. Michael Rater, a board-certified psychiatrist (AR 364-68); and Dr. Jose Perez, Jr., board-certified in internal medicine (AR 386-91). Dr. Perez opined that plaintiff was disabled from May 16, 2014, through January 8, 2015, the last date for which there were available medical records. (AR 390).

         Sedgwick then obtained more recent records, which it provided for review to Dr. Cooper (AR 438-39); Dr. Rater (AR 440-42); Dr. Rajendra Marwah, a board-certified rheumatologist (AR 444-46); and Dr. Perez (AR 434-36). Dr. Perez reaffirmed his opinion that plaintiff met the criteria for short term disability only through January 8, 2015. Sedgwick issued its final denial of plaintiff's STD claim on June 2, 2015, denying her claim for STD benefits from January 9, 2015, going forward. (AR 452-55). However, Sedgwick ...


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