Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-5_04-cv-05106/USCOURTS-arwd-5_04-cv-05106-0/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 29:1001 E.R.I.S.A.: Employee Retirement

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IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

FAYETTEVILLE DIVISION

THOMAS E. BATIE PLAINTIFF

v. Case No. 04-5106

ALBERTSON’S, INC. and

VPA, INC., as a Third Party

Administrator DEFENDANTS

MEMORANDUM OPINION

Plaintiff brings this action pursuant to the provisions of the

Employee Retirement Income Security Act of 1974 (“ERISA”), 29

U.S.C. § 1001 et seq., challenging defendants’ decision to deny him

long-term disability benefits. The parties have submitted the

administrative record (the “AR”) (Doc. 11) and briefs (Docs. 12,

13, 16) on the issues before the Court. The matter is now ripe for

consideration. For the reasons stated below, the Court finds that

defendants’ decision was not supported by substantial evidence and

a separate judgment will be entered in favor of plaintiff.

Background

1. Plaintiff worked for Albertson’s, Inc. as a pharmacist

from April 10, 1996, through March 21, 2001, when he alleges he

became disabled and unable to work due to severe arthritis in his

knees, chronic cellulitis caused by venous insufficiency in his

legs, and his weight. Plaintiff received “Salary Continuation”

from March 21, 2001, through June 20, 2001, and then applied for 

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disability benefits under an employee benefits plan sponsored by

Albertson’s and administered by VPA, Inc. (AR 492.) 

2. Under the terms of the plan, an employee qualifies for

long-term disability benefits when he meets the following

definition of “Totally Disabled”:

“Total Disability” shall mean the complete inability of

the Employee to perform any and every duty of his or her

regular occupation with the Employer... for 24 months of

any continuous period of Total Disability.... [F]ollowing

such 24 month period, Total Disability shall mean the

complete inability of the Employee to perform any and

every duty of any gainful occupation for which he or she

is reasonably fitted by training, education, or

experience ... 

(AR 502) (emphasis added).

3. Defendants awarded plaintiff benefits for the initial 24

month period, finding that he was unable to perform the duties of

his regular occupation as a pharmacist. (AR 492.) Defendants

thereafter conducted a “Two-year Recertification” to determine

whether plaintiff was disabled under the more stringent definition

for post-24 month coverage. Defendants concluded that plaintiff

was not entitled to continuing benefits, as he was capable of

performing sedentary work. (AR 493, 494.)

4. The medical evidence included in the administrative

record reflects the following:

* During the time period in question, plaintiff was

approximately 60 years of age and, at five feet, ten and a half

inches tall, he weighed over 300 pounds. (AR 133, 338.) 

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According to Dr. David Volarich, who, as stated below, 1

conducted an independent medical examination of plaintiff:

Venous insufficiency means that veins of that extremity

are incompetent. They do not adequately return blood

back to the heart. When that happens there is swelling

that occurs in the leg. Certain blood products will

eventually leak out of the venous system and ... cause

skin break down and ulceration[s] to form as well with

time. The skin is also much more predisposed to

infection or what we call cellulitis. It’s kind of a

cascade of events that occurs after the veins have been

incompetent for several years and the involved extremity

is more swollen, erythematous, which means warm to the

touch, and more prone to skin breakdown. (AR 336.)

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* Plaintiff has been diagnosed with severe degenerative

arthritis in both knees, with areas in both knees “where the

cartilage is gone and he basically has bone articulating or rubbing

on bone.” (AR 307.) Plaintiff has also been diagnosed with venous

insufficiency in both legs, resulting in chronic swelling and

cellulitis. Plaintiff has been treated for these conditions on a 1

consistent basis by Dr. Monte Maska, his primary care physician,

and Dr. Michael Nachtigal, an orthopaedic surgeon. As of May 2001,

both doctors opined that plaintiff’s prognosis was poor and that he

should apply for disability benefits.

* In May 2002, at the request of plaintiff’s attorney, Dr.

David Volarich conducted an independent medical examination of

plaintiff. (AR 131-39.) After reviewing plaintiff’s medical

records and interviewing and examining plaintiff, Dr. Volarich

concluded that plaintiff was permanently and totally disabled due

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“Lymphedema” is swelling resulting from the obstruction of 2

lymphatic vessels or lymph nodes and the accumulation of large

amounts of fluid in the affected region. See Stedman’s Medical

Dictionary 1004 (26 ed. 1995). th

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to “lower extremity degenerative arthritis, right lower extremity

venous insufficiency with stasis and his morbid obesity.” (AR

138.) Dr. Volarich listed plaintiff’s restrictions as: 

He is advised to limit repetitive stooping, squatting,

crawling, kneeling, pivoting, climbing and all impact

maneuvers.

He should be cautious navigating uneven terrain, slopes,

steps, and ladders especially if he must handle

weight....

He should limit prolonged weight bearing including

standing or walking to 10 min or to tolerance....

 (Id.) 

Dr. Volarich was deposed in November 2002. When questioned by

defendants’ counsel, Dr. Volarich acknowledged that he placed no

restrictions on plaintiff with respect to sitting and that he would

not “have any problem with [plaintiff] trying” to perform a job

that met the restrictions he identified. (AR 357.)

* Dr. Nachtigal, plaintiff’s orthopaedic surgeon, was also

deposed. When asked whether plaintiff could perform a sedentary

job, Dr. Nachtigal explained:

A. From my standpoint, which would be the knees and

the lymphedema , there could be some frustrations 2

with the lymphedema if he ... remain[]ed seated for

a long period of time. The treatment for

lymphedema involves elevation of the legs.... 

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Q. So you’re saying if he had a sitting job he would

also need the accommodation of having to be able to

elevate his feet, is that correct, or elevate his

legs, I guess?

A. Yeah, spending time with his legs elevated would be

helpful.

(AR 173.)

* On July 14, 2003, plaintiff underwent a functional

capacity evaluation at Healthsouth at defendants’ request. The

evaluation was performed by a licensed physical therapy assistant.

The physical therapy assistant noted that plaintiff had been

diagnosed with bilateral degenerative arthritis, but made no

mention of his venous insufficiency/cellulitis problems. It does

not appear from the written evaluation that the physical therapy

assistant reviewed plaintiff’s medical records; rather, it appears

that she merely questioned plaintiff regarding his medical history

and then performed a battery of functional tests. The physical

therapy assistant concluded that plaintiff could perform sedentary

work. (AR 393-401.)

* Dr. Maska, plaintiff’s primary care physician, reviewed

and addressed the functional capacity evaluation as follows:

It has come to my attention that my patient ... has been

classified in a recent functional capacity examination as

capable of SEDENTARY WORK. I feel that a categorization

of even SEDENTARY work capacity is questionable in light

of the following information previously provided:

- He suffers from severe bilateral knee pain and

lower extremity fluid retention due to degenerative

arthritis and venous insufficiency.

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- In an eight hour work day the patient can stand for

up to thirty minutes at a time and sixty minutes

total in a day. This may be less due to pain.

- In an eight hour work day the patient can sit for

up to two hours total, but only if his legs are

extended and elevated....

In addition, this patient must lay down with his feet

elevated two to three times during the day to control his

swelling and pain. When this patient exceeds these

guidelines[,] he frequently has to seek total bed rest

for the day, or days, following to alleviate the swelling

and pain.

I do not foresee any changes of this patient[‘]s

condition that will ever allow him to return to work. It

is my opinion that he will never again be able to

participate in gainful employment. 

(AR 130.)

* On July 23, 2003, Dr. Michael Lala, a certified

rehabilitation counselor, conducted an independent medical

examination of plaintiff at plaintiff’s attorney’s request. Dr.

Lala reviewed plaintiff’s medical records and the depositions of

Dr. Volarich and Dr. Nachtigal, and he also interviewed and

examined plaintiff. Dr. Lala noted that plaintiff’s “self[-]

report[ed] and associated limitations [were] consistent and

documented in the medical records” and that plaintiff had been

found disabled under the Social Security Administration criteria.

(AR 175, 180.) Dr. Lala concluded:

The medical restrictions in the records provided

translate vocationally to an extremely limited

occupational base. The remaining base of work is

essentially a reduced and limited range of sedentary

work.

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It is noted that he has been prescribed a cane. It has

been suggested that he not stand or walk more than ten

minutes at a time. Federal Regulations indicate that a

person who is limited to the use of a cane and a

sedentary vocational profile has a very limited

occupational base. Essentially some movement either into

the work site, during the work day, or around the work

area is required of all jobs. This includes jobs where

the person is primarily seated most of the work day.

Further, it is medically necessary for him to elevate his

leg above his heart while seated for relief of a medical

condition. Elevation of the legs is not consistent with

even sedentary work. This essentially erodes any

remaining job base....

Pain is felt to be a significant vocational factor in Mr.

Batie’s vocational profile. Medical records document

pain and treatment for these symptoms. There is no

indication that any medical professional doubts the

degree and level of his pain. Pain can and does

interfere with work and work tasks. Sedentary work for

a person with Mr. Batie’s vocational profile would

require the ability to process complex information and

make decisions using data. Given his level of pain it is

not unreasonable to believe that his pain significantly

interferes with his ability to process information. From

a vocational perspective[,] this significantly erodes his

potential occupational base....

Mr. Batie indicated that he suffers from fatigue.

Medical Professionals have indicated that he would not be

able to work on a “full-time” basis day in and day out.

This is essentially inconsistent with sustained work on

a routine and continuous basis....

Based on all this information, it is my professional

opinion, that from a vocational perspective Thomas E.

Batie ... is permanently and totally disabled ....

(AR 181, 193.)

5. On March 23, 2004, defendants issued a final decision

denying plaintiff’s claim for continuing disability benefits.

Defendants reasoned that the functional capacity evaluation

performed on July 14, 2003, indicated that plaintiff was capable of

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performing sedentary work. Defendants further reasoned that there

was no indication in Dr. Lala’s July 27, 2003, evaluation “of any

limits to sitting which is the requirement of a sedentary

occupation.” (AR 10-11.) 

Discussion

6. ERISA provides a plan beneficiary with the right to

judicial review of a benefits determination. See 29 U.S.C. §

1132(a)(1)(B). A denial of benefits by a plan administrator must

be reviewed de novo unless the benefit plan gives the administrator

discretionary authority to determine eligibility for benefits or to

construe the terms of the plan, in which case the administrator’s

decision is reviewed for an abuse of discretion. See Firestone

Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). Under the

terms of plaintiff’s employee benefits plan, the administrator has

the “discretion to make fact findings and to determine all

questions relating to the eligibility of Employees for benefits

....” (AR 523.) Accordingly, defendants’ decision will be

reviewed for an abuse of discretion. 

7. Under the abuse-of-discretion standard, the Court must

determine whether a reasonable person could have reached the same

decision. See House v. Paul Revere Life Ins. Co., 241 F.3d 1045,

1048 (8th Cir. 2001). This inquiry focuses on the presence or

absence of substantial evidence supporting the administrator’s

decision. Id. While the administrator’s decision need not be

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supported by a preponderance of the evidence, there must be “‘more

than a scintilla.’” Id. (citations omitted). Both the quantity

and quality of evidence may be considered. See Norris v. Citibank,

308 F.3d 880, 884 (8 Cir. 2002). th

8. Plaintiff offered overwhelming and uncontradicted

evidence that he suffers from severe degenerative arthritis in both

knees and venous insufficiency in both legs, resulting in chronic

swelling and cellulitis. Plaintiff has been treated consistently

for these conditions and, as pointed out by Dr. Lala, there is no

indication that any medical professional has ever doubted the

degree or level of plaintiff’s complaints of pain. 

Plaintiff’s primary care physician, Dr. Maska, and his

orthopaedic surgeon, Dr. Nachtigal, both opined that plaintiff was

disabled. While plan administrators are not required to “accord

special weight to the opinions of the claimant’s physician,” they

may not “arbitrarily refuse to credit a claimant’s reliable

evidence, including the opinions of a treating physician.” Black

& Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003).

Further, plaintiff has been found to be disabled by the Social

Security Administration. While the disability standards under the

ERISA plan at issue may be different than the social security

standards, the Social Security Administration’s determination

nevertheless supports plaintiff’s ERISA claim for disability

benefits. See Riedl v. General American Life Ins. Co., 248 F.3d

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753, 759 n.4 (8th Cir. 2001); Duffie v. Deere & Co., 111 F.3d 70,

74 n.5 (8 Cir. 1997). th

9. Defendants argue that their decision was supported by

substantial evidence, as the physical therapy assistant who

conducted a functional capacity evaluation of plaintiff in July

2003, found that plaintiff had no limitations with regard to

sitting and could therefore perform the demands of sedentary work.

In the Court’s judgment, a functional capacity evaluation completed

by a physical therapy assistant cannot be construed as substantial

evidence rebutting plaintiff’s treating physicians’ opinions. This

is especially true given the fact that it does not appear that the

physical therapy assistant even reviewed plaintiff’s medical

records. It also does not appear that she considered plaintiff’s

venous insufficiency/cellulitis problems, as the only diagnosis she

noted for plaintiff was bilateral degenerative arthritis. Further,

Dr. Maska, plaintiff’s primary care physician, specifically

addressed the functional capacity evaluation and explained that

plaintiff could not perform sedentary work, because he had to have

his legs elevated when sitting to control his pain and swelling.

Dr. Nachtigal, plaintiff’s orthopaedic surgeon, corroborated this

fact.

10. Defendants also argue that their decision is supported by

the fact that neither Dr. Volarich, who performed an independent

medical examination of plaintiff in May 2002, nor Dr. Lala, who

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performed one in July 2003, placed any restrictions on plaintiff

with regard to sitting. In his written evaluation, Dr. Volarich

concluded that plaintiff was disabled, but, at his deposition, he

acknowledged that he did not place any sitting restrictions on

plaintiff. However, Dr. Volarich was not specifically asked to

address plaintiff’s need to elevate his legs while sitting and

there is nothing in the record controverting plaintiff’s treating

physicians’ opinions that it was medically necessary for him to do

so. 

With regard to Dr. Lala, defendants’ contention that Dr. Lala

placed no sitting restrictions on plaintiff is incorrect. Dr. Lala

specifically stated, “[I]t is medically necessary for [plaintiff]

to elevate his leg above his heart while seated for relief of a

medical condition.” (AR 181.) 

11. Finally, defendants argue that Dr. Lala’s evaluation

failed to discuss “potential jobs that would permit Mr. Batie to

sit while intermittently elevating his leg.” (Doc. 13 at pg. 21

fn. 2.) The Court sees no merit to this argument. Dr. Lala

specifically found: “Elevation of the legs is not consistent with

even sedentary work. This essentially erodes any remaining job

base.”

Conclusion

12. Based on the foregoing, the Court concludes that

defendants’ decision was not supported by substantial evidence and

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that defendants therefore abused their discretion in denying

plaintiff’s claim for continuing disability benefits. 

13. The parties shall have ten days from entry of this order

in which to confer and submit a written stipulation calculating the

total award due plaintiff for past-due benefits. A judgment will

then be entered awarding plaintiff past-due benefits and

reinstating the payment of continuing benefits. 

14. Further, the Court will consider awarding a reasonable

attorney's fee and costs to plaintiff under 29 U.S.C. § 1132(g).

Plaintiff shall submit an application for fees and costs, including

an itemization and affidavit and a brief supporting her argument as

to why an award of fees and costs would be appropriate in this

case, within ten days as well. Defendants shall have ten days

thereafter in which to file a response.

IT IS SO ORDERED this 12th day of May 2006.

/S/JIMM LARRY HENDREN 

JIMM LARRY HENDREN

UNITED STATES DISTRICT JUDGE

 

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