Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-2_05-cv-02173/USCOURTS-arwd-2_05-cv-02173-1/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 29:1132 E.R.I.S.A.-Employee Benefits

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IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

FORT SMITH DIVISION

RONALD W. JACKSON PLAINTIFF

v. Case No. 05-2173

PRUDENTIAL INSURANCE COMPANY

OF AMERICA, a foreign corporation 

doing business in Arkansas; and 

FURNITURE FACTORY OUTLET, INC.,

GROUP POLICY NO. 79190 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., alleging Defendants’

decision to deny his claim for long-term disability benefits

was unreasonable. This disability benefit claim is before the

Court for decision on the stipulated administrative record

(Doc. 4), Plaintiff’s brief (Doc. 7), Defendants’ brief (Doc.

13), Plaintiff’s reply (Doc. 16), Defendants’ reply (Doc. 22),

and Plaintiff’s sur-reply (Doc. 23). For the reasons stated

below, the Court finds the Defendants’ decision was supported

by substantial evidence and is AFFIRMED. Plaintiff’s claim is

DENIED and Plaintiff’s Complaint (Doc. 1) is DISMISSED WITH

PREJUDICE. 

BACKGROUND. 

Plaintiff was the chief financial officer (“CFO”) for

Furniture Factory Outlet (“FFO”) from May 1993 until April 15,

2003. Plaintiff alleges that when he began employment with

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FFO, the business consisted of twelve retail locations in

three states, with approximately $12 million dollars in sales

and eighty employees, with 100% manual accounting, except for

check writing. (Doc. 1). As of April 2003, FFO had expanded

to twenty-four retail locations, in four states, with

approximately $50 million in sales, and more than 350

employees. (Doc. 7). 

Plaintiff’s job as CFO included various duties which

required a minimum of fifty - sixty hours per week. (Rec. at

344). Plaintiff was covered under a group disability

insurance policy funded by Separate Defendant FFO and issued

by Separate Defendant Prudential Insurance Company of America

(“Prudential”). This long-term disability insurance benefit

policy provided for the replacement of income loss due to

disability. On April 26, 2003, Plaintiff filed his claim for

disability benefits from Prudential. By letter dated May 12,

2004, Prudential informed Plaintiff of its decision to

terminate Plaintiff’s LTD benefits. (Rec. a 469).

On December 14, 2005, Plaintiff filed this action under

ERISA seeking to overturn the termination of long-term

disability benefits by the Claims Administrator. 

DISCUSSION. 

Under ERISA, a denial of benefits by a plan administrator

must be reviewed de novo unless the benefit plan gives the

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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. Woo v. Deluxe Corp., 144 F.3d 1157, 1160 (8th

Cir. 1998) citing Firestone Tire & Rubber Co. v. Bruch, 489

U.S. 101, 115 (1989). Accordingly, the Court must be guided

by the language of the plan to determine the proper standard

of review.

The Plan provides, in pertinent part, “Prudential . . .

as Claims Administrator . . . the sole discretion to interpret

the terms of the Group Contract, to make factual findings, and

to determine eligibility for benefits.” (Rec. at 40).

Therefore, Prudential’s decision can only be reviewed for an

abuse of discretion. 

The Eighth Circuit Court of Appeals has "variously

defined . . . an abuse of discretion as being 'extremely

unreasonable,' 'virtually' the same as arbitrary and

capricious, and 'extraordinarily imprudent.'" Shell v.

Amalgamated Cotton Garment, 43 F.3d 364, 366 (8th Cir. 1994)

(citations omitted). "The proper inquiry into the deferential

standard is whether 'the plan administrator's decision was

reasonable; i.e., supported by substantial evidence.'" Cash

v. Wal-Mart Group Health Plan, 107 F.3d 637, 641 (8th Cir.

1997) (quoting Donaho v. FMC Corp., 74 F.3d 894, 899 (8th Cir.

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1996)). 

"While the word 'reasonable' possesses numerous

connotations, this court has rejected any such definition that

would 'permit a reviewing court to reject a discretionary

trustee decision with which the court simply disagrees[.]'"

Id. at 641 (citation omitted). A decision is reasonable "if

'a reasonable person could have reached a similar decision,

given the evidence before him, not that a reasonable person

would have reached that decision.' Id. If the decision is

supported by a reasonable explanation, it should not be

disturbed, even though a different reasonable interpretation

could have been made." Id. (citation omitted). 

Where there is a difference of opinion between a

claimant’s treating physicians and the plan administrator’s

reviewing physicians, the plan administrator has discretion to

find the employee not disabled unless “the administrative

decision lacks support in the record, or . . . the evidence in

support of the decision does not ring true and is . . .

overwhelmed by contrary evidence.” Donaho, 74 F.3d at 901

(8th Cir. 1996). 

Plaintiff completed and submitted to Prudential an

“Employee Statement” in which he reported that his job was

“Sedentary.” The Employee Statement described that term as

“Negligible Weight” and “Mostly Sitting.” (Rec. 405). In the

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Statement, Plaintiff wrote that his condition interfered with

his ability to work because of “inability to concentrate,

memory problems, and inability to exert myself physically,

feeling totally fatigued all the time.” (Rec. At 406). Dr.

Frederick, an internal medicine physician, submitted an

Attending Physician’s Statement (“APS”) dated May 1, 2003, in

which he reported Plaintiff had sleep apnea and impaired left

ventricular systolic function. (Rec. At 401). Dr. Frederick

explained Plaintiff underwent a sleep study that confirmed a

diagnosis of sleep apnea, and an echocardiogram that

demonstrated Plaintiff had an ejection fraction (“EF”) of 20%.

(Rec. at 402). 

Dr. Frederick’s report detailed the Plaintiff’s

condition, and listed his medications, to include use of a

Continuous Positive Airway Pressure (“CPAP”) machine at night

to treat his apnea. (Rec. 412). On January 3, 2003,

Plaintiff underwent a transthoracic echocardiogram at the Mayo

Clinic that reflected an EF of 25%. (Rec. at 363). On

January 7, 2003, Drs. Martha Grogan and Allison Pritchett, of

the Mayo Clinic’s Heart Failure Clinic, each evaluated

Plaintiff. Both doctors concluded the sleep apnea was the

most critical problem, but with treatment, that condition

could yield improvement of Plaintiff’s other conditions.

(Rec. 372). A third Mayo Clinic doctor, Dr. Evans, likewise

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concluded Plaintiff’s left ventricular dysfunction, low EF,

and fatigue symptoms, all “stood a good chance of improvement

with treatment of sleep apnea and weight loss.” (Rec. at

376). 

On April 15, 2003, the last day Plaintiff worked,

Plaintiff saw Dr. Frederick and his progress notes reflect

that he returned for follow-up of his heart condition and EF,

and that he had used his CPAP regularly since his visit to the

Mayo Clinic. Plaintiff reported he had “noticed remarkable

improvement in his sleep and daytime energy.” (Rec. at 397).

The note reported “considerable improvement since the primary

study,” and an echocardiogram was completed and showed an

improved EF from 20% to 45%. (Rec. at 397). 

On June 10, 2003, Plaintiff returned to Dr. Frederick,

who noted that he “remains as active as he can be, does

outside work with string trimmers and the like . . ..” (Rec.

at 395). On July 15, 2003, Plaintiff contacted Prudential to

explain that his most recent test results were unavailable,

but he had been advised that his EF was now 40 - 42%. Based

on this information, Prudential’s registered nurse Mary Ann

DeSantis noted that Plaintiff had worked for years with an EF

of near 20%, and that an EF of 40 - 42% “is sufficient for

light duty work, and [Plaintiff’s] job may be primarily

sedentary.” (Rec. at 416). Nurse DeSantis concluded if

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confirmed that Plaintiff’s job was sedentary, and his EF was

40% or higher, then there was no evidence to support his

inability to return to work. (Rec. at 416). 

Prudential was unable to immediately obtain a copy of

Plaintiff’s echocardiogram but awarded Plaintiff LTD benefits

from July 16 to July 31, 2003, while it awaited a copy of the

report. (Rec. at 417). On July 25, 2003, Separate Defendant

FFO confirmed that Plaintiff’s job as CFO was a sedentary job.

(Rec. at 448). That same day, Prudential attempted to contact

Plaintiff, but learned he could not come to the phone because

he was mowing the yard. (Rec. at 448). Prudential called

back later in the day and was advised Plaintiff was still

mowing because he had “a huge yard.” Id. 

On July 23, 2003, Dr. Frederick’s office supplied

Prudential with a copy of the July 8 Echo report that

reflected the study was limited, due to Plaintiff’s “body

habitus.” (Rec. at 354). The interpreting physician noted if

EF needed to be evaluated, a MUGA scan would be suggested.

Id. On September 15, 2003, Prudential medical director, Dr.

Kowalski, reviewed the available medical information and

determined the documentation did not support Plaintiff’s

alleged disability. (Rec. at 426). On September 18, 2003,

Plaintiff underwent a MUGA scan that demonstrated Plaintiff’s

EF was 48%. (Rec. at 332). 

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An ejection fraction between 55 and 75 percent is considered normal. A low ejection 1

fraction may be a sign the the heart is somewhat weakened. e.g., Definition and Explanation of

Ejection Fraction, http://heart.healthcentersonline.com/heartfailure/ejectionfraction.cfm (last

visited February 21, 2007). 

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Prudential received the September results and updated

records, and conducted a more extensive review by Dr. Fegan.

He noted Plaintiff had a history of activities that indicated

an ability to work in a sedentary job, and that he now had an

EF of 48% . (Rec. at 427). He added the medical information 1

contained no evidence of a cognitive impairment and concluded

the information in the file demonstrated Plaintiff had the

functional capacity to perform his sedentary job. Id. 

On November 13, 2003, claims manager Michael Dalessio

reviewed the file to determine whether Prudential’s initial

termination decision was appropriate. (Rec. at 428). Mr.

Dalessio noted Plaintiff’s ability to perform light yard work,

his improved medical conditions, Dr. Frederick’s notes, Dr.

Kowalski’s opinion, and Dr. Fegan’s opinion. Mr. Dalessio

recommended that Prudential uphold its decision. Id. On

April 15, 2004, a Prudential claims manager referred

Plaintiff’s claim file to a Prudential medical director for an

additional review. (Rec. at 432). 

On April 22, 2004, Prudential medical director Dr. Joyce

Bachman, reviewed the file and authored a summary and analysis

of Plaintiff’s claim in which she concluded there was no

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objective evidence of a physical or mental impairment. (Rec.

at 433 - 437). Based upon its review of the file, and the

opinions of Prudential physicians, Prudential determined that

its original decision was correct. (Rec. at 438). By letter

dated May 12, 2004, Prudential informed Plaintiff of its

decision. (Rec. a 469). 

Plaintiff contends the Claims Administrator was

unreasonable in denying Plaintiff’s long-term disability

benefits for several reasons: Plaintiff’s job as CFO was not

sedentary; Plaintiff qualified for Social Security Disability

benefits; the denial was made in bad faith; the denial

demonstrated a serious breach of the Plan Administrator’s

fiduciary duties to Plaintiff; and the plain language of the

Plan was inconsistent. 

Plan participants are eligible for LTD benefits if they

are “totally disabled.” (Rec. at 28). The FFO Plan defines

“Total Disability” for purposes of LTD benefits as follows: 

“Total Disability” exists when Prudential determines that

all of these conditions are met: 

(1) Due to Sickness or accidental injury, both of these

are true: 

(a) You are not able to perform, for wage or

profit, the material and substantial duties of your

occupation. 

(b) After the Initial Duration of a period of Total

Disability, you are not able to perform for wage or

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profit the material and substantial duties of any

job for which you are reasonably fitted by your

education, training, or experience. The Initial

Duration is shown in the Schedule of Benefits. 

(2) You are not working at any job for wage or profit. 

(3) You are under the regular care of a Doctor. 

Rec. At 28. 

Plaintiff argues the medical history information supports

a conclusion for total disability. Plaintiff buttresses this

theory with the Social Security Administration’s award of

long-term disability benefits for the Plaintiff. (Rec. At 28).

Additionally, Plaintiff argues that Prudential violated a

provision of ERISA by failing to provide Plan documents to

Plaintiff. 

Separate Defendant Prudential contends that substantial

evidence supports its decision to deny long-term disability

benefits to Plaintiff. Plaintiff’s treating doctor, Dr.

Frederick, documented that FFO terminated Plaintiff after

“more frequent arguments with the owners.” (Rec. at 397). The

record contains no evidence to support Plaintiff’s contention

that he quit work in April 2003 because of a medical

disability. All of Prudential’s doctors and nurses who

reviewed the medical evidence concluded that Plaintiff had the

ability to perform his sedentary job. 

Moreover, Dr. Frederick confirmed Plaintiff’s ability to

mow the lawn and exercise for forty minutes on a treadmill.

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For all these reasons, Prudential concluded its decision was

not arbitrary or capricious. Prudential alleges that both

ERISA and the ERISA Statement required the Plan Administrator

to be responsible for providing Plan documents upon written

request from a claimant, not the Claims Administrator.

Separate Defendant FFO was the Plan Administrator and Separate

Defendant Prudential was the Claims Administrator. 

Defendants argue the decision of the Social Security

Administration was not disregarded, but that in any event,

Prudential determined eligibility for benefits based on the

terms of the Plan. Prudential was not simply required to

follow the decision of the SSA. Riedl v. Gen. Arm. Life Ins.

Co., 248 F.3d 753, 759 (8th Cir. 2001)(SSA’s determination is

not binding but it is admissible evidence to support a claim

under ERISA). 

The Court finds Prudential’s decision to terminate

Plaintiff’s LTD claim reasonable and not made in bad faith.

The Court finds Plaintiff’s request for statutory penalties

against the Defendants misplaced and therefore denied. 

CONCLUSION.

Based on the reasons stated above, the Court AFFIRMS the

decision of the Defendants and finds it supported by

substantial evidence of the record. Plaintiff’s claim is

DENIED and hereby DISMISSED WITH PREJUDICE with each party to

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bear its own costs and fees. 

IT IS SO ORDERED this 22nd day of February, 2007. 

/s/ Robert T. Dawson 

ROBERT T. DAWSON

UNITED STATES DISTRICT JUDGE 

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