Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alnd-2_04-cv-02831/USCOURTS-alnd-2_04-cv-02831-0/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

FOR THE NORTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

SUSAN KEITH,

Plaintiff,

vs. CASE NO. CV-04-J-2831-S

THE PRUDENTIAL INSURANCE

COMPANY OF AMERICA d/b/a

PRUDENTIAL FINANCIAL, 

Defendant.

MEMORANDUM OPINION

The plaintiff filed the complaint in this action under the Employee Retirement

Income Security Act of 1974 (“ERISA”), asserting that the defendant wrongfully

terminated her long term disability benefits, in violation of 29 U.S.C. § 1001, et seq.

The case was referred to a United States Magistrate Judge. After full briefing on

cross motions for summary judgment, the magistrate judge entered a Report and

Recommendation that both motions for summary judgment be denied (doc. 18). After

careful consideration of the Report and Recommendation and the defendant’s

objections to the same (doc. 19), the undersigned judge adopted the report of the

magistrate and entered an Order denying both motions for summary judgment (doc.

20). 

FILED

 2006 Dec-12 PM 03:46

U.S. DISTRICT COURT

N.D. OF ALABAMA

Case 2:04-cv-02831-IPJ Document 29 Filed 12/12/06 Page 1 of 23
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By agreement of the parties, this case has been submitted to the court for a

decision on themerits based on the briefs ofthe parties, the administrative record, and

the exhibits filed to date. Upon consideration of the pleadings, briefs of the parties

and evidentiary submissions received, the court concludes that judgment is due to be

granted in favor of the defendant and against the plaintiff for the reasons set forth

fully below.

FACTUAL BACKGROUND

The parties previously agreed to the following relevant facts (doc. 23):

Plaintiff Susan Keith (“Keith”) worked for MBNA Technology as a Team

Manager II and was a participant in the Prudential Group Long Term Disability Plan.

Keith ceased working for MBNA Technology on August 8, 2002, and filed a claim

with Prudential for long term disability benefits on November 21, 2002. Keith’s

claim for benefits was initially approved by Prudential. After a further review,

Prudential denied Keith’s claim and the disability benefits ceased. Keith filed three

requests for reconsideration regarding this denial, however, Prudential continued to

uphold its decision to deny her benefits.

The plaintiff asserts she ceased working on August 8, 2002, due to her medical

disability. Declaration of Keith, ¶ 3. The plaintiff argues she is totally disabled from

performing any type of work due to several medical conditions, including SjÇgren’s

Case 2:04-cv-02831-IPJ Document 29 Filed 12/12/06 Page 2 of 23
3

syndrome, fibromyalgia, Arnold Chiari Malformation Type I, congenital spinal

stenosis and degenerative disk disease. She claims that she was only able to work as

long as she did because her manager allowed her to work only 20-30 hours per week

in the office and less than 6-8 hours per day. Declaration of Keith, ¶ 7. Medication

to manage her symptoms from multiple illnesses prevent her from functioning.

Declaration of Keith, ¶ 8. 

Keith applied for Long Term Disability benefits with Prudential on November

21, 2002. This application was initially approved. See e.g., Keith 0069. Prudential

later reconsidered this award of benefits and ultimately denied benefits as of July 1,

2003. Keith 0055, 0063, 0225. Keith appealed this denial on three occasions, but

was turned down every time. Keith 0113, 0151-158, 0197-201. Prudential denied

benefits after considering each of these appeals. The plaintiff alleges that defendant

ignored the evidence she submitted to demonstrate that her conditions had worsened.

The defendant responds that the plaintiff is not disabled under the policy. 

The defendant relies on the opinions of three different medical professionals

who evaluated plaintiff’s medical records and declared that plaintiff was not disabled.

On May 27, 2003, Adele Glita, a registered nurse, reviewed and analyzed plaintiff’s

medical information and concluded that there was insufficient evidence to indicate

that plaintiff was unable to perform sedentary work. Keith 0007. Next, a medical

Case 2:04-cv-02831-IPJ Document 29 Filed 12/12/06 Page 3 of 23
The July 30, 2003, denial letter to the plaintiff states that “you have been caring for your 1

infant child. The physical requirements needed to care for an infant exceed the physical

requirements needed for you to perform your sedentary occupation.” Keith 0057. 

Plaintiff’s supervisor, Gene White, informed the defendant in August 2004 that the 2

plaintiff had previously come into the office every day, sometimes for 4 hours, sometimes for 6,

depending on how she felt. She would “come in when she was pain free and work until the pain

returned, then go home and work the rest of the day and ice her body.” Keith 0037-0038. 

4

consultant who is board certified in physical medicine and rehabilitation evaluated

plaintiff’s medical information and reached the same conclusion. See Keith 0057. 1

Finally, Plaintiff’s medical records were reviewed by an independent medical

professional, Dr. Joel F. Moorhead, an Assistant Professor at Emory University. Dr.

Moorhead also concluded that the evidence did not support plaintiff’s claim of

disability. Keith 0117-0125. The defendant also interviewed the plaintiff’s

supervisor, who told defendant that he had made accommodations for the plaintiff

previously and would continue to do so, including allowing the plaintiff to work from

home, and assigning her projects which did not require her presence at meetings.2

Keith 0037-0038. 

The Plan

Defendant both insures the long-term disability (LTD) policy and serves as the

claims administrator of the Plan. The Plan states that:

The PrudentialInsuranceCompany of America as Claims Administrator

has the sole discretion to interpret the terms of the Group Contract, to

make factual findings, and to determine eligibility for benefits. The

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decision of the Claims Administrator shall not be overturned unless

arbitrary and capricious.

Keith 0518. Defendant asserts that the plaintiff did not meet the definition of

“disabled” as that term is used in the policy.

The policy contains the following regarding the definition of disability:

You are disabled when Prudential determines that:

• you are unable to perform the material and substantial duties of your

regular occupation due to your sickness or injury; and

• you have a 20% or more loss in your indexed monthly earnings due

to that sickness or injury.

Keith 0495 (emphasis in original). “Material and substantial duties” are defined as

duties that:

• are normally required for the performance of your regular occupation;

and

• cannot be reasonably omitted or modified.

Keith 0495. 

Plaintiff’s Medical Records

Medical records contained in the administrative record reflect that the plaintiff

has had multiple medical problems for many years. 

The plaintiff has been followed by Dr. Louise Kwan, M.D. A March 2002

medical record reflects that the plaintiff had poor stamina and could not carry out her

usual level of activity, but was “very adamant that she does not want to take any

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medication. Medications make her feel fatigued and accentuate her symptoms.”

Keith 0338. Dr. Kwan also noted that the plaintiff had brought in FMLA forms for

her to sign so that the plaintiff could have a month off work to follow through with

intense physiotherapy. Keith 0338. In April 2002 Dr. Kwan’s records reflect that the

plaintiff wanted to try to return to work. Keith 0336. Dr. Kwan released her to four

days per week, six hours per day. Keith 0337. In May 2002 the plaintiff requested

she be allowed to return to work forty hours per week, working both from her office

and from her home. Keith 0336. 

A March 2003 record from Dr. Kwan notes that while the plaintiff felt

relatively well while pregnant, after delivery of her child the pains in her neck, arms

and legs returned. Keith 0328. She had previously been diagnosed with SjÇgren’s

syndrome and fibromyalgia. Keith 0328. Dr. Kwan records that the plaintiff “is right

now coping well but she has been unable to consider going to work and feels that she

will have to stay off of work considering her child care to be a full time job.” Keith

0328. A June 16, 2003, letter from Dr. Kwan states that the plaintiff’s medical

problems date back to the mid-1990’s. Keith 0217. Her symptoms include easy

fatigability, muscle pain, muscle stiffness, poor sleep, and difficulty concentrating.

Keith 0217. Dr. Kwan notes that the plaintiff’s symptoms had recently worsened.

Keith 0217. She further notes that the plaintiff was trying to avoid medications so

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that she could continue to breast feed her child. Keith 0217. Sitting for longer than

one hour was noted to increase the plaintiff’s symptoms. Keith 0217. 

Dr. Kwan completed a Medical Source Statement (Physical) on September 19,

2003. Keith 0162-0165. She believed that the plaintiff could lift and carry less than

ten pounds occasionally, that standing and/or walking were limited to less than two

hours in an eight hour work day due to poor stamina, and that she would have to

alternate standing and sitting. Keith 0162-0163. Pushing and pulling were limited

in the plaintiff’s upper and lower extremities due to body aches, stiffness, and easy

fatigability for any sustained activity such as sitting, standing and keyboarding. Keith

0163. 

Treatment records dated April 18, 2003, from Dr. Joseph B. Stachniak, a

neurosurgeon,reflect that while the plaintiff had multiple medical problems for years,

the plaintiff “noticed that her symptoms significantly improved” while she was

pregnant. Keith 0228. However, she “still has some occasional headaches,” “some

stiffness in her neck on a regular basis,” and some “weakness in her hands,” but

“denies any obvious numbness in her hands or anywhere else in her body.” Keith

0228. The plaintiff’s only medication is listed as Tylenol, as needed. Keith 0228. 

Upon examination, Dr. Stachniak found the plaintiff to have some stiffness in her

neck and minimal muscle spasm. Keith 0228-0229. He recorded that he and the

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plaintiff discussed the Chiari malformation and possible treatments. Keith 0229; see

also Keith 0233. 

The plaintiff was also seen by Dr. Daniel J. Hopson, who is a neurologist. Dr.

Hopson noted diffuse muscle trigger points, but 5/5 motor strength and opined that

the syrinx cervical cord was minimal and not related to her other medical problems.

He included diagnoses of fibromyalgia and SjÇgrens. Keith 0240. At each visit, he

noted the plaintiff complained of diffuse muscle pain in her upper and lower

extremities. Keith 0241, 0243. He also noted that the plaintiff treated her ailments

with therapy massage and chiropractic care. Keith 0243. In February 2003 Dr.

Hopson recorded that the plaintiff’s pain in her neck, shoulder, right hip and back

increased after her pregnancy. Keith 0244. He noted radicular pain in the plaintiff’s

arms and right leg. Keith 0244. Upon examination, Dr. Hopson recorded that the

plaintiff’s neck had diffuse pain and trigger points, and that her lumbar spine was

positive for pain at L5-S1, with pain radiating into her right hip. Keith 0244.

However, the plaintiff had full range of motion and full muscle strength. Keith 0244.

His impression was cervical and lumbar pain and radicular pain, myalgia with a

question of fibromyalgia, arthritis and SjÇgren’s syndrome. Keith 0244. 

A March 2003 MRI found a small syringohydromyelia (a fluid collection in the

spinal cord) at C2, mild congenital narrowing of the central spinal canal at C2

Case 2:04-cv-02831-IPJ Document 29 Filed 12/12/06 Page 8 of 23
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through C7, and an Arnold-Chiari type I malformation (a structural defect in the

cerebellum which may cause a range of symptoms including dizziness, muscle

weakness, numbness, vision problems and headaches). Keith 0234-0235. Previous

MRIs noted a small disc protrusion or spur at T4-T5 and mild degenerative changes

in her cervical spine. Keith 00259-262. After reviewing the MRI results, Dr. Hopson

opined that the plaintiff’s myalgia was of an unknown source, that although there was

the syrinx on the plaintiff’s spine and AC malformation in her brain, these were

unrelated to her symptoms, and that there were no clear findings to explain those

symptoms. Keith 0243. 

A letter dated June 30, 2003, from the plaintiff’s physical therapist states that:

When she started therapy, she was consumed with the idea of returning

to her original job and employer – in spite of the fact that her work

significantly exacerbates her symptoms. In the past several months, I

believe that Susan has come to the realization that her multiple chronic

conditions may not allow return to her corporate job with any acceptable

quality of life, particularly with the added responsibility of caring for her

infant. 

Keith 0218.

The record also contains a letter dated June 20, 2003, from Dr. Ken Connolly,

D.C., who has treated the plaintiff since August 1997. Keith 0219. He notes that the

plaintiff’s body “cannot handle a job that requires constant sitting in a fixed position

as this causes her symptoms of low back and muscle pain to become aggravated. She

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begins to ache all over and eventually she tended to get really fatigued and sick.”

Keith 0219. He concludes that “It is my professional opinion that this patient is

unable to perform her normal work duties at her past job at MBNA due to the

prolonged sitting, keyboard work and the required mental intensity and focus to

perform the job properly. It is my opinion that if the patient was to return to her job,

it would not be long until the patient’s symptoms returned to the point that she was

unable to work due to pain and possible illness from a gradual decline of her health.”

Keith 0219. Dr. Connolly also notes that he has “tested the patient over and over

again for malingering and she is negative all the time.” Keith 0220. 

The plaintiff was also seen regularly by Dr. Dianne L. Petrone, M.D., a

rheumatologist. A record dated April 17, 2002, reflects that the plaintiff walked 30

to 50 minutes a day and reported that she feels well while exercising, but tired

afterward. Keith 0384. She relayed that “her pain is 50% of what it was five weeks

ago. She has been off work for four weeks and goes back Monday....” Keith 0384.

She took no medications regularly and Dr. Petrone recorded that the plaintiff did not

want to take any medications at that time. Keith 0384-0385. In September 2002 Dr.

Petrone found no swelling of any of the plaintiff’s joints. Keith 0382. A record dated

October 18, 2002, states that the plaintiff has been “aching all over.” Keith 0379.

She was again noted to have no major swelling in her joints. Keith 0379. Dr. Petrone

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noted that the plaintiff looked good and was in no acute distress. Keith 0379. She

did have multiple tender points in areas consistent with fibromyalgia. Keith 0379.

Due to her pregnancy, no medications for fibromyalgia could be given. Keith 0380.

SjÇgren’s syndrome was noted to be stable. Keith 0380. A January 2003 record

states that the plaintiff “is having pain again all over. She states that she did well

when she was pregnant.” Keith 0307. She had no swelling of the joints but reported

that she did not feel she could work and had difficulty sitting at a desk doing

sedentary work. Keith 0307. However, she was noted to “look[] great and [was] in

no acute distress.” Keith 0307. Her joints were not warm or swollen, although exam

of her tender points reveal “exquisitely tender” points throughout. Keith 0307. Dr.

Petrone opined the plaintiff suffered from fibromyalgia, worse than it had been.

Keith 0307. 

On August 15, 2003, Dr. Petrone opined that the plaintiff suffered from

significant pain due to the arthralgias and myalgias from fibromyalgia. Keith 0160,

161. Further, the plaintiff suffered fromextreme fatigue, a sleep disturbance and nonrestorative sleep. Keith 0160. Dr. Petrone stated that the plaintiff was compliant with

all recommendations and has tried hard to improve. Keith 0160, 161. The plaintiff

had difficulty with numerous medications, including those prescribed for SjÇgren’s

Syndrome. Keith 0160. Dr. Petrone recorded that upon examination, the plaintiff had

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tender points in the classic areas of fibromyalgia, but that her joints showed no

synovitis. Keith 0160. Dr. Petrone also noted that the plaintiff had an intermittently

positive ANA, which Dr. Petrone believed was related to SjÇgren’s Syndrome as the

plaintiff had no underlying connective tissue disease. Keith 0160. Dr. Petrone

concluded that she believed the plaintiff was unable to work because of her medical

problems. Keith 0161. 

The plaintiff has also been treated by Dr. James Matic, M.D., since September

29, 2003. Keith 0166. He noted the plaintiff’s various past diagnoses and stated that

the plaintiff “is trying very hard to recover and feel like she used to. She tried all

prescribed medicines, but they either did not work or she had side effects. She is very

persistent in following physical therapy, exercise and healthy nutrition.” Keith 0166.

He further noted that the plaintiff’s physical exam was normal, but that she suffered

from an immune dysfunction causing chronic fatigue and other symptoms. Keith

0166. Dr. Matic also wrote that “few patients recover from immune dysfunction” and

that most patients have to “live with their symptoms indefinitely.” Keith 0166. 

The plaintiff also went to Cary F. Camp, a chiropractor, who wrote that:

I regret to inform you but the above referenced individual has a health

condition which is and will prevent her from being able to perform a

task which would allow gainful employment. I feel the patient has a

health disability which will prevent her from working in a capacity

where she could receive gainful employment.

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Keith 0171. The plaintiff was awarded Social Security Disability benefits on

December 11, 2003. Keith 0140-146. 

The administrative record contains a note dated December 17, 2002, that the

plaintiff “will be looking to do something humanitarian. at (sic) age 35 has made life

choice to give up her career to get pregnant and has decided to go out on disability;

as she cannot do her job and have a family at the same time. she (sic) indicated her

pregnancy was fine and it was the fibromyalgia that makes her disabled.” Keith

0001. Further noted is that the plaintiff has had fibromyalgia for years and it was

unclear as to what impairment prevented her from working now. Keith 0001. A

February 2003 record reflects that the plaintiff’s employer was allowing her to work

15 hours per week from home and 25 hours per week in the office. Keith 0003. That

same record also notes that the plaintiff’s obstetrician submitted a statement

supporting the plaintiff being completely off of work due to her pregnancy. Keith

0003. This record also notes that the plaintiff related that she “has made a life choice

to not return to work.” Keith 003. Based on the plaintiff’s medical problems and

pregnancy, a recommendation was made that the plaintiff be approved for benefits

through February 2003. Keith 0003. Benefits were thereafter approved through

March 31, 2003. Keith 0004. 

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The claims record notes that no medical records were provided by the plaintiff

after October 2002. Keith 0004. Her records from prior to that date demonstrate that

she had been on no medication since April 2002. Keith 0004. The record contains

a notation that there “is no objective medical evidence to support [employee’s]

inability to [return to work] to a sedentary job secondary to [employee’s

fibromyalgia.]” Keith 0004. The plaintiff’s only noted problems from SjÇgren’s

syndrome are dry eyes and dry mouth, which were not considered disabling. Keith

0004. Further notes reflect that the available medical documentation was insufficient

to support a severity of symptoms or a condition that would preclude the plaintiff

from performing sedentary work. Keith 0007-0008. 

The record dated May 27, 2003, notes that as plaintiff’s regular occupation is

sedentary in nature, and the medical records support that the plaintiff can perform

sedentary work, she is able to perform her regular occupation and hence not disabled.

Keith 0008. However, benefits through June 30, 2003, were recommended to assist

the plaintiff in returning to work. Keith 0008, 0063. An additional record of July 14,

2003, questions whether secondary gain issues are present due to plaintiff’s desire to

stay home and care for her infant. Keith 0009. 

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Therefore, the issue before the court is whether the plaintiff has established that

she was disabled, as of July 1, 2003, as the term “disability” is defined by the policy.

See e.g., Keith 0039, 0052.

STANDARD OF REVIEW

In ERISA cases, “the plaintiff has the burden of proving her entitlement to

contractual benefits.” Richards v. Hartford Life & Acc. Ins. Co., 2005 WL 2888214,

*2 (11 Cir.2005), citing Horton v. Reliance Standard Life Ins. Co., 141 F.3d 1038, th

1040 (11 Cir.1998). Therefore, the plaintiff has the burden of demonstrating that th

she is unable to perform the material and substantial duties of her own occupation.

See e.g., Stiltz v. Metropolitan Life Ins. Co., 2006 WL 2534406, *6 (N.D.Ga.2006).

The Eleventh Circuit Court of Appeals has set out the following steps to apply

in reviewing “virtually all ERISA-plan benefit denials:”

(1) Apply the de novo standard to determine whether the claim

administrator’s benefits-denial decision is “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).

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(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, then apply heightened arbitrary and capricious

review to the decision to affirm or deny it.

Williams v. BellSouth Telecommunications, Inc., 373 F.3d 1132, 1138 (11 Cir.2004). th

LEGAL ANALYSIS

Applying the rules set forth in Williams, supra, the court must first determine

whether the decision of the defendant was “wrong.” Given the facts of this case, the

court assumes that the administrator’s decision was “de novo wrong.” As detailed

above, several of the plaintiff’s treating physicians opine that she cannot return to her

job. There is also evidence that the plaintiff’s supervisor allowed her to work from

her home approximately fifteen hours per week, because the plaintiff was not able to

perform seated work for eight hours per day, five days per week. She was approved

for Social Security Disability benefits. 

Having concluded for purposes of this opinion that the administrator’s decision

is “de novo wrong,” the court must next determine whether the administrator was

vested with discretion in reviewing claims; if not, the judicial inquiry ends and the

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17

court must reverse the decision. The parties agree that the administrator here is

vested with discretion. Hence, the court continues its analysis.

Because the court finds that the administrator’s decision is “de novo wrong”

and the administrator was vested with discretion in reviewing claims, the court must

determine whether the decision was supported by “reasonable” grounds, based on the

facts as known to the administrator at the time the decision was made. Hunt v.

Hawthorne Assoc., Inc., 119 F.3d 888, 912 (11 Cir.1997) (quoting Jett v. Blue Cross th

and Blue Shield of Ala ., Inc., 890 F.2d 1137, 1139 (11 Cir.1989)). A decision to th

deny benefits is arbitrary and capricious if no reasonable basis exists for the decision.

Levinson v. Reliance Standard Life Ins. Co., 245 F.3d 1321, 1325-26 (11 Cir.2001). th

The defendant undertook to have the plaintiff’s medical records independently

reviewed by Joel F. Moorhead, M.D. Keith 0129-0138. After an in-depth review of

her medical records, Dr. Moorhead concluded that the only change at the time the

plaintiff ceased working was in her tolerance to her symptoms. Keith 0137. Dr.

Moorhead noted that the plaintiff was physically active and that she believed caring

for her infant was a full-time job. Keith 0137. He concluded:

In summary, it appears that this claimant has had musculoskeletal

symptoms since 1995, that she is normally active at home and in the

community, that there has been no change in her medical condition at

the time that she went out of work other than an increase in her

subjective symptoms and in her tolerance of those symptoms, that there

Case 2:04-cv-02831-IPJ Document 29 Filed 12/12/06 Page 17 of 23
The Court explained that: 3

In contrast to the obligatory, nationwide Social Security program, “[n]othing in

ERISA requires employers to establish employee benefits plans. Nor does ERISA

mandate what kind of benefits employers must provide if they choose to have

18

has been a significant change in her personal life in that she has a new

infant and feels that the care of that infant is a full-time job and that no

medically determinable physical impairments that would prevent her

from returning to work immediately promptly (sic) in her sedentary

occupation as a team manager. I see no justification in the enclosed

records for any restrictions and limitations from performing the full

range of office work as would be expected at the sedentary level. The

patient does have an Arnold-Chiari malformation in her neck and has

been noted by her neurosurgeon to have somewhat limited neck range

motion. It would seem a reasonable accommodation for her to have an

ergonomically favorable work station, which allows her to do her work

with a functional neck posture. Outside of that, there appears to be no

justification for Ms. Keith’s continued absence from the workplace.

Keith 0137-0138. 

There is evidence that the plaintiff was able to work for several years with

comparable symptoms, and only after she gave birth to her child did she decide not

to return to work. The administrative record reflects that the plaintiff herself stated

that she decided to give up her career because she cannot do her job and have a family

at the same time. Keith 0001. 

Although plaintiff’s treating doctors seem to support her apparent decision to

stop working, this is not the same as evidence of an inability to work. The United

States Supreme Court has stated that plan administrators are not obliged to accord

special deference to the opinions of treating physicians. Black & Decker Disability 3

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such a plan.” Lockheed Corp. v. Spink, 517 U.S. 882, 887, 116 S.Ct. 1783, 135

L.Ed.2d 153 (1996). Rather, employers have large leeway to design disability and

other welfare plans as they see fit. In determining entitlement to Social Security

benefits, the adjudicator measures the claimant's condition against a uniform set of

federal criteria. “[T]he validity of a claim to benefits under an ERISA plan,” on

the other hand, “is likely to turn,” in large part, “on the interpretation of terms in

the plan at issue.” Firestone Tire, 489 U.S., at 115, 109 S.Ct. 948. It is the

Secretary of Labor's view that ERISA is best served by “preserv[ing] the greatest

flexibility possible for ··· operating claims processing systems consistent with the

prudent administration of a plan.” Department of Labor, Employee Benefits

Security Administration, http://www.dol.gov/ebsa /faqs/faq_ claims_proc_

reg.html, Question B-4 (as visited May 6, 2003). Deference is due that view.

Nord, 538 U.S. at 833-834, 123 S.Ct. at 1971-1972.

19

Plan v. Nord, 538 U.S. 822, 825, 123 S.Ct. 1965, 1967 (2003). Similarly, the

Eleventh Circuit has held that “[g]iving more weight to the opinions of some experts

than to the opinions of other experts is not an arbitrary or capricious practice.

Slomcenski v. Citibank, N.A., 432 F.3d 1271, 1280 (11 Cir.2005); citing Nord, 538 th

U.S. at, 831-34, 123 S.Ct. at 1970-72. The Court admonished that an administrator’s

determination must be upheld if it has a reasonable factual basis, even if the record

also contains contrary information. Slomcenski, 432 F.3d at 1280; citing Jett, 890

F.2d at 1140. As well explained by the District Court in Stiltz, 2006 WL 2534406,

*10 (N.D.Ga.2006):

The reviewing physicians did not dispute that the diagnoses of

fibromyalgia, mild obstructive sleep apnea, and irritable bowel

syndrome were supported by the record or that the Plaintiff suffered

from pain as a result.... However, disability under the terms of a

disability plan is not established simply because there has been a

medical diagnosis or because a claimant suffers pain, even severe pain.

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Jordan v. Northrup Grumman Corp. Welfare Benefit Plan, 370 F.3d

869, 880 (9 Cir.2004); Hamall-Desai, 370 F.Supp.2d at 1307;see also

th

Sarchet, 78 F.3d at 307 (“Some people may have such a severe case of

fibromyalgia as to be totally disabled from working, but most do not and

the question is whether [plaintiff] is one of the minority.”) (internal

citation omitted). Thus, because the medical records did not contain

“any objective examination findings or clinical data to substantiate a

significant functional impairment to support the severity of a medical

condition that would preclude [the Plaintiff's] ability to perform the

requirements of his own light occupation” ... MetLife concluded that the

Plaintiff was no longer disabled as of April 28, 2004. Like the reviewing

physicians who noted the absence of any objective evidence that the

Plaintiff's illnesses rendered him unable to work, the Court finds that the

subjective complaints and opinions regarding pain, fatigue, and lack of

concentration are insufficient to establish that the Plaintiff is unable to

perform the duties of his occupation.

....

InBrucks v. Coca-Cola Co., 391 F.Supp.2d 1193 (N.D.Ga.2005), as part

of its de novo review, the court discussed whether it is appropriate for

a plan administrator to require objective evidence when an illness, in

that case chronic fatigue syndrome, is not readily diagnosed with

objective tests. Emphasizing the distinction between a diagnosis and the

resulting physical limitations, the court determined that it is indeed

appropriate to require objective evidence of the latter.

Stiltz, 2006 WL 2534406, *11 (N.D.Ga.2006). Similarly, receipt of Social Security

benefits is just yet another factor the court may consider in reviewing a denial of

Case 2:04-cv-02831-IPJ Document 29 Filed 12/12/06 Page 20 of 23
In Whatley, the Court stated: 4

We note that the approval of disability benefits by the Social Security

Administration is not considered dispositive on the issue of whether a claimant

satisfies the requirement for disability under an ERISA-covered plan. See

Paramore v. Delta Air Lines, Inc., 129 F.3d 1446, 1452 n. 5 (11 Cir.1997). th

However, we have held that “[a] district court may consider the Social Security

Administration's determination of disability in reviewing a plan administrator's

determination of benefits.” Kirwan v. Marriott Corp., 10 F.3d 784, 790 n. 32 (11th

 Cir.1994).

Whatly, 189 F.3d at 1314 n. 8.

21

ERISA benefits. See Whatley v. CNA Ins. Companies, 189 F.3d 1310, 1314 (11 4 th

Cir.1999).

Given the conflicting opinions before this court, and having reviewed the

evidence which forms the basis for those opinions, the court concludes that the

decision of the administrator was not “unreasonable.” 

Because the court has determined that the decision of the plan administrator

was not unreasonable, the next consideration is whether the administrator operated

under a conflict of interest. If there is no conflict, the court must end the inquiry and

affirm the decision. If there is a conflict, then the court must apply heightened

arbitrary and capricious review to the decision to affirm or deny it.

Because the plan in question grants the claims administrator the discretion to

construe the terms of the plan, and because the defendant serves as both the claims

administrator and pays claims from its own funds, it has a conflict of interest. See

Case 2:04-cv-02831-IPJ Document 29 Filed 12/12/06 Page 21 of 23
22

Brown v. Blue Cross &Blue Shield of Alabama, 898 F.2d 1556, 1568 (11 Cir.1990). th

Under the heightened arbitrary and capricious standard, the burden shifts to the plan

administrator to show that its decision to deny disability benefits was not tainted by

self-interest. HCA Health Servs. of Ga., Inc. v. Employers Health Ins. Co., 240 F.3d

982, 994 (11 Cir.2001). The plan administrator may satisfy the burden of purging

th

the self-interest taint by showing that “its wrong but reasonable interpretation of the

plan benefits the class of participants and beneficiaries.” HCA Health Servs. of Ga.,

Inc., 240 F.3d at 994-95 (internal citations omitted). “A conflicted fiduciary can

purge the taint of self-interest by proving that its wrong but reasonable interpretation

of the plan was ‘calculated to maximize benefits to participants in a cost-efficient

manner.’” Id. at 1001, (quoting Lee v. Blue Cross/Blue Shield, 10 F.3d 1547, 1552

(11 Cir.1994)). th

The plaintiff argues that the defendant’s interpretation was unreasonable, as

defendant required “objective medical evidence from a person with a recognized

disease which cannot normally be found through objective testing.” Plaintiff’s brief,

at 44. However, this is the exact argument rejected by other courts when considering

this same issue regarding ERISA disability claims by individuals with fibromyalgia.

See e.g., Stiltz, 2006 WL 2534406, *11 (N.D.Ga.2006). Defendant’s interpretation

of the plan, finding no ongoing disability, is based on a lack of objective evidence

Case 2:04-cv-02831-IPJ Document 29 Filed 12/12/06 Page 22 of 23
23

of the plaintiff’s claimed limitations, not a lack of evidence of her medical problems.

After review of the entire administrative record, the court is unable to conclude

that the administrator’s benefits denial decision was arbitrary and capricious.

Therefore, under the law as set forth by the Eleventh Circuit Court of Appeals, the

court must affirm the defendant’s decision. 

CONCLUSION

Having considered the foregoing, the court is of the opinion that the defendant

is entitled to judgment in its favor and against the plaintiff. The court shall so Order.

DONE and ORDERED this the 12 day of December, 2006. th

 

INGE PRYTZ JOHNSON

U.S. DISTRICT JUDGE 

Case 2:04-cv-02831-IPJ Document 29 Filed 12/12/06 Page 23 of 23