Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_08-cv-03177/USCOURTS-caed-2_08-cv-03177-0/pdf.json

Parties Involved:
Rite Aid Corporation
Defendant
Claudia Skeen
Plaintiff
Standard Insurance Company
Defendant

Document Text:

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IN THE UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF CALIFORNIA

CLAUDIA SKEEN, )

)

Plaintiff, ) 2:08-cv-03177-GEB-EFB

)

v. ) ORDER GRANTING DEFENDANTS’

) MOTION TO STRIKE AND MOTION

RITE AID CORPORATION and STANDARD ) FOR SUMMARY JUDGMENT

INSURANCE COMPANY, )

)

Defendants. )

)

Defendants Rite Aid Corporation (“Rite Aid”) and Standard 

Insurance Company (“Standard”) filed a motion for summary judgment on

September 24, 2009, in which they seek to have upheld their denial of

Plaintiff Claudia Skeen’s application for Long Term Disability (“LTD”)

benefits. On October 19, 2009, Defendants also filed a motion to

strike declarations Skeen submitted in her Opposition to Defendants’

motion.

Skeen was a Rite Aid store manager, and was covered by Rite

Aid Group Policy 641335-B (the “Policy”) which Standard issued and

insured. (Statement of Undisputed Facts (“SUF”) ¶ 5.) The Policy

provides Skeen was entitled to LTD benefits if as a result of physical

disease or injury she was unable to perform with reasonable continuity

the “material duties of [her store manager] occupation.” 

(Administrative Record (“AR”) 8.) The Policy also required Skeen to

be continuously disabled for “the benefit waiting period” of 91 days

before LTD benefits became payable. (AR 22, 40.) It is undisputed

that Skeen was disabled with Rheumatoid Arthritis (“RA”) from May 25,

Case 2:08-cv-03177-GEB-EFB Document 42 Filed 01/12/10 Page 1 of 15
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2005 to June 22, 2005. However, to be eligible for LTD benefits she

had to be continuously disabled from May 25, 2005 through August 23,

2005. Standard denied Skeen’s LTD benefits claim since it found that

as of June 22, 2005 Skeen’s symptoms did not prevent her from

returning to work. Skeen requested that the Administrative Review

Unit (“ARU”) review this decision. The ARU considered the initial

denial and additional medical records submitted by Skeen and concluded

that the decision to deny Skeen’s claim was correct since Skeen was

not continuously disabled through the benefit waiting period. 

Skeen subsequently filed this lawsuit in state court 

alleging breach of contract and breach of the implied covenant of good

faith and fair dealing claims, based on Defendants’ failure “to

provide [LTD] benefits to [her] pursuant to Group Policy 641335-B

issued [by Standard] to Rite Aid Corporation.” (Defs.’ Notice of

Removal, Ex. 1.) Defendants removed this case from state court under

28 U.S.C. §§ 1331(a) and 1441(a), on the ground that the Employee

Retirement Securities Act of 1974 (“ERISA”), 29 U.S.C. § 1001,

completely preempts Plaintiff’s state claims. (Defs.’ Notice of

Removal 2:9-14.).

A case in which disability insurance benefits are sought

under an ERISA-regulated employee benefit plan is “within the scope of

the civil enforcement provisions of [ERISA and is] removable to

federal court.” Aetna Health Inc. v. Davila, 542 U.S. 200, 209 (2004)

(internal quotations and brackets omitted). ERISA-regulated employee

benefit plans include “any plan . . . established by an employer . . .

for the purpose of providing for its participants . . . benefits in

the event of . . . disability . . . .” 29 U.S.C. § 1002(1), (3). 

Here, Skeen seeks LTD disability benefits under her employer’s ERISACase 2:08-cv-03177-GEB-EFB Document 42 Filed 01/12/10 Page 2 of 15
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regulated employee benefit plan. Therefore, ERISA preempts her

complaint and an ERISA analysis is used to decide the summary judgment

motion.

I. Background

On Wednesday May 25, 2005, Skeen met with her 

Rheumatologist, Doctor Paul Sussman. At this meeting, she told Dr.

Sussman “she has been having nausea and vomiting following the Sunday

methotrexate dose” of medication and that “she is under quite a bit of

work related stress and is having increased RA symptoms with pain in

her hips and knees, prolonged AM stiffness and functional disability.” 

(SUF 2; AR 252.) Dr. Sussman conducted a physical examination and

noted the following conditions: “increased RA symptoms with pain in

her hips and knees, prolonged AM stiffness and functional disability

 . . . [;] right hand shows trace[s of] puffiness in a nonacute

fashion. Elbows lack a few degrees of full extension. No synovitis. 

Knees, discomfort on ROM, trace right popliteal fullness.” (AR 252.) 

Dr. Sussman gave Skeen a note excusing her “from work for the next

four weeks,” reduced her Methotrexate dosage, and wrote “consider

disability.” (AR 252.) 

Standard informed Skeen in a letter dated June 8, 2005, that 

it approved her claim for a short term leave of absence for an initial

three weeks, through June 15, 2005, but that additional information

would be needed to continue coverage for the remainder of the 90-day

short term disability period. (AR 83-84.) 

Skeen was again examined by Dr. Sussman on June 22, 2005. 

(AR 202, 248; SUF 4.) He noted, “Now that she has been off work, she

is feeling somewhat better.” (AR 248.) “The reduction in

methotrexate has lessened her nausea on Monday and Tuesday, but is to

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the point [] where [it] is now tolerable.” (AR 248.) He further

noted, “Hands, decreased puffiness of the right hand. Wrists, no

swelling, good range of motion. Elbows, lack a few degrees of full

extension. Knees show no swelling.” (AR 248.) He wrote under “Plan”

to “Continue Disability for three more months.” (AR 248.)

Dr. Sussman completed a Short Term Disability Attending 

Physician Statement dated June 22, 2005, in which he requested an

additional three months of disability for Skeen and stated October 1,

2005 was the date on which Skeen planned to return to work. (AR 107.) 

Standard informed Skeen in a letter dated July 1, 2005, that her short

term leave of absence ended August 23, 2005, and that since she did

not plan on returning to work until October 1, she had initiated a

claim for LTD benefits. (AR 86.) Standard again acknowledged it had

received Skeen’s application for LTD benefits in a letter dated July

15, 2005, and stated it planned on reviewing her claim. (AR 54.)

Skeen again saw Dr. Sussman on August 1, 2005. (AR 247.) 

Dr. Sussman noted the following: “Overall, she is about the same as

last visit. She has had no interval acute flare activity. No

prominent AM stiffness. She is complaining of knee discomfort, but no

swelling. From time to time she will take ibuprofen 800 mg averaging

once or twice a week.” He also noted: “Hand shows no swelling. She

has good function of wrist and no swelling. Elbows lack a few degrees

of full extension. Knees, no swelling.” (AR 247.)

Standard’s claim analyst solicited the opinion of Dr. Ronald 

Frabeck, a Rheumatology physician consultant, to assist in the

decision whether to grant Skeen’s LTD benefit claim. Dr. Fraback

reviewed Dr. Sussman’s records on August 25, 2005, and submitted a

report concluding:

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In summary, this woman has mild to moderate

rheumatoid arthritis. At the time she ceased work

she was having more joint pain, as well as side

effects from her medication. By 6/22/05 she

appears to have improved significantly. Her nausea

was tolerable. A note dated 8/1/05 indicated that

she was unchanged. On the basis of this, I think

that she should have been able to return to her

usual light level occupation by approximately

6/22/05 and ongoing. Her prognosis is fair. She may

worsen with time and require additional medication.

(AR 238.) Based on Dr. Frabeck’s report and Skeen’s medical records

from Dr. Sussman, Standard’s claim analyst determined that Skeen was

not eligible for LTD benefits.

Standard informed Skeen that her claim for LTD benefits was 

denied in a letter dated September 8, 2005, because as of June 22,

2005 her symptoms had lessened and did not prevent her from returning

to work. (AR 143-146.) The letter included the statement: “If there

are medical reasons why you could not work after June 22, 2005, please

have your physician complete the enclosed Attending Physician’s

Statement and return it to us.” (AR 145.) However, this letter was

returned to Standard on September 28, 2005 because Skeen had moved. 

(AR 142; Skeen Decl. ¶ 3.)

On September 26, 2005, Skeen called Standard regarding her 

claim and spoke with Standard employee Mary Jane Clarke. (AR 176.) 

Skeen told Clarke she had not received the letter and that her address

had recently changed. (AR 176.) Clarke informed Skeen her claim had

been denied, updated Skeen’s address, told Skeen she could appeal the

decision, and that she “could” resend Skeen a copy of the letter. (AR

176.) It is disputed whether the September 8, 2005 letter was resent

to Skeen on September 26, 2005.

//

//

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Subsequently, Skeen responded to a customer service survey 

in which she stated she did not understand why her claim was denied

and why it took two months to decide her claim. (SUF 14.) Standard

responded in a letter dated March 6, 2006, in which Standard informed

Skeen of her ability to request review of the denial decision and that

Skeen could submit additional information to be considered in the

review. (AR 140.) Standard enclosed the September 8, 2005 letter

denying Skeen’s LTD benefits with the March 6, 2006 letter. (AR 140.)

Skeen retained counsel who notified Standard of Skeen’s

intent to appeal the LTD claim and requested a copy of all documents

pertaining to the claim in a letter dated October 5, 2007. (AR 139.) 

Skeen’s attorney also stated in that letter: “There are substantial

medical records which we are currently obtaining which establish that

she has long term disability.” (AR 139.)

Standard responded in a letter dated October 11, 2007, by 

requesting additional information required to be sent within the next

45 days, including any Social Security Awards Skeen had received, and

an authorization to release Skeen’s medical records to her attorney. 

(AR 59.) Standard received the “Authorization to Release Information”

on November 26, 2007. (AR 63.) Standard sent Skeen’s attorney a

letter dated November 30, 2007, in which it enclosed a copy of Skeen’s

LTD Benefit claim file. (AR 63.) Standard also sent Skeen’s attorney

letters in December 2007 and January 2008 in which it requested any

additional medical records. (AR 124.) 

Skeen enclosed with a letter dated February 12, 2008, nearly 

600 pages of medical records from six health care providers for review

in consideration of her LTD claim. (AR 104-105; 287-880.) However,

none of the doctors in the referenced medical records met with Skeen

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during the benefit waiting period of May 25, 2005 through August 23,

2005, except Dr. Sussman. (SUF 22.) Standard notified Skeen in a

letter dated February 22, 2008, that her file was sent to the ARU for

review of the LTD benefit denial decision. (AR 103.)

Standard hired Rheumatologist Doctor David S. Knapp to 

review all medical records Skeen submitted in February 2008, for the

purpose of assisting the ARU in its review of the LTD benefit denial 

decision. (AR 226.) Dr. Knapp summarized Skeen’s medical records and 

concluded that as of May 24, 2005:

Ms. Skeen did have restrictions and limitations

when she ceased work on 5/24/05. The records

document a flare up of rheumatoid arthritis

symptoms and intolerance of medication

characterized as nausea and vomiting for which she

was released from work for 4 weeks. Examination

revealed chronic swelling of the right hand, knee

pain with range of motion and right knee fullness.

Elbow flexion deformities without synovitis are

noted. In this clinical setting the claimant was

not able to continue her light level work duties.

(AR 228.) He further concluded, however:

The restrictions and limitations would not have

prevented the claimant from performing a light

level occupation through 8/24/05 and beyond. The

subsequent records document clinical improvement as

of 6/22/05 with unremarkable examinations. No

clinically significant orthopedic or medical

impairments are noted from 6/22/05 onward that

would result in restrictions and limitations for a

light level occupation through 8/24/05.

(AR 229.) Dr. Knapp also stated: “The additional records, while

documenting multiple intercurrent medical problems of a limited

nature, do not support clinically significant progression of the

claimant’s rheumatoid arthritis.” (AR 229.)

Standard notified Skeen in a letter dated April 18, 2008, 

that the ARU had completed its review and concluded that the decision

to deny Skeen’s LTD claim was correct since Skeen was not continuously

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disabled through the benefits waiting period. (AR 94-98.) The April

18 letter also discussed Skeen’s medical records, the physician

consultants’ findings, and informed Skeen that “this concludes the

administrative review process” and that she had “a right to file suit

under Section 502(a) of [ERISA] or state law, whichever is

applicable.” (AR 97.)

II. Standard of Review

The parties agree this case is governed by the abuse of 

discretion standard. (Def.’s Mot. for Summ. J. 10:6-7; Plt.’s Opp’n

2:16-18.) “[A] denial of benefits is to be reviewed under a de novo

standard unless the benefit plan gives the administrator discretionary

authority to determine eligibility for benefits or to construe the

terms of the plan.” Burke v. Pitney Bowes, Inc. Long Term-Disability

Plan, 544 F.3d 1016, 1023 (9th Cir. 2008). Where the plan “does grant

such discretionary authority, we review the administrator’s decision

for abuse of discretion.” Saffon v. Wells Fargo & Co. Long Term

Disability Plan, 522 F.3d 863, 866 (9th Cir. 2008). Here, Group

Policy 641335-B grants the following discretionary authority to the

administrator of the Policy:

Except for those functions which the [Plan]

specifically reserves to the Policyowner or

Employer, we have full and exclusive authority to

control and manage the [Plan], to administer

claims, and to interpret the [Plan] and resolve all

questions arising in the administration,

interpretation, and application of the [Plan]. Our

authority includes, but is not limited to . . . The

right to determine . . . eligibility for benefits .

. . .

(AR 38.) Identical language has been found to “clearly confer[]

discretion on Standard to decide whether a claimant is disabled.” 

Bendixen v. Standard Ins. Co., 185 F.3d 939, 943 (9th Cir. 1999),

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overruled on other grounds by Montour v. Hartford Life & Acc. Ins.

Co., 588 F.3d 623, 631 (9th Cir. 2009). In Mountour, the court

explained:

The manner in which a reviewing court applies the

abuse of discretion standard, however, depends on

whether the administrator has a conflicting

interest. In the absence of a conflict, judicial

review of a plan administrator’s benefits

determination involves a straightforward

application of the abuse of discretion standard.

In these circumstances, the plan administrator’s

decision can be upheld if it is grounded on any

reasonable basis. In other words, where there is

no risk of bias on the part of the administrator,

the existence of a single persuasive medical

opinion supporting the administrator’s decision can

be sufficient to affirm, so long as the

administrator does not construe the language of the

plan unreasonably or render its decision without

explanation. Commonly, however, the same entity

that funds an ERISA benefits plan also evaluates

claims, as is the case here. Under these

circumstances, the plan administrator faces a

structural conflict of interest: since it is also

the insurer, benefits are paid out of the

administrator’s own pocket, so by denying benefits,

the administrator retains money for itself.

Application of the abuse of discretion standard

therefore requires a more complex analysis. Simply

construing the terms of the underlying plan and

scanning the record for medical evidence supporting

the plan administrator’s decision is not enough,

because a reviewing court must take into account

the administrator’s conflict of interest as a

factor in the analysis.

Id. at 630 (citations and quotations omitted).

Here, the parties agree that Standard operates under a 

structural conflict of interest since it both decides whether

claimants will receive benefits and is responsible for paying benefits

when they are awarded. (Def.’s Mot. for Summ. J. 10:6-9.) The

presence of a structural conflict of interest does not change the

standard of review, but rather it is one of “numerous case-specific

factors” weighed when determining whether the plan administrator

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abused its discretion in denying benefits. Montour, 588 F.3d at 630. 

“The weight the court assigns to the conflict factor depends on the

facts and circumstances of each particular case.” Id. at 631. Courts

are to apply the level of skepticism appropriate to the egregiousness

of the particular conflict of interest:

The level of skepticism with which a court views a

conflicted administrator’s decision may be low if a

structural conflict of interest is unaccompanied,

for example, by any evidence of malice, of selfdealing, or of a parsimonious claims-granting

history. A court may weigh a conflict more heavily

if, for example, the administrator provides

inconsistent reasons for denial, fails adequately

to investigate a claim or ask the plaintiff for

necessary evidence, fails to credit a claimant’s

reliable evidence, or has repeatedly denied

benefits to deserving participants by interpreting

plan terms incorrectly or by making decisions

against the weight of evidence in the record.

Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 968-69 (9th Cir.

2006) (citations omitted).

Skeen argues Defendants committed procedural irregularities 

by failing to engage in a “meaningful dialogue” with Skeen and by

relying on an incomplete record in making the LTD benefit denial

decision. Procedural irregularities made in connection with a denial

of benefits decision affect the standard of review in an ERISA case. 

When an administrator commits “wholesale and flagrant” procedural

violations, courts are to apply a de novo standard in reviewing the

administrator’s decision. Abatie, 458 F.3d at 972. Procedural

violations that are less than “wholesale and flagrant” constitute a

factor in determining whether a plan administrator abused its

discretion. Id. To avoid committing procedural violations, “[a]n

administrator must provide a plan participant with adequate notice of

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the reasons for denial, and must provide a full and fair review of the

participant’s claim.” Id. at 974.

Skeen argues she never received the September 8, 2005 

letter denying her claim and therefore she was never advised that her

medical evidence was considered insufficient “until the final denial

letter on appeal.” It is undisputed that the September 8, 2005 letter

was returned to the sender because Skeen had recently moved. (AR 142;

Skeen Decl. ¶ 3.) However, it is also undisputed that the claims

administrator told Skeen over the phone on September 26, 2005 that her

claim had been denied and that the letter could be resent. (AR 176.)

The record shows the letter was resent on March 2, 2006 (AR 140),

November 30, 2007 (AR 63), and January 29, 2008 (AR 67). In each of

these letters, Skeen was advised that she was not eligible for

benefits because she was not disabled during the 91-day benefit

waiting period of May 25, 2005 through August 23, 2005. Each letter

sets forth the terms of her Group Policy, a summary of her meetings

with Dr. Sussman, and a request for any additional information that

would be helpful in reviewing the decision. The letters also state,

“If there are medical reasons why you could not work after June 22,

2005, please have your physician complete the enclosed Attending

Physician’s Statement and return it to us.” Further, each letter

notified Skeen of her right to request a review of the decision, and

the right to file suit if the decision was upheld. The record also

reveals in October 2007, Skeen’s attorney notified Standard of Skeen’s

intent to request review of the decision to deny benefits; and that 

Standard subsequently sent letters to Skeen’s attorney requesting any

additional medical records. When those medical records were received

in February 2008, they were reviewed by Dr. Knapp. Therefore, the

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record does not show that Standard committed a procedural irregularity

in its handling of Skeen’s claim.

Skeen also challenges the completeness of the administrative

record relying on her declaration and her attorney’s declaration,

which are attached to Skeen’s Opposition to Defendants’ motion for

summary judgment. Defendants move to strike these declarations since

they were not before the claims administrator when the LTD denial

decision was made and are outside the administrative record.

Under an abuse of discretion review of the administrator’s 

decision, the court is generally limited to review of the

administrative record. Abatie, 458 F.3d at 970. An exception to this

general rule is when the court considers evidence outside the

administrative record to determine the appropriate weight to assign a

conflict of interest:

The district court may, in its discretion, consider

evidence outside the administrative record to

decide the nature, extent, and effect on the

decision-making process of any conflict of

interest; the decision on the merits, though, must

rest on the administrative record once the conflict

(if any) has been established, by extrinsic

evidence or otherwise.

Id. 

Both Skeen and her attorney declare the administrative

record is incomplete since it does not contain records of various

phone conversations or Skeen’s customer service survey to which

Standard replied in a letter dated March 6, 2006. (AR 140-141.) 

Additionally, attached as an exhibit to Skeen’s attorney’s declaration

is the April 15, 2009 decision in Skeen’s Social Security Hearing, in

which the Administrative Law Judge (“ALJ”) makes a “fully favorable

decision” based on Skeen’s “period of disability and disability

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insurance benefits application filed on December 13, 2006.” (Cooke

Decl., Ex. 1.) The ALJ concluded:

I found you disabled as of May 23, 2005 because of

Rheumatoid Arthritis, Fibromyalgia, Cervical Spine

Degenerative Disc Disease, COPD, Depression and

Obesity so severe that you are unable to perform

any work existing in significant numbers in the

national economy.

(Cooke Decl., Ex. 1.) 

The decision in the Social Security Hearing could not have 

been before the claims administrator since it was made over one year

after the ARU found the decision denying Skeen’s LTD benefits was

correct. Skeen argues this social security evidence “is significant

from the standpoint of what the medical evidence supports.” (Plt.’s

Opp’n to Mot. to Strike 2:16-18.) This argument does not pertain to

the weight to be given to Standard’s conflict of interest. Nor do the

averments in the proffered declarations Standard seeks to strike

support Skeen’s argument that the Administrative Record is incomplete. 

Therefore, the Court’s review is limited to the administrative record,

and the declarations are stricken.

Since Skeen’s evidence does not support drawing a reasonable

inference that Standard gave inconsistent reasons for its denial of

her claim, failed to investigate her claim, failed to ask for

necessary evidence, or failed to credit competent medical evidence in

the record, Standard’s conflict of interest merits only a “low” level

of skepticism. See Abatie, 458 F.3d at 967, 968-69.

III. Motion for Summary Judgment

“An abuse of discretion is found only when there is a

definite conviction that the [decisionmaker] made a clear error of

judgment in its conclusion upon weighing relevant factors.” Hummell

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v. S.E. Rykoff & Co., 634 F.2d 446, 452 (9th Cir. 1980). Factors

frequently considered in the ERISA context include: 

the quality and quantity of the medical evidence,

whether the plan administrator subjected the

claimant to an in-person medical evaluation or

relied instead on a paper review of the claimant’s

existing medical records, whether the administrator

provided its independent experts with all of the

relevant evidence, and whether the administrator

considered a contrary [Social Security] disability

determination, if any.

Montour, 588 F.3d at 630. 

Here, Standard could reasonably have concluded, based on Dr.

Sussman’s reports on June 22 and August 1, 2005 that Skeen was able to

return to work. Skeen has submitted evidence showing that since 2005

she has suffered from various conditions including RA, but she has not

provided any evidence in the administrative record that she was

disabled from June 22, 2005 through August 25, 2005. Further,

Standard was not obligated to follow Dr. Sussman’s recommendation that

Skeen remain on disability beyond August 2005. See, e.g., Toth v.

Automobile Club of Cal. Long Term Disability Plan, 2005 WL 1877150,

*30 (C.D. Cal. 2005) (affirming denial of benefits despite Doctor’s

contrary opinion supported by “only minor objective findings” in favor

of alternative conclusion supported by objective findings).

Standard’s conclusion that Skeen was not disabled beyond

June 22, 2005 is supported by Dr. Sussman’s medical records which

indicate that other than Skeen’s elbows lacking “a few degrees of full

extension,” Skeen was healthy enough to return to work. (AR 248.) 

Dr. Sussman’s notes from his August 1 meeting with Skeen state Skeen

“is about the same as [her] last visit.” (AR 247.) Additionally,

Skeen’s visits with Dr. Sussman on September 13, 2005, November 7,

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2005, and January 23, 2006 yielded “unremarkable examinations.” (AR

226.) 

Further, Dr. Shapiro, the Rheumatologist who replaced Dr.

Sussman as Skeen’s treating physician in April 2006, stated he did not

believe RA was disabling Skeen. He summarized, “I know she has

rheumatoid arthritis but I believe fibromyalgia is the cause of her

current and increased musculoskeletal pain.” (AR 485.) Finally,

Standard’s denial decision was also based on Dr. Knapp’s independent

review of all of Skeen’s medical records. Dr. Knapp concluded, “No

clinically significant orthopedic or medical impairments are noted

from 6/22/05 onward that would result in restrictions and limitations

for a light level occupation through 8/24/05.” (AR 229.)

Therefore, the administrator did not abuse of its discretion

in denying Skeen LTD benefits. 

VI. Conclusion

For the stated reasons, Defendants’ motion for summary

judgment is GRANTED.

Dated: January 12, 2010

 

GARLAND E. BURRELL, JR.

United States District Judge

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