contention on the fact the Plan states that benefits expire when the participant recovers. While

this might be true, there is nothing in the record.to. show that Adams ever recovered from her

malady. Rather, the medical opinions which le IGNA to terminate her LTDB simply found
that she could perform light to sedentary work, not that she had recovered from the ailment in her
right extremity. Moreover, a number of courts have found that a claimant became disabled after

her condition worsened, when at first she was found not to be totally disabled. See, ¢.g., Ladd,

148 F.3d at 754; Poulos, 93 F. Supp. 2d at 931. Therefore, the Court finds this contention

unavailing.

Additionally, CIGNA contends that the SSA’s decision was irrelevant to its decision
because “ERISA does not require the claim administrator to follow the SSA’s disability
determination.” While it is true that CIGNA did not need to follow the decision of the SSA, it
does not appear that CIGNA even considered it,or that it gave it to Dr. Franz in his examination
of the medical records. As such, this Court finds that CIGNA’s decision was not based on a

complete review if the record. See, e.g., Coles v. LaSalle Partners Inc. Disability Plan, 2003 WL

22400710, at * 3-5 (N.D. Ill. Oct. 17, 2003).

Consequently, based on the fact that Dr..Franz based his report on a dated test conducted
by another physician and failed to take into consideration or discuss Dr. Flimlin’s May 1998
report or the SSA’s determination, this Court.finds that a genuine issue of material fact exists as
to whether the reasons given by CIGNA for denying Adams’ appeal for reinstatement of her
LTDB under the Plan were “ downright unreasonable.” As such, even under the “arbitrary and
capricious” standard, this Court cannot at this time grant CIGNA’s Motion for Summary

Judgment.

13



Consequently, on November 18, 1996, based on the results of the two FCEs and the
transferable skill study test, CIGNA notified Adams that it was terminating her LTDB under the
Plan because she no longer met the Plan’s definition of disabled.

E. Appeal of the Termination of LIDB

In response to the termination of her benefits, Adams filed several appeals with CIGNA.
In her first appeal, Adams submitted reports from.three doctors, including a report from Dr.
Flimlin stating that Adams’ “pain [was reported by her to be] intolerable” and that her condition
had deteriorated. CIGNA, however, denied this appeal because the three doctors’ reports did not
contradict their earlier findings that Adams could perform “light-medium work” and did not
contain clinical evidence in support of their medical conclusions.

Adams subsequently filed a second appeal with a report from Dr. Flimlin. In her updated
report, Dr. Flimlin noted that Adams continued to. suffer a “significant exacerbation of pain” and
is now taking several medications which make her drowsy and unable to “attend task.” Based on
this, Dr. Flimlin stated that Adams “is unable to participate ina light duty sedentary job” and
“strongly recommend(s] a permanent disability for neuropathic pain.”

In addition to Dr. Flimlin’s updated report, Adams sent CIGNA a decision from the
Social Security Administration (“SSA”), on June 5, 1997, finding that she was disabled as
defined by the Social Security Act and awarding her disability benefits. The SSA found that
Adams suffered “severe . . . pain in the right lower extremity and depression” which “prevent[s]
{her} from performing even sedentary unskilled Work.” This conclusion, according to the SSA, is
supported by the fact that Adams’ “pain is documented through voluminous medical records over
the years from numerous treating sources.”

Despite Dr. Flimlin’s new opinion and the decision of the SSA, CIGNA denied Adams



ANALYSIS

With the above standards in mind, the question before this Court is whether CIGNA’s
decision not to reinstate Adams’ LTDB after receiving Dr. F limin’s updated reports and the
decision of the SSA was “downright unreasonable.’ CIGNA contends that “the evidence in this
case precludes [Adams], as a matter of law, fromestablishing that CIGNA acted unreasonable in
finding that she was not disabled from any occupation.” In response, Adams appears to argue that
Dr. Flimin’s updated reports and the decision of the SSA present a question of fact as to whether
the reasons given by CIGNA for denying Adams’ appeal for reinstatement of her LTDB under
the Plan were reasonable.’

To determine whether CIGNA’s decision.was “down right unreasonable,” the Court will
first examine the language in the Plan. To receive LTDB under the Plan, Adams was required to
show that she was “unable to do any job for any employer for which [she] is qualified; or may
become reasonably qualified by training, education, or experience, other than a job that pays less
than 50% of [her] Eligible Base Pay at the time [she] became disabled.”

Cigna contends that its decision cannot be found unreasonable because Dr. Franz’s report

“establishes a reasonable basis for [its] finding that [Adams] was not disabled.” On November

2 The Court agrees with CIGNA that the initial decision to terminate Adams’ benefits was
reasonable, and therefore, the Court will not discuss this issue. As discussed in detail above, the
initial termination decision was based on the results of the two FCEs and the transferable skill
study test, which concluded that Adams, at that time, could perform light to sedentary work ina
number of occupations.

3 The Court notes that Adams did not file a response to the motion but did file a
Supplemental Rule 56.1 Statement of Facts, which impermissibly set forth legal arguments.
Nevertheless, the Court will consider these arguments in this opinion.



F. Procedural History

After CIGNA denied her final appeal, Adams filed the instant action in the Circuit Court
of Cook County on March 15, 2002, alleging that CIGNA “negligently, willfully and wrongfully
terminated the contractual rights of this Plaintiff”. CIGNA subsequently removed the case to the
United States District Court of the Northern District of Illinois, Eastern Division based on 28
U.S.C. §§ 1441 and 1446 because Adams’ complaint invokes federal question jurisdiction, a
violation of the Employee Retirement Income Security Act (“ERISA”) (29 U.S.C. §
1132(a)(1)(B)), and then moved for summary judgment.

STANDARD OF REVIEW

Because this is a motion for summary judgment for a claim for wrongful denial of
benefits under ERISA, two standards of review govern this Court’s review.

A. Federal Rule of Civil Procedure 56

Summary judgment is appropriate “if the pleadings, deposition, answers to
interrogatories, and admissions on file, together with the affidavits, if any, show that there is no
genuine issue as to any material fact and that the moving party is entitled to judgment as a matter

of law.” Fed. R. Civ. P. 56(c). See also Celotex Corp. v. Catrett, 477 U.S. 317, 322-23 (1986);

Cheek v. Western & Southern Life Ins. Co., 31 F.3d 497, 500 (7th Cir. 1994). A genuine issue of

material fact is one that might affect the outcome of the lawsuit, and factual disputes that are

irrelevant will not be considered. Anderson v. Liberty Lobby, Inc, 477 U.S. 242, 249 (1986). In

determining whether a genuine issue of material fact exists, the court must construe the alleged

facts in a light most favorable to the party opposing the motion. United States v. Diebold, Inc.,

369 U.S. 654, 655 (1962); Dale v. Chicago Tribune Co., 797 F.2d 458, 460 (7th Cir. 1986).

The moving party carries the initial burden of establishing that no genuine issue of



appeal on the grounds that Dr. Flimlin did not submit any clinical evidence to support her new
opinion. The SSA’s award of benefits was apparently not considered by CIGNA because it was
not mentioned in the denial of her appeal.

After the denial of her second appeal, Adams submitted another letter from Dr. Flimlin,
who again examined Adams in May of 1998. In.this report, the doctor stated that Adams
reported a “significant exacerbation of right lower, extremity pain and a new left lower extremity
pain” and difficulty sleeping and performing sittiple tasks. After performing a “musculoskeletal
exam,” Dr. Flimlin found that Adams’ “right lower extremity is swollen” and that she had a loss
of strength there. She also concluded that Adams “was unable to go up on the toes or heel on the
right” and that “[s]he had difficulty sitting in one position for greater than 2 minutes, needed to

My assessment is this patient has had an,acute exacerbation of a chronic right lower
extremity pain. I do not feel that she could tolerate a light duty sedentary job, as she is
unable to tolerate sitting for greater thap.2. minutes or standing. With a neuro exam, she
could recall 1 of 3 objects immediately. [feel that she is also having difficulty sleeping
and emotionally distraught . . . . I do not feel that she can participate in a sedentary light
duty job and her clinical exam today has significantly deteriorated since my last office
visit.

To determine the validity of Dr. Flimlin’s new diagnosis, CIGNA sent Adams medical
records to Dr. Franz. In contrast to Dr. Flimlin, Dr. Franz concluded that Adams was not

suffering from sympathetic pain syndrome and. was capable of performing “light to sedentary

duties.” Dr. Franz based his opinion solely on the fact that Adams did not respond to a
“sympathetic blockade even temporarily,” which was a test performed by Dr. Carobene in June
of 1995. Consequently, following the opinion of. Dr. Franz, CIGNA once again denied Adams’

LTDB claim.



authority to construe and interpret the Plan, decide all questions of eligibility and determine the
amount, manner and time of payment of benefits”).
Here, the Plan states that CIGNA, as the claims administrator, has:
the sole and complete discretionary authority to determine conclusively for all parties, and
in accordance with the terms of the documents or instruments governing the Plan, any and
all questions arising from the administration of the Plan and interpretation of all Plan
provisions, determination of all questions arising from the administration of the Plan and
interpretation of all Plan provisions, determination of all questions relating to
participation of Eligible Employees . . . and eligibility for benefits, determination of all
relevant facts, the amount and type of benefits payable to any Eligible Employee . . . and
construction of all terms of the Plan. »
Because the Plan here makes clear that its administrators retain discretion to determine eligibility
for benefits, the decision of CIGNA will be reviewed under the arbitrary and capricious standard.
In applying the arbitrary and capricious standard of review, courts examine whether the
administrator’s denial of benefits was “downright unreasonable,” see Donato v. Met. Life Ins.
Co., 19 F.3d 375, 380 (7th Cir. 1994), and will uphold the decision as long as it was based on a
reasonable interpretation of the plan's language and the evidence in the case. See Infantino v.
Waste Management, Inc., 980 F. Supp. 262, 266 (N.D. Ill. 1997). Questions of judgment are left
to the administrator of the plan, and ‘‘a court must be very confident that the administrator
overlooked something important or seriously erred in appreciating the significance of the

evidence” to overturn the administrator's determination. See Patterson v. Caterpillar, Inc., 70

F.3d 503, 505 (7th Cir. 1995).


‘Minute Order Form (06/97)

United States District Court, Northern District of Illinois

Name of Assigned Judge
or Magistrate Judge

Blanche M. Manning

Sitting Judge if Other
than Assigned Judge

CASE NUMBER 02 C 3044 DATE January 20, 2004

CASE anne Adams v. CIGNA

TITLE

ad
[In the following box (a) indicate the party filing the motion, e.g., plaintiff, defendant, 3rd party plaintiff, and (b) state briefly the
MOTION: nature of the motion being presented.]
DOCKET ENTRY: =
=
(1) o Filed motion of [ use listing in “Motion” box above.]
(2) Brief in support of motion due
(3) o Answer brief to motion due . Reply to. answer brief due
(4) ia) Ruling/Hearing on set for at.
(5) o Status hearing[held/continued to] [set for/re-set for] on set for at
(6) o Pretrial conference[held/continued to] [set for/re-set for] on set for at
(7) Oo Trial{set for/re-set for] on at
(8) oO [Bench/Jury trial] [Hearing] held/continued to. at
(9) Q This case is dismissed [with/without] prejudice and without costs[by/agreement/pursuant to]
O FRCP4(m) O General Rule2l OFRCP41(a(1) 0 FRCP41(a)(2).
(10) @ [Other docket entry] For the reasons set forth.in the attached Memorandum and Order, this Court
DENIES Defendants’ Motion to Dismiss Plaintiff's Constructive Discharge Claim is DENIED [31-1
and 31-2].

(eu) a (For further detail see order on the reverse side.of the original minute order.]

No notices required, advised in open court. | Document

. A Number
No notices required. poe
umber of otis

V_ | Notices maited by judge's staff. “ wf HDA

Notified counsel by telephone.
Docketing to mail notices.

Mail AO 450 form.

Jenoampan! sic sn

Copy to judge/magistrate judge.

courtroom

depaty's
initials

RTS

Date/time received in
central Clerk’s Office

mailing deputy initials



Employees, 2002 WL 441479, at *6 (N.D. Ill. Mar. 21, 2002) (finding denial of LTDB arbitrary
and capricious, where decision was based on conclusion by non-examining physician who did
not examine the entire medical record and discounted relevant medical evidence).

Here, after reviewing the entire administrative record, this Court finds a number of
problems with CIGNA’s reliance on Dr. Franz’s.conclusion. First and foremost, the Court notes
that Dr. Franz, who completed his review on November 16, 1998, based his opinion entirely on
the fact that Adams did not respond to a “sympathetic blockade even temporarily,” which was a
test performed by Dr. Carobene in June of 1995. The problem with relying on Dr. Carobene’s
exam is that it was conducted in June of 1995, well before Dr. Flimin’s updated reports, in
October 1997 and May 1998, and the decision ofthe SSA, in June of 1997, Dr. Franz’s report
states that he obtained the reports from Dr. Flimin.. In his report, however, Dr. Franz did not
even discuss Dr. Flimlin’s October 1997 and May 1998 reports, let alone address whether they
were valid. As for the SSA report, it is not even mentioned in Dr. Franz’s report.

As discussed in detail above, in his May 1998 report, after administering a
“musculoskeletal exam,” Dr. Flimlin found that: (1) Adams’ condition had significantly
worsened, (2) her “right lower extremity is swollen”; (3) she had a loss of strength as
demonstrated by the fact that she “was unable to go up on the toes or heel on the right”; and
(4) “[s]he had difficulty sitting in one position for greater than 2 minutes, needed to change
position from sitting to standing.” Based on her exam of Adams, Dr. Flimlin opined that Adams
“had an acute exacerbation of a chronic right lower extremity pain” and that she “could not
tolerate a light duty sedentary job, as she is unable to tolerate sitting for greater than 2 minutes or
standing.”

Similarly, on June 5, 1997, the SSA found that Adams suffered “severe . . . pain in the

li



concluded that Adams was not suffering from sympathetic pain syndrome and was capable of
performing “light to sedentary duties.” Consequently, this Court must examine CIGNA’s
decision in light of the contradictory findings of Dr. Flimlin and the SSA versus Dr. Franz’s
findings.

In Black & Decker Disability Plan v. Nord, — U.S. —, 123 S. Ct. 1965, 1967 (2003), the
Supreme Court struck down the “treating physi¢ian rule,” in holding that “plan administrators are
not obligated to accord special deference to the opinions of treating physicians.” The Court
noted, however, that plan administrators “may not arbitrarily refuse to credit a claimant’s reliable
evidence, including the opinions of the treating physician.” Id. at 1972.

Consequently, in light of the Supreme Court’s decision in Nord, it appears to this Court
that “[t}he findings of treating physicians are [still] entitled to some weight,” and “[i]n cases
which the plan administrator rejects the findings ‘of the claimants treating physician, the court

must evaluate whether such a rejection is rational and justifiable.” Houston y. Provident Life and

Accident Ins. Co., 2002 WL 31779921, at *6 (N.D. Ill. Dec. 11, 2002) (finding denial of LTDB
arbitrary and capricious, despite finding by non-examining physician that claimant was not
disabled).

Where an independent physician reviews.the claimant’s medical records without
performing an exam, the physician’s conclusions must be supported by competent medical

evidence. See Hightsue v. AIG Life Ins. Co., 135.F.3d 1144, 1148 (7th Cir. 1998). Several

courts have found the denial of LTDB arbitrary and capricious, where the decision was based on
a conclusion by a non-examining physician whose “opinion was based upon incomplete
information” and who did not “take into account.the results of relevant objective medical tests.”

Houston, 2002 WL 31779921, at *7. See also Carugati v. Long Term Disability Plan for Salaried

10

aiieigiiatbiones:


material fact exists. Fed. R. Civ. P. 56(c); Celotex Corp., 477 U.S. at 323. Once the moving
party has met its burden, the nonmoving party must.set forth specific facts showing that there is a

genuine issue for trial. Fed. R. Civ. P. 56(e); Becker v. Tenenbaum Hill Assoc., Inc., 914 F.2d

107, 110 (7th Cir. 1990). The nonmoving party must do more than “show that there is some
metaphysical doubt as to the material facts.” Matsushita Elec. Indus. Co. v. Zenith Radio Cop.,
475 US. 574, 586 (1986). The nonmoving party may not merely rest upon the allegations or
denials in its pleading, but instead, must “set fourth specific facts showing that there is a genuine
issue for trial.” See Anderson, 477 U.S. at 248. If the evidence presented is “merely colorable”
or is not “significantly probative,” summary judgment may be granted. Id. at 250-51 (citations
omitted).

B. Judicial Review of a Denial of ERISA Benefits

Under ERISA, de novo review ofa denial of benefits is the default rule, “unless the
benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility

for benefits or to construe the terms of the plan.” Postma v. Paul Revere Life Ins. Co., 223 F.3d

533, 538 (7th Cir. 2000). Where a plan confers such discretionary authority, a deferential
arbitrary and capricious standard of review applies. Id, For decisions to be subject to this
arbitrary and capricious standard, the plan must “make clear” that its administrators retain

discretionary authority. Herzberger v. Standard Ins. Co, 205 F.3d 327, 331 (7th Cir. 2000). In

Herzberger, 205 F.3d at 331, the court suggested the following “safe harbor” language for plans
that wish to avoid de novo review: “[b]enefits under this plan will be paid only if the plan
administrator decides in his discretion that the applicant is entitled to them.” See also Gerlib v.
R.R. Donnelley & Sons Co., No. 95 C 7401, 2001 WL 1313794, at *6 (N.D. Ill. Oct. 26, 2001)

(applying an arbitrary and capricious standard of review to a plan that gave its administrator “the


Cc. Appeal and Approval of Temporary LTDB

Adams subsequently appealed this denial. and submitted records from another treating
physician, Dr. Flimlin, medical director of the Ingalls Center for Outpatient Rehabilitation,
Dr. Flimlin opined that Adams should be considered disabled until she completed a “functional
restoration program.” After reviewing her claim, a CIGNA claims representative found that: (1)
Adams had been “diagnosed with chronic pain’ syndrome”; (2) “various treatments . . . have been
tried [over] three years, but with no real improvement in [Adams”] symptoms”; and (3) the
doctors, “who have attempted to diagnose and treat” Adams, “feel [her] pain is real.”
Based on this information, the claims representative stated that CIGNA “should approve this
claim.” CIGNA subsequently approved her claim and granted Adams LTDB on a preliminary
basis.

D. Termination of LTDB

To make a final determination of her claim, CIGNA scheduled Adams to take a
functional capacities evaluation (“FCE”), so that an occupational specialist could make a more
definite determination as to whether she qualified for LTDB under the Plan. Adams
subsequently underwent two separate FCEs, one by her own doctor, Dr. Flimlin, and one by an
independent occupational therapist. A FCE measures a person’s physical capacity to perform
various types of jobs. Based on the result of the ECE, Dr. Flimlin opined that Adams would be
able to return to “light or medium work.” Likewise, the occupational therapist concluded that
Adams could perform light to medium work. CIGNA also had Adams perform a “transferable
skills study,” which identified occupations which she could perform based on her physical
limitations, work experience, and education. According to this study, Adams could work at a

number of occupations given her physical condition.



CONCLUSION
For the foregoing reasons, this Court DENIES Defendant CIGNA Group Insurance Life

Accident Disability Co.’s Motion for Summary Judgment [12-1].

ENTER: Wael Mn at Lee hang

BLANCHE M. MANNING i
U.S. DISTRICT COURT JUDGE

Ad


A. Relevant Policy Provisions

At issue in this case is whether Adams was. “disabled” as set forth in the Plan, and
therefore entitled to LTDB. To receive benefits under the Plan, Adams was required to show that
she was “unable to do any job for any employer for which [she] is qualified; or may become
reasonably qualified by training, education, or experience, other than a job that pays less than
50% of [her] Eligible Base Pay at the time [she] became disabled.”

B. Claim for Long-Term Disability Benefits

AT&T employed Adams as a customer sérvice representative from February 2, 1987 to
December 5, 1994. On November 30, 1993, almost a year before she was terminated, Adams
went on short-term disability leave, for which she.teceived benefits from AT&T. After her short-
term benefits expired, Adams completed an application for LTDB under the Plan on December 1,
1994,

Adams claimed that she qualified for LTDB because she suffered “systematic dystrophy
in her right leg which led her to suffer from constant pain in her right leg and thigh.” As a result
of this pain, Adams contended that she was prevented from sitting, standing, or walking for long
periods of time. The medication which Adams took to relieve the pain allegedly caused her
drowsiness which prevented its use during work hours. Consequently, Adams asserted that she
qualified for LTDB because she could not engage “in any gainful employment” at that time.

At CIGNA’s request, Adams submitted medical records from her doctors. On March 23,
1995, after reviewing her medical records, CIGNA denied Adams’ claim. This denial was based
in large part on the fact that one of Adams’ doctors, Dr. Zelkowita, stated that she could
“perform work which requires no physical activity.” Therefore, because her position at AT&T

was “sedentary in nature,” CIGNA found that Adams was not disabled as defined in the Plan.



a

IN THE UNITED STATES DISTRICT COURT }
FOR THE NORTHERN DISTRICT OF ILLINOIS avy 9
EASTERN DIVISION 2 2004

DELORES ADAMS,

Plaintiff,
Hon. Blanche M. Manning
ve.
No. 02 C 3044
CIGNA GROUP INSURANCE LIFE
ACCIDENT DISABILITY CO.,

Defendant.

weer rv SS

MEMORANDUM AND ORDER

Plaintiff Delores Adams brought this action against CIGNA Group Insurance Life
Accident Disability Co. (“CIGNA”), alleging that. CIGNA wrongfully terminated her long term
disability benefits (““LTDB”). This matter comes before this Court on CIGNA’s motion for
summary judgment, pursuant to Federal Rule of. Civil Procedure 56. For the following reasons,
the motion is DENIED.

BACKGROUND'

This action stems from a long-term disability insurance plan (“the Plan”) established and

funded by Adams’ former employer, the AT&T, Corporation (“AT&T”), and administered by

CIGNA.

' The facts in the Background section arederived from the parties’ Local Rule 56.1

statements and other pleadings. The facts in Defendant’s Local Rule 56.1(A)(3) statement that
Plaintiff did not controvert in its Local Rule 56,1(b)(3)(A) statement are deemed admitted for
purposes of this motion. Schulz v. Serfilco, Ltd., 965 F.2d 516, 519 (7th Cir. 1992). Likewise,
the facts that Plaintiff provides in his Local Rule 56.1 statement and that Defendant did not
controvert are also deemed admitted. Id. The facts that Plaintiff objected to but did not deny are
deemed admitted. McGuire v. United Parcel Serv., 152 F.3d 673, 679 (7th Cir. 1998). Lastly,
responses that did not cite to “specific references to the affidavits, parts of the record, and other
supporting materials relied upon” as required under Local Rule 56.1(b)(3)(A) are subject to the
court’s discretion as to their admission. Brasic v. Heinemann’s Inc., 121 F.3d 281, 284 (7th Cir.
1997).



right lower extremity and depression” which “prevent [her] from performing even sedentary
unskilled work.” This conclusion, according ioThe SSA, is supported by the fact that Adams’
“pain is documented throughout voluminous medical records over the years from numerous
treating sources.”

CIGNA contends that this Court should not consider Dr. Flimlin’s report or the decision

of the SSA. According to CIGNA, Dr. Flimlin’s opinion that Adam’s condition had worsened

was “not supported by clinical evidence” and did not explain “how” her condition had changed.
While this might be true for the October 1997 report, as explained above, Dr. Flimlin’s May
1998 report was based on a “musculoskeletal. exam” and her long-time experience treating
Adams’ condition.’ As for how her condition ‘hanged, this would seem irrelevant so long as it
was the original condition for which she was denied benefits, A number of courts have found
claimants to be disabled where their conditions had worsened over time, without the examining
physicians explaining precisely how the condition worsened. See, ¢.g., Ladd v. IIT Corp., 148
F.3d 753, 754 (7th Cir. 1998); Poulos v. Motorola Long Term Disability Plan, 93 F. Supp. 2d
926, 931 (N.D. Ill. 2000). Moreover, Dr. Flimin opined that, based on his exam, Adam’s
changed condition was the result of “an acute exacerbation of a chronic right lower extremity
pain.” In this Court’s view, this finding seems,to explain how and why Adams’ condition
changed for the worse.

CIGNA also contends that Dr. Flimlin’s report and the SSA’s decision are irrelevant

because Adam’s “benefits were terminated effective November 1996.” CIGNA bases this

4 A “clinical diagnosis” is defined as “ftjhe determination of a medical condition (such as a

disease) by physical examination or by a study_of its symptoms.” Black’s Law Dictionary464
(7th ed, 1999). Here, despite CIGNA’s asse: , Dr. Flimlin’s opinion based on his
“musculoskeletal exam” of Adams appears to. bea clinical diagnosis.

12