Opinion ID: 201856
Heading Depth: 2
Heading Rank: 2

Heading: The Denial of Benefits and Subsequent Appeals

Text: 23 Prudential examined Buffonge's medical records and denied his claim for long-term disability benefits on September 20, 1996. It noted that (1) the February 1996 physical therapy discharge summary had deemed Buffonge pain-free, (2) Dr. Kermond had opined that Buffonge could perform a desk job, and (3) Wang had made physician-requested accommodations for Buffonge, including placing him on light duty and permitting him to get up and walk around every hour. It therefore concluded that there was no objective medical evidence in our file to support Total Disability. 24 Buffonge's employment was terminated on October 21, 1996. 4 A month later, he administratively appealed Prudential's benefits decision. Prudential upheld its denial in a letter dated November 26, 1996. It stated that Buffonge did not qualify for long-term disability because (1) according to Dr. Kermond, he could perform a job involving desk work or light lifting as of June 1996, and therefore (2) he had not been totally disabled for 26 weeks after he left work in February 1996, as required under the plan's definition of total disability. Buffonge again appealed, and Prudential affirmed its denial again, on the same grounds, in a letter dated June 9, 1997. 25 On July 25, 1997, Buffonge filed his final administrative appeal. This time he submitted additional reports and letters from two physicians — his primary physician, Dr. Duhme, and another examining physician, Dr. Emilio Jacques — in support of his claim. Dr. Jacques, an orthopedist, examined Buffonge on April 9, June 11, and July 9, 1997, and concluded each time that Buffonge was fully disabled. 5 His report of June 11, submitted with Buffonge's final appeal, stated that Buffonge had told him his pain is constant and . . . he is only able to maintain activity for one to two hours. Dr. Jacques concluded that Buffonge was disabled and unable to resume his occupation and that the disability was causally related to his 1993 work accident. 26 A follow-up examination by Dr. Jacques, conducted on August 27, 1997, produced a report that Buffonge submitted as a supplement to the appeal. In the August 27 report Dr. Jacques detailed his findings on examination and then reiterated the conclusion he had reached in all his earlier reports, stating: [I]n my opinion [Buffonge] is disabled from any gainful employment at the present time. He also added: 27 In my opinion he is disabled from repetitive bending, lifting, pushing, pulling and carrying over fifteen to twenty pounds and he is disabled from any repetitive squatting and crawling positions. 28 The letter from Dr. Duhme, dated July 16, 1997, stated the doctor's conclusion, based on numerous examinations of Buffonge, 6 that Buffonge was completely disabled by chronic neck pain due to cervical disc disease and low back pain due to lumbar disc disease. He wrote that Buffonge was unable to perform any job that I can think of, that [e]ither sustained activity or sustained sitting will aggravate these pains, and that Buffonge was unable to devote his attentions to any work. 29 As part of its handling of Buffonge's appeal, Prudential hired Dr. Jonathan Rutchik as a consultant. Rutchik spent a total of three hours reviewing Buffonge's records and writing a report; he did not examine Buffonge personally. In his report, dated October 31, 1997, Dr. Rutchik wrote that a consensus exists about the fact that Mr. Boffonge [sic] can perform work tasks such as sedentary duties and keyboard work. He therefore concluded that Buffonge could have performed the largely desk-bound duties of his job as a field logistics coordinator at Wang. 30 Dr. Rutchik reached this conclusion by parsing and in part disregarding the findings of physicians who had examined Buffonge. For example, he quoted Dr. Jacques' assessment that Buffonge was disabled from repetitive bending, lifting, pushing, pulling and carrying over fifteen to twenty pounds and followed it with this comment: Dr. Jacques was specific about the tasks that Mr. Buffonge could not do and thus inferred that there were jobs he could do. He thus ignored Dr. Jacques' statement in the same report that Buffonge was disabled from any gainful employment at the present time. As to Dr. Duhme's conclusion, based on multiple physical examinations and years of handling Buffonge's case, that [e]ither sustained activity or sustained sitting will aggravate these pains, Dr. Rutchik wrote: [t]his letter provided no objective evidence that he has a condition where he could not do sustained sitting or sustained activity. He did not address Dr. Duhme's statements in the same letter that Buffonge was unable to perform any job that I can think of and unable to devote his attentions to any work. 31 Prudential subsequently denied Buffonge's appeal in a letter dated November 25, 1997. It stated: 32 [B]ased on a review of [Buffonge's] medical file, the restrictions provided by Dr. Kermond on June 26, 1996 and by Dr. Jacques on August 27, 1997 and the information provided by Dr. Rutchik, we do not find that Mr. Buffonge's symptoms impaired him from performing the duties of his occupation for the period February 21, 1996 through August 20, 1996. Therefore, we are upholding our decision to deny Mr. Buffonge's claim . . . . 33 Prudential thus identified four bases for its denial: (1) Buffonge's full medical file, (2) the Kermond report, (3) the August 27 Jacques report, and (4) the Rutchik report.