Opinion ID: 2972013
Heading Depth: 3
Heading Rank: 1

Heading: caused by injury or sickness

Text: b. that started while insured under this policy; and 2. After 36 months of benefits have been paid, the insured is unable to perform with reasonable continuity all of the material and substantial duties of his own or any other occupation for which he is or becomes reasonably fitted by training, education, experience, age and physical and mental capacity. B. Processing of Lee’s LTD Claim and Relevant Procedural History
In 1997, MBNA Marketing Systems, Inc. (“MSI”) hired Lee as a part-time Customer Service Satisfaction Specialist. MSI is a subsidiary of MBNA America, which is in turn a subsidiary of MBNA. Lee’s duties included answering telephone calls, preparing, reviewing, and approving customer requests for credit line increases, processing incoming mail, and tracking incoming calls. She was also required to possess strong written and oral communication skills, work in a high-volume environment, be self-motivated, and identify and resolve customer concerns. In February of 1998, Lee was hired full-time and became eligible for coverage under MBNA’s benefit plan, which included short term disability (“STD”) and LTD benefits. Relevant plan provisions are set forth and discussed below. In December of 1998, Lee applied for and received STD benefits as a result of fatigue, snoring, daytime somnolence, irregular heartbeat, and shoulder pain. Lee 4 returned to work at the end of March 1999. In September of 1999, Lee again applied for STD benefits for sleep apnea, high blood pressure and shoulder problems. She received these benefits until October 1999.2 After Lee exhausted her leave under the Family Medical Leave Act, she was placed on leave pending her application for LTD benefits. On December 30, 1999, Lee completed an LTD claim form, on which CSI’s name and address appears at the top. Lee described her disability as follows: “walking at night unable to breath [sic] and cardiac distress several times weekly[,] extreme fatigue[,] muscle weakness[,] unable to think clearly[,] began falling asleep behind the wheel of auto each time driving.” MBNA completed its portion of the form outlining Lee’s job duties on February 1, 2000, at which time it was submitted to CSI. Lee’s form was accompanied by a physician’s statement of January 3, 2000 from her treating physician, Dr. Chagin, who diagnosed “sleep apnea, HTN, chronic insomnia, possible narcolepsy.” He listed restrictions of “no driving” and “nothing involving concentration for prolonged periods.” It is undisputed that Lee’s alleged onset of disability, for purposes of LTD benefits, is October of 1999. On February 14, 2000, CSI identified itself as the claims advisory agent for SAFECO, the LTD carrier for MBNA, and informed Lee that it had received her claim. CSI also received the following medical documentation: treatment notes from Dr. 2 Lee apparently challenged the termination of her STD benefits. However, the matter was later resolved and is not the subject of this appeal. 5 Chagin from February 1999 to February 14, 2000; treatment notes from Dr. Hershey, a cardiologist, from June 1999 to October 5, 2000; and three of Lee’s STD forms. Dr. Hershey’s records show that cardiac test results were essentially normal. Dr. Chagin’s notes outline Lee’s several complaints over time, and include diagnosis of sleep apnea, obesity, shoulder pain, chronic insomnia, fibromyalgia, and hypertension. None of Dr. Chagin’s notes indicate that Lee’s sleeping difficulties prevent her from working. On March 27, 2000, Trina Couture at CSI documented a phone call from Lee in which she stated, inter alia, that her Continuos Positive Airway Pressure (“CPAP”) machine was not working, she has trouble keeping it on at night, and she subconsciously removes it. On May 9, 2000, CSI, though Couture, referred Lee’s file to Dr. Barry Gendron, a consulting physician specializing in rehabilitation and physical medicine. Dr. Gendron completed a Memorandum dated May 14, 2000, in which he stated: It is unclear what Ms. Lee’s alleged primary impairing condition is. There is no objective medical evidence to corroborate attention/concentration deficits related to sleep apnea syndrome. We also do not have the results of the sleep study to review. I see no formal neuropsychiatric or psychiatric assessment of cognitive capacity, nor do I see even a baseline mini-mental status exam attempting to document cognitive function. From the medical information available, I do not see adequate evidence from 8/99 to present which would support complete impairment from a sedentary occupation. It is entirely unclear why the claimant left work; her hypertension was under fair control and her sleep apnea was apparently fairly longstanding. It is unclear if her job/motivational issues have impacted her leaving work. Dr. Gendron recommended obtaining results of the sleep study, as well as considering contacting her attending physician to better understand her restrictions and limitations. 6 Later in May, CSI received additional medical records relating to Lee’s sleep apnea, insomnia, and possible narcolepsy. These records show that Lee was diagnosed with sleep apnea in 1998. On November 18, 1998, Lee underwent a sleep study at Akron General Medical Center at the direction of Dr. Chagin. The study documented “prolonged sleep latency” of more than one hour and found “moderately severe” obstructive sleep apnea. A repeat study was conducted on December 10, 1998 that showed that Lee’s apnea was well controlled with the use of a CPAP device. On June 6, 2000, Dr. Gendron spoke with Dr. Chagin regarding Lee’s condition. The substance of the conversation is memorialized in a letter from Dr. Gendron to Dr. Chagin, also dated June 6, 2000, which Dr. Chagin signed and returned. Dr. Chagin indicated that he supported a period of disability from August 30, 1999 until September 30, 1999 relative to Lee’s hypertension. After that time, Dr. Chagin indicated that her condition was well controlled and did not affect her job duties. They also discussed Lee’s work restrictions, to which Dr. Chagin stated that Lee had been diagnosed in February of 1999 with left rotator cuff tendinitis and that a restriction of not lifting greater than ten pounds was in place from February 1999 to August 1999. They did not discuss Lee’s sleep apnea; either Dr. Gendron did not inquire about the condition and/or Dr. Chagin did not mention it. Also on June 6, 2000, Dr. Gendron completed a second Memorandum regarding Lee’s condition. As to her sleep apnea, he stated that “[a]lthough comorbid conditions of sleep apnea syndrome and possible narcolepsy are listed, the objected evidence show that 7 she is well controlled on 10 cms of water CPAP.” His summary of the condition noted that her limitation was to wear a CPAP at night. He found no evidence limiting her regarding her hypertension, tendinitis or fibromyalgia. Based on this information, CSI denied Lee’s claim in a letter dated June 21, 2000. The letter discusses Lee’s treatment for hypertension and tendinitis, as well as the conversation with Dr. Chagin; it does not mention Lee’s sleep apnea. Lee, through counsel, appealed the decision. Counsel for Lee wrote CSI, agreeing that her hypertension was not in and of itself disabling, but that Lee’s primary disability was “sleep apnea” that had resulted in a decreased ability to concentrate, chronic fatigue, and short-term memory loss. Counsel indicated that medical records from Dr. Chagin would support her condition and would be forwarded to CSI. CSI agreed to hold the file open for 30 days for receipt of the additional information. CSI, however, did not receive any additional information. Accordingly, on September 29, 2000, CSI notified Lee that her appeal was denied. The letter references the conversation between Dr. Chagin and Dr. Gendron and states in part as follows: Dr. Chagin did not indicate there were any work restrictions which would carry forward with respect to the sleep apnea. The medical records reflect that your client’s sleep apnea improved with treatment with the CPAP. There is no indication that a new polysomnography was done showing that the CPAP treatment from the previous polysomnogram of 12.10/98, which was effective in controlling abnormalities, was no longer valid. Nor have we been provided with any neuropsychological results outlining any cognitive impairments. The letter further indicated that CSI would review any additional medical information received within sixty days. 8 On October 2, 2000, Lee’s counsel advised CSI that he had requested a detailed medical report from Dr. Chagin and would forward it to CSI. CSI, however, did not receive such a report. More than seven months later, on May 17, 2001, CSI received a telephone call from Lee’s new counsel requesting a copy of Lee’s claim file. On June 2, 2001, CSI received a copy of a letter dated September 4, 2000 that Dr. Chagin wrote to Lee’s former counsel. In that letter, Dr. Chagin stated: Tracey Lee has been seen by me for persistent Hypertension, Chronic Fatigue, Chronic Insomnia, Fibromyalgia and Sleep Apnea. Her sleep apnea most likely is the causative problem for her other health concerns. She had persistent symptoms from her sleep apnea even though she is equipped with a home CPAP machine. She has seen a neurologist and is currently seeing an ear, nose, and throat specialist. She continues to be aggravated by fatigue, headaches and stress. Tracey is seen periodically by me to monitor response to therapy. Should you have need for further information, feel free to contact my office. CSI also received the following information: treatment notes from Dr. Chagin through July 19, 2001; the results of a sleep study performed by Dr. Raymond Salomone on October 9, 2000; treatment notes from Dr. Frankie Roman, a sleep specialist, from July 3, 2001 to November 2, 2001; and an affidavit of Kelly Bevington, Lee’s roommate, a nursing assistant. These records show that the sleep study by Dr. Salomone reported “moderately severe obstructive sleep apnea,” which was treated adequately with the use of a CPAP. It also recommended that other alternatives, such as a different device or surgery, could be explored if Lee continued to have problems. Dr. Roman performed a sleep study in July 2001. The results showed “no clinically significant snoring or sleep 9 related disturbance, abnormal decreased architecture with severely decreased sleep efficiency ....” It also stated that “if the clinical suspicion for obstructive sleep apnea remains high, ...[Lee should] return to the sleep center for a repeat polysomnogram after correcting the difficulty initiating and maintaining sleep.” None of Dr. Roman’s or Dr. Chagin’s treatment notes indicate any restriction on Lee’s ability to work. However, Dr. Roman wrote a letter dated November 2, 2001 in which he opined: Ms. Tracey Lee has been disabled as defined by her employer’s guidelines since August 1999 when she left work to the present. She has been unable and is still unable to perform the substantial and material duties of her regular occupation as a clerk. Furthermore, I am pessimistic that there will be dramatic improvement in the near future. Nonetheless we will continue to work with Ms. Lee and her other healthcare providers towards improving her overall condition. On October 30, 2001, Dr. Gendron telephoned Dr. Salomone to discuss the October 9, 2000 sleep study. The substance of the conversation was confirmed in a letter of the same date written by Dr. Gendron and signed and returned by Dr. Salomone. Dr. Salomone confirmed the results of the sleep study that Lee had “moderately severe obstructive sleep apnea” that was controlled with a CPAP. He stated he did not believe based on the study that Lee was precluded from engaging in a sedentary occupation, such as Lee’s job as customer satisfaction specialist. Dr. Salomone stated the only restriction he would impose would be that Lee not perform shift work, work around dangerous or heavy equipment, or be employed as a bus or truck driver. Dr. Gendron attempted to contact Dr. Chagin to obtain information regarding his letter to Lee’s former counsel and the statement in the June 22, 2000 letter following their 10 conversation in which he opined that Lee could return to work after October 5, 1999. Dr. Chagin, however, did not respond. Dr. Gendron submitted additional Memoranda of his review of the medical evidence on November 1, 2001 and December 27, 2001, in which he essentially concluded that Lee was not disabled. He noted that the data from Dr. Roman comes nearly two years following Lee’s disability onset of August 1999 and in his opinion was not supportive of a finding of disability as of August 1999. On February 20, 2002, CSI informed Lee of its decision to uphold the denial of benefits. Five days later, Lee filed the instant action, claiming a wrongful denial of benefits and a breach of fiduciary duty under ERISA.
At a case management conference on July 15, 2002, Lee claimed to have new evidence supporting her claim for LTD benefits as of August 1999. The district court ordered Lee to submit the evidence to CSI for review and a final decision. Lee submitted the following additional information: treatment notes from Dr. Deborah Reed, a neurologist; a letter dated August 14, 2002 from Adele Webb; and a letter dated August 19, 2002 from Dr. Roman. Lee claimed to be disabled since August of 1999 based on newly discovered evidence of a brain lesion. Most of Dr. Reed’s studies were normal or unremarkable. However, a May 14, 2002 MRI of the brain noted a “single high signal intensity lesion within the anterior aspect of the basal ganglia measuring 5 mm.” The radiologist indicated that the lesion was “non specific and may be related to ischemia or demyelination.” Dr. Reed diagnosed, among other things, sleep apnea and memory 11 problems. Webb, a registered nurse specializing in AIDS care, submitted a letter which indicated she reviewed Lee’s file (it does not appear that she saw Lee) and opined: Based on the appearance and exacerbation of symptoms since 1988 and the failure of conventional therapies to alleviate Ms. Lee’s health concerns, it is probable that this brain lesion occurred on or around April 1998, the date of the onset of her symptoms. Dr. Reed’s August 19, 2002 letter stated that he had recently reviewed Lee’s old medical records and opined that Lee’s “brain lesion probably existed in 1998 and contributed to her ongoing problems.” He stated that Lee continued “to have cognitive dysfunction with decreased attention span, poor concentration and excessive daytime sleepiness.” Based on this information, CSI requested a review of Lee’s file by Dr. David Webster, an independent medical expert who is board certified in psychiatry and neurology. On October 7, 2002, Dr. Webster submitted a report in which he stated that he agreed with Dr. Reed’s diagnosis of pseudodementia, but did not agree with the radiologist’s assessment of the brain lesion as being ischemic or demyelinating based on its location, noting that such lesions are not uncommon in smokers or those with hypertension, such as Lee. He also opined, contrary to Webb and Dr. Roman, that it was “physiologically impossible” for the lesion to be responsible for her sleep symptoms because lesions in the basal ganglia are not involved in sleep disorders or cognitive disorders. He also disputed the assertion that all of her symptoms appeared in 1998, as Webb suggested. Dr. Webster further stated that it was impossible to determine when the 12 lesion occurred. He also stated that there was no medical evidence to suggest that Lee was sufficiently impaired from performing her occupation as of August 1999. On October 15, 2002, CSI determined that Lee was not entitled to LTD benefits as of August 1999 and therefore again denied her claim.
A second status conference was held on October 30, 2002, where the district court permitted Lee to depose Dr. Chagin and Dr. Gendron. The case was later transferred to the docket of another district judge. Lee filed a motion for a bench trial on her claim for benefits and a jury trial on her claim for breach of fiduciary duty. MBNA and D&H, together with Security Life, filed separate motions to dismiss and for entry of judgment on the administrative record. D&H and Security Life filed a motion to strike Lee’s references in her briefs to materials outside the administrative record, including the depositions of Drs. Chagin and Adams, certain items “taken from the Internet,” and references to the facts of a reported case. The district court granted in part and denied in part the motion, noting that the deposition of the doctors were permitted by the district court to establish Lee’s argument regarding a conflict of interest. Faced with the voluminous filings, on June 12, 2003, the district court ordered that no further motions would be entertained without leave of court. On June 16, 2003, Lee moved to file a favorable decision from the Social Security Administration (“SSA”) issued on June 7, 2003. The district court denied the motion on the grounds that it was 13 not part of the administrative record. Lee moved for reconsideration, which was also denied. On December 30, 2003, the district court issued an opinion denying Lee’s motion for a bench trial and a jury trial and granting defendants’ motions for entry of judgment on the administrative record. The district court found that Lee’s ERISA claim for breach of fiduciary duty failed as a matter of law, that she had not pled a state-law claim for breach of fiduciary duty, that the arbitrary and capricious standard of review applied, there was no conflict of interest, and CSI did not act arbitrarily or capriciously in denying her LTD claim. Lee appeals from the district court’s December 30, 2003 order as well as its order denying her motion to file her favorable SSA decision.