Opinion ID: 783621
Heading Depth: 2
Heading Rank: 3

Heading: Ability of Dr. Lasser to Perform the Material Duties of His Regular Occupation

Text: 27 We next determine whether Dr. Lasser's medical condition precludes him from safely performing material duties of his regular occupation. He argues that he cannot safely perform emergency surgery or perform on-call duties. To fulfill our appellate review function under the arbitrary and capricious standard, we examine the entire record to determine whether Reliance's determination is supported by substantial evidence. Pinto, 214 F.3d at 387. 28 Reliance's primary motivation for discontinuing Dr. Lasser's benefits in December 1997 appears have been a report issued by Dr. Burke. He examined Dr. Lasser, subjected him to a treadmill test in November 1997, and concluded that Dr. Lasser does not demonstrate any cardiovascular disability. 7 During an earlier treadmill test performed by Dr. Steven Roth in April 1997, Dr. Lasser achieved greater than 90% of age-predicted maximum [heart rate] and experienced only mild fatigue [after] 14 minutes. A nuclear cardiologist, Dr. Christos Christou, noted that planar imaging of Dr. Lasser's heart conducted during the cardiovascular testing revealed only a very small and probably clinically insignificant heart defect. 29 Furthermore, Reliance notes that Dr. Lasser's physician, Dr. Aldrich, considered Lasser to be in New York Heart Association Functional Class II (Patients with cardiac disease with slight limitation of physical activity. They are comfortable with mild exertion but experience symptoms with the more strenuous grades of ordinary activity.) and Therapeutic Class C (Patients with cardiac disease whose ordinary physical activity should be moderately restricted and whose more strenuous efforts should be discontinued.) — classifications that do not suggest significant limitations on Dr. Lasser's ability to work as an orthopedic surgeon. 8 30 Dr. Lasser, however, contends that Reliance's conclusion is unsupported by substantial evidence. He notes that, after appealing the discontinuation of his benefits, Reliance engaged two other physicians to evaluate him, both of whom issued reports supporting his position. The first, Dr. Raska, concluded that Dr. Lasser should avoid stressful situations — i.e., those that require night call [and] medical emergencies, and that [a] reduced stress work environment and schedule is absolutely necessary to maintain this patient's health. Dr. Raska reasoned that [s]tress regardless of exercise tolerance is a recognized independent risk factor for recurrent coronary artery disease ... [and that] there are multiple studies ... which demonstrate that stress causes flux in the level of catecholamines in the circulation which have been shown to be a precipitant of acute myocardial infarction and sudden death. In Dr. Raska's opinion, Lasser's unsuccessful vein graft made stress reduction especially important, as increased stress could bring about even earlier failure of the graft. In this context, he opined that Dr. Lasser's disability benefits should not have been revoked because he cannot safely perform the material duties of an orthopedic surgeon. 9 31 After receiving this report, however, Reliance realized that Dr. Raska had a conflict of interest: he practiced in the same physician group as a doctor from whom Dr. Lasser previously sought an evaluation, Dr. Lubow (whose evaluation is discussed below). In response, Reliance engaged Dr. Field as another evaluating physician. While Dr. Field noted that [t]here is little definitive evidence that emotional or job stress is causally related to the development or acceleration of coronary artery disease, he did acknowledge that both physical and emotional stress are identified triggers of acute myocardial infarction [heart attack]. He concluded that Dr. Lasser could work a forty-hour week, but is not capable of resuming all of the customary duties and responsibilities of an orthopedic surgeon. In particular, Dr. Field opined that Lasser should restrict his on-call or emergency surgery duties, given their stressful nature. 32 Dr. Lasser also relies on the evaluation of his treating cardiologist, Dr. Aldrich, as well those of Drs. Barry Lowell and Lawrence Lubow, who all opined that he is disabled. First, Lasser argues that the evaluation issued by Dr. Aldrich suggests that he is incapable of working in his regular occupation. When Reliance asked Dr. Aldrich to complete a form detailing Dr. Lasser's current restrictions and limitations, he responded that Lasser should limit exposure to physical and emotional stress. He noted also that [s]tress is a well-documented risk factor not only for the development of coronary artery disease itself, but within that context, to the precipitation of a myocardial infarction. As a result, in a letter to Reliance dated June 3, 1998, Dr. Aldrich expressed to Reliance that he believed Dr. Lasser is disabled and incapable of resuming all of the customary duties and responsibilities of an orthopedic surgeon on a full-time basis[,] or at least that he could not do so without exposing himself to a high degree of risk. Dr. Aldrich's reasoning underlying this conclusion was that, even though by all objective criteria Dr. Lasser is doing very well at this point in time, work-related stress might induce a deterioration in Dr. Lasser's condition. Moreover, according to Dr. Aldrich's reasoning, a favorable classification under the New York Heart Association guidelines is of limited use in Dr. Lasser's situation, as that classification system addresses a cardiac patient's ability to perform certain physical tasks without regard to stress. 33 Dr. Lowell, who performed a cardiac catheterization on Dr. Lasser, also opined that Lasser was disabled. He agreed with Dr. Burke that Lasser's functional stress test at the present time is excellent, but cautioned that the stress of his profession will contribute to poorer control of blood pressure and lipid therapies and that a less stressful environment would contribute to his graft longevity. Dr. Lowell concluded that the severity of Dr. Lasser's heart condition, while not readily measured by traditional testing methods, renders him just as disabled as the patient whose disability would not be questioned because he presents with more overt symptoms. 10 34 Finally, Dr. Lubow, a physician who examined Dr. Lasser at the request of Lasser's counsel, reached a conclusion similar to that of Drs. Aldrich, Raska, and Lowell. He opined that, [b]ased on the recurrence of significant arteriosclerotic heart disease manifest[ed] by an acute infarction plus the need for urgent angioplasty and stenting after a ten year hiatus when he had no symptoms, the decision to grant this patient permanent partial disability was certainly correct, particularly in view of his anatomy. 11 35 Thus, all evaluating physicians — with the exception of Dr. Burke, whose report the others discredited — agreed that Dr. Lasser's heart condition precludes him from safely performing on-call duties and emergency surgery. Reliance's conclusion to the contrary thus is arbitrary and capricious. To the extent that Reliance's determination of nondisability was that it was unreasonable ... to expect Reliance ... to simply accept the opinion [that stress would exacerbate Dr. Lasser's condition] without any range of the probability or actual proof that Dr. Lasser was at increased harm, we believe its determination was faulty.
36 We conclude with a clarification regarding the burden of proof in disability cases. While the burden of proving disability ultimately lies with Dr. Lasser, to require him to provide statistics detailing the harm that working in his regular occupation might precipitate — as the dissent would require — raises the bar too high. 12 Most disability claimants will not have the means at their disposal (financial or otherwise) to obtain this kind of evidence. Therefore, once a claimant makes a prima facie showing of disability through physicians' reports (as Dr. Lasser has done here through physicians' reports stating that stress will exacerbate his heart condition) and if the insurer wishes to call into question the scientific basis of those reports (as Reliance has attempted to do here), then the burden will lie with the insurer to support the basis of its objection. It has not met that burden here. 37