Opinion ID: 148924
Heading Depth: 3
Heading Rank: 2

Heading: Reliance on surveillance evidence

Text: Rizzi also contends Hartford’s “surreptitious surveillance is [not] of any value 21 Unpublished opinions are not binding precedent. 10th Cir. R. 32.1(A). We mention Loughray and other unpublished cases as we would any other non-binding source, persuasive because of its reasoned analysis. - 22 - when it fails to demonstrate any ability to perform work activity on a continuous basis.” (Appellant’s Opening Br. at 38.) She cites three cases to support this argument: Morgan v. Unum Life Ins. Co. of Am., 346 F.3d 1173, 1178 (8th Cir. 2003); Osbun v. Auburn Foundry, Inc., 293 F.Supp.2d 863, 871 (N.D. Ind. 2003); and Holoubek v. Unum Life Ins. Co. of Am., 2006 WL 2434991 at -3 (W.D. Wis. Aug. 22, 2006). None of these cases offer the support Rizzi seeks. In each case, the plan administrators violated the terms of their plan or disregarded medical evidence and relied solely on surveillance evidence to support the denial of benefits. In Morgan, the plan administrator initially paid long-term benefits based in large part on cognitive disabilities supported by medical evidence. The administrator ultimately terminated benefits after an in-house physician observed surveillance evidence showing the claimant exercising and engaging in routine daily activities. However, the administrator had known he engaged in these activities when approving his initial claim. 346 F.3d at 1177-78. The Eighth Circuit said the surveillance evidence “revealed nothing new and was not substantial evidence supporting UNUM’s decision to discontinue Morgan’s disability benefit.” Id. at 1178. Furthermore, the opinion of the plan administrator’s doctor, which was based on the surveillance evidence, “was at best tangentially relevant to Morgan’s circumstance of being disabled by the cognitive deficits” he suffered due to his medical condition. Id. at 1178 (emphasis added). In Osbun, the court rejected the administrator’s “decision to terminate benefits . . . with no supporting medical evidence.” 293 F.Supp.2d at 870 (emphasis added). More specifically, the denial of benefits concluded - 23 - a mentally retarded, illiterate, partially blind, partially deaf, arthritic man with arteriosclerotic heart disease, thyroid insufficiency, and high blood pressure is capable of gainful employment, simply because he performed 1.5 hours of light physical tasks over the course of two days, and in spite of three medical reports finding total disability. This conclusion is downright unreasonable. Id. at 871 (quotations omitted). The third case, Holoubek, involved a termination of benefits after surveillance observed the claimant “engaged in numerous activities which were inconsistent with his reported activity level and limitations.” 2006 WL 2434991 at . On review, the court acknowledged the surveillance created disparities between the record and the claimant’s reported abilities. However, it ultimately rejected the administrator’s denial of benefits on narrow grounds -- the record did not include any specific finding that the claimant “could perform the material and substantial duties of his occupation” as required under the terms of the plan. Id. at  (emphasis added). Rizzi alleges the surveillance showing her ability to manage some daily tasks does not demonstrate she can manage a full-time job. She argues “there is no requirement on the disabled to become inert in order to avoid having their disability benefits denied,” quoting Crespo v. Unum Life Ins. Co. of Am., 294 F.Supp.2d 980, 996 (N.D. Ill. 2003). While this is true, Hartford relied on more than surveillance evidence in denying Rizzi’s claim; it also considered Rizzi’s subjective complaints of pain, medical opinions of Drs. Dibble and Siegel (who spoke with Dr. Dvorak on multiple occasions), and the results of objective medical tests in her file. For example, Dr. Siegel acknowledged in writing that “the videotape surveillance does not tell the entire story . . . .” (Appellant’s App. Vol. III - 24 - Rizzi Rec. at 242.) He noted Rizzi exhibits “no indication . . . of diffuse muscle atrophy or wasting, shiny or atrophic skin, allodynia, problems with her skin and nails, abnormal temperature or color changes in her right upper extremity, or marked pain behavior such that she is unable to do gripping, grasping, or using her right upper extremity.” (Id. at 239.) This corresponded with Dr. Dibble’s observation that there was “no evidence of any muscular atrophy, reflex impairment, impaired range of motion of her joints, or peripheral circulation . . . .” (Id. at 329.) In rejecting Rizzi’s request for reconsideration, Hartford “considered the reported symptoms and to what extent the findings on physical examination and testing results confirm the symptoms.” (Appellant’s App., Vol. II Rizzi Rec. at 222.) Of course Hartford gave some weight to the surveillance evidence. But it “also considered Ms. Rizzi’s self-reported and observed activities of daily living which provide[d] a picture of function in spite of any medical condition(s) . . . . [and also considered] the physical demands of her occupational work activity . . .” (Id. at 222-23.) As discussed above, it also considered the medical opinions of Drs. Dvorack, Dibble and Siegel. Reliance on surveillance evidence in conjunction with medical evidence is not improper. Rizzi identifies no case law and we have found none which holds the denial of a disability claim based on surveillance evidence in conjunction with objective medical evidence or opinions of independent physicians is unreasonable or an abuse of discretion. C. Disregard of Rizzi’s subjective complaints of pain Rizzi also alleges Hartford failed to give proper consideration to her subjective reports of pain. She compares her diagnosis of occipital neuralgia to cases involving - 25 - fibromyalgia for which the claimant’s subjective, uncorroborated complaints of pain constitute the only evidence of the ailment’s severity. See Welch v. Unum Life Ins. Co. of Am., 382 F.3d 1078, 1087 (10th Cir. 2004) (noting “fibromyalgia presents a conundrum for insurers and courts evaluating disability claims” because, among other things, no objective test exists to identify the disease) (quotations omitted). In such cases, a plan administrator’s medical inquiry naturally involves questions regarding the claimant’s credibility. See Jordan v. Northrop Grumman Corp. Welfare Benefit Plan, 370 F.3d 869, 878 (9th Cir. 2004) (“[T]he patient’s pain reports for their diagnoses . . . cannot be unchallengeable. That would shift the discretion from the administrator, as the plan requires, to the physicians chosen by the applicant, who depend for their diagnoses on the applicant’s reports to them of pain.”) overruled on other grounds by, Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 969 (9th Cir. 2006) (en banc). In considering Rizzi’s complaints of disabling pain, the lack of any tangible evidence of it is important. Objective medical testing revealed no cause for her condition or confirmation of her limitations. Her own treating physicians indicated Rizzi should be functioning at a higher level. Dr. Isaacs predicted a nearly pain-free existence following Rizzi’s subjective reports of reduced pain after radio frequency neurotomy treatments. Dr. Dvorak confirmed to Drs. Dibble and Siegel he saw no physical symptoms of decreased function in Rizzi. And no other treating physicians documented any physical symptoms (like muscle atrophy, hair loss or nail discoloration) associated with an inability to mobilize or use her extremities. Hartford then looked to the surveillance evidence in an attempt to corroborate - 26 - Rizzi’s complaints. But surveillance showed Rizzi functioning with no visible signs of disabling pain. We find it noteworthy the surveillance occurred for two days in February and two days in March. Her capability of performing significant activity without indication of pain on separate occasions decreases the likelihood of coincidence. Given the opportunity to respond to this evidence, Rizzi provided no tangible support of her claim -- no neurological study, no additional tests, and no supporting documentation of witnesses to her physical limitations. A plan administrator need not ignore reliable medical evidence in deference to subjective reports; nor is it unreasonable to expect some supporting evidence to buttress a claim of disability. See Holcomb, 578 F.3d 1194 (no abuse of discretion when independent medical evidence indicated claimant “was fit for multiple gainful occupations that reasonably matched her education, training, and experience”); Meraou v. Williams Co. Long Term Disability Plan, 221 Fed. App. 696, 706 (10th Cir. 2007) (unpublished) (rejecting wholly subjective complaints of pain without further medical evidence in concluding denial of ERISA benefits was not unreasonable); Frizzell v. Shalala, 37 F.3d 1509, 1994 WL 562026 at  (10th Cir. Oct. 13, 1994) (unpublished) (where none of claimant’s doctors stated her fibromyalgia was disabling, the denial of ERISA benefits was not unreasonable). Hartford’s consideration of the surveillance evidence was not unreasonable. 1. Failure to consider anxiety and depression as a separate cause of disability Rizzi argues Hartford failed in its duty to consider the possibility that anxiety and depression made her unable to work. For support, she cites Gaither v. Aetna Life Ins. Co., 394 F.3d 792 (10th Cir. 2004). In Gaither we noted a plan administrator “cannot - 27 - shut their eyes to readily available information when the evidence in the record suggests the information might confirm the beneficiary’s theory of entitlement and when [the administrator has] little or no evidence in the record to refute that theory.” Id. at 807 (emphasis added). An administrator may have a duty to independently request more information from the claimant if the “information is needed to make a reasoned decision . . . .” Id. (quoting Gilbertson v. Allied Signal, Inc., 328 F. 3d 625, 635 (10th Cir. 2003)). However, it has no duty to “pore over the record for possible bases for disability that the claimant has not explicitly argued, or consider whether further inquiry might unearth additional evidence when the evidence in the record is sufficient to resolve the claim one way or the other.” Id. While Rizzi’s theory of entitlement is not limited solely to her initial application for benefits, it provides the clearest statement of her alleged qualification for disability payments. Specifically, she was “unable to perform [her] job duties due to extreme pain [and] discomfort. Extreme pain and not being able to use [her] right extremities properly.” (Appellant’s App., Vol. IV Rizzi Rec. at 518.) She later explains her diagnosis is myofascial pain syndrome. Her six-page log of symptoms, doctor appointments, and other information did not suggest depression, anxiety, or any other psychological condition made her unable to work. One sentence in her log mentioned depression; it said “Dr. Quan felt I was very depressed because of my disability and prescribed [medication].” (Id. at 529 (emphasis added).) Depression was not raised by Rizzi until her administrative appeal, when she said she “became and continue[s] to be disabled because of . . . anxiety and depression . . . .” - 28 - (Appellant’s App. Vol. III Rizzi Rec. at 271.) Rizzi argues Dr. Dvorak repeatedly noted she was depressed and Hartford should have investigated it further. Dr. Dvorak noted Rizzi was “just very frustrated that she is no[t] able to get back to work” (id. at 403 (March 2006)); she “remains extremely frustrated with this ongoing pain and the inability to get a firm diagnosis and to get better” (id. at 314) (May 2006)); and she “continue[s] to have a significant amount of depression” and needs to have her Cymbalta prescription increased “for pain modification . . . [and] depression” (id. at 265 (July 2006)). The most extensive treatment notes from Dr. Dvorak relating to depression are from August 2006 where he indicated anxiety and depression were secondary diagnoses to her pain issues. He explained Rizzi was having “significant psychological overlay . . . because of the ongoing pain” and was distraught because insurance no longer covered particular medications. (Id. at 258.) In October 2006, Dr. Dvorak’s notes indicate Rizzi was no longer taking Cymbalta because she “felt more depressed on it.” (Id. at 256.) At no time did Dr. Dvorak’s notes reflect that her depression was debilitating or a separate issue worthy of consideration. Rizzi also contends her April 25, 2006, statement of abilities written with the investigator identifies symptoms of depression which Hartford ignored. The statement says she cannot concentrate and has headaches, fatigue, and insomnia. More specifically, Rizzi states she is “not able to concentrate because of the pain and headaches” and is “not able to sleep well because of the pain . . . [and] feel[s] fatigued during the day.” (Appellant’s App. Vol. III Rizzi Rec. at 377 (emphasis added).) No one disputes Rizzi was depressed because of her issues with pain. But the - 29 - statements noting this fact in the record are equally as important for what they do not say— that she could not work because of her depression. At one point, Dr. Quan said Rizzi’s psychiatric state is “[e]ssentially good functioning in all areas. Occupationally and socially effective.” (Appellant’s App. Vol. IV Rizzi Rec. at 522.) Dr. Dvorak repeatedly and explicitly identified anxiety or depression as a secondary diagnosis caused by her financial instability and pain. Even the statements in the April 25 report do not indicate Rizzi was unable to work because of these issues or that they were worthy of investigation. Our focus in Gaither limited the administrator’s duty to investigate to the issues identified in “the claim” or “the beneficiary’s theory of entitlement.” Gaither, 394 F.3d at 807. Hartford is not expected to conceive, consider, and investigate every possible theory of entitlement for Rizzi; it must only examine the theory (or theories) she asserts. Because Rizzi never claimed her anxiety or depression made her unable to function within her job separate from the primary diagnosis of pain, Hartford did not abuse its discretion in failing to create that theory for her. 2. Alleged Regulatory Violations Finally, Rizzi alleges Hartford’s bias is demonstrated by its violations of ERISA regulations. Specifically, she alleges violations of 29 CFR § 2560.503-1(h)(2)(ii)-(iv) (opportunity to comment and disclosure of documents)22 and 29 C.F.R. § 2650.50322 29 CFR § 2560.503-1(h)(2)(ii)-(iv) requires the administrator to: (ii) Provide claimants the opportunity to submit written comments, documents, records, and other information relating to the claim for benefits; - 30 - 1(g)(i)-(ii) (requiring administrator provide a claimant with the specific reasons for the denial of benefits and the specific plan provisions upon which the denial was based).23 These arguments are without merit. First, Hartford clearly identified the specific (iii) Provide that a claimant shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant’s claim for benefits. Whether a document, record, or other information is relevant to a claim for benefits shall be determined by reference to paragraph (m)(8) of this section; [and] (iv) Provide for a review that takes into account all comments, documents, records, and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. “Documents” as used in subsection(h)(2)(iii) is later defined to include documents “relied upon in making the benefit determination; [or] . . . submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination.” 29 CFR § 2560.503-1(m)(8)(i)-(ii). 23 Rizzi also alleges Hartford violated 29 CFR § 2560.503-1(f)(3) which says in relevant part: “In the case of a claim for disability benefits, the plan administrator shall notify the claimant . . . of the plan’s adverse benefit determination within a reasonable period of time, but not later than 45 days after receipt of the claim . . . .” Rizzi argues the December 11, 2005, letter stating Hartford would respond to the appeal within 45 days was an improper extension of time under the regulations. We do not consider this issue. The record reveals no evidence this objection was raised by Rizzi upon receipt of the letter. Thus, she waived the issue by not allowing Hartford the opportunity to correct any error it may have made. In any event, the regulation allows the 45-day period to be extended for 30 days if the administrator (1) “determines that such an extension is necessary due to matters beyond the control of the plan;” and (2) “notifies the claimant, prior to the expiration of the initial 45-day period, of the circumstances requiring the extension of time and the date by which the plan expects to render a decision.” 29 CFR § 2560.503-1(f)(3). Arguably, both criteria were satisfied when Hartford communicated with Rizzi’s attorney about what it believed were missing records (including the neurological study and nerve conduction study) and later announced the date by which its review would be completed. Furthermore, extending the time to allow submission of additional medical records actually benefited Rizzi by enlarging the administrative record. - 31 - reasons it denied Rizzi’s claim and the specific plan provisions involved. The original determination letter quoted the Plan’s definition of disabled and cited numerous documents in her file as the bases for its decision she no longer qualified under that definition.24 Hartford then discussed her complaints of pain and disability and “the medical, investigative, and vocational information on file” before concluding “the information . . . shows a level of function that would be consistent with your ability to return to [work]” and “the medical information on file does not show any evidence warranting any physical limitations.” (Appellant’s App. Vol. II Rizzi Rec. at 136.) Second, Rizzi was given full opportunity to supplement the record during her administrative appeal. Hartford specifically requested the neurological and nerve examinations referenced by Dr. Dvorak but not included in Rizzi’s submissions. Rizzi’s attorney assured Hartford it had all information for the administrative appeal. Finally, the administrative appeal decision letter again identified the definition of disabled and discussed all information in the medical file, including Rizzi’s subjective complaints. While Rizzi claims Hartford failed to provide her the resumes of Drs. Dibble and Siegel, she does not explain how this information would qualify for mandatory disclosure under the relevant regulations.25 In short, we detect no regulatory violation. 24 Documents cited included Quan’s “Attending Physician Statement,” a “telephonic interview with [Rizzi], Rizzi’s “Continuation of Disability Statement taken . . . on 4/25/06” (the statement she created with the investigator), “Medical records from Dr. Richard Dvorak . . . through 3/16/06,” and a “Fax communication from Dr. Dvorak dated 5/17/06.” (Appellant’s App., Vol. II Rizzi Rec. at 133-34.) 25 Indeed, when asked for Dr. Siegel’s curriculum vitae, Hartford informed Rizzi’s attorney it “do[es] not have that information and you need to contact [UDC] directly.” - 32 - Rizzi argues she was denied her right to reply to Dr. Siegel’s record review on appeal. In Metzger v. Unum Life Ins. Co. of Am., we held: [The regulations do] not require a plan administrator to provide a claimant with access to the medical opinion reports of appeal-level reviewers prior to a final decision on appeal. Instead, the regulations mandate provision of relevant documents, including medical opinion reports, at two discrete stages of the administrative process. First, relevant documents generated or relied upon during the initial claims determination must be disclosed prior to or at the outset of an administrative appeal. Second, relevant documents generated during the administrative appeal-along with the claimant’s file from the initial determination-must be disclosed after a final decision on appeal. So long as appeal-level reports analyze evidence already known to the claimant and contain no new factual information or novel diagnoses, this two-phase disclosure is consistent with full and fair review. 476 F.3d 1161, 1167 (10th Cir. 2007) (quotations and citations omitted) (emphasis added); see also Sage v. Automation, Inc. Pension Plan & Trust, 845 F.2d 885, 893-94 (10th Cir. 1988) (holding a “full and fair review” under ERISA requires “knowing what evidence the decision-maker relied upon, having an opportunity to address the accuracy and reliability of the evidence, and having the decision-maker consider the evidence presented by both parties prior to reaching and rendering his decision”) (quotations omitted). Rizzi acknowledges Metzger but claims Dr. Siegel’s recommendation was not identical to Dr. Dibble’s and, thus, is new factual information to which she should be allowed to respond. Here, Rizzi knew all the facts considered by Hartford and Dr. Siegel. To that end, she had the opportunity to provide additional information to support her claim when she submitted her appeal and her claim rests on the information she then (Appellant’s App., Vol. II Rizzi Rec. at 194.) - 33 - submitted. “Permitting a claimant to receive and rebut medical opinion reports generated in the course of an administrative appeal . . . would set up an unnecessary cycle of submission, review, re-submission, and re-review.” Metzger, 476 F.3d at 1166.