Opinion ID: 173275
Heading Depth: 2
Heading Rank: 1

Heading: The Long-Term Disability Benefits Plan

Text: Loughray worked as a salesperson for Ultimate Electronics, beginning in September 1992. She worked five days per week, eight or nine hours per day, and she was paid based on sales commissions. As a salesperson, her job duties included interacting with customers, demonstrating products, and operating credit card processors, cash registers, and other store equipment. Her job also involved frequent standing and walking. 2 During her employment at Ultimate Electronics, Loughray was covered by the Ultimate Electronics Group Disability Plan (“the Plan”). Both parties agree that Hartford both administered and insured the Plan.1 Under the Plan, a disabled employee under age 61, such as Loughray, would receive long-term disability benefits for as long as she was disabled, up until she reached age 65. The Plan defines disability as follows: Disability means that during the Elimination Period [90 days after an eligible employee becomes disabled] and the following 24 months, Injury or Sickness causes physical or mental impairment to such a degree of severity that You are: 1. continuously unable to perform the Material and Substantial Duties of Your Regular Occupation; and 2. not working for wages in any occupation for which You are or become qualified by education, training or experience. After the Monthly Benefit has been payable for 24 months, “Disability” means that Injury or Sickness causes physical or mental impairment to such a degree of severity that You are: 1. continuously unable to engage in any occupation for which You are or become qualified by education, training or experience; and 2. not working for wages in any occupation for which You are or become qualified by education, training or experience. (Aple. Supp. App. at 10-11.) Loughray claims she falls within this definition of disabled and is entitled to receive long-term disability benefits under the terms of the Plan. 1 At the time Loughray’s disability claim first arose, Continental Casualty Company, also referred to as CNA or CNA Group Benefits, insured and administered the plan. On January 1, 2004, however, Hartford “acquired CNA Group Benefits” (Aplt. App. at 3), and Loughray accordingly named Hartford in her suit. For purposes of convenience, we will refer to Hartford as if it had always insured and administered the plan. 3 B. Loughray’s Initial Health Problems and Approval for Disability Benefits On April 20, 2000, Loughray stopped working at Ultimate Electronics because of health problems. For several years, Loughray had been treated for a thyroid condition; however, her endocrinologist had altered her dosage of thyroid medication, which caused her to have low levels of thyroid stimulating hormone. Consequently, on April 20, Loughray went the hospital suffering from a thyroid dysfunction, which caused her to feel tired, feverish, shaky, anxious, nervous, weak, and confused, as well as to have concentration problems and suicidal thoughts. The hospital instructed her to resume her original dosage of thyroid medication and released her the same day. After her release, Loughray continued to suffer from headaches, loss of consciousness and other ailments. On April 26, Loughray’s thyroid stimulating hormone levels remained low, but by May 15, Dr. Zacharias, Loughray’s original primary care physician, indicated that her thyroid condition was “much better (but persists).” (Aple. Supp. App. at 748.) And on May 30, blood tests indicated that Loughray’s thyroid stimulating levels had stabilized. Nonetheless, Loughray’s subjective symptoms persisted and she would undergo several examinations before filing her first claim for long-term disability benefits with Hartford. In June 2000, Loughray underwent a Magnetic Resonance Imaging (MRI) and a Magnetic Resonance Angiogram (MRA) (to rule out a brain aneurysm), as well as a lumbar puncture (to rule out meningitis). All three tests produced normal results. Later in June, Loughray obtained a neurological consult from Dr. H. Rai Kakkar. Dr. Kakkar found no “neurological/musculoskeletal” problems, (Aple. Supp. App. at 787) but he 4 prescribed her Depakote for her headaches and gave her samples of Celebrex for her pain. Dr. Kakkar also indicated that Loughray suffered for the past two months from a headache and fever “of undetermined etiology” and was not “able to perform work of any kind.” (Id. at 773.) On the same day she visited Dr. Kakkar, Loughray was also examined by an endocrinologist, Dr. Thomas Higgins, who found that her thyroid was functioning normally and that her current symptoms were not related to her thyroid. After these examinations, Loughray twice contacted her primary care physician, Dr. Zacharias, informing him that she felt better overall, but still had a headache, though the Depakote was ameliorating the headaches to some degree. Soon after these examinations, on July 15, 2000, Loughray applied with Hartford for long-term disability benefits under the Plan. She submitted reports from her examinations in support of her claim. Loughray would later supplement this information with reports from a new primary care physician, Dr. Pierre Brunschwig, who she began to see in place of Dr. Zacharias. Loughray began to see Dr. Brunschwig around the same time she applied for longterm disability benefits. To Dr. Brunschwig, she reiterated her previous complaints of fatigue, headaches, intermittent fever, nausea, and high blood pressure. Additionally, she discussed not only her previous thyroid problems with Dr. Brunschwig, but also revealed to him, apparently for the first time with any doctor, that she had fallen in 1999, hit her head, and lost consciousness. After Dr. Brunschwig examined Loughray a few times, he and a nurse practitioner, Carol Dalton, authored a letter to Hartford indicating that Loughray had “been diagnosed with Fibromyalgia, Chronic Fatigue Syndrome and 5 uncontrollable fluctuating thyroid function resulting in hyperthyroidism alternating with hypothyroidism.” (Aple. Supp. App. at 511.) The letter further explained that “[w]ith any activity, such as walking for one or two blocks, Loughray develops a fever, vertigo, blurred vision, severe nausea, and hypertension” and is therefore “currently unable to work without increasing her symptoms.” (Id.) After Hartford requested clarification, Dr. Brunschwig’s office clarified that Loughray’s thyroid condition was in fact the cause of her disability and that her chronic fatigue and fibromyalgia were symptoms of the thyroid condition. In September 2000, upon receiving this clarification, Hartford readily approved Loughray’s application for long-term-disability benefits. Hartford deemed Loughray to have been disabled since April 20, 2000, when Loughray first went to the hospital complaining of her symptoms. Because the Plan provided for a 90-day elimination period, Hartford retroactively paid Loughray’s benefits starting from July 19, 2000, ninety days after the onset of Loughray’s disability. Hartford also informed Loughray that the Plan “requires that you be under the regular care of a licensed physician and provide proof of your continuing disability,” and that a Hartford case manager would be “periodically contacting your doctor direct[ly] for more detailed updated reports regarding your functionality and ability to return to work.” (Aple. Supp. App. at 728.) Loughray received long-term disability benefits until January 2002, at which point Hartford terminated her benefits after engaging an independent medical examiner. During the approximately 18-month period during which Loughray received disability benefits, Hartford indeed checked on her progress. The administrative record 6 indicates that, after seeing Dr. Brunschwig in mid-August 2000 and being approved for long-term disability benefits in September 2000, Loughray did not return to Dr. Brunschwig, or any other doctors, until late March 2001.2 Nonetheless, when Hartford requested updates, Dr. Brunschwig’s office continued to respond that Loughray remained disabled. After Loughray made an unsuccessful attempt to return to work part-time, Dr. Brunschwig, on January 15, 2001, recommended that Loughray could work a maximum of ten hours per week, with a goal of returning to work full-time by June 2001. By April 2001, however, Loughray reported to Hartford that she had suffered a setback in her efforts to return to work. Ultimate Electronics would eventually terminate her a few months later on June 8, 2001. After apparently not having seen any doctors for eight months, Loughray underwent a flurry of medical tests and examinations beginning in late March and early April 2001. She visited Dr. Brunschwig twice, complaining of extreme fatigue, loss of appetite, and sleep problems. She reported that her headaches had generally decreased slightly, but that they worsened with exertion. Blood tests revealed that Loughray had been exposed to or was suffering from bacterial and viral infections. On April 5, 2001, Dr. Brunschwig and Nurse Dalton together wrote Hartford that Loughray “continues to be plagued with her thyroid problem” and that, as a result of her weakened immune system, “she has contracted 3 infections that will require treatment for 2 to 3 more months.” (Aple. Supp. App. at 702.) 2 The record does contain a document indicating that Loughray went to Boulder Internal Medicine, P.C., as a new patient for a consultation regarding her thyroid condition, but the record contains no other information about this visit. 7 In light of these infections, Loughray, complaining of chronic fatigue and “slight headaches,” was examined in May 2001 by Dr. Rebekah Gass of Infectious Disease Consultants. (Id. at 718-19.) Dr. Gass opined that Loughray was not suffering from infections, but “that it is more likely that this is [Loughray’s] body’s slow recovery from all the endocrine disorders, which are now coming under control with therapy.” (Id.) Dr. Gass’ examination also produced normal neurological results, blood tests that showed a normal level of thyroid stimulating hormone and no hepatitis, and a chest x-ray that did not produce abnormal results. When Loughray returned to Dr. Gass in June 2001, Dr. Gass noted that she was concerned about Loughray’s “persistent endocrine abnormality.” (Id. at 343-44, 438-39, 455, 820.) After Dr. Gass’s examination, Dr. Brunschwig’s office wrote Hartford. First, on June 26, 2001, Dr. Brunschwig and Nurse Dalton, notwithstanding Dr. Gass’s conclusion that Loughray was not currently suffering from any infections, together wrote that Loughray’s thyroid condition “has resulted in a severely compromised immune system, which has resulted in her contracting four chronic and debilitating infections.” (Id. at 701.) They concluded that “[t]hese infections and her thyroid condition have created extreme exhaustion for [Loughray] . . . [and] [i]t would be impossible for her to maintain any type of work schedule.” (Id.) In late July 2001, after blood tests indicated Loughray had high insulin levels, Dr. Brunschwig wrote to Hartford that he had been treating Loughray for “disabling fatigue” and that “she has also been diagnosed with hyperinsulinemia [i.e., excess levels of insulin] for which she is being treated [and she] remains completely disabled relative to her previous employment.” (Id. at 675.) 8 In September 2001, Loughray was diagnosed with moderate sleep apnea, for which she began using oxygen. Also in September 2001, Loughray underwent a CAT scan that produced what her doctors appeared to treat as normal results. C. Hartford’s Subsequent Denial of Loughray’s Disability Benefits Claim In October 2001, Hartford notified Loughray that, “as part of [its] ongoing evaluation” of her claim, it was referring her case for an “independent medical review.” (Aple. Supp. App. at 659.) The independent medical examiner, Dr. Eugene Truchelut, reviewed Loughray’s records, but did not examine her. (Id. at 646-52.) Dr. Truchelut also spoke with Dr. Brunschwig, who informed Dr. Truchelut that he had not seen Loughray in three months, was unaware of her diagnosis of sleep apnea, and could not offer an opinion on her current state of health. After reviewing the records, Dr. Truchelut, on October 28, 2001, concluded that “the medical information furnished . . . does not support a current loss of functions capacity which would preclude the claimant from performing the type of work activities described in the employer’s [Physical Demands Analysis form regarding Loughray’s job duties].” (Id. at 652.) Dr. Truchelut observed that, based on the medical record, Loughray’s thyroid condition was stabilized by late May 2000, but he declined to comment on Loughray’s sleep apnea diagnosis because, at that time, “the recent evaluation at the National Jewish Medical Center Sleep Lab was incomplete.” (Id.) Loughray, upon learning that Hartford was sending her records for an independent review, obtained several more medical opinions indicating she remained disabled. For instance, in December 2001, Joyce Campbell, a licensed professional counselor indicated 9 that Loughray remained “unable to work at this time,” despite her “strong work ethic and desire to be back in the marketplace.” (Id. at 654.) Similarly, Betty James, a registered nurse who was also a “friend and colleague” of Loughray’s, wrote two statements indicating the difficulties from which Loughray suffered. (Id. at 629-33.) No medical records, however, were included with these letters. Based upon Dr. Truchelut’s review of Loughray’s records and despite the disability opinions of Campbell and James, Hartford notified Loughray, in January 2002, that it was terminating her long-term disability benefits because [m]edical information in file [sic] does not support a current loss of functional capacity, which would preclude you from performing the duties of your occupation. Although we acknowledge that you have a condition, there is no medical evidence presented to illustrate that a functional impairment is present to such a degree it could reasonably be expected to prevent you from performing your job duties as a Sales Commissioned employee. (Id. at 628.) D. Loughray’s First Administrative Appeal Hartford’s termination notice to Loughray also invited her to file a formal administrative appeal and to submit any additional evidence she might have supporting her disability claim. Loughray did pursue an administrative appeal and, after obtaining a six-month extension of time from Hartford, Loughray submitted additional evidence in support of her disability claim. Loughray’s additional evidence confirmed her sleep apnea diagnosis. Loughray also underwent an EEG and MRI of her brain, and other blood and stool sample tests, none of which produced results showing a disabling condition. The examiner noted a 10 blood test that showed Loughray’s thyroid stimulating hormone level was low, but this test was apparently not included in the administrative record and a test dated April 23, 2002 indicated a stabilized level of the hormone. In support of her appeal, Loughray submitted a letter to Hartford in July 2002. For the first time, Loughray asserted her symptoms of fatigue and cognitive difficulties were the result of sleep apnea and a closed head injury she suffered in 1999, one year before the April 2000 onset of her disability. Loughray offered reports from Dr. Ronald Murray of the Rocky Mountain MS Center in which Dr. Murray opined that she did not suffer from multiple sclerosis and suggested that her symptoms were “probably” caused by sleep apnea and/or a prior closed head injury. (Id. at 278.) His neurological exam, however, revealed normal results. Loughray also submitted pieces of other medical records, such as an August 2001 blood test that suggested she had been exposed to the parvovirus two or three months before, and notes from Dr. Julie Stapleton, M.D., and Dr. Thomas Groover, a chiropractor, opining on Loughray’s disability, but no indication of when or for what these doctors treated Loughray. After examining this additional evidence, Hartford’s independent medical examiner, Dr. Truchelut, concluded that the evidence established only one medical problem: sleep apnea, as “documented on the polysomnogram.” (Id. at 254.) Dr. Truchelut further noted that this problem, however, was treated effectively with oxygen, which Loughray had begun using in October 2001, and even without this treatment, the occupational restrictions would be unrelated to Loughray’s employment as a sales 11 commissioned employee (e.g., “avoidance of . . . unprotected heights or moving machinery”). (Id.) In light of Dr. Truchelut’s conclusions, Hartford, on August 5, 2002, upheld its January 2002 decision to terminate Loughray’s long-term disability benefits. It justified its decision based on a lack of medical evidence to support Loughray’s “self-reported complaints” as disabling and that the sleep apnea disorder appeared under control. (Id. at 237.) Hartford concluded by informing Loughray that “[a]ll administrative remedies offered by the Appeals process have been exhausted” and that the “decision is final and binding.” (Id. at 238.) E. Loughray’s Additional Administrative Appeals In response to Hartford’s decision upholding its denial of Loughray’s claim, Loughray protested that the decision should not be “final and binding” since she was still receiving treatment and being evaluated. Loughray now asserted there were three conditions preventing her from working: “post-concussion syndrome, chronic migrainous disorder, and central sleep apnea.” (Id. at 217.) In support of these claims, Loughray submitted additional evidence, including reports from a physician’s assistant at the Mayo Clinic Scottsdale that indicated Loughray suffered from “post multiple head trauma with postconcussive syndrome” and [n]ewonset chronic daily headache” and recommended treatment with Botox injections, a diagnosis based on Loughray’s reporting that she had suffered four head injuries between the ages of 3 and 19, plus a final fall in 1999 that caused her to lose consciousness (Id. at 222-23); a note from a doctor regarding her allergies and an apparent need to visit the 12 emergency room regularly to control the allergic reactions, but no information regarding this doctor’s treatment of Loughray nor evidence of any emergency room visits; and another letter from her chiropractor, Dr. Groover, asserting that she could not work because of severe migraines, but no treatment records from him. Despite referring to its earlier appeals decision as final, Hartford considered this evidence and, on August 30, 2002, again upheld its decision denying Loughray disability benefits. Harford informed Loughray, “[t]here will be no further review of your claim” and “the decision remains final and binding, and your administrative record remains closed.” (Id. at 211.) However, a month later, after receiving a complaint from Loughray, the Colorado Division of Insurance requested that Harford consider still more evidence from Loughray because she was struggling financially. Hartford again agreed to consider Loughray’s additional evidence, even though it had already “met its obligation under ERISA requirements.” (Id. at 158-60.) This time, Loughray presented Hartford with a report of Dr. Andrea Cohen. Dr. Cohen examined Loughray in September 2002, noting some neurological deficits, some diminished sensations and reflexes, and “slowed” cognitive processing. (Id. at 169-70.) Dr. Cohen indicated Loughray’s cognitive dysfunction had been present since her fall in 1999, though there is no such indication in Loughray’s earlier medical records. Dr. Cohen concluded that Loughray’s cognitive complaints were consistent with a closed head injury. According to Dr. Cohen, this injury combined with her headaches rendered Loughray “unable to work due to continued symptoms” from her 1999 head injury. (Id.) 13 Loughray also submitted reports from two other doctors. Dr. Eric Eross treated Loughray’s headaches with Botox injections in August 2002. And in a letter dated October 2002, Dr. Steven Gulevich also indicated that Loughray needed Botox injections for headaches and that Loughray reported she made “two to three visits to the Emergency Department every month for extreme head pain” (id. at 151), though the administrative record does not contain medical records of any such trips to the emergency room. Despite this additional evidence, Hartford’s independent medical examiner, Dr. Truchelut, remained unconvinced, explaining that “the additional medical information supplied here does not clearly establish a functional impairment, at least from the physical standpoint, which would have precluded the claimant from her work activity as of 12/20/01 and continuing.” (Id. at 84.) He further noted the significant gaps in Loughray’s medical treatment or history that undermine Loughray’s claim of “a continuous and significant functional impairment.” (Id.) Accordingly, on October 31, 2002, Hartford affirmed—for the third time—its decision to terminate Loughray’s benefits. Hartford informed Loughray the decision was “final and binding,” but that she “does have the right to pursue civil action following an adverse decision under ERISA.” (Id. at 87.) Almost 18 months later, in March 2004, Loughray again submitted additional evidence to Hartford in support of her disability claim. This evidence consisted of a report by Dr. Stuart Kutz, Jr., Ph.D., who had conducted neurological tests on Loughray one year earlier, in March 2003. These tests indicated that Loughray, who had several years of college experience, had an IQ of 71. Dr. Kutz expressed his belief that 14 Loughray’s efforts on the tests seemed genuine, diagnosed her as suffering from dementia, and suggested she would have difficulty working. Loughray did not offer any other evidence supporting a diagnosis of dementia. Hartford, however, refused to even consider Dr. Kutz’ report because it had already issued its final decision and closed the administrative record. Loughray ultimately brought a civil action against Hartford in August 2005. The magistrate judge, however, explained that although “Loughray’s medical records show a plethora of symptoms and extensive evaluations by numerous physicians without any definitive conclusions . . . the physical, laboratory, and radiological findings were inconclusive.” (Aplt. App. at 16-17.) Thus, the magistrate concluded that “the record supports Hartford’s termination of disability benefits.” (Id. at 17.) Loughray now appeals from that determination. II.