Opinion ID: 173275
Heading Depth: 3
Heading Rank: 6

Heading: Closed Head Injury

Text: Loughray next argues that Hartford acted arbitrarily and capriciously regarding her claim that she suffers a disabling condition from a closed head injury. Loughray appears first to have revealed that she fell and lost conscious in 1999 to her original primary care physician, Dr. Brusnchwig, in mid-2000. Dr. Brunschwig, however, did not conclude she suffered from a closed head injury. 23 In contrast, Dr. Cohen specifically diagnosed Loughray as having a closed head injury from her 1999 fall. Dr. Cohen examined Loughray in September 2002 and identified some neurological defects and “slowed” cognitive processing. Dr. Cohen’s diagnosis was based in part on his belief that Loughray’s cognitive dysfunction had been present since her fall in 1999. The administrative record, however, lacks any objective medical evidence that Loughray had previously suffered any cognitive or neurological dysfunction. In fact, several doctors performed exams that produced normal results. In June 2000, Dr. Kakkar found no “neurological/musculoskeletal problems” (Id. at 787) and Louhray’s MRI and MRA produced normal results. In May 2001, Dr. Gass’s neurological exam produced normal results, as did a CAT scan in September 2001 and a later neurological exam by Dr. Murray. Thus, Hartford could have reasonably concluded in January 2002 when it terminated Loughray’s benefits that she did not suffer from a closed head injury. The subsequent report of Dr. Cohen submitted during the appeals process could have reasonably been viewed as inconclusive given Loughray’s prior neurological and cognitive history. The other medical evidence offered by Loughray also fails to render Hartford’s termination decision unreasonable. A physician’s assistant at the Mayo Clinic suggested she suffered a closed head injury, but he failed to examine her level of disability. In fact, his neurological exam produced normal results, and he described Loughray as “alert, [and] oriented to person, place, time, and situation.” (Id. at 222.) Dr. Groover, Loughray’s chiropractor, also identified Loughray as disabled because “her head injury and spinal misalignment” had resulted in “her sympathetic nervous system [being] in 24 constant fight or flight.” (Id. at 515.) Dr. Groover, however, failed to specify any medical basis underlying his opinion and later suggests an endocrine problem could be causing Loughray’s difficulties. Dr. Murray, of the Rocky Mountain MS Center examined Loughray to determine if she suffered from multiple sclerosis. In concluding that she did not, Dr. Murray suggested that her symptoms were “probably” caused by sleep apnea and/or a prior closed head injury. (Id. at 278.) As mentioned, however, his neurological exam of Loughray produced normal results, and his examinations do not appear to have established any objective findings that would support these two diagnoses or that they were disabling conditions, though his sleep apnea diagnosis ultimately proved true. A letter provided by Nurse Arlene James is equally inconclusive. Nurse James explained specific functional difficulties Loughray suffered, but there is no indication that Nurse James ever saw Loughray professionally or treated her for anything. Moreover, Nurse James’ statements were not entirely consistent with other evidence in Loughray’s medical records. For example, she noted a “dramatic change” that Loughray underwent “[i]n 1998,” which “result[ed] in overwhelming fatigue, slurred and missing speech and halted and missing thoughts.” (Id. at 629.) But Loughray claimed that her disabling condition began in April 2000, and the fall on which Dr. Cohen relied for his diagnosis occurred in 1999. vii. Hartford’s Refusal to Consider Dr. Kutz’ Report Nearly 18 months after Hartford upheld its termination decision for the third time, Loughray, in March 2004, submitted another piece of medical information, a report by 25 Dr. Kutz, Ph.D. Although the other doctors that examined Loughray had not diagnosed Loughray with dementia, Dr. Kutz concluded that Loughray suffered from dementia. Dr. Kutz believed Loughray suffered serious cognitive problems because she earned a 71 on an IQ test administered in March 2003, notwithstanding Loughray’s college education. Hartford, however, refused to consider the additional evidence submitted by Loughray. This decision by Hartford does not render Hartford’s termination decision arbitrary and capricious. ERISA requires that a fiduciary “afford a reasonable opportunity to any participant whose claim for benefits has been denied for a full and fair review by the appropriate named fiduciary of the decision denying the claim.” 29 U.S.C. § 1133(2). Here, Hartford first terminated Loughray’s benefits in January 2002, and as discussed above, with a reasonable basis for doing so. As permitted by ERISA, Loughray then sought a review of that decision, supplementing her request with additional medical information. Hartford granted Loughray an extension of time to gather material for her appeal before upholding its decision. Then, Hartford twice reopened the file to reconsider its decision and allow Loughray to supplement her file— once at her request and once at the request of a state agency. Both times Hartford affirmed its termination decision. At least by the time Hartford issued its third decision affirming its original termination decision, Hartford had satisfied its obligation to provide Loughray “a reasonable opportunity . . . for a full and fair review.” See 29 U.S.C. § 1133(2). Neither ERISA nor the Plan required Hartford perpetually to hold open Loughray’s file and to go above and beyond this requirement by reopening her file nearly 18 months later. Cf. 26 Metzger v. UNUM Life Ins. Co. of Am., 476 F.3d 1161, 1166 (10th Cir. 2007) (“Permitting a claimant to receive and rebut medical opinion reports generated in the course of an administrative appeal—even when those reports contain no new factual information and deny benefits on the same basis as the initial decision—would set up an unnecessary cycle of submission, review, re-submission, and re-review.”). Deadlines and finality in ERISA administrative decisions are important aspects of the ERISA framework. See Gilbertson v. Allied Signal, Inc., 328 F.3d 625, 635 (10th Cir. 2003) (stating that “deadlines play a crucial role” in ERISA administrative appeals). Once Hartford completed its “full and fair” administrative review, it was not obliged indefinitely to continue considering information submitted by Loughray. See Davidson v. Prudential Ins. Co. of Am., 953 F.2d 1093, 1096 (8th Cir. 1992) (recognizing that, where the administrator reviewed a claim three times but later declined to reopen claimant’s file to take new evidence, “the administrative review process must end at some point and in this case [the claimant] has not been denied the opportunity for a full and fair review” (alterations, quotations, and citations omitted)). viii. Other Medical Evidence of Disability Loughray also criticizes Hartford’s “disregard” of a variety of other pieces of medical evidence she feels confirms her disability. Much of this medical evidence was, at best, inconclusive, and given the other information in the administrative record, Hartford acted reasonably in concluding that the evidence that Loughray was not disabled outweighed the remaining pieces of evidence provided by Loughray. 27 For example, the letters submitted by Drs. Stapleton and Fliege, as well as one submitted by Joyce Campbell, do not show that Hartford abused its discretion in denying Loughray’s benefits. Dr. Stapleton’s note, a single sentence written on prescription paper, asserts that Loughray was disabled, but lacks any indication of when or for what she treated Loughray. Nor does it precisely identify the ailments that render Loughray disabled. Similarly, Dr. Fleige, in a two sentence note, informed Hartford that Loughray had “frequent allergic reactions[] that often . . . leav[e] her incapacitated for days” and that she “needs to be able to go to the ER for shots of adrenaline” to ameliorate these reactions. (Aple. Supp. App. at 224.) Dr. Fleige, however, does not identify these allergies. And the record fails to contain any information to clarify this diagnosis. Moreover, the record fails to show any visits to the emergency room for allergic reactions. Finally, Campbell, a licensed counselor, also stated that Loughray was “unable to work at this time,” but it did not contain any of the specific facts on which Campbell relied to determine Loughray suffered a disability. (See id. at 654.) Thus, Harford had good reason to credit other medical evidence over these letters.