Opinion ID: 165188
Heading Depth: 1
Heading Rank: 1

Heading: facts

Text: 5 Mr. Gaither's problems began in October 1996 when he hurt his back playing golf. When that pain, along with pain from a previous rib injury, did not subside, Mr. Gaither saw a doctor. After several tests, he was diagnosed with multiple myeloma. In victims of that disease, the affected plasma cells (known as myeloma cells) multiply and gather in the bone marrow. Typically, they accumulate in the cavities of multiple bones, where they eventually cause numerous small lesions, often resulting in fractures, and weakness in the bone structure. As in Mr. Gaither's case, a common early symptom of the disease is pain in the ribs or lower back caused by such lesions and fractures. 6 As a Monsanto employee, Mr. Gaither was eligible for disability benefits under the Monsanto Disability Income Plan (the Plan), Appellees' Supp.App. 48-72, an ERISA plan partially administered by Aetna. Under the Plan, for the first two years of disability, a claimant is eligible for benefits if he is not able, solely because of disease or injury, to perform the material duties of [his] own occupation.  Group Coverage Plan Booklet 3, App. Vol. II. 561 (emphasis added). After two years, the requirements tighten, and the claimant becomes eligible only if, as a result of the disease or injury, he becomes disabled from any reasonable occupation. Id. 7 After talking with Mr. Gaither and his supervisor at work, and after confirming his condition with his doctors, Aetna certified Mr. Gaither's disability through mid-July of the following year while he underwent chemotherapy. He was also in and out of the hospital trying to wean himself from prescription pain medications during that time. Under Mr. Gaither's disability plan, during the first six months of that leave, his benefits were 100% of his normal salary; after that point he entered a Long-Term Disability status and received only 65% of his salary. 8 Feeling mounting pressure to provide for his family of four children, Mr. Gaither returned to work in July 1997. Despite his earnest desire to return to work, Mr. Gaither's recovery was far from complete. At the end of September, Monsanto informed Aetna that in Mr. Gaither's first two months back on the job, he had missed more than a month of work and occasionally had trouble completing his twelve-hour shifts when he did show up. When questioned, Mr. Gaither stated that he had missed those days because of pain. Aetna refused to certify Mr. Gaither's disability for that period, although the case file notes explaining why appear to be missing from our copy of the record. 9 The next development in Mr. Gaither's case came in April 1998, when Susan Shean, Health Services Supervisor at Monsanto, contacted Aetna because Mr. Gaither had apparently stopped working again two months earlier. She stated that this was a difficult case and that she would handle it directly. Ms. Shean tracked down Mr. Gaither's new oncologist, Dr. Brunk, and forwarded his medical records to Aetna. Those records showed that his multiple myeloma condition was improving. Dr. Brunk's office also indicated that the biggest prob[lem was] back pain and gross fatigue, and reported that Mr. Gaither's dosage of Oxycontin was being increased as of April 23. That same day, Mr. Gaither had a three-way phone conversation with Ms. Shean and Aetna's case worker. He expressed a desire to return to work immediately (rather than returning to 65% disability pay) and claimed that although he had just had his Oxycontin prescription increased, he was not taking the drug. Ms. Shean, on the other hand, noted that he had not managed to fulfill his job duties consistently, and questioned whether it was appropriate for him to resume working. The upshot of the conversation was that Ms. Shean would send Dr. Brunk a description of Mr. Gaither's job specifications and ask for his evaluation of Mr. Gaither's ability to return to work with or without restrictions. On May 6, 1998, Ms. Shean wrote the following in her request to Dr. Brunk: 10 The Team Leader's guidance, judgments, and decision making abilities are crucial to the safety of the operation and the personnel on his shift. Our concerns about his ability to function safely are heightened by the knowledge that he may be using the analgesic Oxycontin at work, in either sustained release or immediate release formulations. 11 Letter from E. Susan Shean to Fred Brunk, M.D. (May 6, 1998), App. Vol. II 402. 12 By May 11, Ms. Shean had determined which days Mr. Gaither missed, and based on her report, Aetna retroactively certified Mr. Gaither's disability for eight days in September 1997, six days in January 1998, and from February 10, 1998 until May 15. Ms. Shean stated, however, that Mr. Gaither would not be allowed to return to work until she had received more information from his treating physicians and he had obtained clearance from Monsanto's medical department. Mr. Gaither's physicians were somewhat slow to respond, and even when Dr. Brunk indicated that he thought Mr. Gaither could return to work, Ms. Shean remained worried that he had not recognized the dangers involved in letting Mr. Gaither perform his duties while on pain medications. On several occasions, Aetna extended Mr. Gaither's disability certification based solely on Monsanto's continuing concerns about safety and refusal to let Mr. Gaither return to his job. 13 Finally, on June 16, 1998, Aetna successfully reached Dr. Sorenson, Mr. Gaither's pain specialist, who was unsure about Mr. Gaither's situation in particular but noted that his patients could usually perform at their jobs without any problems. Because of this uncertainty, a reviewing Aetna physician ordered an independent medical evaluation from a doctor in occupational medicine. On July 9, 1998, that evaluation was performed by Dr. William Gillock. He concluded that until Mr. Gaither stopped taking narcotic pain medications, he should refrain from using or supervising hazardous machinery, using company vehicles, and working on unguarded elevations. 14 After consulting with Mr. Gaither's supervisor, Ms. Shean reported to Aetna that Monsanto could not accommodate Dr. Gillock's restrictions. As a result, Aetna's case worker transferred Mr. Gaither's case to a rehabilitation specialist who could help Mr. Gaither retrain for other occupations. 15 Threatened with the loss of his position and the need to seek new employment, Mr. Gaither spoke with Ms. Shean, assuring her that he was pain free and in a program to withdraw[ ] from his pain medications. She therefore requested that Aetna continue to certify Mr. Gaither's disability and delay retraining until September 1998, when Mr. Gaither was scheduled to finish his drug weaning program. However, when Aetna's onsite representatives finally tracked Mr. Gaither down in September, he had only just started reducing his dosage on September 24. Although he claimed he would be ready to return to work in another five weeks, his wife disagreed, stating that he would always be limited in his ability to work even though he would say anything so that he can [return to work] due to his family and [four] children. 16 Around the beginning of November, when Mr. Gaither and his wife met with Aetna's onsite representatives, he had made some progress in reducing his Oxycontin dosage, although there had been a lot of pain and he had been very jumpy and unable to control his temper during the first three weeks of withdrawal. Mr. Gaither's biggest problem at that point was his lack of stamina, which allowed him to do no more than thirty minutes of yard work at a time. After talking with Dr. Sorenson about Mr. Gaither's progress weaning himself from Oxycontin, Aetna's rehabilitation specialist and Ms. Shean agreed on November 4 that Mr. Gaither could gradually return to work while participating in a work hardening program to build his stamina. On November 16, however, Ms. Shean talked with Aetna again, explaining that Mr. Gaither had fallen behind his drug weaning schedule and that his pain management clinic reported that Mr. Gaither was not as pain-free as he claimed to be. Ms. Shean stated that the plant manager in Ok[lahoma] will not allow [Mr. Gaither] to return to work with any drugs; therefore, [he] must be totally detoxed from the medications. Mr. Gaither completed his drug weaning program and underwent another independent medical evaluation by Dr. Gillock on January 9, 1999. Dr. Gillock approved him to work without restrictions (subject to the caveat that if Mr. Gaither began taking narcotic pain medications again, the old restrictions would need to be reinstated). Mr. Gaither gradually resumed working, and was finally back to full-time work by February 7, 1999. 17 Mr. Gaither apparently continued to work for several months until the incidents that resulted in his leave of absence. As determined by Monsanto's internal investigation, the facts are these: On July 15, 1999, Mr. Gaither went to Okmulgee Memorial Hospital to be treated for chest pain resulting from a sneeze. The doctor gave him a shot of Demerol and a prescription for two to three days of Lortab. Two days later, early on a Saturday morning, Mr. Gaither returned to the hospital, complaining about an injury that happened when a wrench slipped, striking his sternum. Mr. Gaither received a shot of Demerol at 1:15 a.m., took a Lortab orally, and went to work on the swing shift. At work, he aggravated the injury to his sternum and left work without informing his supervisor. When questioned the following Monday about his disappearance, Mr. Gaither ultimately admitted to visiting the hospital and obtaining prescription medications. Mr. Gaither was placed on leave and sent for drug testing. In the meantime, he saw Dr. Sorenson for his sternum pain and received another prescription for Lortab. Then, on August 10, Mr. Gaither's drug test results confirmed the presence of at least two narcotic pain killers. App. 91. In a letter dated August 27, 1999, Vera Daniel, the Oklahoma plant's human resources manager, recounted these events and concluded that being under the influence of these medications rendered you unfit for duty for your position as a Utilities Team Leader. Id. The letter also explained that because Mr. Gaither had broken his promise not to come to work under the influence of narcotics, he was to be placed on probation and receive a one-week disciplinary leave without pay. This letter was never delivered, however, because in early September 1999, Mr. Gaither was terminated for incurring more than $2,000 of unauthorized personal expenses on his company credit card. 18 On August 11, 1999, Mr. Gaither called Aetna to begin processing his claim for disability pay. Two days later, Ms. Shean called about the case, and as a result of the discussion between Aetna's claims nurse and Ms. Shean, Ms. Shean said she would have Ms. Daniel call Aetna about the disposition of this case. (At the time, Ms. Daniel was gathering detailed information about Mr. Gaither's drug use.) The next recorded action on the case was a call from Ms. Shean on September 20, directing Aetna to close the case because Mr. Gaither had been terminated. Apparently without any further consideration of Mr. Gaither's eligibility for benefits prior to his termination, Aetna closed the file. The record does not indicate whether Mr. Gaither was ever notified of this decision. 19 That might have been the end of the matter if Mr. Gaither had not written a letter to his plant manager, Mike Veltri, arguing that his lapse in ethical judgment was due to his medications, and begging him to set aside Mr. Gaither's termination so that he could apply for long-term disability benefits. In December 1999, Ms. Daniel wrote back, telling Mr. Gaither that he was eligible to apply for Total and Permanent Disability benefits for all occupations, and that he should call a Monsanto disability representative in Saint Louis (Kim Paulson) to start his application process. App. 65. Ms. Daniel also explained that Mr. Gaither and his physician would have to work closely with Aetna, which was entirely in charge of the process. 20 On December 7, Ms. Paulson contacted Aetna and explained that it would need to assess the medical necessity for Mr. Gaither's leave, and also whether Mr. Gaither was totally and permanently disabled as of his termination. The caseworker assigned to handle Mr. Gaither's claim, Bobbie DeNucci, attempted to reach Ms. Shean that same day, and Ms. Shean called back three days later. According to Aetna's records, Ms. Shean had told Mr. Gaither that he would need to contact his physicians and have them supply clinical information to Aetna so it could determine whether he was disabled while on leave. It was agreed that Ms. Shean would contact Mr. Gaither again to stress that he would have to contact his doctors because Aetna did not know their numbers. On December 13, Ms. Shean explained to Mr. Gaither that he should choose one of his doctors who would best represent his case for consideration of total disability from his usual and customary occupation, and give that doctor's name to Aetna for follow-up. In an internal e-mail sent the next day, Monsanto's disability representative corrected Ms. Shean, stating that Mr. Gaither must be found disabled from any occupation. 21 Mr. Gaither did not provide any information for some time, so Ms. DeNucci called him on January 6, 2000. He called back, with the assistance of his father, on January 10, and provided the names and telephone numbers of Drs. Jin, Brunk, and Sorenson. His wife was to call their offices and authorize the release of medical information to Aetna. The next day, Ms. DeNucci called Dr. Jin's office, which had received the release form, and requested his records. The administrative record, which generally documents all of Aetna's communications about the case, shows no attempt to contact either of the other two physicians. 22 On February 10, the record reports that numerous calls have been received from father to inquire if r[e]cords have been received. Mr. Gaither's father was told that Dr. Jin's office notes and answers to an Aetna questionnaire were still missing. He said he would contact Dr. Jin's office again. Finally, on February 15, Dr. Jin's materials were received, and Mr. Gaither's file went to Dr. Bonner for review. In his review, Dr. Bonner stated that the issue I must decide is whether Mr. Gaither was medically disabled for any work during [the] period of time of Mr. Gaither's leave and subsequent termination. App. Vol. II 364, Appellees' Supp.App. 237 (emphasis added). After reviewing Dr. Jin's psychiatric notes, Dr. Bonner concluded that [t]he medical records provided DO NOT indicate that Mr. Gaither was unable to continue working as of the beginning of September and thus was not disabled for any occupation at that time. App. Vol. II 365, Appellees' Supp.App. 238. 23 Aetna's letter explaining its decision was internally inconsistent. It quoted part of the Plan's definition of disability, applicable during the first two years of disability, which provides that a claimant is eligible for benefits when he is not able, solely because of disease or injury, to perform the material duties of [his] own occupation and told Mr. Gaither that he was denied due to definition of disability. App. 114. It elaborated: 24 Medical Records provided do not indicate that you were unable to work as of the beginning of September and thus were not disabled for any occupation at the time. 25 In view of the above, Aetna is upholding our termination decision of your claim for disability benefits on the basis that you are not totally disabled from your own occupation based [on] the medical information provided. 26 Id. (emphasis added). Ms. DeNucci also talked with Mr. Gaither's father by telephone, explaining that he could appeal and that he would need to obtain detailed information from all of Mr. Gaither's attending physicians explaining the rationale for total disability. Mr. Gaither's father wrote a letter explaining about his son's reliance on painkillers, enclosing notes of treatment from Dr. Brunk and hospital records showing Dr. Sorenson as the attending doctor. He also included a copy of Mr. Gaither's letter to Mike Veltri indicating that his medications had caused his lapse in judgment. On second-level review, Dr. Hellman determined that Mr. Gaither's multiple myeloma was stable and therefore found inadequate documentation of functional disability preventing the performance of the essential duties of [Mr. Gaither's] occupation ... during the period from July 1999 through September. App. 117. Dr. Hellman's determination made no mention of drug use or dependency, which was the basis for his inability to perform his job. 27 Mr. Gaither appealed that determination in district court. The district court upheld the decision as reasonable. 2