Opinion ID: 1438791
Heading Depth: 2
Heading Rank: 3

Heading: Prudential's Review for Disability Benefits

Text: Jones worked for Mountaire as a sales representative, selling animal feed products. He promoted sales to dealers and feeders within a five-state region. His job included traveling frequently, attending trade shows, setting up displays for dealers, and conducting quarterly inventories. He also recommended proper feeds for animals, visited farms, and occasionally worked with large animals. His job required him to spend long hours on his feet, stoop, and lift and move inventoryup to fifty-pound bags of feedin a dusty, dirty environment. Jones's last day at Mountaire was on September 30, 2005. Jones filed a claim for long term disability benefits on November 2, 2005, and indicated his job was sedentary. Jones stated that he was unable to work because he had emphysema and could no longer work around dust and chemicals. Mountaire completed an employer statement, which also stated that Jones's job was sedentary. In November 2005, the physician and surgeon filled out forms, certifying that Jones could not return to work. The physician stated that stress and physical exertion would increase Jones's breathing problems and that Jones was incapacitated and would likely worsen in the future. He diagnosed Jones with progressive chronic emphysema and coronary artery disease. The physician noted, however, that Jones had the functional ability to do sedentary work. The surgeon stated that due to progressive lung disease, Jones should not do physical labor or be exposed to chemical agents. Prudential denied Jones's claim on December 20, 2005 based on the opinion of its nurse, Nurse Gillis, who reviewed Jones's medical records and found that the alleged disability lacked support. The nurse noted the lack of recent chest x-rays or pulmonary function tests to support the physician's assertion that breathing problems rendered Jones disabled and noted Jones was stable from a cardiac standpoint. Prudential explained that the medical records indicated no sudden worsening of his condition at the date of disability and that Jones previously had worked despite his condition. Jones appealed the denial and submitted additional medical records. Jones's three treating doctors wrote letters stating that because of the combined effects of coronary artery disease and emphysema, Jones was incapable of returning to work. The cardiologist opined that Mr. Jones is totally disabled for performing anything more than the most sedentary type occupation. The physician stated that Mr. Jones is totally and permanently disabled to hold gainful employment. The physician also placed restrictions on Jones relating to standing, walking, lifting, climbing, balancing, kneeling, crawling, and reaching overhead, as well as restrictions relating to exposure to gas, dust, fumes, or changes in temperature. The surgeon opined that Jones is presently incapacitated and likely will remain so in the future. Jones also submitted a job description showing that his job was not sedentary. The description indicated that Jones's duties included lifting up to fifty-pound bags of feed. Mountaire also added duties to the job description: visiting farms, handling large animals, and participating in quarterly inventories, which require standing, stooping, lifting, and moving inventory for hours in a dusty and dirty environment. Prudential's rehabilitation specialist, Mr. Chretien, reviewed Jones's job description and determined his regular occupation as defined by the plan. The rehabilitation specialist concluded that it was Sales Representative, Animal-Feed Products [4] under the DOT. The DOT classified the job as light, which means the job includes the ability to exert up to twenty pounds of force occasionally and up to ten pounds of force frequently and to walk and stand for periods of time. Prudential Medical Director Dr. Kowalski reviewed Jones's medical records and concluded that his medical history did not prevent Jones from doing a light-duty job. Prudential contacted Jones and asked if there was any supplemental information. In response, the surgeon submitted an office visit note dated November 2005. In it, the surgeon stated that Jones has markedly improved from his [first visit post-surgery] although he continues to have pleuritic type right chest wall pain, appears well and in no distress, and has rhythmic heart tones. Finally, the surgeon stated that the chest x-ray today is satisfactory and showed marked resolution of his right upper lobe infiltrates noted earlier in June of this year. Prudential also contacted Jones to inquire about his heart treatment. Jones responded that his last stress test was prior to his last day at work and that he had not seen his cardiologist since his surgery in October 2005. Prudential Claim Manager Mr. Furman summarized Jones's medical history and concluded that Jones could perform light work. The claim manager noted specifically that Jones's cardiologist reported that Jones had been doing well, that Jones made no reports of shortness of breath, and that no diagnostic test results supported a finding of an impairment. On March 3, 2006, Prudential notified Jones that he did not meet the plan's definition of disabled, based on Mountaire's job description and the DOT's definition of light work. On March 16, 2006, Jones appealed again, requesting that Prudential look at Jones's actual job duties to make sure the chosen DOT job title accurately portrayed his work requirements. Jones noted that the DOT job description did not reflect that he was exposed to various chemicals, frequently stooped, kneeled, and crouched, and lifted up to fifty-pound bags of feed. Jones also requested an independent review by a third-party specialist. Jones included a copy of a treadmill stress test conducted earlier that month. The cardiologist's final impression was that Jones had a fair to poor exercise tolerance. Jones also indicated he was having a breathing test performed that day. Jones lastly requested that Prudential contact Jones's treating doctors to receive a report on his physical abilities and limitations. Prudential complied with Jones's requests. First, a second vocational rehabilitation specialist, Mr. Schwartzkopf, reviewed Jones's and Mountaire's job descriptions and found the chosen DOT job title was accurate even if it described less physical exertion than Jones's actual job. The second rehabilitation specialist noted that Jones could share or delegate the heavier work if necessary. A Prudential medical director, Dr. Bachman, reviewed Jones's pulmonary function test (PFT) and concluded that the results were consistent with very mildly impaired PFT. After considering the treadmill test in addition to the other information, the medical director opined that Jones was in poor physical conditioning, had poor exercise tolerance, but was not impaired from performing his job as a result of his lung and heart conditions. Second, Prudential sent work status forms to Jones's primary care physician and surgeon. The surgeon indicated that Jones was no longer a patient. The physician reported that Jones could not drive, be exposed to gas, dust, or fumes, and could stand only one hour per day, due to his lung disease. Third, Prudential gave Jones's claim file to a third-party specialist, Dr. Brown, who was an internal medicine physician specializing in pulmonology, for an independent review. After reviewing the file, the third-party specialist stated Jones's tests results were on the lower limit of the normal range and showed no progression of worsening. He concluded Jones had no functional impairments and only is limited by poor physical fitness. Ultimately, Prudential issued a final denial of benefits to Jones. Jones, having exhausted his appeals with Prudential, filed this appeal in district court. See 29 U.S.C. § 1132(a)(1)(B) (authorizing a claimant to bring suit). The district court awarded long term disability benefits, after granting Jones's motion for summary judgment. The district court reviewed de novo Prudential's decision because the court determined that Prudential had a conflict of interest as insurer and claims administrator and because Prudential failed to examine all relevant facts. The district court found five procedural irregularities in the administrative record, including a narrow and outdated application of the Department of Labor's occupational information. The district court criticized Prudential's vocational experts for relying on the DOT because it was last updated in 1977, was superceded by the ONet, and did not give a detailed description of work environments. Further, the district court accused the experts of being either unqualified or dishonest because they failed to keep abreast of the latest information. The district court focused on Prudential's failure to consult the ONet, which superceded the DOT and was more descriptive of Jones's work setting and job, categorized as 49005A Sales Representatives, Agricultural. [5] The district court criticized Prudential for failing to reference the ONet, which stated that Jones's work context involves frequent exposure to pollutants, gases, dust, and extremes in temperatures. The district court noted that Jones repeatedly requested Prudential to review whether it had selected the proper job description title and repeatedly submitted evidence personally and from his treating doctors that he worked in a dusty environment, which adversely affected his breathing and lung condition.