Opinion ID: 774209
Heading Depth: 2
Heading Rank: 3

Heading: The Plan Terminates Marshall's Long Term Disability Benefits

Text: 17 On March 30, 1998, the Plan sent a letter to Marshall informing him that, based on Dr. Diner's IPE, the Functional Capacity Evaluation performed by the physical therapist, Dr. Blankenship's IME, and surveillance reports indicating that Marshall was seen walking without a cane and driving a car, Marshall no longer met the eligibility requirements for long-term disability benefits. The Plan was therefore terminating Marshall's benefits effective April 1, 1998. The letter also explained Marshall's appeal rights. 18 When the Plan terminates an employee's long-term disability benefits, the employee may appeal that decision administratively. That process has two levels. At the first level, a subcommittee (whose members are appointed by the Administrative Committee of the Plan) reviews the challenged decision. 7 If the subcommittee decides the appeal against the employee, the employee may appeal that decision to the Administrative Committee itself. At each level, the employee may submit any written evidence or arguments that he wishes to support his claim for benefits. 19 Marshall timely appealed the termination of his benefits to the subcommittee. In support of that appeal, Marshall submitted additional medical documentation from Drs. Chakales and Remmel. Dr. Remmel stated, in a report dated April 6, 1998, that he cannot and will not release Mr. Marshall to return to work. Dr. Chakales described Marshall as suffering from post lumbar laminectomy syndrome with chronic low grade spinal arachnoiditis with chronic nerve root irritation and reported on April 24, 1998, that Marshall was still disabled and was a poor rehabilitative candidate. Marshall also submitted to the Plan a vocational assessment report from Pinnacle Rehabilitation. The vocational assessment indicated that, based upon the medical evaluations of Drs. Chakales and Remmel, it was neither physically nor psychologically appropriate for Marshall to return to work. 8 20 In response to Marshall's appeal, the Plan asked Marshall to undergo two further IMEs. On June 17, 1998, Marshall underwent an Independent Orthopaedic Evaluation by Tad Pruitt, M.D. Dr. Pruitt spent approximately one and a half hours examining Marshall and another two hours reviewing his medical records and preparing his report. Dr. Pruitt concluded that Marshall might, from a physical standpoint, be able to perform a sedentary clerk's job if he were able to ease into the job by starting with just a couple of hours at a time and if he were able to move around as needed. Dr. Pruitt stated, however, that he could not appropriately comment on Marshall's mental ability to perform the job and noted that Marshall's subjective issues -- his mental problems and chronic pain -- may continue to limit him. Dr. Pruitt also raised a concern about Marshall's dependence on chronic pain medicines. 21 Two days later, Marshall underwent an IME by neurological surgeon, Anthony Russell, M.D. Dr. Russell concurred in Dr. Pruitt's findings and stated his belief that Marshall was not totally disabled to the point that he could no longer engage in any gainful employment. Dr. Russell continued: 22 I realize it is not proper to use specific illustrations in order to form an opinion, however, if we use someone who is severely injured, such as Christopher Reeves, a patient with a C1-C2 fracture, who is unable to walk or breath for himself, then obviously Mr. Marshall's injury falls somewhere short of that degree of disability. On the other hand, Mr. Reeves has been able to resume employment. The ability to work is typically more a function of motivation rather than actual ability to engage in certain activities. 23 Dr. Russell concluded that the main limiting factor for Marshall was his subjective pain. The Plan submitted additional documents from Marshall's treating psychiatrist to Dr. Diner, the psychiatrist who had completed Marshall's 1997 IPE, for his review. Dr. Diner concluded that Dr. Remmel's letter did not change the opinion he expressed in 1997. 24 Marshall was accepted as permanently and totally disabled by the Arkansas Worker's Compensation Commission on September 1, 1998, a fact known to the Plan. On September 22, 1998, the subcommittee notified Marshall that it was affirming the Plan's initial decision to terminate Marshall's benefits based on the evidence presented that [Marshall] is able to perform some type of work other than his customary occupation. By a letter dated December 15, 1998, Marshall appealed this determination to the Administrative Committee. On February 22, 1999, the Administrative Committee notified Marshall that his appeal was denied because medical evidence showed that he was physically and psychologically capable of doing some work.