Opinion ID: 77773
Heading Depth: 2
Heading Rank: 2

Heading: Oliver's Claim

Text: Oliver is a former Systems Support Specialist II at Coca-Cola, and a participant in the Plan. The responsibilities of a Systems Support Specialist II involve providing administrative and technical support for Coca-Cola's voice mail system. Most of Oliver's work was performed at a personal computer, although he was sometimes required to [w]alk to telephone switch rooms to do system backups and provide voice mail training to groups and individuals. R2-56, Exh. 3. In October 1999, Oliver was involved in an automobile accident. Shortly after the accident, he began to complain of pain, stiff[ness] and ach[es] in his neck and upper back, and severe headaches. R1-24, Exh. 11 at CCCID0192. Oliver applied for and received 26 weeks of short term disability benefits from Coca-Cola under a separate benefit program that is not part of an ERISA-governed plan. In April 2000, after the short term disability benefits terminated, Oliver timely applied for long term disability (LTD) benefits under the Plan. Because Oliver's application was filed during the first 24 months following the date of his automobile accident, the own occupation standard applied. In support of his claim for LTD benefits, Oliver submitted statements from two attending physicians, and one physician who had examined Oliver but did not consider herself an attending physician and declined to complete Broadspire's evaluation form regarding Oliver's prognosis and limitations. One of Oliver's attending physicians, Dr. Scott Arrowsmith, indicated that Oliver suffered fibromyalgia of neck/shoulders (post-traumatic). Id. at CCCID0040. On the line on Broadspire's form labeled Objective Findings, Dr. Arrowsmith wrote: [p]ositive EMG for chronic [illegible] radiculopathy and cervical [illegible]; unremarkable cervical MRI. [2] Id. In response to a question asking him to list activities Oliver should not do, Dr. Arrowsmith wrote: [d]oes not tolerate cervical motion or prolonged sitting  limited tolerance to driving. Id. at CCCID0041. The form then asked Dr. Arrowsmith to list activities your patient cannot do. Id. Dr. Arrowsmith wrote: cannot lift over 10 [pounds], cannot sit for over 1 hour. Id. Under a section of the form asking the doctor to indicate level of impairment, Dr. Arrowsmith checked a box labeled marked limitation of functional capacity/capable of sedentary work, but drew a question mark next to the check box. Id. Dr. Arrowsmith then completed a section of the form labled Estimated Physical Abilities, and indicated that Oliver could sit for no more than three hours per day, in short episodes, could stand no more than four hours per day, and could walk no more than three hours per day. Id. at CCCID0042. In response to the question, [c]an patient now work?, Dr. Arrowsmith responded: [n]ot when last seen on 1-3-00. Id. at CCCID0043. Oliver's other attending physician, Dr. James Fugedy, diagnosed Oliver with [c]hronic pain syndrome, headaches secondary to neck injury; insomnia. Id. at CCCID0044. On the form provided by Broadspire, Dr. Fugedy also wrote: the patient continues to have serious headaches, neck pain and right arm pain requiring narcotic analgesics and developing tolerance. Cannot function due to pain. Id. at CCCID0045. Dr. Fugedy also wrote: Mr. Oliver is incapacitated due to continuous headaches, neck pain and right arm pain, which no longer responds to medications. Id. Under the section of the form labeled Estimated Physical Abilities, Dr. Fugedy indicated that Oliver could [n]ever lift, carry, bend/stoop, squat, crawl, climb, or [r]each above shoulder level. Id. He further indicated that Oliver could not crouch, kneel, balance, [p]ush/[p]ull, or [d]rive automobile. Id. Nor, according to Dr. Fugedy, could Oliver use [his right] hand[ ] for repetitive actions such as . . . [s]imple [g]rasping[,] [p]ushing & [p]ulling[,] [or] [f]ine [m]anipulating, or use his right hand and neck in the `[s]tatic [p]osition,' for frequent flexing, or for frequent rotating. Id. In response to the question, Can patient now work?, Dr. Fugedy wrote: No. Id. at CCCID0046. On 15 June 2000, Dr. Norman Moskowitz conducted a peer review, on behalf of Broadspire, of the evaluation forms submitted by Oliver's attending physicians. Dr. Moskowitz did not examine Oliver. Dr. Moskowitz concluded, in relevant part: [T]here is no objective evidence to determine any kind of disability in this person's own specialty and job description. There is no evidence that a prolonged limited disability is documented. There are arbitrary checkpoints by a physician without any concrete objective evidence of any physical capacity limitations. There are no medicals to support any disability at this time. This is a medical certainty. Id. at CCCID0039. On 19 June 2000, Broadspire sent Oliver a letter denying his claim. After receiving Broadspire's denial of his claim, Oliver filed a written appeal with Broadspire. On 7 July 2000, Oliver began visiting Dr. Husham Mishu, a neurologist. Dr. Mishu examined Oliver, performed an EMG and a nerve conduction test, prescribed Oxycontin and Celebrex, ordered an epidural injection with nerve root sleeve injection, and recommended that Oliver strongly consider long term disability. [3] R3-59, Exh. 15 at TOL000106-107. According to Dr. Mishu, Oliver's EMG revealed a C5 active and chronic radiculopathy on the right. Id. at TOL000106. Dr. Mishu also examined the results of Oliver's earlier MRI, and found that it showed ligamentum flavum hypertrophy and a C5 disk. [4] Id. On 7 August 2000, Dr. Mishu treated Oliver with injections of Lidocaine and Celestone near his nerve roots in his spine. Dr. Mishu examined Oliver again on 10 August 2000. He noted that Oliver had been taking 40 milligrams of Oxycontin twice daily, with an additional 20 milligrams at night, and that Oliver said that this has practically `saved his life.' Id. at TOL000118. Dr. Mishu stated that he had treated Oliver with an epidural/nerve root injection, as well as a Botox injection, which seemed to help, but that Oliver still ha[d] a significant problem with his shoulder and spasms of his neck, shoulder, and posterior trunk muscles. Id. On 22 August 2000, Oliver visited Dr. Mishu again, and Dr. Mishu wrote that while he believed Oliver was feeling better overall, he still had a significant amount of breakthrough pain, and that he believed Oliver needed physical therapy and further Botox injections in his spine. Id. at TOL000115. Dr. Mishu also noted that [Oliver's] physical examination today is essentially unchanged, and that he continued to have the same problems with his right arm and cervical spine. Id. He observed that [Oliver] is able to get around more, do some cleaning up at home, etc., but once he starts to do these things, he then has more pain and has to go lie down. Id. Dr. Mishu increased Oliver's Oxycontin prescription from 40 milligrams twice daily to 80 milligrams twice daily. Id. In support of his appeal of the initial denial of his LTD benefits claim, Oliver submitted the medical records from his treatment by Dr. Mishu, including Dr. Mishu's notes and the results of the EMG and nerve conduction tests conducted by Dr. Mishu. Broadspire submitted Oliver's file to Dr. Gerald Goldberg for a peer review. Dr. Goldberg did not examine Oliver. Dr. Goldberg began his report, dated 21 September 2000, by summarizing Oliver's symptoms as myofascial pain, chronic pain in chest, cervical pain, right shoulder pain and numbness in his right four fingers, pain and palpation of the right triceps . . . EMG examination reveals C5 active and chronic radiculopathy on the right and MRI showed ligamentum flavum hypertrophy and C5 disk. R1-24, Exh. 11 at CCCID0084. Dr. Goldberg summarized the results of Dr. Mishu's treatment of Oliver, and noted Dr. Mishu's conclusion that the EMG test showed a right C5 active and chronic radiculopathy. Id. at CCCID0085. Dr. Goldberg also noted Dr. Mishu's observation that even [ ] very minimal activity . . . seemed to aggravate [Oliver's] pain. Id. Dr. Goldberg stated that Dr. Arrowsmith's report rated the patient as having a class 4 restriction, indicating he could do sedentary work; however, Dr. Goldberg omitted from his report the fact that Dr. Arrowsmith annotated the check box for class 4 restriction with a question mark. Id. Dr. Goldberg concluded his peer review by stating his belief that Oliver could perform his job, based on documents that indicated Oliver's job was mostly done with the patient sitting and using the computer. Id. He further stated that Oliver's history was far from typical, and that his reports of pain were not particularly in a C5 radicular distribution. Id. at CCCID0086. He characterized Oliver's prescription of 40 milligrams of Oxycontin twice daily as fairly strong narcotic doses, but concluded that the Oxycontin would certainly make him much more functional. Id. Dr. Goldberg stated that the EMG test did not support any C7-8 radicular disturbance, but did not dispute Dr. Mishu's conclusion that the EMG showed a C5 chronic radiculopathy. Id. Dr. Goldberg concluded [t]he two Attending Physician's Statements that were obtained do not list any objective findings, and that therefore he could not support the long term disability claim from a neurological standpoint. Id. Shortly after conducting his first peer review, Dr. Goldberg conducted a follow-up review in response to information that Oliver's dosage of Oxycontin had been increased from 40 milligrams twice daily to 80 milligrams twice daily. Dr. Goldberg stated that the high dosage would not present a problem. He opined: [i]f anything, the medicine helps the pain quite a bit and in the patient's own words `it saved my life.' Since the medicine helps so much, this lends further support to the fact that he is capable of carrying out his job. Id. at CCCID0089. Via a letter dated 16 October 2000, Broadspire informed Oliver that it had denied his first-level appeal. The letter stated that Broadspire had conducted a peer review of Oliver's file in an effort to afford [Oliver] every consideration under the Plan. R1-15, Exh. 7 at CCCID0090. The letter contained a summary of Dr. Goldberg's peer review, and concluded by stating that the medical documentation within your file does not support your claim that you are totally disabled from your own occupation, and that [i]n order for us to reconsider your claim for LTD benefits, you must submit objective medical evidence. . . . Id. On 17 November 2000, Oliver visited Dr. Kenneth Lazarus. Dr. Lazarus conducted a physical examination and found, in relevant part: Examination of the neck reveals it to be exquisitely tender bilaterally. The patient has significant spasm noted in the cervical paraspinal regions bilaterally. He has pain in scalene muscles bilaterally and has exquisite spasm. He has bilateral trapezius trigger points noted on exam. He has pain with lateral bending and with forward bending, and has markedly limited range of motion. He has normal mobility of the shoulders, although elevating the right arm of the shoulder seems to trigger a lot of neck and shoulder pain. Any sort of movement in the neck appears to trigger some arm discomfort. He reports arm discomfort radiating from the axilla through the medial arm and into the hand. Elbows and wrists function normally. No Tinel or Phalen signs are noted. Hand temperature is symmetrical. Distal pulses are intact. The lower back is nontender. He tolerates straight leg raising well. Distal pulses are intact in the lower extremity. R3-60, Exh. 24 at TOL000172. Dr. Lazarus described his impressions as (1) Cervical myofascial pain syndrome. (2) Pseudo-radiculopathy secondary to # 1 above. (3) Rule out cervical disc herniation, not demonstrated on the patient's imaging. Id. at TOL000173. Further, on 27 November 2000, Dr. Mishu completed a questionnaire submitted to him by Oliver's attorneys. Dr. Mishu indicated that Oliver suffered [c]ervical [r]adiculopathy with muscle spasms, with symptoms including severe pain in c. spine radiating down his [a]rm (R) and center of back w/[a]ssociated muscle spasms. R3-60, Exh. 23 at TOL000175. He responded affirmatively to questions asking whether the limitations associated with the symptoms of [Oliver's] condition and/or side effects from his medications prevent him from performing material and substantial duties of his past work as a Systems Support Specialist eight hours a day, forty hours a week[;] . . . cause lack of concentration, fatigue, drowsiness or other symptoms inhibiting his ability to mentally complete the most sedentary or basic work tasks[;] . . . [and] cause substantial impairment to his ability to concentrate and/or focus on tasks. Id. at TOL000176. He also indicated that Oliver would be required to lay down periodically throughout the day, and that his reliability in most job settings [would] be poor. Id. On 13 December 2000, Oliver, through his attorney, filed a second-level appeal of the denial of his claim. In support of his appeal, he included Dr. Lazarus's report and the additional information from Dr. Mishu. In a letter dated 15 December 2000, Broadspire acknowledged receipt of the appeal, but again requested objective evidence, such as current diagnostic test results and medical records.  R3-60, Exh. 25 (emphasis in original). Broadspire's letter did not mention the MRI, EMG, and nerve conduction tests already submitted by Oliver. See id. In response to the 15 December 2000 letter from Broadspire, Oliver submitted additional materials related to his LTD benefits claim, including a report signed by Dr. M.R. Mani of the Atlanta Pain Center. Dr. Mani observed that Mr. Oliver's reproductions on the pain drawing were concise and matched his complaints of pain. They did not appear to be histrionic or exaggerated. R3-61, Exh. 28 at TOL001206. His report concluded that Oliver suffered [a]djustment disorder with physical complaints and mixed mood, as well as upper torso, extremity and cervical pain; migraine headache. Id. at TOL001207. After receiving this additional information from Oliver, Broadspire again had Dr. Goldberg conduct a peer review. In pertinent part, Dr. Goldberg concluded: [T]he patient has complaints of severe neck pain without a true organic etiology being determined. An MRI scan of the thoracic spine is reported as normal and except for perhaps a disc bulge in the cervical spine, there is no evidence of major disc herniation. Basically, we have the patient's own subjective complaints of his particular pain and level of activity without any objective data to support this. Based on the above, the determination is made that the patient is not disabled from carrying out the duties of his job which is a sedentary position. R3-60, Exh. 26 at TOL000730. Dr. Goldberg did not examine Oliver as part of this peer review. Another Broadspire physician, Dr. Barry Glassman, submitted an evaluation form dated 16 April 2001 regarding Oliver's claim for LTD benefits. Like Drs. Moskowitz and Goldberg, Dr. Glassman did not examine Oliver. Dr. Glassman wrote that he had reviewed Dr. Mani's report concluding Oliver suffered from certain psychological disorders, and that it was his opinion that the psychological disorders at issue did not render Oliver disabled. Id. Dr. Glassman did not consider whether Oliver was physically disabled; rather, his report was limited solely to psychological issues. On 30 April 2001, Coca-Cola, through the Committee, denied Oliver's second-level appeal. The letter contained an itemized list of the materials reviewed by the Committee, but did not include the two EMG tests and the nerve conduction test submitted by Oliver, which supported the diagnosis of cervical radiculopathy. The letter from the Committee repeated Broadspire's frequent objection that Oliver had failed to submit objective evidence of his disability, and stated that a true organic etiology had not been determined for Oliver's severe neck pain. R3-61, Exh. 30 at TOL001223. The letter concluded with the statement that there is no objective evidence to support Mr. Oliver's subjective complaints. . . . Although Mr. Oliver may still require treatment for pain management, the existing medical documentation does not support his claim that he has a Disability, as defined in the Company LTD Plan. Id. at TOL001224.