Opinion ID: 204142
Heading Depth: 2
Heading Rank: 2

Heading: Richards' claim, termination and internal appeals

Text: Richards applied for long-term benefits in May 1991, at the age of thirty-nine. He cited chronic fatigue immune dysfunction and fibromyalgia as the causes of his disability, which left him unable to work after January 15, 1991. Prudential accepted Richards' claim in October 1991 and commenced paying benefits retroactive to July 1991. In 1992 Richards was awarded Social Security disability benefits. Since the Plan required proof of ongoing disability as a condition to continued receipt of benefits, Prudential regularly required Richards to provide a statement of his current condition and releases enabling Prudential to obtain his medical records. Although Richards occasionally balkedat least once referring to the requests as harassmenthe uniformly complied with Prudential's requests, and his benefits continued apace. In January 2001, Prudential, using releases provided by Richards a month earlier, requested medical records from three treating physicians Richards had previously identified in his periodic submissions to Prudential. The records request covered the period from January 1999 forward. On February 5, 2001, one of the physicians, Dr. Carol Englender, reported that she had not seen Richards in her office since prior to January 1999. A few weeks later, in response to Dr. Englender's information, and consistent with plans to review Richards' claim developed in March 2000, Prudential sought an independent review of Richards' claim from Dr. Gwen Brachman, whose practice included internal medicine, rheumatology and occupational medicine. After reviewing Richards' medical history, Dr. Brachman submitted a report to Prudential, concluding that although Richards qualified for a diagnosis of fibromyalgia, he was not physically impaired from performing the essential functions of a sedentary job. Relying on Dr. Brachman's report, Prudential informed Richards on March 26, 2001 that he was no longer eligible for long-term disability benefits and that payments would cease as of June 1, 2001. The letter terminating Richards' benefits also contained information about the appeals process, as did a follow-up letter sent approximately one month later. Over the next three years, Richards contacted Prudential on numerous occasions. Many of the calls were requests for details on the appeals process. Others were direct requests to immediately reinstate his benefits while he prepared his appeal. Still other calls contained accusations by Richards of Prudential's professional malfeasance and threats to bring Prudential's alleged misconduct to the attention of entities ranging from the federal government to television exposé programs. On July 26, 2004, Richards submitted a formal written appeal of Prudential's March 2001 decision. He set forth three arguments for reinstatement of his benefits: first, that Dr. Brachman was not only unqualified to review his disability, but that she also used improper evaluation techniques and made false statements in her review; second, that Prudential should have deferred to the opinions of Richards' treating doctors; and third, that Prudential should have given deference to the 1992 decision of the administrative law judge who awarded Richards Social Security disability benefits. Prudential denied the appeal by letter dated September 28, 2004. Responding to Richards' specific complaints, Prudential noted that Dr. Brachman specialized in occupational medicine and rheumatology, and was thus qualified to review Richards' medical records, his diagnoses of fibromyalgia and chronic fatigue, and to offer an opinion on his ability to work. Prudential further noted that it did take the Social Security determination into consideration, but that Prudential's determinations are independent from the agency's. Prudential also indicated that it had reviewed Richards' records before making its original determination in 2001, and since three years had passed, it also considered additional records that Richards had provided since the decision. Finally, Prudential buttressed its decision by pointing to a transferable skills analysis that concluded that Richards could perform a number of sedentary occupations which fit within his education, training or experience. In response to the September 28, 2004 letter, Richards submitted a letter and additional records from one of his treating physicians, Dr. Mark Hryniewich, and requested that Prudential again review its decision. On February 8, 2005, following review of the additional materials, Prudential again informed Richards that its original decision was correct. The February 2005 letter also instructed Richards about his rights to pursue further appeals. Richards availed himself of this opportunity by submitting his second written appeal in August 2005. This appeal set forth three chief claims. First, Richards accused Prudential of ignoring Dr. Hryniewich's opinion that Richards' fibromyalgia had left him chronically disabled. Richards also protested the fact that Prudential did not contact Dr. Hryniewich personally. Finally, Richards claimed that Prudential's benefit termination notification was legally deficient because it lacked detailed instructions on how to appeal and explicit instructions about the particular information Richards would need to supply to get his benefits reinstated. In response, Prudential conducted another review, and again affirmed the decision to terminate Richards' benefits. Relying on a medical record review performed by its Medical Director, Dr. Richard Day, Prudential reiterated its finding that Richards could perform the duties of a sedentary job for which he was qualified. The denial letter also noted that previous neurological assessments Richards had undergone were completely normal, as were laboratory findings, and there were no rheumatological laboratory or physical findings consistent with synovitis or an inflammatory process. [4] Additionally, Prudential informed Richards of Dr. Day's opinion that any treatment he was receiving for chronic fatigue syndrome was incomplete, given the lack of cognitive behavioral therapy. [5] In connection with Dr. Day's report, Prudential also referred back to the transferable skills analysis performed the previous year, which identified a number of sedentary positions suitable for Richards, given what Prudential contended was his residual functioning capacity. Richards, this time through counsel, availed himself of Prudential's final level of appeal on January 30, 2006. In addition to repeating the claim that Richards was in fact totally disabled from performing any occupation, the appeal alleged that the previous rejectionthe September 29, 2005 decisiondid not set forth with the required specificity the reasons that Richards' benefits were discontinued. Also, Richards took issue with Dr. Day's reference to cognitive behavior therapy, likening it to years ago, [when] epileptics were locked away in institutions for the mentally insane. Finally, Richards' attorney asked to meet with Prudential's appeals committee prior to its decision. Although the substantive decision on Richards' last appeal was still months away, Prudential responded quickly to his attorney's missive. In a letter dated February 6, 2006, Prudential expressed its view that its various benefit termination letters adequately detailed the reasons for its decisions. Specifically, Prudential noted that its letters cited policy provisions, medical reviews and vocational assessments. Additionally, Prudential rejected Richards' demand that it contact his physicians, as it was not contractually obligated to do so and because it was unnecessary given the information already in his medical file. Further, Prudential rejected Richards' attorney's request to appear before the appeals committee, as that committee doesn't `meet' with claimants or their representatives; rather the panel provides a third and voluntary level of appeal review. Prudential originally set an April 1, 2006 deadline for Richards to submit materials in support of his final appeal. Due to various communication breakdowns regarding deadlines, Prudential extended the deadline to June 2006. Richards used the additional time to supplement the record. [6] In a letter dated June 5, 2006, one day before the deadline, Richards' attorney submitted a report from Dr. Hryniewich, dated the same day, in which he opined that Richards has been totally and permanently disabled from engaging in and maintaining any gainful employment activity since 1991, up to and including the present, and further, it is likely that his total and permanent disability will continue for the foreseeable future. Dr. Hryniewich noted that Richards tested positive for fibromyalgia, and that while symptoms could be treated with pain medication, side effects made his return to gainful employment impossible. [7] During the pendency of Richards' final appeal, Prudential sought additional medical record reviews from two rheumatologists. One of these reviews, from Dr. Paul Howard, took place after receipt of Dr. Hryniewich's June 5 report. On July 18, 2006, Prudential informed Richards' attorney of its determination that the decision to terminate Richards' benefits in 2001 was appropriate. After rehashing some of the lengthy procedural history of the case, the denial letter detailed the findings of Dr. Howard and Dr. Dayton Dennis Payne, who reviewed Richards' records in April 2006. Dr. Payne's report noted Richards' diagnoses of chronic fatigue syndrome, chronic fatigue immune dysfunction syndrome and fibromyalgia. He also noted Richards' myriad other symptoms, including short-term memory issues, irritable bowel syndrome, depression and possible bursitis. Dr. Payne found that Richards' records showed that his symptoms had remained essentially unchanged over the fifteen years since he began receiving benefits, and also noted the statements by others that he would never be able to return to gainful employment. Dr. Payne also determined, however, that he could find no evidence of destructive rheumatic findings, or that Richards had limitation of motion in his joints, weakness or atrophy, or specific organ system abnormalities. In light of these findings, Dr. Payne concluded that: 1) the records did not support a finding of functional impairment existing from June 2001 forward; 2) the records contained no objective evidence of any disease process that would be expected to lead to any restrictions or limitations; 3) while there was no evidence of malingering, no physical examination or testing procedure revealed objective evidence of impairment; and 4) because the objective findings did not support any degree of restrictions or limitations, Richards would be expected to have age-appropriate functional capacity. Dr. Howard's report, dated July 6, 2006, noted that Richards' rheumatological symptoms between 2001 and 2006 were consistent with fibromyalgia, but that the resulting functional impairments were mild in nature. Dr. Howard noted the 1991 opinions from Dr. O'Leary and Dr. Englender that posited that Richards' symptoms should allow him to eventually return to work. Dr. Howard also pointed out that a comprehensive physical examination conducted by Dr. Hryniewich in 2001 contained normal neurological findings, with no indication of any reported physical examination abnormalities. Regarding Dr. Hryniewich's June 2006 letter, Dr. Howard implied that its conclusion of total disability was somewhat suspect, given that a November 2005 examination yielded normal results, other than a complaint of foot pain. Additionally, Dr. Howard noted that while Dr. Hryniewich's letter cited side-effects of pain medication, the medical records themselves lacked any reference to side effects. Moreover, Dr. Howard suggested that Richards' non-compliance with recommended exercise programs deprived him of an opportunity to improve his functional capacity. Relying on what he described as an absence of any abnormalities by radiological study, laboratory studies and ... repeated physical examinations, Dr. Howard expressed his opinion that Richards, despite a mild degree of impairment, would be able to perform sedentary work involving sitting, walking occasionally, standing frequently, lifting ten pounds frequently (occasionally twenty), working at a desk, and using his hands and fingers without restriction. As noted, Prudential, relying in large measure on the opinions of Drs. Payne and Howard, rejected Richards' final appeal, concluding that the medical evidence overwhelmingly supports that Mr. Richards has been capable of returning to work on a full time basis in both his own occupation as well as in an alternate, gainful occupation since at least June 01, 2001.