Opinion ID: 618491
Heading Depth: 3
Heading Rank: 1

Heading: Evidence Relied upon by the Plan

Text: I begin by assessing the evidence that, in the view of the Plan, calls Maher's limitations into question, the foremost of which is the alleged inconsistency between Maher's reported capabilities and the level of activity confirmed by surveillance. Liberty conducted surveillance of Maher on nineteen days between October 2002 and October 2006, portions of which were recorded on video.16 The Plan and its doctors highlighted a handful of examples of increased activity by Maher captured in the surveillance. On one occasion, Maher was observed walking to the front of her property carrying what appeared to be a flower / plant and a large bucket, and, four minutes later, walking back with the same bucket. On another, she drove herself a short distance (a fourminute drive) to a local school, where she went inside and returned carrying her son (then close to three years old), whom she placed inside the car before departing for her home. On a third occasion -- and the one on which the Plan places the most emphasis -- Maher's husband drove Maher and her son to a local soccer field on a Saturday morning. There, Maher was periodically observed as she and her husband flew a kite with the young boy, as she walked and jogged around the soccer field, and as she at one point lifted 16 This included six days of surveillance in 2002, three days in 2005, and ten days in 2006. -37- the small boy and swung him around in her arms. The outing lasted thirty-four minutes. This surveillance evidence does not have the significance that the Plan ascribes to it. In the activity questionnaires she submitted to Liberty, Maher consistently reported that the level of activity she can sustain is entirely dependent on her pain, nausea, and level of medication. For example, in her latest questionnaire, dated September 2006, Maher indicated that the amount of time she can tolerate sitting, standing, and riding in or driving a car depends on the presence of pain, nausea, vomiting, and diarrhea. She also noted that she leaves the house during the week two to three times a day (one to two times on weekend days), and that she helps take care of her children and perform small chores when she is able. As the majority points out, Liberty's surveillance is not inconsistent with Maher's own account of her activities. Over nineteen days of surveillance, there were a number of days in which Maher was confirmed to be at home and never left the residence. On other days, she left the house -- either as a passenger or driving herself -- to run a limited number of errands, mostly picking up or dropping off her children at school, and once to go to dinner at a restaurant. She was also observed outside on two brief occasions involved in what could generously be described as yard chores: carrying a flower pot and, on another occasion, sitting in the bed -38- of her husband's truck holding a broom or rake while her husband appeared to be cleaning up. All of this activity is consistent with her description of a low level of activity dependent on the ebb and flow of her symptoms. It would be unusual for a mother of three children to be able to avoid all activity. With regard to the kite-flying episode, which strays the farthest from Maher's reported limitations, Maher has indicated that the outing was a special event for which she premedicated with morphine. In other circumstances, this explanation might strain credulity. Here, however, the notion that Maher premedicates to prepare for activities that may trigger pain finds support in records that predate the incident.17 In a March 2003 activity questionnaire, for example, Maher noted that she travels by plane only with pre-medication for pain and nausea from increased cabin pressure on abdomen. In her September 2006 questionnaire, Maher also noted that her ability to carry out various activities of daily life always depend[s] on how much pain medicine I use . . . to help myself. Moreover, the entire outing 17 The district court concluded that, assuming that Maher's outing with her family can be explained by premedication, it is a reasonable inference that she could also pre-medicate to perform a sedentary job. I cannot agree. Maher takes a large amount of narcotics daily to address her background pain. The fact that she can, on top of this background dosage, take additional pain medications to ward off pain during the occasional short episodes of increased activity does not suggest that it would be feasible for her to regularly take extra medication to make it through an eight-hour workday. -39- at the athletic fields was very brief, lasting just over half an hour. It would be unfair to read too much into one short episode of increased activity, given the consistency of the larger record of surveillance with Maher's reported capabilities. Turning to an evaluation of the medical opinions concerning Maher's limitations, my conclusion again diverges from that of the Plan and its doctors. Among Maher's treating doctors, there is thin support for her capacity to return to a sedentary job. The most direct evidence is found in a questionnaire, completed by Dr. Gale Haydock, indicating that Maher is OK to perform sedentary duties. However, Dr. Haydock treated Maher only once, in the winter of 2006, when Maher was admitted to the hospital for several days to treat a flare-up of abdominal pain, and thus Dr. Haydock had no opportunity to observe the course of Maher's symptoms over time. One could also, as the Plan has, read various statements by Maher's primary care physician (Dr. Cuevas) to support Maher's ability to perform sedentary work. Most notably, in a conversation with Dr. Malinoff, Dr. Cuevas stated her agreement with Dr. Malinoff's opinion that, from a purely internal medicine perspective, there is no identifiable physical exam or anatomic / laboratory abnormality that would prevent [Maher] from working at a very minimum at a sedentary level. This awkwardly precise statement is technically true and is, undoubtedly, an accurate -40- reflection of Dr. Cuevas's medical opinion.18 It is also transparently misleading. Maher's medical records make clear that no doctor has been able to identify a physical or anatomic abnormality that causes her symptoms. However, the absence of a diagnosed medical condition says nothing about the reliability of Maher's complaints or whether her reported symptoms prevent her from working. On those questions, Dr. Cuevas's opinion is unequivocal. In a letter dated March 2007, Dr. Cuevas wrote that Maher remains in significant disability, both from her chronic pain and from the side effects the pain medication cause, and that she is unable to reliably perform duties because her pain can become so severe so quickly. Lastly, the record also contains opinions from the three doctors retained by the Plan -- Dr. Millstein, Dr. Malinoff, and Dr. Dean Hashimoto, Chief of Occupational and Environmental Medicine at MGH -- concluding that the available evidence does not support Maher's claimed inability to work a sedentary job. I find the opinions rendered by these doctors unpersuasive. Each doctor relied to a significant degree on the surveillance records in evaluating Maher's capabilities, focusing on the episodes of activity detailed above and finding them inconsistent with Maher's 18 Following their conversation, Dr. Malinoff mailed a letter to Dr. Cuevas that recapitulated the substance of their conversation and asked that she sign to verify its accuracy. She did so and returned the letter to Dr. Malinoff. -41- claims. Dr. Malinoff and Dr. Hashimoto also interpreted Dr. Cuevas's statements as supportive of Maher's ability to return to work. For the reasons stated, I have reached contrary conclusions based on the same evidence. Additionally, Dr. Hashimoto observed that, even accepting the veracity of Maher's reported symptoms, there has been no attempt to evaluate through neuropsych testing, scans, or other available means the extent to which Maher's pain and use of narcotics affect her cognition and ability to function. This failing can be attributed, to some degree, to the Plan's decision not to pursue an independent medical evaluation of Maher to assist in the assessment of her claim.19 Nevertheless, as I discuss below, I find the record evidence of Maher's limitations sufficient even absent the sort of testing suggested by Dr. Hashimoto. 19 Indeed, I find the Plan's failure to conduct an independent medical examination somewhat troubling. There is no requirement that a plan administrator arrange for a medical examination prior to terminating benefits, see Orndorf, 404 F.3d at 526, but here the circumstances certainly should have suggested its utility. As early as 2004, Dr. Millstein counseled that [i]f it is felt to be important to ascertain whether impairment due to abdominal pain exists, I would suggest consideration of functional assessment by some alternative means. After her benefits had been denied, Maher even offered to make herself available for a physical examination by a doctor of the Plan's choice. The record reflects that the Plan's administrators internally discussed the possibility of an independent medical examination in September 2007, but declined to pursue one due, in part, to concern for slowing down the process. -42-