Opinion ID: 173652
Heading Depth: 3
Heading Rank: 1

Heading: Analysis of the Plan and Medical Evidence

Text: Appellants argue that the administrative record supports Reliance’s determination that Gunn was not disabled. Appellants do not dispute that Gunn is unable to work due to a mental or nervous disorder, namely, severe depression, nor does Reliance dispute that Gunn suffers from multiple sclerosis and has some physical symptoms as a result of the disease. Appellants’ position is that the language of the mental illness exclusion required Gunn to show that he was totally disabled solely due to his physical condition stemming from his multiple sclerosis, without taking into account the disabling effects of any mental or nervous disorders. This interpretation of the limitation for mental and nervous disorders does not conflict with other Plan terms and is reasonable. The records of Gunn’s treating physicians support Reliance’s finding that Gunn’s multiple sclerosis alone was not disabling. In his treatment notes of April 9 9, 2001, Dr. Robert Andiman, M.D., a neurologist, stated that Gunn had “M.S. - no exacerbation.” Dr. Andiman’s notes of April 15, 2002, indicated that Gunn reported problems with balance, but his notes for May 13, 2002, reported that Gunn had completed seven physical therapy sessions and that his strength was improving. In his report of October 27, 2003, Dr. David W. Brandes, M.D., a neurologist, diagnosed Gunn as having a remitting/relapsing form of MS. In his treatment notes dated December 23, 2003, Dr. Brandes referred to Gunn’s multiple sclerosis as “mild.” Reliance also relied on the independent medical examination of Gunn by Dr. Carl Orfuss, M.D., a board-certified neurologist and psychiatrist, which included a physical examination of Gunn and a review of Gunn’s medical records. Dr. Orfuss noted that Gunn had physical impairment in the form of mild gait instability, which was not in itself a disabling symptom, and he expressed the opinion that Gunn would not be prevented by his multiple sclerosis from working at a sedentary job. Reliance also obtained a records review by Dr. William Hauptman, M.D., who is board certified in internal medicine, gastroenterology and quality assurance and utilization review. Dr. Hauptman opined that the medical records did not support impairment from sedentary work predicated upon Gunn’s multiple sclerosis. Some medical records stated that Gunn was disabled “both” as a result of 10 multiple sclerosis and depression. However, the use of the word “both” in these records could be interpreted as meaning that either severe depression or multiple sclerosis, viewed independently, rendered Gunn disabled, but also simply that multiple sclerosis and severe depression were two conditions which contributed to Gunn’s overall disability. The opinion that multiple sclerosis and severe depression, considered together, resulted in total disability is not sufficient to avoid the policy limitation precluding benefits where mental or nervous disorders caused “or contributed to” the applicant’s disability. Although Gunn’s treating physicians documented Gunn’s symptoms of multiple sclerosis, they never addressed the specific question of whether Gunn would meet the definition of total disability based solely on his multiple sclerosis without considering his severe depression. Gunn argues that even if his disability must be due solely to multiple sclerosis, his mental symptoms of depression and cognitive dysfunction were attributable to multiple sclerosis, a physical disease; therefore, these mental symptoms could be considered in establishing disability without violating the limitation for mental and nervous disorders. Under this interpretation, the mental illness limitation would only apply if the mental or nervous disorder causing or contributing to the participant’s disability was a condition totally independent from any depression, fatigue, and cognitive deficits that would normally occur when a 11 person suffers from multiple sclerosis or some other physical illness. The Plan definition says nothing about the mental or nervous disorder having to originate from a cause completely independent from the claimant’s physical illness. However, even assuming that Gunn’s interpretation of the mental illness limitation is correct, the medical records fail to establish that Gunn’s depression and cognitive dysfunction were solely attributable to his multiple sclerosis or attributable to a degree sufficient to result in disability based on the symptoms of multiple sclerosis. Although Dr. Michael P. Gross, Gunn’s treating psychiatrist, raised the issue of whether Gunn’s depression arose from his multiple sclerosis in his April 1, 2002, report , he reached no conclusion in that regard, stating, “It is not clear, and probably irrelevant, whether there is a direct neurological connection between the psychiatric symptoms and the multiple sclerosis for this patient.” On the questionnaire completed that same date, he stated that Gunn “has multiple sclerosis and mood and thinking difficulty” and that “multiple sclerosis contributes to mental picture,” thus suggesting that there were other causes for Gunn’s mental problems. The records of Dr. Brandes likewise do not establish that Gunn’s depression was solely attributable to his multiple sclerosis. In his report of October 27, 2003, Dr. Brandes stated that “the main cause of the disability is the MS related fatigue and cognitive dysfunction.” However, Dr. Brandes provided a 12 multiple axis diagnosis of: (1) relapsing-remitting multiple sclerosis; (2) severe depression; (3) fatigue secondary to #1; and (4) cognitive dysfunction secondary to #1 and/or #2. This diagnosis indicates that he viewed Gunn’s “severe depression” as a separate illness which was at least a contributing cause of Gunn’s cognitive dysfunction and disability. The fact that in his treatment notes of December 23, 2003, Dr. Brandes described Gunn’s multiple sclerosis as “mild” but noted that he had “severe depression” also indicates that he did not regard Gunn’s severe depression as being solely a symptom of his multiple sclerosis. In contrast, Dr. Orfuss diagnosed Gunn as being“severely disabled because of ongoing psychiatric illness manifested by severe depression, excessive fatigue, lack of energy, sleeplessness, etc.” Dr. Orfuss stated that he “would attribute [Gunn’s] disability ... to the psychiatric problem and not to the multiple sclerosis.” Dr. Hauptman agreed with the opinion of Dr. Orfuss that Gunn’s cognitive deficits were based on psychiatric disease and not on multiple sclerosis. There is additional evidence in the record which supports a finding that Gunn suffered from severe depressive and anxiety disorders of psychiatric origin which were independent of his multiple sclerosis, including: the finding of the Social Security Administration law judge that the severity of Gunn’s depression met the requirements for an affective disorder; the February 28, 2001, emergency 13 room records diagnosing severe anxiety disorder with catatonia; the March 8, 2001, diagnosis of depressive disorder given by psychiatrist Dr. Drest Gorchynski; Dr. Gross’s April 1, 2002, report stating that Gunn was “clinically depressed” and giving a diagnosis of bipolar disorder (there is no evidence in the record that multiple sclerosis can cause bipolar disorder); the April 29, 2002, diagnosis of severe depression offered by Dr. Leslie P. Weiner, a neurologist; and the December 23, 2003, treatment notes of Dr. Brandes, stating that Gunn suffered from severe depression. The record includes several reports indicating that Gunn had a documented history of depressive episodes long before he was diagnosed with multiple sclerosis, including one severe episode with suicidal thoughts while in his teens, which also supports a finding of a separate origin for his psychiatric problems. Reliance’s decision to deny benefits was grounded on a reasonable factual basis for concluding that Gunn’s multiple sclerosis alone was not disabling, and that, but for his psychiatric mental and nervous disorders, he would be able to work. Reliance adequately explained the reasons for its decision in its letters of September 10, 2003, and March 11, 2004, and demonstrated that it considered the evidence presented by Gunn. Reliance had discretion to weigh the conflicting evidence, and did not abuse that discretion in denying benefits. See Black & 14 Decker Disabil. Plan v. Nord, 538 U.S. 822, at 831-34 (2003).