Opinion ID: 620674
Heading Depth: 2
Heading Rank: 1

Heading: The medical evidence in the administrative record

Text: Jajuga worked for MBUSA from 1982 until 1997, first holding the position of National Business Management Manager, then a regional management position, and his position for the last year was classified as special assignments. The last day he worked was May 5, 1997, and he was then fifty-two years old. From May 6, 1997, until his death on December 31, 2008, Jajuga never returned to work at MBUSA or anywhere else. On May 13, 1997, a few days after leaving work, Jajuga had an MRI scan of his cervical and lumbar spine. A consultation report by Dr. Claude Borowsky written on April 17, 2002, describes the results of the scan: I have reports [on the MRI scan of May 13, 1997] which state the existence on the cervical spine of multi-level cervical spondylosis, moderate foraminal and lateral recess encroachment at C6-7, greater on the right than on the left and bulging discs at C5-6 and C6-7 with a disc herniation at C3-4. His MRI of the lumbar spine showed degenerative disc changes throughout the lumbar spine with especially advanced disc space collapse at L3-4. Bulging discs were noted at L3-4 and L5-S1. There was a disc herniation at L4-5. There was mild-to-moderate central canal narrowing at L3-4 and L4-5, moderate lateral recess narrowing at L3-4 and L4-5 and foraminal stenosis at L3-4 through L5-S1 bilaterally. On May 24, 1997, Jajuga was admitted for psychiatric hospitalization at the Valley Hospital in New Jersey for alcohol detoxification and depression. A Valley Hospital social worker wrote in Jajuga's progress report of May 26, 1997: Has not been to work in approx. 3 1/2 weeks due to back pain [and] is in [the] process of obtaining disability papers so he can receive short-term disability from employer. He is unsure about his future employment at Mercedes. Jajuga was discharged from his psychiatric care at the Valley Hospital on June 11, 1997. Dr. David Semar, the discharging physician, recorded a psychiatric diagnosis. [1] Dr. Semar also wrote up the following discharge plan: The patient will continue with outpatient treatment with Dr. Francis [a psychiatrist] and attend rehabilitation at Silver Hill. The patient will continue with AA. He will continue with medical follow-up with Dr. Scham and return to work as soon as possible. Diet will be regular. Activities will be normal. Jajuga did not return to work; he continued to see medical specialists and sought long-term disability benefits in 1997 and then the waiver of premiums at issue in 1998. A neurologist, Dr. Patricia Klein, completed two attending physician statements as part of Jajuga's applications for disability benefits. [2] On October 23, 1997, Dr. Klein completed an attending physician statement form in support of Jajuga's application for long-term disability benefits from MBUSA. On the form, Dr. Klein provided diagnoses, by code, of cauda equina syndrome, cervical disc disease with myelopathy, and spinal stenosis of the lumbar region. In the field for subjective symptoms, she wrote weakness and bladder and bowel incontinence. And in the field labeled objective findings, she wrote MRI 5/13/97. As to Jajuga's physical impairment, Dr. Klein checked the box for Class 5Severe limitation of functional capacity; incapable of minimum (sedentary) activity (75-100%). In response to the question, Is patient now TOTALLY disabled? Dr. Klein checked yes boxes for patient's occupation and for any other work. Dr. Klein also stated on the form that Jajuga was incapable of performing all duties, that he would never recover, and that he was not a candidate for rehabilitation. As recounted later, MBUSA found this evidence of disability adequate, allowed Jajuga's claim, and paid long-term disability benefits from at least October 1, 1997, until his death. Further, Prudential found that Jajuga met the conditions for waiver of premiums under his Individual Policy. Later, on March 30, 1998, Dr. Klein completed a separate attending physician's statement form, this one in support of Jajuga's claim for the waiver of premiums under the Group Policy at issue here. On the form, Dr. Klein stated that Jajuga had stopped working due to numbness in both legs [and] severe pain [in his] low back [and] legs and [a]cute [l]umbar [d]erangement. She wrote that the usual duration of the condition was [i]ndefinite. In response to the question, What work duties can employee perform? she wrote None; and as to the question, What duties can employee not perform? she wrote All. The report also stated that no changes would allow Jajuga to work at his own job or any other job and that he could not work while receiving treatment because he could not sit. For reasons attributable to Prudential and in violation of ERISA regulations, the report of the MRI of May 13, 1997, the records related to Jajuga's hospitalization for detoxification and depression, and the attending physician statements of Dr. Klein comprise the only evidence in the administrative record of Jajuga's medical condition roughly in the same period as when he stopped working in May of 1997. The administrative record contains a more detailed picture of Jajuga's health from 2002 until his death on December 31, 2008.