Opinion ID: 2821415
Heading Depth: 3
Heading Rank: 5

Heading: Shaw’s Appeal of the Denial of LTD Benefits

Text: On February 15, 2011, Shaw appealed the denial of his LTD benefits claim. Along with his appeal form, Shaw attached numerous exhibits documenting his condition, including the Michigan Disability Parking Placard signed and certified by Dr. Reincke, the Matrix Pain Management Clinic report, Dr. Reincke’s residual-functional-capacity questionnaire, and the medical records of Drs. Sciotti, Pasia, and Hoover. The functional-capacity questionnaire, provided by the Social Security Administration (“SSA”) to assess Shaw’s ability to work, was completed by Dr. Reincke on February 9, 2011. Dr. Reincke’s assessment showed that Shaw had persistent neck pain aggravated by prolonged sitting and standing. Dr. Reincke indicated that Shaw “[c]onstantly” had “pain or other symptoms severe enough to interfere with attention and concentration needed to perform even simple work tasks.” (R. 14-3, PageID 304 (emphasis in original).) Dr. Reincke noted that Shaw could sit or stand only for 30 minutes at a time and would need to lie down for an hour at a time to recuperate. In a typical eight-hour workday, Dr. Reincke said Shaw could stand or walk for less than two hours. Overall, Dr. Reincke said Shaw has “good days” and “bad days.” (Id. at 306.) No. 14-2224 Shaw v. AT&T Umbrella Plan Page 8 In addition to submitting these materials, Shaw requested an additional 30 days to submit further medical documentation. On February 21, 2011, Sedgwick sent Shaw a letter granting his request. On March 17, 2011, Shaw submitted additional medical documentation, including the entire examination report from the Matrix Pain Mangement Clinic, further records from Dr. Reincke, and records from Mercy Hospital. On March 21, 2011, Shaw also submitted an Employability Assessment by Jen Kaiser or Jennifer Turecki. The report states that Shaw’s “prognosis is poor. . . . [and he] experiences headaches with the pain level of 7 to 10 . . . 3 to 4 times per week, lasting 4 to 24 hours each occurrence.” (R. 14-10, PageID 604.) The report concludes that Shaw cannot engage in “competitive employment” because “[t]here is no competitive employment that allows an individual to lie down” or “allow[s] for missing more than 2 days per month.” (Id.) Sedgwick forwarded Shaw’s file to two independent physician advisors to perform a medical review: Dr. Imad Shahhal and Dr. Jamie Lee Lewis. On March 23, 2011, Dr. Shahhal, a neurosurgeon, called and left messages with Drs. Reinke and Hoover, requesting that they call back within 24 hours; otherwise, he would complete the report “based on available medical information.” (R. 14-10, PageID 614–15.) Drs. Reinke and Hoover did not call back in the time provided and Dr. Shahhal completed the report on March 28, 2011. After reviewing Shaw’s medical documentation, Dr. Shahhal concluded that Shaw was “not disabled from any occupation.” (Id. at 616.) As the rationale for this conclusion, Dr. Shahhal stated that “[a]lthough the patient does have evidence of cervical disc disease and radiculopathy over a prolonged period of time, the most recent examination of 9/03/10 showed a positive Spurling test on the right with normal strength, sensation, and reflexes.” (Id.) On March 23, 2011, Dr. Lewis, a specialist in physical medicine and rehabilitation and pain medicine, also called and left messages with Drs. Reincke, Smith, Payne, and Pasia, requesting that they call back within 24 hours; otherwise, he would complete the report “based on available medical information.” (Id. at 619–20.) They did not call back in the time specified and Dr. Lewis completed the report on March 28, 2011. After reviewing Shaw’s medical documentation, Dr. Lewis concluded that Shaw was “not disabled from any occupation.” (Id. at 621.) Dr. Lewis found that because Shaw decided against surgery, “medical documentation No. 14-2224 Shaw v. AT&T Umbrella Plan Page 9 would suggest noncompliance with medical care.” (Id. at 622.) Dr. Lewis further concluded that “[t]he above findings would not support a musculoskeletal condition that would preclude performance of sedentary work, nor is there evidence that performance of sedentary work would result in objectively measurable exacerbation of an underlying physical condition that would be expected to further exacerbate underlying pain level.” (Id.) While Sedgwick’s physician advisers conducted their review, on April 22, 2011, the SSA granted Shaw a “fully favorable decision.” (14-11, PageID 662.) The SSA found Shaw “disabled from July 31, 2009” as a result of “cervical herniation at C6-7 with radiculopathy, and degenerative disc disease at C5-6.” (Id. at 668, 670.) It further found that Shaw’s “medically determinable impairments could reasonably be expected to produce the alleged symptoms, and that [Shaw’s] statements concerning the intensity, persistence and limiting effects of these symptoms [were] generally credible.” (Id. at 671.) On April 28, 2011, Sedgwick sent Shaw a letter informing him that his claim for LTD benefits had been denied. Sedgwick found that Shaw did not provide “objective medical documentation” showing that he cannot engage in “any occupation or employment . . . for which [he] is qualified.” (Id. at 674.) Sedgwick stated that the QRU and two independent physician advisors reviewed all of the information supporting his claim, which included, among other things, documentation from Drs. Reincke, Pasia, Sciotti, Czuk-Smith, and Hoover. The letter also noted the transferable-skills analysis that identified three alternative occupations Shaw was qualified to perform based on his “training, education and experience.” (Id. at 675.) Accordingly, Sedgwick upheld the denial of Shaw’s LTD benefits.