Opinion ID: 172826
Heading Depth: 2
Heading Rank: 2

Heading: Review of the Administrative Record

Text: Resolving the Plan's ambiguity in Mr. Rasenack's favor, we proceed to our review of the record. The first piece of relevant information is a preadmission assessment dated June 20, 2003, performed by Nurse Karen Hildebrand from Craig Hospital. She noted that Mr. Rasenack had no volitional or spontaneous movement on his left side and only very limited movement in his right upper and lower extremities. On July 1, in a referral update, Nurse Hildebrand noted that Mr. Rasenack's left side remained plegic. On July 7, the date of Mr. Rasenack's admission to Craig Hospital, Dr. Weintraub wrote in the section entitled History of Present Illness: He is moving the right upper extremity more so than the lower extremity and does not move the left side.  Id. at 240 (emphasis added). In the Neurologic section, Dr. Weintraub recorded: The left upper extremity is plegic and spastic, held in an extensor position. Left lower extremity is plegic as well, spastic and hyperreflexic . . . . He had a painful sense with pressure throughout the entire left extremities. Id. at 243 (emphasis added). Under Impressions, Dr. Weintraub noted Mr. Rasenack's condition as bilateral hemiparesis, left worse than right. Id. [10] A brain injury evaluation performed by a physical therapist at Craig Hospital on October 10, 2003, noted that Mr. Rasenack required assistance for all functional mobility and had limited left upper extremity uses. Id. at 248. An Outpatient Rounds Note, dated October 21, 2003, describes Mr. Rasenack's progress after one week of outpatient care: PT reports that the patient is physically making good progress. He is now minimum assist for squat pivot transfers. . . . He is, in therapy, walking in the parallel bars for two lengths, which is approximately 30 feet, with minimum assistance and verbal cues. . . . The patient can do most self-care right-handed and uses his left for a stabilizer. Active movement is increased in his left upper extremity muscle groups, which is important as the patient was left dominant. Id. at 160 (emphasis added). In a Clinic Note dated November 12, 2003, Dr. Weintraub observed: Hans-Gerd is making nice progress. He is improving in his ambulation. He is still using an assistive device. He is starting to navigate stairs. He is gaining range of motion and strength of the left side. He still has limits in range of motion at the left elbow, left knee and ankle that in the future he may need some surgery in this regard. Id. at 154. On February 20, 2004, Dr. Weintraub noted, We discussed the eventual goal of household ambulation with a walker. . . . We anticipate the need for wheelchair use for longer distances, etc. over the next six months. Id. at 141. Nurse Kellianne Boris, hired by AIG to assist with the processing of Mr. Rasenack's claim, interviewed him in December 2004, seven months after the 365-day period had passed. Mr. Rasenack remained belted into a wheelchair for the duration of the interview, and Nurse Boris did not observe any leg movements. He did occasionally squeeze a therapy ball with his left hand, but she did not see him make any other motions with the left hand. Id. In correspondence with AIG, Nurse Boris advised that Dr. Weintraub used the term hemiparesis, but that it means the same as hemiplegia. Id. at 111. We turn next to the assessments of Dr. Weintraub, Mr. Rasenack's treating physician, and Drs. Ronald DeVere and James Sarno, the physicians hired by AIG to review Mr. Rasenack's file. When Dr. Weintraub was asked by AIG in October 2004 whether Mr. Rasenack suffered hemiplegia, he responded affirmatively, Yes, the accidental injury . . . did result in hemiplegia. Id. at 170. He stated that Mr. Rasenack's paralysis does appear to be complete and irreversible, although from a quantitative standpoint, he has benefitted from rehabilitation treatment. Id. In February 2005, AIG sought review from an outside physician. It sent Dr. DeVere the claim file as well as a series of questions to complete. We quote AIG's questions (indicated by italics) and Dr. DeVere's answers at length, as they are instructive: 1. Did Mr. Rasenack sustain any of the above paralysis conditions as a direct result of the May 21, 2003 accident? According to the medical records, the best that I can tell from the detailed review is that this claimant was comatose and very poorly responsive the first few weeks of his hospital stay after the injury. . . . It appears from his current evaluations and throughout his progress in the last couple of years, that he currently has a left hemiparesis involving the left arm and left leg. Hemiparesis is a weakness of the left arm and leg, or right arm and leg, i.e., weakness in one side of the body due to a disturbance in brain function. . . . He does not appear to be hemiplegic, which means no movement at all of the left or right side. . . . [I]t appears that the claimant has some movement and strength in [the] left arm and leg, which classifies the weakness as hemiparesis. 2. Did the paralysis occur within 365 days of the May 21 accident date? It appears that the hemiparesis, which is the term that I am using, occurred within 365 days of the May 21, 2003, accident date. 3. Does he have complete and irreversible paralysis of the entire limbs? . . . According to the recent notes of November of 2004[,] the claimant still continued to have hemiparesis. The exact details of that weakness are not evident on review of the record. There is no detailed evaluation of specific muscle groups in his left arm and leg in regard to how much weakness there is. Hemiparesis is the only term used. I cannot give you a definite description of function of his left arm and leg muscles because of the incompleteness of records available for my review at this time. After this length of time, which is almost two years, there is a remote possibility that he could make a little bit more improvement. But more likely than not, he would not improve much more in his weakness of his left upper and left lower extremities after the next months. 4. If the paralysis is not complete, but permanent, please indicate his level of functioning regarding activities of daily living, ambulation, and transfer? [M]ost likely his hemiparesis is likely permanent, but not complete. The exact level of functioning of his left arm and leg and capabilities is poorly described in the medical records that I have reviewed. The best I can state from the information available to me is that the claimant still requires continued assistance and supervision for all of his activities of daily living. . . . It appears that he has some function of his left upper and left lower extremities that enable him to assist in these activities of daily living. . . . Unfortunately, the specific functional abilities of his left arm and leg are not well documented or described in this record to give you any further information. . . . 6. One of the letters from the insurance company to one of the claim examiners asked about Dr. Weintraub's response that the accident resulted in hemiplegia with severe balance and coordination difficulties and the paralysis appears complete and irreversible. As stated previously, in all medical probability, I believe that the current state of the claimant is a hemiparesis, which I have already defined, and which may very well be complete and irreversible at this point in time, the beginning of 2005. Id. at 83-85. Dr. DeVere undoubtedly concluded that Mr. Rasenack suffered from hemiparesis, not hemiplegia, a distinction that became the basis for AIG's denial of Mr. Rasenack's claim. It is less clear whether or not Dr. DeVere considered Mr. Rasenack to be completely and irreversibly paralyzed. He did not say, for example in response to Question 2, that because Mr. Rasenack has hemiparesis, he is not paralyzed. Rather, Dr. DeVere predicts that the weakness will not improve much. Id. at 84. In response to Question 4, he indicated that the hemiparesis is permanent but not complete, but then later that it may very well be complete and irreversible. Id. at 85. Significantly, he stressed repeatedly that the records were insufficient regarding the exact level of functioning of Mr. Rasenack's left arm and left leg. Finally, the file Dr. DeVere reviewed did not contain the medical records from Craig Hospital dated June 20, July 1, and July 7, 2003, which were notable as early assessments of Mr. Rasenack's condition. AIG hired a second outside physician, Dr. Sarno, to review Mr. Rasenack's file while the appeal was pending. AIG asked Dr. Sarno whether the accidental injury resulted in hemiplegia. He responded: No. . . . This claimant is a hemiparetic with the left lower extremity worse than the left upper extremity. The left lower extremity is spastic and rigid and demonstrates a righting reaction which keeps him up. The left upper extremity is also spastic and limited. However, he is able to use it somewhat in helping the right side in various activities of daily living. Although he was a left handed individual prior to this[,] he can no longer use that left hand the way he did previously. Hemiplegic means paralysis of one side of the body. There was no paralysis of either side. He is able to use the left side. . . . The word hemiparesis applies to this situation. The fact that he had sensory loss has nothing to do with hemiplegia. That is a hemisensory dysfunction based on the injury to the sensory parietal cortex vs. the posterior frontal cortex for motor activity. Id. at 397. In response to the question, Is the paralysis complete and irreversible, Dr. Sarno concluded, The claimant has made significant strides. Nonetheless he has a significant hemiparesis on the left side. This will be permanent. He may have some slight improvement but beyond what he has presently I doubt that there will be much more improvement. Id. (emphasis added). In the comment section, Dr. Sarno wrote, This person is one who sit[s] on [the] cusp, enough to be called hemiparetic and not enough to be hemiplegic or uniplegic. He is . . . severely disabled and will be disabled permanent [sic] and totally but just outside the meaning of this policy. Id. at 398. Ms. Trioblet submitted a detailed affidavit regarding her husband's condition. She reported that he had no control over or sensation in the left side of his body during the 365 days following the accident. She explained that the references to movement in the medical record refer to therapists placing Mr. Rasenack's arms and legs in a passive motion machine. She provided the following chronology: At the time he transferred to Craig Hospital, [Hans-Gerd] could move only his right hand and occasionally but not consistently, he could twitch the toes of his right foot. The left side of his body, including left arm and left leg, remained paralyzed. . . . Throughout the 365 days after the accident, Hans-Gerd did not have muscular control or sensation in his left arm and left leg. . . . From a standing position, Hans-Gerd learned to lift his left foot off the floor and swing it forward with his hips. His left leg and left foot remain straight and stiff during this motion. He swings his left leg in a semi-circular arc so it lands in front. He maintains balance by grasping my shoulder with his right hand. Hans-Gerd uses his stiff left leg to bear weight like an amputee uses a prosthesis. This imitation of walking is only possible with assistance from me or a therapist. Using a walker for support, Hans-Gerd can move forward, if I am beside him or behind him to give verbal cues and prevent falls. Without a walker and human assistance, Hans-Gerd cannot walk. Id. at 222-23. The overall picture that emerges from the record is that Mr. Rasenack was unable to move his left arm and leg immediately after the accident but made some gains in mobility and strength as a result of intense physical therapy over the course of the year following the accident. In the letter to Mr. Rasenack denying his claim for benefits, AIG explained its decision: After careful review of the information received, we have determined that we must decline payment of this claim as there is no evidence in the information received that you sustained a complete and irreversible paralysis of your limbs. Rather, it appears that you have hemiparesis and are not paraplegic or hemiplegic. Id. at 69. AIG provided a similar explanation in its letter denying Mr. Rasenack's administrative appeal: The Committee reviewed the entire administrative records of this claim and concluded that the record contains substantial evidence that Hans-Gerd Rasenack did not sustain a complete and irreversible paralysis of his limbs. . . . Rather, it appears that he has hemiparesis and is not paraplegic or hemiplegic. Id. at 402. In the section entitled Pertinent Facts, AIG also noted, In addition, you failed to file the Proof of Loss and Notice within the time line set forth in the Policy and Summary Plan description. Id. at 402.