Court Opinion

ID: 2968366
Source: CourtListenerOpinion
Date Created: 2015-09-22 04:58:25.761846+00
Date Added: 2024-06-11T11:43:18.457088
License: Public Domain

PUBLISHED

UNITED STATES COURT OF APPEALS
                FOR THE FOURTH CIRCUIT

DEBORAH DONOVAN,                        
               Plaintiff-Appellee,
                 v.
                                                  No. 05-2243
EATON CORPORATION, Long Term
Disability Plan,
                 Defendant-Appellant.
                                        
            Appeal from the United States District Court
          for the District of South Carolina, at Greenville.
                Henry M. Herlong, Jr., District Judge.
                          (CA-05-217-HMH)

                        Argued: May 22, 2006

                      Decided: September 5, 2006

      Before WIDENER and MICHAEL, Circuit Judges, and
    Joseph R. GOODWIN, United States District Judge for the
     Southern District of West Virginia, sitting by designation.

Affirmed by published opinion. Judge Widener wrote the opinion, in
which Judge Michael and Judge Goodwin concurred.

                             COUNSEL

ARGUED: Jeffrey David Zimon, BENESCH, FRIEDLANDER,
COPLAN & ARONOFF, L.L.P., Cleveland, Ohio, for Appellant.
Robert Edward Hoskins, FOSTER LAW FIRM, L.L.P., Greenville,
South Carolina, for Appellee. ON BRIEF: Anna K. Raske, Tamara
2                      DONOVAN v. EATON CORP.
L. Karel, BENESCH, FRIEDLANDER, COPLAN & ARONOFF,
L.L.P., Cleveland, Ohio, for Appellant.

                              OPINION

WIDENER, Circuit Judge:

   Eaton Corporation appeals the district court’s order reversing its
decision to deny Deborah Donovan long term disability benefits
under an ERISA plan pursuant to 29 U.S.C. § 1132(a)(1)(B). The
issue before this court is whether Eaton, which makes its own ERISA
decisions, made a reasonable decision to deny Ms. Donovan’s claim.
Because we find Eaton did not act reasonably in denying Ms. Dono-
van long term disability benefits, we affirm.

                                  I.

   Ms. Donovan worked for Eaton Corporation ("Eaton") in Green-
ville, South Carolina, as an in-put shaft operator. In 1993, Ms. Dono-
van quit working because of degenerative disc disease and chronic
back pain. At that time she filed a claim for long term disability
("LTD") benefits, and the Eaton Corporation Long Term Disability
Plan ("the Plan") paid her LTD benefits for a period of ten years. The
Plan is self-insured and administered by Eaton. Broadspire Services,
Inc., ("Broadspire") is the Plan’s claims administrator and was hired
by Eaton to process and review disability claims and decide initial
appeals of the denial of disability benefits.

   Broadspire periodically reviews a claimant’s entitlement to bene-
fits. In February 2004, Broadspire reviewed and denied Ms. Dono-
van’s claim for disability benefits, alleging that there was
"insufficient objective clinical documented [evidence] to support a
level of functional impairment that would render [Ms. Donovan]
unable to perform any occupation."

    The relevant Plan language reads as follows:

      You are considered to have a covered disability . . . under
      the Plan if:
                      DONOVAN v. EATON CORP.                         3
                                 ...

    • During the continuation of such total disability following
      the first 24 months, you are totally and continuously
      unable to engage in any occupation or perform any work
      for compensation or profit for which you are, or may
      become, reasonably well fitted by reason of education,
      training or experience—at Eaton Corporation or else-
      where.

   Prior to the review and denial, Ms. Donovan submitted a June 15,
2003, statement of her treating physician, Dr. Larry Smith, which
indicated that she had low back pain and leg pain and was disabled.
Ms. Donovan also provided evidence that she was approved for
Social Security disability benefits and submitted her own statement
noting that she had undergone four back surgeries to repair herniated
disks.

   Broadspire reviewed Ms. Donovan’s medical records and con-
cluded that her condition had improved. It relied on Dr. Smith’s medi-
cal records dated May 3, 2000, December 27, 2001, April 16, 2002,
August 6, 2002, and July 24, 2003, indicating that Ms. Donovan was
doing well, was improving, and had no significant complaints or
problems. Further, Ms. Donovan stated in Eaton’s long term disability
questionnaire dated March 28, 2001, that she was able to bathe, walk,
and dress herself. On June 12, 2003, she stated in a resource question-
naire that she was able to perform back exercises and drive to the
store and the doctor’s office. Finally, Ms. Donovan underwent a func-
tional capacity evaluation in December 2003, which suggested that
she could perform light work for eight hours a day.

   Dr. Tamara Bowman, a Broadspire in-house peer reviewer special-
izing in internal medicine, reviewed Dr. Smith’s records from April
2002 to September 2003, the resource questionnaire, and Dr. Smith’s
July 15, 2003, statement. In her review dated December 10, 2003, Dr.
Bowman concluded that there were insufficient objective clinical
findings to support the conclusion that Ms. Donovan was unable to
perform any occupation. Specifically, Dr. Bowman found that "al-
though the claimant is noted to have low back and leg pain, there was
no documentation of objective muscle weakness, signs of radiculo-
4                     DONOVAN v. EATON CORP.
pathy, abnormal gait-joint deformity or effusion or synovitis." She
also found that there was "no documentation of any radiographic
abnormalities, and no evidence of a herniated disc or spinal canal ste-
nosis." Broadspire issued a denial letter on February 10, 2004, and
indicated that, based on an employability assessment report, Ms. Don-
ovan could work as a claims clerk, waitress, and counter attendant in
a cafeteria.

   On April 30, 2004, Ms. Donovan requested an appeal of her claim.
She supplemented her file with medical records from Dr. John A.
Welshofer of Total Spine Specialists dated March 4, 2004, indicating
that examination and x-rays of her lumbar spine revealed that she suf-
fered from "probable chronic permanent lumbar radiculopathy, severe
lumbar degenerative disc disease status post surgery x4, [and] cervical
degenerative disc disease." Further, she provided a statement dated
April 8, 2004, from Dr. Welshofer that there was "objective evidence
of chronic radiculopathy on electrodiagnostic testing." Dr. Welshofer
further stated that Ms. Donovan could not lift, pull, push or carry
more than 10 pounds, could perform occasional bending, could per-
form "[n]o stooping, squatting, kneeling or repetitive motion about
the lumbar spine," could only stand, sit or walk for 15 or 20 minutes
at a time without changing positions or resting, and that she would
require intermittent leaves of absences from work for physical therapy
and steroid injections. In sum, Dr. Welshofer concluded that Ms.
Donovan could only perform a sedentary occupation with the above-
listed limitations.

   Dr. Martin Mendelssohn, another Broadspire in-house peer
reviewer specializing in orthopedic surgery, concluded in his review
on May 28, 2004, that Ms. Donovan was not precluded "from per-
forming any occupation effective 03/01/04 provided it is sedentary in
nature with restrictions as outlined by her treating physician." Dr.
Mendelssohn found that there was no evidence of peripheral neuropa-
thy or other nerve damage. As such, on June 3, 2004, Broadspire
again denied Ms. Donovan’s claim on appeal, concluding that there
was insufficient objective medical evidence to support a finding that
Ms. Donovan was entitled to LTD benefits.

   On June 21, 2004, Ms. Donovan filed a second appeal. She submit-
ted an affidavit outlining her subjective complaints about her daily
                      DONOVAN v. EATON CORP.                        5
activities. Further, Ms. Donovan challenged Broadspire’s functional
capacity evaluation, which concluded that she was able to work eight
hours a day, contending that the evaluation only lasted several hours,
and she was unable to do anything the next day because she was sore.
As such, she alleged, the evaluation only established that she could
perform certain tasks on a good day.

   Ms. Donovan also provided an electrodiagnostic report dated July
22, 2004, indicating that she suffered from "mild to moderate [right]
median nerve entrapment at the wrist and mild R C6 radiculopathy."
Further, she submitted July 2004 radiology reports, as well as Dr.
Welshofer’s notes indicating that she had radiating symptoms down
her arm and paresthesias. The July 13, 2004, MRI of Ms. Donovan’s
cervical spine found "moderate to marked degenerative changes of the
cervical spine most prevalent at C5-6 resulting in mild spinal cord
compression." As a result of the July 2004 findings, Dr. Welshofer
referred Ms. Donovan to a surgeon, Dr. Robert E. Lins, for evaluation
on July 22, 2004. In addition to Dr. Welshofer’s notes, Ms. Donovan
submitted Dr. Lins’ notes indicating that her MRI of July 13, 2004,
found marked spinal canal stenosis at C5-C6.

   On August 17, 2004, Ms. Donovan submitted Dr. Welshofer’s affi-
davit in which he opined that, as a result of her condition, Ms. Dono-
van has been totally disabled since 1993 and could not perform any
job on a full-time basis. Moreover, Dr. Welshofer declared that the
functional capacity evaluation was not "an accurate indicator of [Don-
ovan’s] ability to work on a consistent basis or her disability."

   Dr. James Wallquist, a third Broadspire in-house peer reviewer
specializing in orthopedic surgery, concluded in a review dated
August 30, 2004, that residual cervical and lumbar radiculopathy
were not sufficient objective findings to support the conclusion that
Ms. Donovan could not perform any occupation in light of the func-
tional capacity evaluation and Dr. Welshofer’s April 2004 statement.
Dr. Wallquist noted in his review that Dr. Smith did not perform a
neurological exam, and that Ms. Donovan’s pain was not quantified.
In addition, Dr. Wallquist stated that Dr. Smith’s notes were silent
regarding any "spasm or gait analysis or tension signs."

  On September 24, 2004, Ms. Donovan underwent "C4-C5 and C5-
C6 anterior cervical diskectomies and foraminotomies, placement of
6                      DONOVAN v. EATON CORP.
interbody device at C4-C5 and C5-C6 with Cornerstone allograft and
anterior cervical plating . . . at C4-C5 and C5-C6." Dr. Wallquist’s
final conclusion after reviewing the medical records concerning Ms.
Donovan’s surgery was that "the documentation would not support a
functional impairment that would preclude this claimant from engag-
ing in any occupation from 3/01/04 through 9/22/04 prior to cervical
surgery. The documentation would support impairment from any
occupation, from 9/23/04 through the present, while recovering from
cervical surgery."

   An independent orthopedic surgeon who reviewed Ms. Donovan’s
records for Broadspire found in a December 20, 2004, report that
there was no evidence that Ms. Donovan could not perform any occu-
pation as of March 1, 2004, when the denial of her disability benefits
was effective. Thus, Broadspire denied Ms. Donovan’s second appeal
and issued a final denial letter on January 11, 2005. Litigation in the
district court ensued.

   The district court found that Eaton’s decision to deny Ms. Donovan
LTD benefits was unreasonable. Further, the district court found, in
light of Dr. Welshofer’s affidavit and the medical evidence from July
to September 2004, Eaton’s decision was not supported by substantial
evidence in the record. Thus, the district court found that Eaton
abused its discretion in denying Donovan LTD benefits. The district
court reversed the denial of LTD benefits and ordered the Plan to pay
LTD benefits to Ms. Donovan. This appeal by Eaton followed.

                                  II.

                                  A.

   Following an established framework for reviewing the denial of
disability benefits, we review the district court’s decision de novo.
Feder v. Paul Revere Life Ins. Co., 228 F.3d 518, 522 (4th Cir. 2000);
Ellis v. Metropolitan Life Ins. Co., 126 F.3d 228, 232 (4th Cir. 1997).
A reviewing court must initially decide de novo whether the ERISA
plan’s language grants the plan administrator discretion to determine
the claimant’s eligibility for benefits, and if so, whether the adminis-
trator acted within the scope of that discretion. See Haley v. Paul
Revere Life Ins. Co., 77 F.3d 84, 89 (4th Cir. 1996). If the reviewing
                       DONOVAN v. EATON CORP.                           7
court determines that the language of the plan confers discretion on
the administrator to determine eligibility, then a court reviews the
decision to deny benefits for abuse of discretion. See Firestone Tire
and Rubber Co. v. Bruch, 489 U.S. 101, 111 (1989); Ellis, 126 F.3d
at 232. This deferential standard of review requires that a reviewing
court not disturb an administrator’s decision if it is reasonable, even
if the court would have reached a different decision. See Bruch, 489
U.S. at 115; Haley, 77 F.3d at 89.

   We will find discretionary authority in the administrator if the
plan’s language expressly creates discretionary authority, such as in
this case. The Plan provides Eaton, as the Plan Administrator, shall
have "sole authority to control and manage the operation and adminis-
tration of the Plan," as well as the "sole and absolute authority and
responsibility for construing and interpreting the provisions of the
Plan." Accordingly, we may not disturb a long term disability deter-
mination made by Eaton in its capacity as Plan Administrator so long
as its decision is reasonable. If, however, a coverage decision is
unreasonable, then Eaton has abused its discretion, and such an abuse
warrants reversal of an affected coverage determination. See Booth v.
Wal-Mart Stores, Inc. Assocs. Health & Welfare Plan, 201 F.3d 335,
342 (4th Cir. 2000); Feder, 228 F.3d 522.

   The parties do not dispute and the district court so found that the
Plan confers discretion upon the Administrator. The Plan argues,
however, that the district court decided this case without the benefit
of Colucci v. AGFA Corp. Severance Pay Plan, 431 F.3d 170 (4th
Cir. 2005). In Colucci, this court determined that a conflict of interest,
in which a plan’s administrator is also its funder, should not cause the
court to reduce deference to the administrator. The Plan contends that
the district court incorrectly applied a modified abuse of discretion
standard and encourages us to review independently of the district
court’s findings. Bynum v. Cigna Healthcare of North Carolina, Inc.,
287 F.3d 305, 312 (4th Cir. 2002). Conceding that a conflict of inter-
est should not be a factor in reducing deference in light of Colucci,
Ms. Donovan argues first that it is unclear whether or not the district
court reduced deference. Second, and more importantly, Ms. Donovan
contends, the issue in this case is whether the Plan’s denial of benefits
to Ms. Donovan was supported by substantial evidence in the record.
8                     DONOVAN v. EATON CORP.
She argues it was not; thus, the Plan’s decision was unreasonable and
an abuse of discretion. We agree.

                                  B.

   Ms. Donovan stopped working in 1993 because of degenerative
disc disease and chronic back pain. The Plan paid her LTD benefits
for ten years. She was awarded Social Security disability benefits in
August 1994 for impairments considered to be "severe" under the
Social Security Act and Regulations: three failed back surgeries and
chronic back and leg pain.

   Finding "insufficient documentation of a functional impairment
that would preclude [her] from the job duties of any occupation,"
Broadspire denied Ms. Donovan’s entitlement to benefits in February
2004. Broadspire acknowledged Dr. Smith’s Attending Physician’s
Statement of June 2003 indicating Ms. Donovan had low back pain
and leg pain and that she is disabled, but pointed out that Dr. Smith
did not note any objective findings. Broadspire also noted Ms. Dono-
van’s history of failed back surgery on three occasions. Relying on
the peer reviewer’s opinion, the Functional Capacity Evaluation, an
Employability Assessment, and a labor market survey, Broadspire
stated that there were numerous positions "in keeping with [her] phys-
ical capacity, and numerous positions . . . available in the labor mar-
ket in [her] area."

  Dr. Bowman, in-house peer reviewer, emphasized the lack of
objective findings in Ms. Donovan’s medical records, stating:

    In the submitted records, although the claimant is noted to
    have low back pain and leg pain, there is no documentation
    of objective muscle weakness, signs of radiculopathy,
    abnormal gait, joint deformity or effusion, or synovitis.
    There is no documentation of any radiographic abnormali-
    ties, and no evidence of a herniated disc or spinal canal ste-
    nosis.

Dr. Bowman also referenced Ms. Donovan’s answers on a Resource
Questionnaire dated June 12, 2003, noting:
                      DONOVAN v. EATON CORP.                          9
    she is able to cook, do shopping, do laundry, and clean the
    dishes, on a regular basis. She is able to perform all of her
    activities of daily living, and she still drives. These capaci-
    ties are compatible of performance of a sedentary or light
    level of work.

   This recitation of the evidence ignores Ms. Donovan’s statements
that she suffers from "chronic pain in [her] neck, back, and legs." In
her affidavit she states she is also plagued by "profound fatigue" and
she has "difficulty sleeping" which "also contributes to [her] severe
fatigue." Moreover, Ms. Donovan states that she "cannot sit, stand, or
walk for any period of time without having to change positions
because of the severe pain" in her neck, back and legs. She also sub-
mits that the results of the Functional Capacity Evaluation do not
reflect her ability to work. After the test was administered, Ms. Dono-
van was "still sore the next day and [she] did nothing the next day."
She states that the evaluation "measured what [she] could do for the
very brief window of time that [she] was present with the evaluator."

   Further, the peer reviewer disregarded Ms. Donovan’s qualification
of her activities on the Resource Questionnaire. Ms. Donovan said she
does daily back exercises; she has difficulty sleeping because of pain
and numbness; and, she only drives to the drug store, grocery store,
and doctor. Also, she does not climb stairs, dust, vacuum, or garden
on a regular basis. Based on the evidence as a whole, it was unreason-
able for the Plan to deny benefits to Ms. Donovan.

   Subsequently in May 2004, Dr. Mendelssohn, a second in-house
peer reviewer, made similar determinations, concluding "the docu-
mentation does not reveal a functional impairment that would pre-
clude the claimant from performing any occupation effective 03/01/04
provided it is sedentary in nature with restrictions as outlined by her
treating physician." Dr. Mendelssohn’s determinations, as well as the
determinations of a third peer reviewer, Dr. Wallquist, were based
primarily on an evaluation done by Dr. Welshofer at Total Spine Spe-
cialists on March 4, 2004. Dr. Mendelssohn noted that Dr. Welshofer
"did not feel any additional surgical intervention would be warranted
and felt that the claimant would be able to function within a sedentary
capacity." Dr. Welshofer’s opinion of Ms. Donovan is a source of
10                       DONOVAN v. EATON CORP.
controversy in this case because he changed his position in an affida-
vit dated August 17, 2004.*

   Dr. Wallquist was called upon again in November 2004 to review
Ms. Donovan’s case. He acknowledged Dr. Welshofer "concluded
that he did not feel the claimant could perform in any type of seden-
tary job on a full-time and consistent bases." Dr. Wallquist goes on,
however, to say, "[t]here were no updated quantitative objective phys-
ical findings referenced in that affidavit to support a change in posi-
tion from 4/08/04 to the time of the affidavit of 8/17/04 to support his
conclusions."

   Ms. Donovan’s July 2004 radiology reports revealed that she had
stenosis, spinal cord compression, right median nerve entrapment in
her wrist, and R C6 radiculopathy. This discovery in July of cervical
back problems, in addition to Ms. Donovan’s severe low back prob-
lems, lends substantially greater weight to Dr. Welshofer’s affidavit
in August 2004 than his April 2004 statement. Moreover, Dr. Wel-
shofer’s change of opinion would be entirely consistent with a wors-
ening condition, from which Ms. Donovan suffered to the point of
surgery on September 23, 2004. In his affidavit, Dr. Welshofer states,

     The nature of Ms. Donovan’s problems are such that she has
     good days and bad days. On a good day Ms. Donovan can

   *The Plan makes much of Dr. Welshofer’s notes from April 8, 2004,
in which he states that Ms. Donovan could perform sedentary work with
certain limitations. The Plan fails to address Dr. Welshofer’s entire state-
ment, in which he says, "I certainly don’t feel that the patient will qualify
for any light, medium or heavy duty occupation. It would have to be an
occupation within the sedentary level as mentioned above with the afore-
mentioned accommodations." The restrictions included:
     (1) The patient should [not] lift, pull, push or carry greater than
     10 pounds; (2) Only occasional bending; (3) No stooping, squat-
     ting, kneeling or repetitive motion about the lumbar spine; (4)
     No prolonged sitting, standing or walking for more than 15 or 20
     minutes at a time without a change in positions or rest; (5) The
     patient, based upon Americans with Disabilities Act may require
     intermittent leaves of absences for treatment to include: either
     physical therapy and possible epidural steroid injections.
                       DONOVAN v. EATON CORP.                          11
     perform as [she] did during the Functional Capacity Evalua-
     tion. However, if she does exert herself to that extent then
     it is likely that [she] will need several days of complete
     inactivity to recover. Additionally, the Functional Capacity
     Evaluation does not accurately measure or evaluate the type
     of fatigue which is frequent and severe with persons suffer-
     ing from Ms. Donovan’s conditions.

The Functional Capacity Evaluation, in Dr. Welshofer’s words, "is
not an accurate indicator of her ability to work on a consistent basis
or her disability." He also opined that her condition may become
worse as she ages. Further, Dr. Welshofer stated, "Ms. Donovan’s
problems do consist of real medical conditions and subjective symp-
toms caused thereby. The nature of those problems are such that it is
not reasonable to expect that a person suffering from Ms. Donovan’s
conditions could be able to work on a full-time consistent, or continu-
ous basis at any occupation." Dr. Welshofer concludes:

     It is my opinion, based upon my medical education and
     experience and based upon my specific knowledge of Ms.
     Donovan’s problems and treatment history that she is and
     has been completely and totally disabled from performing
     any job on a full-time basis, consistent with the definition
     of disability above and consistent with my knowledge of
     Ms. Donovan’s training, education, and experience.

The district court found that the Plan’s wholesale disregard of Dr.
Welshofer’s affidavit in favor of his earlier April 2004 statement,
which was based on incomplete information, was unreasonable. We
agree. Dr. Welshofer’s affidavit is further supported by Dr. Lins’
office notes in August 2004 that Ms. Donovan’s neck and right arm
pain had been getting worse over the previous six months but that the
pain had been present for the last three years. In light of this evidence,
Ms. Donovan is entitled to LTD benefits from March 2004 to Septem-
ber 2004.

                                   III.

  Thus, Eaton’s decision to deny Ms. Donovan long term disability
benefits is not supported by substantial evidence in the record. We are
12                  DONOVAN v. EATON CORP.
of opinion that Eaton abused its discretion in denying benefits.
Accordingly, we affirm the judgment of the district court.

                                                    AFFIRMED