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Pitts v. SCANA Corporation Health and Welfare Plan

United States District Court, D. South Carolina, Anderson/Greenwood Division

October 14, 2016

Joyce Ann Pitts, Plaintiff,
v.
SCANA Corporation Health and Welfare Plan, Defendant.

          ORDER AND OPINION

         This matter is before the court for review of the decision by Defendant SCANA Corporation Health and Welfare Plan (“Defendant”), through its third-party administrator, Reed Group Ltd. (“Reed Group”), to deny a claim by Plaintiff Joyce Ann Pitts (“Plaintiff”) for long term disability (“LTD”) benefits under Defendant's health insurance plan (the “Plan”), which is governed by the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§ 1001-1461 (“ERISA”). Plaintiff seeks an order awarding her LTD benefits under the Plan, pursuant to 29 U.S.C. § 1132(a), and attorney's fees and costs, pursuant to 29 U.S.C. § 1132(g). The parties have filed a joint stipulation and memoranda in support of judgment pursuant to the court's Specialized Case Management Order for ERISA benefits cases. The matter came before the court for a hearing on October 11, 2016. For the reasons set forth below, the court affirms Defendant's denial of Plaintiff's LTD claim and declines to award Plaintiff attorney's fees and costs.

         I. RELEVANT FACTUAL AND PROCEDURAL BACKGROUND

         Plaintiff's claim arises under the Plan, a policy of group insurance to provide disability benefits to Defendant's employees who chose to participate. (See ECF No. 17-4.) There appears to be no dispute that Plaintiff was covered by the Plan. Under the terms of the Plan, “[i]n order for [a covered employee] to qualify for LTD Benefits, [the employee] must be under the care of a Physician who must certify that [the employee's] medical condition has rendered [her] Disabled, and [the employee] must apply and be approved for LTD Benefits.” (Id. at 27.) The term “Disabled” means, in relevant portion, that the employee is “receiving appropriate care and treatment from a Physician due to a medical condition related to an illness, injury or accident that permanently prevents [the employee] from performing one or more of the material and substantial duties of [the employee's] own occupation.” (Id.) Importantly, the term “permanently” is not defined by the Plan. The Plan also provides that employees “may be asked to re-certify that [they] continue to be eligible for LTD Benefits as often as is deemed necessary by the Plan Administrator” and “at least every two years.” (Id. at 27, 30.)

         The Plan grants discretionary authority to the SCANA Corporation Long-Term Disability Plan Initial Review Committee (“LTD Committee”) and Appeals Committee (“Appeals Committee”) to interpret the terms of the Plan and make benefit determinations under the Plan. (Id. at 10-11, 29, 31-32, 35-39.) Defendant entered into an administrative services agreement with Reed Group, under which Reed Group provided case management and administrative services with respect to LTD benefits under the Plan. (Id. at 33.)

         Plaintiff claimed short disability (“STD”) benefits based on lower back and elbow pain. On July 12, 2012, Defendant approved Plaintiff's claim with on onset date of June 25, 2012, and extended her STD benefits until December 26, 2012. (See ECF No. 17-1 at 59, 74, 87; ECF No. 17-3 at 57.) The approval of the STD benefits were grounded largely on the following medical evidence.

         On July 9, 2012, Plaintiff was examined by her primary physician Doctor Benjamin C. Pinner (“Dr. Pinner”) and was diagnosed with “low back pain” and “tennis elbow.” (ECF No. 17- 1 at 51.) The statement from the examination asks, “[h]as the patient been totally unable to work?” (Id.) Dr. Pinner checked “yes, ” wrote that Plaintiff was “unable to work, ” stated the inability was from June 25, 2012 to August 6, 2012, and estimated that Plaintiff would return to work on August 8, 2012. (Id.)

         On July 31, 2012, Dr. Pinner completed the first of three history and physical reports for Plaintiff, noting that he would need to determine whether Plaintiff needed stronger pain medication. (Id. at 73.) On August 2, 2012, for the second report, Dr. Pinner noted that Plaintiff's condition was “[p]ersistent, actually progressing. No relief from her first injection. She is still unable to work.” (Id. at 72.) On August 13, 2012, for the third report, Dr. Pinner noted that Plaintiff was “[i]mproving today, ” and that he would “need to taper pain medication before she can return to work. Will plan to return to work on [Septmber 10, 2012].” (Id. at 70.) In response to a questionnaire from Reed Group sent on August 8, 2012, Dr. Pinner stated that Plaintiff was diagnosed with lumbago and lumbosacral disc disease, that she was absent from work from June 25, 2012, to September 10, 2012 and that her estimated return-to-work date was September 10, 2012. (Id. at 66.)

         In August 2012, Plaintiff made four visits to physicians with Moore Orthopaedics, which resulted in several brief medical reports focusing on Plaintiff's lower back pain. (See Id. 78-83.) In response to a questionnaire from Reed Group sent on August 24, 2012, Doctor Michael W. Peelle (“Dr. Peelle”) stated that Plaintiff was diagnosed with sacroilitis and facet syndrome. In response to questions regarding whether Plaintiff had been absent from work, the dates of any absences, an expected return-to-work date, and whether any restriction or accommodations were required, Dr. Peelle answered all with “N/A.” (Id. at 77.)

         On September 10, 2012, Dr. Pinner completed and submitted a return to work form from Reed Group. (Id. at 86.) He stated that Plaintiff was medically fit to return to work on September 10, 2012, but that her medical condition would continue to impact her ability to perform the essential functions of her job. (Id.) Dr. Pinner stated that Plaintiff was restricted to sedentary work, frequently sitting; occasionally standing, walking, driving, grasping, and reaching; and never bending, twisting, squatting, climbing, pushing, or pulling. (Id.)

         In October 2012, Dr. Pinner completed another three history and physical reports based on Plaintiff's visits. In the October 4 report, Dr. Pinner noted that her condition was unchanged, that she had returned to physical therapy, that she had not returned to work as there were no light duties available, and that he may need to consider a functional assessment for her. (ECF No. 17-2 at 27-28.) In the October 23 report, Dr. Pinner noted that Plaintiff still could not return to work, that he anticipated that she might return to work in a month, and that, if she did not improve in a month, he would contact Defendant regarding a functional assessment test. (Id. at 25.) In response to a questionnaire, Dr. Pinner informed Reed Group that Plaintiff would be absent from work until November 23, 2012, on which date he estimated that Plaintiff could return to work. (Id. at 21.) In another statement, apparently submitted to Reed Group around the same time, Dr. Pinner again stated that he estimated that Plaintiff could return to work on November 23, 2012. (Id. at 31.)

         Also in October 2012, Reed Group sent Dr. Peelle a questionnaire regarding Plaintiff's status. (Id. at 12, 34.) After examining Plaintiff on October 1 and October 24, Dr. Peelle and his colleague, Doctor David B. Fulton, noted that Plaintiff's symptoms had not improved despite treatment. (Id. at 35-37.) In his statement submitted to Reed Group on October 24, 2016, Dr. Peelle stated that he estimated that Plaintiff could return to work on November 2, 2012. (Id. at 32.)

         In November and December of 2012, Dr. Pinner completed another three history and physical reports based on Plaintiff's visits. In his November 23 report, Dr. Pinner noted that Plaintiff had only minimally improved despite therapy and that he would contact Reed Group to discuss functional capacity testing. (Id. at 84.) In his December 6 report, Dr. Pinner noted that he would arrange functional assessment testing with MedFit, that he would extend Plaintiff's STD excuse until January 4, 2013, and that he would determine her disability based on MedFit's functional assessment testing. (Id. at 80.) In a statement submitted to Reed Group on December 11, 2012, Dr. Pinner stated that Plaintiff had been “totally unable to work” from June 25, 2012, to January 4, 2013, and that he expected Plaintiff could return to work on January 4, 2013. (Id. at 72.) On the same day, Dr. Pinner completed and submitted a form sent to him by Reed Group regarding Plaintiff's potential LTD. (Id. at 74-75.) Dr. Pinner did not fill out the requested information because Plaintiff was “scheduled for testing, ” and he would “determine disability once results are received.” (Id.)

         On December 28, 2012, Plaintiff submitted to Reed Group an application for LTD benefits. (ECF No. 17-3 at 8-12.)

         MedFit completed its functional assessment testing on December 28, 2012. (Id. at 20-33.) After numerous tests, MedFit concluded that Plaintiff's “return-to-work status” was to receive “further treatment.” (Id. at 33.) In its summary, MedFit stated that Plaintiff had a “decrease in functional status, ” that, as part of her physical therapy goals, Plaintiff would “be able to perform work related tasks with no more than minimum difficulty in order to return to work within 10 weeks, ” and that the “potential to reach [this] goal[]” was “good.” (Id. at 21.) After reviewing the MedFit report, Dr. Pinner stated that he had “no revisions to this plan of care” and that Plaintiff's prognosis was excellent. (Id.)

         On January 4, 2013, Dr. Pinner completed another Reed Group LTD statement. (Id. at 17-18.) He marked boxes stating that Plaintiff “is . . . now totally disabled, ” that he “expects a fundamental or marked change in the future, ” that Plaintiff would “recover sufficiently to perform [her] duties” in one to three months after “10 weeks of therapy, ” and that Plaintiff was not “permanently disabled.” (Id. at 18.) He again stated that Plaintiff was scheduled for functional testing and that he would determine her disability after results were received.[1] (Id.) On January 7, 2013, Dr. Pinner completed a form sent to him by Reed Group. (Id. at 54-56.) Asked whether Plaintiff is “[p]ermanently disabled, ” Dr. Pinner wrote “yes.” (Id. at 54.) Asked whether Plaintiff had reached “Maximum Medical Improvement (MMI), ” Dr. Pinner wrote “no, ” and wrote that he would be “able to make a determination” by February 19, 2013. (Id.) He also stated that Plaintiff “may [r]eturn to [w]ork with [n]o [l]imitations effective [February 19, 2013].” (Id. at 56.) Asked whether Plaintiff could perform no work, sedentary work, light work, medium work, or heavy work, Dr. Pinner replied that she could perform “[n]o [w]ork - [n]ot capable of gainful employment at this time.” (Id. at 55.) Having noted no other work restriction (see Id. at 55-56), Dr. Pinner stated that the duration of the restriction was ten weeks and would be complete on February 19, 2013 (id. at 55.)

         On February 20, 2013, an initial LTD case review was completed by Donna Cruz, LPN. (Id. at 58-59). Cruz noted that, per Dr. Pinner, Plaintiff's primary physician, Plaintiff is permanently disabled, but she also noted that Dr. Pinner expected Plaintiff to be able to return to work on February 19, 2013. (Id. at 59.) Cruz explained that her attempts to have Dr. Pinner clarify his opinion were ineffective. (Id.) Cruz concluded that, although the evidence “supports that [Plaintiff] is currently incapable of performing her job duties[, ] it does not support that her condition will permanently prevent her from performing her job.” (Id.) Accordingly, Cruz recommended that Reed Group deny the LTD claim. (Id.)

         On February 20, 2013, the LTD Committee denied Plaintiff's claim for LTD benefits. (Id. at 60-61.) In its explanation of the decision to Plaintiff, the LTD Committee stated that “[w]hile the documentation received supports that you are currently incapable of performing your job duties, it does not support that your condition will permanently prevent you from performing your job. While your treating physician indicated a permanent disability, he has also advised that he anticipates you will be able to resume work activities . . . .” (Id. at 63.) Plaintiff appealed the LTD Committee's decision on March 11, 2013. (Id. at 68.) On May 9, 2013, the Appeals Committee upheld the LTD Committee's decision. (Id. at 85.) In its explanation, the Appeals Committee noted that “no additional information was ...


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