Balmert v. Reliance Standard Life Insurance

594 F.3d 496, 49 Employee Benefits Cas. (BNA) 1027, 2010 U.S. App. LEXIS 2439, 2010 WL 393878
CourtCourt of Appeals for the Sixth Circuit
DecidedFebruary 5, 2010
Docket08-4433
StatusPublished
Cited by5 cases

This text of 594 F.3d 496 (Balmert v. Reliance Standard Life Insurance) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Balmert v. Reliance Standard Life Insurance, 594 F.3d 496, 49 Employee Benefits Cas. (BNA) 1027, 2010 U.S. App. LEXIS 2439, 2010 WL 393878 (6th Cir. 2010).

Opinion

OPINION

SILER, Circuit Judge.

Pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et seq., Maribea Balmert appeals the district court’s judgment upholding the benefits determination of Reliance Standard Life Insurance Company (“Reliance Standard”). Concluding that Balmert received a full and fair review of her claim and that Reliance Standard’s benefits determination was not arbitrary and capricious, we affirm.

BACKGROUND

Balmert began her employment with Big Lots, Inc. as an accountant-tax analyst in 2001. Her position required her to sit most of the day and manipulate her hands, fingers, and wrists to use a computer. As a Big Lots employee, Balmert subscribed to an employee benefit plan offering long-term disability insurance under a contract insured and administered by Reliance Standard.

In August 2004, she stopped working because of symptoms she believed were related to her rheumatoid arthritis. Balmert was evaluated by her rheumatologist, Kevin V. Hackshaw, M.D., on August 26, 2004, but the results of the examination were inconclusive. According to Dr. Hackshaw, Balmert described symptoms of pain in her hands, but “the pain that she complains of is disproportionate relative to the amount of synovitis that I see.” 1 Noting that Balmert’s symptoms suggested “some other etiology” — with stress as a possibility — Dr. Hackshaw referred her to a neurologist and a psychologist and placed her on temporary medical leave in order to obtain evaluations and recommendations from his colleagues.

On August 30, 2004, Balmert had her first consultation with her psychologist, Wanda McEntyre, Ph.D. Balmert told Dr. McEntyre that she had experienced pain from rheumatoid arthritis for a number of years, but her pain level had recently intensified. Dr. McEntyre noted that Balmert “expresses a strong desire to return to her job, but acknowledges that she does not perceive herself as capable of managing the hours, the pressure, and stress at this time.” Balmert began meeting with Dr. McEntyre approximately once every two weeks until she discontinued counseling in December 2004. These counseling sessions generally focused on stress management techniques to prepare Balmert to return to work.

After evaluating Balmert on October 21, 2004, Dr. Hackshaw noted that he detected “[n]o active synovitis,” that she was “doing well,” and that her rheumatoid arthritis “seems to be under good control.” Dr. Hackshaw also told Balmert that she could return to work with some limitations, but advised that she may wish to find a less stressful position or explore some type of flex plan that would allow her to take some of her computer typing work home. A few days later, Balmert tearfully expressed her concern to Dr. McEntyre regarding Dr. Hackshaw’s determination that she could return to work. At future counseling sessions, Balmert continued to express concerns about her ability to return to work.

Following an evaluation of Balmert on February 10, 2005, Dr. Hackshaw noted *499 that she had “no tender points and no synovitis that I could detect, so I think in general she is doing well.” Regarding Balmert’s work status, Dr. Hackshaw reported that “we had allowed her to return to work with limitations and they apparently stated that she would not be able to return to work due to the limitations.”

After evaluating Balmert on May 19, 2005, Dr. Hackshaw noted that Balmert’s rheumatoid arthritis was “somewhat stable,” that she had “no synovitis,” and that she had “[fjull range of motion of joints.” Dr. Hackshaw noted, after evaluating Balmert on August 18, 2005, that he was generally “pleased with how she is doing.” After evaluating Balmert on November 21, 2005, Dr. Hackshaw observed “[mjinimal synovitis” and stated that “she is doing well with current medications.”

Balmert filed for long-term disability benefits on February 15, 2005. In a letter dated June 2, 2005, Reliance Standard denied Balmert’s claim for long-term disability benefits, stating that “there is no documentation of a physical condition that would preclude you from performing the material duties of your own occupation.” Balmert appealed Reliance Standard’s denial of her disability benefits. In support of her administrative appeal, Balmert provided Reliance Standard with additional medical and other information pertaining to her claim.

The most important item submitted by Balmert in support of her appeal was a modified Functional Capacity Evaluation (“FCE”), conducted on March 15, 2006. Based on Balmert’s modified FCE, Matthew T. Crill, a physical therapist, stated:

I do not believe it would be safe or prudent to place Ms. Balmert in any type of formal work setting. This conclusion is based on her lack of sitting tolerance, lack of standing tolerance, severe deficits in upper extremity strength, severe deficits in fine motor skills, and chronic and intractable subjective pain rating. She would not be able to perform any of her previous work requirements under modified or full duty in the context of a full work [day]. These recommendations are pending the referring physician’s final evaluation.

In a letter dated July 25, 2006, Dr. Hackshaw stated: “I have received a functional capacity evaluation on Ms. Balmert from March 15th 2006 and agree with the findings from this evaluation. I have been following Ms. Balmert since 2004 and would agree her condition was the same at that time as it is now.”

After reviewing this material, Reliance Standard arranged for Balmert to be evaluated by an independent medical examiner, Marvin Thomas, M.D. On September 29, 2006, Dr. Thomas reported:

While the diagnosis of rheumatoid arthritis as mentioned seems firm there is very little evidence of active disease and one would guess that it is in relative remission. Prognosis is always uncertain in this disease but looks reasonably good for her at this point.... I would place very little limitation on her in terms of the use of her upper extremities. She might have some difficulty because of her knees with prolonged standing and negotiating steps. In summary while she has a diagnosis of rheumatoid arthritis, it seems controlled. I see no reason why she cannot continue in her present position.

He also noted that “[t]here is no rheumatological basis for disability.” On November 2, 2006, he supplemented his report with a statement that “[b]ased on the records that were sent to me it would appear initially that [Balmert] would have difficulty keyboarding and other use of her hands. *500 Based on what I see now this would be much less of a problem.”

After reviewing the record, Reliance Standard determined that Balmert would have been precluded from performing her own occupation for a closed period of time between August 26, 2004 to September 29, 2006. The determination to grant Balmert benefits for a closed period of time was evidently based on Dr. Thomas’s opinion that Balmert initially would have had difficulty keyboarding and with other use of her hands. Balmert was informed of the resolution of her administrative appeal by letter dated December 14, 2006. The letter states, in pertinent part:

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594 F.3d 496, 49 Employee Benefits Cas. (BNA) 1027, 2010 U.S. App. LEXIS 2439, 2010 WL 393878, Counsel Stack Legal Research, https://law.counselstack.com/opinion/balmert-v-reliance-standard-life-insurance-ca6-2010.