Dramse v. Delta Family-Care Disability & Survivorship Plan

269 F. App'x 470
CourtCourt of Appeals for the Fifth Circuit
DecidedMarch 12, 2008
Docket07-10287
StatusUnpublished
Cited by6 cases

This text of 269 F. App'x 470 (Dramse v. Delta Family-Care Disability & Survivorship Plan) is published on Counsel Stack Legal Research, covering Court of Appeals for the Fifth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Dramse v. Delta Family-Care Disability & Survivorship Plan, 269 F. App'x 470 (5th Cir. 2008).

Opinion

PER CURIAM: *

Defendant-appellant Delta Family-Care Disability and Survivorship Plan appeals the district court’s judgment awarding plaintiff-appellee Toni Dramse long-term disability benefits, attorneys’ fees, costs, and interest. Delta Family-Care Disability and Survivorship Plan argues that the district court impermissibly imposed a per se duty to investigate Dramse’s claims and substituted its own judgment for the reasonable judgment of the plan administrator. Because we find that the plan administrator’s decision was supported by substantial evidence, we VACATE the district court’s judgment and REMAND for further proceedings consistent with this opinion.

I.

Toni Dramse was employed by Delta Air Lines, Inc. (“Delta”) for over sixteen years, starting as a luggage handler on May 17, 1984, and later working as a reservations agent until she was terminated on November 16, 2000. Dramse’s work as a reservation agent was sedentary in nature, it required no lifting, standing, bending, or stooping. The Delta Family-Care Disability and Survivorship Plan (the “Plan”) is an employee welfare benefits plan established and maintained under the Employee Retirement Income Security Act of 1974 (“ERISA”). The Plan provides both short-term and long-term dis *472 ability benefits to non-pilot Delta employees.

Delta does not pay any of the monies awarded under the benefits plan directly. Instead, Delta periodically contributes money into a trust fund (the “Benefits Trust”), and the Benefits Trust then pays out disability benefits. Delta’s contributions to the Benefits Trust cannot revert back to Delta under any circumstances. The Administrative Committee of Delta (the “Committee”) is the plan administrator and named fiduciary for purposes of the Plan’s operation and administration. The Committee is granted exclusive authority to interpret and construe the benefits plan and to decide all questions of eligibility. The Committee delegates the initial determination of disability to Aetna Life Insurance Company (“Aetna”). If Aetna determines that disability benefits should be denied (or discontinued), an employee can appeal that decision to Aetna and, if denied, then to the Committee.

Generally, short-term disability benefits are available under the benefits plan for up to twenty-six weeks if the participant is unable to perform her customary job. If a claimant exhausts her short-term disability benefits, she may apply for long-term disability benefits. Section 4.03 of the benefits plan states that an “employee shall be eligible for Long-Term Disability provided [s]he is disabled at that time as a result of demonstrable injury or disease (including mental or nervous disorders) which will continuously and totally prevent [her] from engaging in any occupation whatsoever for compensation or profit, including part-time work.” A claimant must be totally and continuously disabled on the date that her short-term disability benefits expired.

On August 9, 2000, Dramse contacted Aetna alleging that she was suffering from an on-the-job injury that originally occurred in 1997 and was exacerbated in late

1999, when she fell backwards from her chair and hit her head. Dramse’s medical records reveal that around this time she was suffering from multiple physical and mental ailments, including fibromyalgia, cervical facet syndrome, chronic lower back pain, obesity, alcoholism, and symptoms of bipolar disorder and depression. Dr. Michael Gray, Dramse’s chiropractor, opined in a letter to the Texas Workers’ Compensation Commission that Dramse was unable to work, although she would be able to return to work on August 21, 2000. Aetna, therefore, certified Dramse for short-term disability benefits through August 20, 2000.

Dramse did not return to work on August 21, 2000, as planned, but used sick time and vacation days to delay her return. She did attempt to work on August 29, September 4, September 29, and October 13, 2000, but was unable to work a full shift on any of those days. Ultimately, Dramse was terminated on November 16, 2000. She had neither exhausted her short-term disability benefits nor filed for long-term disability benefits. Nevertheless, Dramse filed suit against Delta, and as consideration for settlement of that lawsuit, she was permitted to file a claim for long-term disability benefits. 1

In May 2003, Dramse filed a claim with Aetna seeking short-term and long-term disability benefits based on both alleged *473 physical and mental ailments. On May 7, 2003, Aetna denied Dramse any benefits after August 20, 2000, but gave her sixty days to appeal the denial. Dramse appealed the decision and submitted additional medical records. On August 27, 2003, Aetna reversed its decision in pai't, granting Dramse short-term disability benefits for the period from May 10 through November 7, 2000. On the other hand, Aetna denied Dramse’s claim for long-term disability benefits because it concluded that Dramse was not totally and continuously disabled as of November 8, 2000. Although there was sufficient evidence to prove that Dramse could not perform her customary job, Aetna determined there was insufficient evidence to conclude that she could not perform any occupation, including part-time work. On February 17, 2004, Dramse appealed the denial of long-term disability benefits to Aetna. Aetna denied her appeal on May 5, 2004, but then reopened the case for further consideration. On November 2, 2004, Aetna again denied the claim.

While Aetna’s reconsideration was still pending, on August 26, 2004, Dramse appealed Aetna’s decision to the Committee. In support of her claim, she submitted her medical records, including contemporaneous medical notes and reports, and some retrospective opinions from health care providers. Although Dramse was previously awarded social security disability benefits on October 14, 2000, due to “affective/mood disorders,” she did not submit the medical records or findings underlying that award. The most relevant medical records were the notes and letters of Dr. Gray, Mary Orndorff, a licensed master social worker, and Dr. Martin Fisher. 2

Dr. Gray’s medical notes revealed that Dramse began seeing Dr. Gray sometime in 1997 for a series of injuries, the most serious occurring when she struck her head in 1999. Dr. Gray repeatedly stated in his notes that Dramse suffered from fibromyalgia and other physical injuries that periodically limited her ability to work. Yet he was also of the opinion throughout 2000 that Dramse was recovering and he often encouraged her to return to work. For example, on March 13, 2000, Dr. Gray stated that Dramse was “75%-85% recovered from her injury!,]” and, on August 28, 2000, he noted that Dramse had made a “smooth return to full [work] duty and [he was] encouraged she [would] be able to handle decreasing frequency of visits [to him].” Dr. Gray also remarked that Dramse’s emotional health was recovering and, on one occasion, he noted that Dramse should return to work to help improve her mental health. None of his notes indicated that Dramse should be restricted from working in or around November of 2000.

Dr. Gray’s contemporaneous letters were similar to his notes. In an August 21, 2000, report to the Texas Workers’ Compensation Commission, Dr.

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Bluebook (online)
269 F. App'x 470, Counsel Stack Legal Research, https://law.counselstack.com/opinion/dramse-v-delta-family-care-disability-survivorship-plan-ca5-2008.