Raymond Shaw v. AT&T Umbrella Benefit Plan

795 F.3d 538, 2015 FED App. 0171P, 60 Employee Benefits Cas. (BNA) 1723, 2015 U.S. App. LEXIS 13194, 2015 WL 4548232
CourtCourt of Appeals for the Sixth Circuit
DecidedJuly 29, 2015
Docket14-2224
StatusPublished
Cited by73 cases

This text of 795 F.3d 538 (Raymond Shaw v. AT&T Umbrella Benefit Plan) 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
Raymond Shaw v. AT&T Umbrella Benefit Plan, 795 F.3d 538, 2015 FED App. 0171P, 60 Employee Benefits Cas. (BNA) 1723, 2015 U.S. App. LEXIS 13194, 2015 WL 4548232 (6th Cir. 2015).

Opinions

COLE, C.J., delivered the opinion of the court which GILMAN, J., joined. KETHLEDGE, J. (pg. 552), delivered a separate dissenting opinion.

OPINION

COLE, Chief Judge.

Plaintiff Raymond Shaw sued defendant AT & T Umbrella Benefit Plan (“the Plan”), alleging that the Plan denied his claim for long-term disability (“LTD”) benefits in violation of the Employee Retirement Income Security Act of 1974 (“ERISA”). The district court granted summary judgment to the Plan, finding that the Plan had properly denied Shaw benefits. Because we find that the Plan acted arbitrarily and capriciously in denying Shaw LTD benefits, we reverse the district court’s judgment. Further, because Shaw has demonstrated that he was denied benefits to which he was clearly entitled, we remand this case to the district court and direct it to enter an order awarding Shaw LTD benefits.

I. BACKGROUND

Shaw is a 39-year-old male who was employed as a customer service representative for Michigan Bell until he stopped working as a result of chronic neck pain. Shaw was covered under the AT & T Midwest Disability Benefits Program, a component of the AT & T Umbrella Benefit Plan No. 1.

A. Disability Plan

Under the disability plan, short-term disability (“STD”) benefits of full or partial wage replacement are available to employees for up to 52 weeks. To be eligible for STD benefits, an employee must have a “sickness, pregnancy, or an off-the-job illness or injury that prevents [him] from performing the duties of [his] job (or any other job assigned by the Company for which [he is] qualified) with or without reasonable accommodation.” (R. 15-5, Pa-gelD 1129.) After STD benefits run out, an employee may be eligible for LTD benefits. To be eligible for such benefits, an employee must have “an illness or injury, other than accidental injury arising out of and in the course of employment by the Company or a Participating Company, supported by objective Medical Documentation.” (Id. at 1142.) Further, “[s]uch illness or injury [must] prevent[] [him] from engaging in any occupation or employment (with reasonable accommodation as determined by the Claims Administra[542]*542tor), for which [he is] qualified or may reasonably become qualified based on education, training or experience.” (Id.) In determining eligibility for either STD of LTD benefits, the Plan reserves the right to conduct its own “examination by a Physician chosen by the Claims Administrator, if the Claims Administrator determines that such an examination is necessary.” (Id. at 1134, 1146.)

The disability plan provides that “[t]he Plan Administrator (or, in matters delegated to third parties, the third party that has been so delegated) will have sole discretion to interpret [the disability plan], including ... determinations of coverage and eligibility for benefits, and determination of all relevant factual matters.” (Id. at 1156.) The disability plan also states that “[t]he Claims Administrator has been delegated authority by the Plan Administrator to determine whether a particular Eligible Employee who has filed a claim for benefits is entitled to benefits” and that “[t]he Appeals Administrator has been delegated authority by the Plan Administrator to determine whether a claim was properly decided by the Claims Administrator.” (Id.)

Sedgwick Claims Management Services, Inc. (“Sedgwick”) is the third party that administers benefits claims and appeals. Sedgwick’s AT & T Integrated Disability Service Center (“IDSC”) handles disability-benefits claims. Sedgwick’s Quality Review Unit (“QRU”) decides appeals of denied disability claims.

B. Shaw’s STD Benefits

Shaw suffered from chronic neck pain for years. On August 12, 2009, Sedgwick contacted Shaw about his absence from work and informed him that he might be eligible for STD benefits. To qualify, Sedgwick told Shaw to submit medical documentation demonstrating that his illness or injury “prevents [him] from performing the duties of [his] job with or without reasonable accommodations.” (R. 15-1, PagelD 708.)

After “a thorough review” of Shaw’s medical documentation, Sedgwick notified Shaw on September 17, 2009, that his STD benefits claim had been approved retroactively to August 7, 2009. Over the course of the next year, Sedgwick conducted various reviews and reapproved Shaw’s STD benefits claim on numerous occasions.

Throughout his time receiving STD benefits, Shaw was treated by Dr. Laura Reincke, a family-medicine practitioner. Dr. Reincke ordered cervical epidural steroid injections to manage his pain. According to Dr. Reincke, these injections helped, but Shaw was “still getting neck pain.” (R. 14-1, PagelD 131.) In her medical charts, Dr. Reincke reported that Shaw was unable to drive longer than a half-hour and could “only sit for 20 min[utes]” due to his condition. (R. 14-3, PagelD 262.) In November 2009, Dr. Reincke recommended that Shaw contact Dr. Neil Pasia, an orthopedic specialist, for further evaluation.

Dr. Pasia examined Shaw in December 2009 and January 2010. On December 15, 2009, Dr. Pasia ordered an MRI of Shaw’s cervical spine. The MRI revealed a “herniated nucleus pulposus at C6/7 causing right foraminal stenosis” and a “right par-acentral disc bulge with effacement of the thecal sac.” (R. 14-1, PagelD 138.) A physical examination by Dr. Pasia also revealed “some paravertebral spasm at the base of the neck” and “limited range of motion with flexion, extension, rotation, and bending secondary to pain.” (Id.) However, the Spurling’s test1 result was negative. Dr. Pasia told Shaw that he may benefit from a cervical discectomy [543]*543and fusion and that surgery “would allow him to increase his current level of activity including job functions and would decrease his pain medication intake.” (R. 14-2, Pa-gelD 140.) Dr. Pasia also informed Shaw of the risks of surgery, including “bleeding, infection, decreased or loss of motion, malunion, nonunion, need for further surgery, nerve damage, dural tear, paralysis, heart attack, and/or potential death.” (R. 14-1, PagelD 137.)

Shaw was evaluated further by Dr. Devon Hoover, a neurologist. On May 28, 2010, Dr. Hoover found that Shaw had “neuroforaminal narrowing at C5-6 and C6-7.” (R. 14-4, PagelD 325.) Dr. Hoover opined, “[tjhough the symptoms seem a bit pronounced for the MRI findings, I do believe the MRI likely explains the pain.... I do feel that he would be a candidate for a C5-6 and C6-7 anterior cervical discectomy and fusion.... At this point, he wants to do physical therapy and we will see him back in a couple of months to reassess.” (Id.)

While receiving STD benefits, Shaw was also treated by Dr. Pasia’s colleague, Dr. Matthew Sciotti. On June 30, 2010, Dr. Sciotti examined Shaw. His physical examination revealed “reduced range of motion” and “slight pain to palpation over the cervical paraspinal muscles.” (Id. at 353.) The “Spurlings [were] negative bilaterally.” (Id.) Dr. Sciotti also performed an electromyography (“EMG”), with a nerve conduction study to test the electrical activity of Shaw’s muscles. The EMG revealed “few spontaneous waveforms in the right triceps and cervical paraspinal muscles.” (Id. at 352.) Dr. Sciotti referred Shaw to the Matrix Pain Management Clinic.

In June and July of 2010, Shaw saw a physical therapist, Dr. Sandy Payne.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
795 F.3d 538, 2015 FED App. 0171P, 60 Employee Benefits Cas. (BNA) 1723, 2015 U.S. App. LEXIS 13194, 2015 WL 4548232, Counsel Stack Legal Research, https://law.counselstack.com/opinion/raymond-shaw-v-att-umbrella-benefit-plan-ca6-2015.