Wood v. Prudential Insurance CV-99-229-M 06/14/00 UNITED STATES DISTRICT COURT
DISTRICT OF NEW HAMPSHIRE
Peter G. Wood, Plaintiff
v. Civil No. 99-229-M Opinion No. 2000 DNH 136 The Prudential Insurance Company of America, Defendant
O R D E R
Plaintiff, Peter G. Wood, brings this action under Section
502(a)(1)(B) of the Employee Retirement Income Security Act of
1974 ("ERISA"), 29 U.S.C. § 1132(a)(1)(B), to recover short term
disability ("STD") benefits, and attorney's fees (29 U.S.C.
§ 1132(g)).1 Defendant, The Prudential Insurance Company of
America ("Prudential" or "the company"), denies that Wood is
1Wood originally brought this suit in state court seeking a declaratory judgment that he is entitled to coverage under the terms of an insurance policy providing disability income coverage. After removal to this court. Wood amended his complaint to state an ERISA claim. entitled to benefits. Both parties have moved for summary
judgment.
Standard of Review
Summary judgment is appropriate when the record reveals "no
genuine issue as to any material fact and . . . the moving party
is entitled to a judgment as a matter of law." Fed. R. Civ. P.
56(c) . In this context, "a fact is ''material' if it potentially
affects the outcome of the suit and a dispute over it is
'genuine' if the parties' positions on the issue are supported by
conflicting evidence." Intern'1 Ass'n of Machinists and
Aerospace Workers v. Winship Green Nursing Center, 103 F.3d 196,
199-200 (1st Cir. 1996) (citations omitted). Thus, a motion for
summary judgment "against a party who fails to make a showing
sufficient to establish the existence of an element essential to
that party's case, and on which that party will bear the burden
of proof at trial," should be granted. Celotex Corp. v. Catrett,
477 U.S. 317, 322 (1986). In ruling on a motion for summary
judgment, the court must view the record in the light most
2 favorable to the nonmoving party, "indulging all reasonable
inferences in that party's favor." Griqqs-Rvan v. Smith, 904
F .2d 112, 115 (1st Cir. 1990).
Background
Wood was employed by Prudential for some 26 years, from
September 4, 1972, to March 10, 1998. As a Prudential employee.
Wood participated in The Prudential Welfare Benefits Plan (the
"Plan"), which provided disability income benefits for qualifying
employees.
On February 26, 1998, Wood was seen by a practicing
physician's assistant, Richard Renner, PA-C, for "burn-out
stress." (Progress Note, 2/26/98, ex. to Renner Aff.) Renner's
office notes indicate that Wood had been "feeling blue, sad,
tearful, chokey, [and had been having] difficulty sleeping." Id.
Renner diagnosed Wood as suffering from hypertension and
depression, and prescribed Accupril and Prozac, noting that he
felt that Wood "should be on short-term disability and not make
any rash judgments until he is feeling better." Ri. Wood
3 stopped working on March 9 , 1998 (his first day of absence), and then, or shortly thereafter, notified Prudential of his claim for
disability benefits.
Renner saw Wood again on March 19, 1998, for a complete
physical examination. Renner noted that Wood's neurological
examination was normal and that his affect had improved since his
last visit. Because Wood refused to take the Prozac he had
prescribed, however, Renner strongly recommended that he seek
psychological help. Wood agreed and suggested the name of a
psychiatrist, Marie Guay, P.O.
Wood met with Dr. Guay on April 17, 1998. Dr. Guay noted
that Wood presented with symptoms including "marked anxiety,
insomnia, heart palpitations, awakening from sleep in a cold
sweat, nausea and vomiting prior to going to work in the morning,
a decrease in energy, weight loss and elevated blood pressure."
(R. at PW0413; see also Dr. Guay's psychiatric assessment of Wood
at R. at PW0068-70.)2 Dr. Guay diagnosed Wood as suffering from
2Citations to the record ("R.") are to the Plan Administrative Record submitted with defendant's motion for summary judgment. Pages of the record are cited by the bates-
4 "panic disorder without agoraphobia," a condition classified by
the diagnostic code 300.01 in the Diagnostic and Statistical
Manual of Mental Disorders, fourth edition3 (R. at PW0083). She
prescribed a trial of Paxil along with individual psychotherapy
(R. at PW0070).
By letter dated April 17, 1998, Prudential notified Wood
that his claim for disability benefits had been denied because he
did not file it on the required Group Disability Claim Form (and
so did not provide all of the information needed to rule on it).
Wood completed and filed the form on or about April 21, 1998. He
reported on the form that the nature of his disabling sickness or
injury was "stress, pressure, anxiety[,] High Blood pressure +
pulse rate [and] Panic attack Disorder." (R. at PW0076.)
In support of Wood's claim for disability benefits, Renner
and Dr. Guay each completed an Attending Physician's Statement of
numbers used in that document, which run from PW0001 through PW0 730.
diagnostic and Statistical Manual of Mental Disorders (4th ed., American Psychiatric Association 1994), hereinafter referred to as the DSM-IV™.
5 Disability. Renner listed diagnoses of hypertension, anxiety,
and depression and symptoms of "[f]atigue, panic attacks, nausea,
[and] sleep disorder." (R. at PW0082.) Dr. Guay diagnosed panic
disorder without agoraphobia and noted symptoms of "marked
anxiety, elevated BP [blood pressure], palpitations, vomiting,
[and] fatigue." (R. at PW0083.) Neither PA Renner nor Dr. Guay
predicted when Wood would be able to return to work.
In addition, Renner conducted a "mental status
exam[ination]" (MSE) of Wood on May 8, 1998, and diagnosed acute
depression and acute panic attacks. Renner described Wood's
attitude as "depressed" and his mood as "nervous/anxious" with a
flat affect, but noted nothing unusual or abnormal about Wood's
appearance, behavior, thought content, intellectual function, or
insight and judgment.4 (R. at PW0096.)
By letter dated June 23, 1998, Prudential again denied
Wood's claim for STD benefits, writing:
The medical information from Dr. [sic] Renner and Dr. Guay indicate that you have been experiencing
4Renner's assessment of Wood's thought processes is illegible.
6 difficulties related to anxiety and depression. However, the mental status exam from Dr. [sic] Renner indicates that your thought content, intellectual functioning, insight and judgment are normal. Additionally, the psychiatric assessment provided by Dr. Guay indicates that you are not suffering from major depression or severe anxiety.
(R. at PW0101.) Prudential therefore concluded that Wood was not
"suffering from an impairment that would render [him] totally
disabled from [his] job as a Prudential Representative." Id.
Wood, through counsel, appealed the denial of benefits by
letter dated August 20, 1998. In response to the representation
that Dr. Guay had not found his anxiety to be severe. Wood
submitted a letter from her confirming that he had exhibited
"symptoms of a serious panic disorder" and that the severity of
that disorder rendered him "currently completely disabled" and
unable to perform his job at Prudential. (R. at PW0413.) To
clarify Renner's finding of normal mental function. Wood
submitted Renner's office notes of August 13, 1998, which state
in relevant part:
In subsequent visits, in any discussion regarding going back to work, [Wood] becomes incredibly nervous, anxious, nauseous, has ultimately sleep disorder and ruminating thoughts which put him into a complete
7 panic. My sense is that despite the fact that on a day to day basis that he has a normal mentation, is able to carry on a conversation with appropriate affect. However whenever he discusses any kind of work related business that he immediately has anticipatory anxiety and gets himself into a panic attack. I certainly think that you can have co-existing mental states particularly when the aggravating factor you are avoiding because you are out of work, [sic] I have discussed this with [Wood's attorney] and feel that, along with Dr. [Guay], that he does not have at this time the physical and emotional capacity to work in the line of field [sic] that he has been working for the last 20 years as this induces an acute panic state.
(R. at PW0414.)
Prudential retained Marc Sageman, M.D., Ph.D, a specialist
in forensic and organizational psychiatry, psychotherapy, and
pharmacotherapy, to review Wood's file. Prudential asked Dr.
Sageman to "determine if there is any evidence of an acute mental
impairment at the time Mr. Wood ceased work on March 9, 1998, or
if he continues to suffer from an acute mental impairment at this
time." (R. at PW0430.)
After reviewing the file. Dr. Sageman informed Prudential
that he found Renner's and Dr. Guay's diagnoses of Wood
"puzzling." (R. at PW0434.) Dr. Sageman first opined that Wood
could not have a depressive disorder (and noted that Dr. Guay did not diagnose one) because such a disorder does not occur
selectively. In other words, depression does not strike a person
only at work and not at home; it is "general throughout the day."
Id.
Similarly, Dr. Sageman noted that a diagnosis of panic
disorder requires that the patient suffer from "recurrent
unexpected Panic Attacks." Id.
By definition, an unexpected (spontaneous, uncued) Panic Attack is defined as one that is not associated with a situational trigger (i.e., it occurs "out of the blue"). Furthermore, Mr. Wood's alleged attacks do not even occur situationally, e.g., at work. They occur when he thinks about returning to work, and affect him so that he is unable to sleep. This does not sound that [sic] any psychiatric disorder that I know.
Id. Dr. Sageman opined that at most. Wood may have suffered a
panic attack, a common event in the general population and a
single occurrence of which does not constitute a panic disorder.
He concluded that the materials he reviewed disclosed no evidence
of mental impairment. Citing Dr. Sageman's conclusions.
Prudential upheld its denial of benefits by letter dated October
12, 1998.
9 Wood appealed that decision to the Appeals Committee of the
Prudential Insurance Company of America ("Appeals Committee").
By letter dated February 11, 1999, the Appeals Committee upheld
the prior decision. Wood challenges, in this suit. Prudential's
denial of his claim for disability benefits.
Discussion
As a preliminary matter, the parties do not agree on the
applicable standard of review. Each party, however, claims
entitlement to judgment on the merits regardless of the standard
of review employed.
In Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115
(1989), the Supreme Court held that "a denial of benefits
challenged under [29 U.S.C.] § 1132(a) (1) (B) is to be reviewed
under a de novo standard unless the benefit plan gives the
administrator or fiduciary discretionary authority to determine
eligibility for benefits or to construe the terms of the plan."
The Court of Appeals for the First Circuit has interpreted
Firestone to require "de novo review of benefits determinations
10 unless a benefits plan clearly grants discretionary authority to
the administrator. Where the clear discretionary grant is found.
Firestone and its progeny mandate a deferential arbitrary and
capricious standard of judicial review." Terry v. Baver Corp.,
145 F.3d 28, 37 (1st Cir. 1998) (citations, internal quotation
marks, ellipses, and brackets omitted).
Under the Plan, a committee of three or more employees
appointed in accordance with Section 3.3(a) of the plan (the
"Committee") is designated the plan administrator. (R. at
PW0584.) The Plan provides that "Subject to oversight by the
Compensation Committee, the Committee . . . shall have full and
absolute discretion and authority to control and manage the
operation and administration of the Plan, as specifically
described herein." (R. at PW0584.) The Committee is granted
"all powers necessary to carry out" the terms of the Plan (R. at
PW0589.), including "the broadest possible discretion to
interpret any and all provisions of the Plan and to determine any
questions arising thereunder or in connection with the
administration of the Plan." (R. at PW0590.)
11 Wood argues that the foregoing language is similar to that
found insufficient to satisfy the Firestone standard in Cooke v.
Lynn Sand & Stone Co., 70 F.3d 201, 204 (1st Cir. 1995). "There,
the plan language stated only that the administrator had
''exclusive control and authority over administration of the
Plan.'" Terry, 145 F.3d at 37 (quoting the district court
opinion in Cooke at 875 F. Supp. 880, 883-84 (D. Mass. 1994)).
As in Terry, however, the Plan language here goes well beyond
that described in Cooke, in that it plainly grants discretionary
determinative and interpretive authority to the Committee.
Terry, 145 F.3d at 37 ("In contrast [to the plan in Cooke],
Bayer's Plan specifically allocates to the Company the right to
find necessary facts, determine eligibility for benefits, and
interpret the terms of the Plan."). Accordingly, the arbitrary
and capricious standard of review is applicable here. See id.
Under the arbitrary and capricious standard of review.
Prudential's5 interpretation of Plan terms cannot be disturbed if
5The Plan authorizes the Committee to delegate its administrative duties to others. (R. at PW0584.) With regard to disability benefits coverage, the Committee has delegated its
12 that interpretation is reasonable. See id. at 40. And, of
course, the court cannot substitute its judgment for
Prudential's. See id. Rather Prudential's denial of benefits
must be upheld if that denial was "within [Prudential's]
authority, reasoned, and supported by substantial evidence in the
record. Substantial evidence, in turn, means evidence reasonably
sufficient to support a conclusion." Doyle v. The Paul Revere
Life Ins. C o ., 144 F.3d 181, 184 (1st Cir. 1998) (citation and
internal quotation marks omitted).
Prudential denied Wood's claim for STD benefits because it
determined that he failed to meet eligibility criteria requiring
him to be "totally disabled," as that term is used in the Plan.
The Plan provides that an employee is considered disabled for
purposes of eligibility for STD benefits when the employee is
"completely unable to perform any and every duty of [his]
duties as plan administrator to Prudential. (R. at PW0585-87, PW0722, PW0368.) As Wood does not appear to contend that the Committee did not or could not delegate its discretionary authority to Prudential, the court will treat Prudential as the Committee's full substitute as plan administrator without further discussion.
13 occupation as a Prudential Representative, due to sickness or
injury or both; and [is] not engaged in any gainful occupation."
(R. at PW0024 (italics omitted); see also R. at PW0220.)6 Wood
argues that Prudential arbitrarily and capriciously interpreted
the Plan to require that he meet additional criteria, not
expressly set out in the written Plan.
Wood correctly points out that it is impermissible, under
even the arbitrary and capricious standard of review, for a plan
administrator to impose benefit eligibility criteria that do not
appear in the plan. See e.g., Mitchell v. Eastman Kodak Co., 113
F.3d 433, 443 (3d Cir. 1997)(finding denial of disability
benefits arbitrary and capricious where plan administrator
imposed a requirement, not stated in the plan, that the claimant
establish the etiology of her disabling condition through
clinical evidence). Wood argues that Prudential did just that
6The Plan's provisions for disability benefits are incorporated by reference (R. at PW0707) from "all of the summary plan descriptions, insurance contracts, third party agreements. Employer policies, and other documentation maintained by the Employer regarding [disability benefits]." (R. at PW0722.) The court will refer to such documents as the Plan without further specification.
14 when it (1) asked Dr. Sageman to "determine if there is any
evidence of an acute mental impairment at the time Mr. Wood
ceased work on March 9 , 1998, or if he continues to suffer from an acute mental impairment at this time," (R. at PW0430); and (2)
denied Wood's claim for benefits for the stated reasons that his
"functioning outside of the workplace is within normal limits"
and "the medical records do not support a mental impairment."
(R. at PW0440.) These statements by Prudential, Wood argues,
show that it impermissibly construed the Plan to impose the
additional requirement that he have an "acute mental impairment
and/or disability in personal and/or social functioning." (Pl.'s
B r . at 12.)
Prudential may have been imprecise in its communications to
Dr. Sageman and the plaintiff, but those ambiguities do not raise
a genuine issue of material fact as to whether Prudential
required Wood to meet eligibility criteria for disability not
found in the Plan. The Plan's definition of disability for
purposes of STD benefit eligibility requires that the employee be
15 occupation as a Prudential Representative, due to sickness or
injury or both." (R. at PW0024 (italics omitted)(emphasis
added).) Dr. Sageman's conclusions, after reviewing Wood's file,
reveal that he plainly determined and advised Prudential that
Wood did not meet the diagnostic criteria for the medical
conditions his psychiatrist and physician's assistant claimed he
had. (Parenthetically, it is doubtful that a physician's
assistant is qualified to offer an expert diagnosis of mental
illness, though the parties do not raise the issue.)
Dr. Sageman disputed Renner's diagnosis of depression
because "any Depressive Disorder . . . is not selective in its
occurrence." (R. at PW0434.) Dr. Sageman cited the DSM-IV™
criteria for Major Depressive Episode, which require that the
patient experience either "depressed mood most of the day, nearly
every day" or "markedly diminished interest or pleasure in all,
or almost all, activities most of the day, nearly every day."
DSM-IV™ at 32 7.
Similarly, Dr. Sageman disputed Dr. Guay's diagnosis of
panic disorder because the DSM-IV™ diagnostic criteria for that
16 condition (either with or, as Dr. Guay diagnosed, without
agoraphobia) require that the patient experience "recurrent
unexpected Panic Attacks." (R. at PW0434 (citing DSM-IV™ at
402).) The DSM-IV™ provides that "[b]y definition. Panic
Disorder is characterized by recurrent, unexpected (spontaneous,
uncued, 'out of the blue') Panic Attacks." DSM-IV™ at 400. Dr.
Sageman pointed out that the panic attacks Wood described were
not uncued, but were apparently triggered by thoughts of
returning to work.7
7While Dr. Sageman's report might give a contrary impression, panic attacks having situational triggers are recognized. The DSM-IV™ categorizes panic attacks into three types, one of which is described as "situationally bound (cued) Panic Attacks, in which the Panic Attack almost invariably occurs immediately on exposure to, or in anticipation of, the situational cue or trigger (e.g. seeing a snake or dog always triggers an immediate Panic Attack)." DSM-IV™ at 395 (bold type omitted). This type of panic attack is most closely associated with phobias. Id.
The DSM-IV™ also describes situations in which an unexpected panic attack can lead to phobic avoidance: "For example, an individual who had not previously feared or avoided elevators has a Panic Attack in an elevator and begins to dread going to work because of the need to take the elevator to his office on the 24th floor." DSM-IV™ at 40 9 (the DSM-IV™ describes that situation as falling between the prototypes of Panic Disorder with Agoraphobia, which "is characterized by the initial onset of
17 Prudential therefore argues that it properly relied on Dr.
Sageman's conclusions to determine that Wood was not totally
unexpected Panic Attacks and the subsequent avoidance of multiple situations thought to be likely triggers of the Panic Attacks," and Specific Phobia, Situational Type, which "is characterized by situational avoidance in the absence of recurrent unexpected Panic Attacks," and notes that appropriately diagnosing a specific presentation of symptoms as one or the other of those disorders requires the exercise of clinical judgment. Id.)
The foregoing observations raise the question whether Wood might have a mental impairment other than those diagnosed by Renner and Dr. Guay. Dr. Sageman, undoubtedly familiar with the recognized types of panic attacks, appears to have concluded that the medical records before him did not support a diagnosis involving situationally bound panic attacks. He wrote "[t]here is no evidence that Mr. Wood suffered from a traumatic experience so severe at work that the mere mention of work triggers panic attacks." (R. at PW0434.)
That conclusion does not, of course, resolve whether Wood's alleged panic attacks are, in fact, attributable to an undiagnosed mental disorder. But that was not the question before Dr. Sageman, notwithstanding Prudential's instructions. Dr. Sageman's assigned duty was to determine whether the medical evidence presented by Wood supported the diagnoses of the conditions he claimed disabled him. Neither Dr. Sageman nor Prudential was required to speculate as to whether there existed other evidence not presented that might support a finding of disability. Cf. Donato v. Metropolitan Life Ins. Co., 19 F.3d 375, 380 (7th Cir. 1994) (noting that insurer/plan fiduciary "was bound only to consider what evidence and information it had before it"). Nor is the court in a position to determine whether Wood is actually disabled by an undiagnosed mental illness.
18 disabled by any "sickness or injury" as required by the Plan.
The court agrees, although Prudential has not taken the argument
far enough. In determining that Wood did not meet the criteria
for total disability. Prudential must have implicitly interpreted
the "sickness or injury" requirement8 as mandating that a
claimant satisfy a two part test: that he (1) meet the diagnostic
criteria generally recognized or accepted by the relevant medical
community (here, the accepted diagnostic criteria of the mental
health community as reflected in the DSM-IV™) for (2) the
sickness or injury he claims to have (here, depression.
8The Plan documents define sickness, in relevant part, as "[a]ny disorder of the body or mind of a Covered Person, but not an Injury." (R. at PW0055.)
19 "anxiety,"9 and panic disorder without agoraphobia) .10 That
necessary interpretation of the eligibility criteria is not
unreasonable, and therefore, not arbitrary or capricious. Cf.
DuMond v. Centex Corp., 172 F.3d 618 (8th Cir. 1999) (upholding
denial of benefits where, although plan administrator admitted
that Chronic Fatigue Syndrome ("CFS") was an organic disease
covered under the plan, an independent medical review determined
that claimant did not meet the Center for Disease Control's
diagnostic criteria for CFS); Donato, 19 F.3d at 382-82 (noting
9In his attending physician's statement of disability, Renner diagnosed Wood as suffering from "anxiety" in addition to depression and hypertension. (R. at PW0082.) Although "anxiety" is not a diagnosis classified in the DSM-IV™, Renner appears to have also listed the diagnostic code 300.00, id., which indicates the diagnosis of "Anxiety Disorder Not Otherwise Specified" - essentially a catch-all diagnosis for "disorders with prominent anxiety or phobic avoidance that do not meet criteria for any specific" listed disorder. DSM-IV™ at 444.
10Wood's description of his disabling sickness or injury in his claim for disability benefits also listed "stress" and "pressure," as well as high blood pressure and pulse rate. (R. at PW007 6.) Neither Renner nor Dr. Guay, however, appears to have considered Wood's diagnosed hypertension, by itself, to be disabling. Rather, they listed it as a symptom or objective clinical finding associated with the anxiety and depression that they believed caused Wood to stop working. (See R. at PW0082- 83. )
20 that "ERISA and its implementing regulations . . . did not
require [the insurer/plan fiduciary] to assess an alternative
diagnosis to the one [the claimant] submitted for disability
benefits . . . much less to determine whether that alternative
diagnosis constitutes a total disability").11
Finally, Wood argues that Prudential acted arbitrarily and
capriciously in (1) failing to request or obtain an independent
medical examination ("IMF") if it had doubts about his disability
- which it could have done under the Plan's terms, and (2)
rejecting the opinions of his treating physicians in favor of
that of Dr. Sageman, who never examined him. Prudential
correctly points out, however, that while an IME is authorized by
the Plan, it is not required. See R. at PW0220, PW0719; see also
11It is doubtful that the physician's assistant's "catch all" diagnosis obligated Prudential to scour the record and the DSM-IV™ to determine whether Wood might have a mental disorder not identified by his psychiatrist. In any event. Dr. Sageman appears to have considered other possible diagnoses, see supra note 7, and concluded that the evidence was insufficient to support any of them. (See R. at PW0434 (stating that Wood's symptoms did not sound like "any psychiatric disorder that I know.") Wood has raised no genuine issue of material fact regarding whether that conclusion was unreasonable.
21 Eriksen v. Metropolitan Life Ins. Co., 39 F. Supp. 2d 864, 871
n.6 (E.D. Mich. 1999) (failing to order an IME was not arbitrary
and capricious where Plan did not require one). Two days prior
to contacting Dr. Sageman about the case, a Prudential disability
claim manager recorded the following explanation for not
requiring an IME:
[Wood's] attny is appealing our decision to deny [Wood's] claim effective 3-9-98. After discussion of information already in file, in addition to letter submitted by attny, it appears that our best course of action at this time would be to have a file review done of the information already contained in [Wood's] claim. This appears to be a better choice than an IME b/c we want to evaluate [Wood's] condition at the time we denied claim and do not necessarily want exam done that would present us with information as to [Wood's] condition presently.
(R. at PW0482.) That analysis also seems reasonable. Cf.
Robinson v. Phoenix Home Life Mu t . Ins. Co., 7 F. Supp. 2d 623,
632 (D. Md. 1998) (holding insurer's claim review not defective
for failure to order IME where employee claimed he was totally
disabled on October 28, 1994, and "[i]t would have been only
marginally relevant to plaintiff's medical condition in 1994 to
22 have had an independent examination made two years later in
1996").
The court also rejects the argument that Prudential's
decision was based on an improper favoring of a non-examining
physician's conclusions over the opinions of Wood's treating
physicians, particularly when the reviewing physician indicated
that his own opinion may not be reliable. Wood first notes that
in a telephone conversation with a Prudential disability claim
manager. Dr. Sageman stated that "it might not be possible to
make a thorough evaluation based on records alone." (R. at
PW0554.) Prudential counters by pointing out that Dr. Sageman
made the statement before ever seeing the records he was asked to
review. Dr. Sageman, once in receipt of the records, commented
that the documentation on Wood's alleged panic attacks was
"rather flimsy," (R. at PW0434), but that comment is consistent
with his conclusion that the records did not establish that Wood
suffered from the illnesses claimed - indeed, the "flimsy" record
is attributable to Wood's failure to establish his claim. Cf.
Hiqhtshue v. AIG Life Ins. Co., 135 F.3d 1144, 1148 (7th Cir.
23 1998) (Claims administrator was entitled to rely on conclusions
of independent non-examining physician where the physician was
provided all medical records the administrator had and there was
"nothing in the record to suggest that [the physician] felt that
he did not have adequate information to render a reliable
opinion.")
Furthermore, Dr. Sageman did not disregard the clinical
findings and observations of Wood's treating physician and
physician's assistant. Rather, accepting them completely. Dr.
Sageman found that those reports simply did not support the
diagnoses Wood's psychiatrist and physician's assistant made.
That type of expert medical review was not unreasonable in this
case. Cf. DuMond, 172 F.3d at 622 (finding the argument that the
court "should give more weight to the treating physician than a
reviewing physician . . . unavailing as the records submitted by
[claimant's] doctors do not support a diagnosis of [claimant's
allegedly disabling illness]").
Whether Wood can perfect his claim with a more apt, and
better supported, diagnosis is of course not the issue here. See
24 supra note 7. The pending issue is whether the Plan acted
arbitrarily in denying his claim as. presented, and clearly it did
not. If Wood was and remains disabled within the meaning of the
Plan, he must adequately present and establish the illness he
suffers from and its debilitating effects.
Conclusion
For the foregoing reasons Prudential's denial of Wood's
claim for disability benefits was not arbitrary or capricious.
Accordingly, Wood's motion for summary judgment (document no. 12)
is necessarily denied and Prudential's motion for summary
judgment (document no. 13) is necessarily granted. The Clerk of
the Court is directed to enter judgment in accordance with this
order and close the case.
25 SO ORDERED.
Steven J. McAuliffe United States District Judge
June 14, 2000
cc: Gregory D. Wirth, Esq. Edward A. Haffer, Esq. Lonie A. Hassel, Esq.