The case summarized here involves Damon Zaeske (“Zaeske”), who was a project manager employed by Walmart. He ceased working on April 4, 2014, as a result of chronic back pain. Walmart’s insurance plan was underwritten by Liberty Life Assurance Company of Boston (“Liberty Life”); Zaeske applied for long-term disability (LTD) benefits through this plan.
When reviewing Zaeske’s claim for benefits, Liberty Life collected medical records from his doctors, Dr. Garrett, Dr. Nunley, and Dr. Potts. Those records were then given to Dr. Shannon, an independent consulting physician who reviewed the files and provided an assessment for Liberty Life. Upon Dr. Shannon’s review, she diagnosed Zaeske with chronic low back pain and disc protrusion with severe stenosis. Because of this, she opined that Zaeske’s work abilities were limited to that of sedentary work, as opposed to the light work he had to do in his job. Further, Dr. Shannon stated that Zaeske should recover from the pain in three to six months. Based on this, Liberty Life approved the claim, to be reviewed periodically.
Zaeske started receiving benefits on July 6, followed by requests for updated records in October. Dr. Potts responded, but Dr. Nunley did not. As a result, Liberty Life stated that it would suspend Zaeske’s benefits until it received updated records. On December 15, Dr. Potts, Dr. Nunley, and Dr. Randolph provided updated medical records. The same day, those records were forwarded to Dr. Glassman, a second independent consulting physician. He attempted to reach out to each of Zaeske’s doctors but did not receive a response.
Dr. Glassman’s report stated that Zaeske’s issues were the result of back pain and lumbar degenerative disc disease. He further opined that “a gentleman who is 51 years old with a history of lumbar degenerative disc disease, but no evidence of any disc herniation” would be able to handle full-time work for an eight-hour day, five days a week. Based on this, Liberty Life denied Zaeske’s claim for further benefits.
Zaeske appealed and provided additional documents in support of the claim, including treatment notes and a letter from Dr. Potts. Liberty Life, however, refused to change its mind because no additional medical evidence had been submitted. Zaeske additionally submitted the results of a magnetic resonance imaging and an additional note from Dr. Potts. All of this information was passed on to Dr. Reecer, a third independent consulting physician.
Dr. Reecer attempted to contact Dr. Potts on four occasions but was unable to reach her. Therefore, he rendered a report anyway, stating that Zaeske had a herniated disc, stenosis, and moderate lumbar degenerative disc disease. Even with those conditions, Dr. Reecer stated that Zaeske could work an eight-hour shift, for forty hours a week. Because of this assessment, Zaeske’s claim was again denied and he filed suit.
The trial court held that the termination of Zaeskes’ LTD benefits was not supported by enough evidence and was an abuse of discretion. More specifically, the trial court held that Dr. Reecer and Dr. Glassman both provided unreliable opinions. This court now seeks to review that decision.
The trial court’s impression of Dr. Reeser was that his opinion was unreasonable and unsupported by any medical evidence. Even though Dr. Reeser identified Zaeske’s medical issues as chronic pain, a herniated disc, and degenerative disc disease, “he omitted from his report any consideration of whether Mr. Zaeske’s chronic pain would impact his ability to function in the workplace.”
The trial court also found Dr. Glassman’s opinion unreliable since he “ignored verified proof in the medical file that Mr. Zaeske suffered from disc protrusion, herniation, and lumbar stenosis.” Further, the trial court held that Dr. Glassman’s alleged misdiagnosis led him “to assume that Mr. Zaeske was less impaired than he actually was—and contributed to a domino-effect of faulty assumptions and unsupported recommendations.”
On appeal, the court of appeal disagreed with the trial court’s opinions of Dr. Glassman and Dr. Reeser. In fact, the appeals court held that the doctors’ opinions were reasonable and were not an abuse of discretion. The court appeal found that Dr. Glassman’s opinion stemmed from a reasonable understanding of Zaeske’s records, and he did not ignore “verified proof in the medical file that Mr. Zaeske suffered from disc protrusion, herniation, and lumbar stenosis.” In fact, the herniation evidence was noted in an MRI from January 2015, which was unavailable until three weeks after Dr. Glassman’s assessment.
Further, the court held that Dr. Reeser also had a reasonable understanding of Zaeske’s medical records. The trial court stated that Dr. Reecer did not consider the affect of Zaeske’s chronic pain in the workplace. However, the appeals court found that it was not an abuse of discretion for Liberty Life to believe Dr. Reecer’s opinion that back pain treated with medication would not prevent Zaeske from working.
Additionally, the trial court considered that disagreements between Dr. Reecer’s 2015 assessment and Dr. Shannon’s 2014 opinion meant Dr. Reecer could not be relied upon. However, the appeals court found that the assessment and opinion were not irreconcilable. In fact, the court of appeals held that, even with inconsistencies, Dr. Reecer’s opinion was not required to be discounted.
Generally, where there are differing opinions between two reliable medical professionals, the plan administrator has the discretion to choose the medical opinion it will follow. The administrator can even choose an opinion given by its own physician over that of the applicant’s treating physician. In this case, while Dr. Shannon’s report was given first, that does not mean that Liberty Life was required to choose that report.
In sum, the court of appeal held that Dr. Reecer’s opinion was sufficiently reliable to support Liberty Life’s denial of Zaeske’s benefits. It therefore reversed the trial court’s ruling (that was in favor of the claimant), and even reversed the lower court’s award of Zaeske’s benefits and vacated the prior award of attorney’s fees to the claimant.
Disclaimer: This was not a case handled by disability attorney Nick A. Ortiz. The court case is summarized here to give readers a better understanding of how Federal Courts decide long term disability ERISA claims.
Here is a PDF copy of the decision: