Kamholtz v. Madison Nat'l Life Ins. Co.

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JEANIE B. KAMHOLTZ, Plaintiff, v. MADISON NATIONAL LIFE INSURANCE COMPANY INC, Defendant.

No. 22-cv-617-jdp

United States District Court, W.D. Wisconsin

January 22, 2024

OPINION AND ORDER

JAMES D. PETERSON, DISTRICT JUDGE

Plaintiff Jeanie Kamholtz worked as a receptionist at Madison Teachers Inc. Kamholtz stopped working in January 2021 when pain and an intermittent sensation of spasming inside her eyes made it difficult for her to keep her eyes open for long periods of time. In May 2021, Kamholtz applied for long-term benefits through her Madison Teacher's disability insurance plan which was administered by defendant Madison National Life Insurance Company. Madison National denied her claim initially and on appeal. Kamholtz brings this action under the Employee Retirement Income Security Act (ERISA) to challenge the denial. The parties have filed cross-motions for summary judgment. Dkt. 12 and Dkt. 15.

The central issue in this case is whether Madison National properly considered evidence of Kamholtz's eye pain and sensations of spasming. Kamholtz contends that Madison National's decision was arbitrary and capricious because it focused on her normal eye examination results and absence of an identified cause of her symptoms while ignoring her physicians' observations that she could not keep her eyes open because of pain. Kamholtz also contends that Madison National's decision was arbitrary and capricious because it failed to properly review the totality of her mental and physical conditions and did not comply with ERISA's procedural requirements for appeals.

The court concludes that Madison National fully and fairly reviewed the evidence related to Kamholtz's claim and that its decision had rational support in the record. The court will grant Madison National's motion, deny Kamholtz's, and enter judgment for defendant.

UNDISPUTED FACTS

The following facts are undisputed unless otherwise noted.

A Kamholtz's work and health history

Plaintiff Jeanie Kamholtz began working at Madison Teachers as a receptionist in 2008. Her duties included welcoming visitors as well as secretarial work such as receiving and preparing mail, distributing agendas and minutes for meetings, and helping maintain group calendars. Dkt. 11-2, at 42-43.

In 2010, Kamholtz began experiencing lightheadedness, fatigue, neck pain, muscle tightness, and muscle spasms. Id., at 98. She was referred to the Mayo Clinic for testing and was diagnosed with the genetic condition Ehlers-Danlos Syndrome (EDS) and Postural Orthostatic Tachycardia Syndrome (POTS) in 2011. Id., at 78-79. EDS is a group of genetic disorders that affect connective tissue. Id., at 66. Symptoms can vary among individuals and include joint, muscle, and nerve pain, loose or unstable joints, muscle tension and weakness, and nerve disorders. Id. POTS is a cardiac condition that can cause lightheadedness and fatigue. Kamholtz began taking medicine and made lifestyle changes to manage her conditions and was able to return to work with accommodations for her neck and hand spasms.

B. Kamholtz's disability claim

In the fall of 2020, Kamholtz began experiencing a sensation of intermittent spasming inside her eyes that made her feel that she could not focus her eyes and that it was difficult to keep them open. In October 2020, Kamholtz saw an optometrist who prescribed her bifocals. Dkt. 11-4, at 128. In January 2021, Kamholtz's symptoms of eye spasming got worse and she stopped working.

In the months after she stopped working, Kamholtz saw numerous providers about her eye spasms and associated eye pain. In February, Kamholtz saw an advanced practice nurse practitioner who referred her to ophthalmology and prescribed medicine for the spasms. Id., at 33. The nurse practitioner noted that Kamholtz reported having eye spasms when she tried to focus her eyes but that her eye examination results were unremarkable. In March, Kamholtz saw the same nurse practitioner, an optometrist, two ophthalmologists, her primary care physician Dr. Lorna Belsky, and a neuro-ophthalmologist. When Kamholtz saw the neuro-ophthalmologist she was able to keep her eyes open, but all the other providers noted that Kamholtz kept her eyes closed for most of her visit with them. Dkt. 11-3, at 172, 174, 178, 185; Dkt. 11-4 at 36, 99.

None of the providers were able to identify the cause of Kamholtz's symptoms. All her providers reported that she could open her eyes for testing, and the ophthalmologists all noted that that her eye exams were “unremarkable.” Dkt. 11-3, at 179; 11-4 at 99, 118. The optometrist noted “when her eyes were open for testing, she appeared comfortable.” Dkt. 11-3, at 185. The first ophthalmologist saw no spasms and noted “unclear if psychosomatic” as the basis for suggesting that Kamholtz be examined by a neuro-ophthalmologist. Id., at 179. The second ophthalmologist noted that Kamholtz could open her eyes for testing “fully and without visible strain.” Id., at 174. The neuro-ophthalmologist reported that various types of eye examinations were normal and that “no further neurophthalmology investigation is indicated.” Dkt. 11-4, at 99-100.

In May 2021, Kamholtz submitted her claim for disability benefits to Madison National. As an employee of Madison Teachers, Kamholtz was eligible for group long-term disability insurance administered by Madison National. The long-term disability policy at issue is governed ERISA. The policy provides that “Disability and Disabled mean you are, as a result of Physical Disease, Injury, Mental Disorder, Substance Abuse or Pregnancy, unable to perform a majority of the Material Duties of your Own Occupation” and that Madison National will pay disability benefits “after [it] receive[s] satisfactory Proof of Loss.” Dkt. 11-5, at 16, 19.

The insured individual must provide objective medical evidence to support her disability, as outlined in the following provision:

You must submit periodic evidence from your Physician that substantiates, to our satisfaction, that you remain Disabled. This required evidence includes, but is not limited to, objective medical and/or psychiatric evidence from a Physician that confirms your Disability. Subjective complaints alone will not be considered conclusive evidence of a Disability. The attending Physician must be able to provide objective medical evidence to support his/ her opinion as to why you are not able to perform the Material Duties of your Own Occupation or Any Occupation. You must obtain and provide this information at your own expense.

Dkt. 11-5, at 25. The policy also contains a catchall provision that requires the insured to “promptly provide [Madison National] with all information that [it] reasonably decide[s] is necessary to verify and administer your claim for benefits.” Id., at 26. An insured individual may request an administrative appeal “[i]f all or part of a claim is denied.” Id., at 27. If an individual requests an administrative appeal, she may send “written comments or other items to support the claim.” Id., at 28.

In her disability claim, Kamholtz listed her disabling condition as “[EDS], difficulty focusing eyes, spasms, headaches and eye pain, movement in jaw/skull area.” Dkt. 11-2, at 27. Dr. Belsky, her primary care physician, submitted an “Attending Physician's Statement” that described Kamholtz symptoms as “weakness, fatigue, unable to focus eyes for vision” and said that Kamholtz was “unable to work at all right now due to neurological symptoms.” Dkt. 114, at 158-59. Dr. Belsky also opined that “no modifications can help with [Kamholtz's] current eyesight/vision problems.” Id., at 159. Although Dr. Belsky listed EDS as a “primary diagnosis,” she provided a separate diagnosis code for Kamholtz's eye condition and did not opine that Kamholtz's eye pain and spasming were a symptom of her EDS. Id., at 158.

Madison National reviewed Kamholtz's submission and her medical records. Madison National asked an independent ophthalmologist to review the records and to discuss Kamholtz's condition with the neuro-ophthalmologist she saw. Dkt. 11-5, at 50. The independent ophthalmologist disagreed with Dr. Belsky's assessment that Kamholtz could not focus her eyes and opined that “[f]rom an ophthalmology perspective, there is no clinical evidence that supports functional impairment.” Dkt. 11-4, at 206-07. The independent ophthalmologist tried calling the neuro-ophthalmologist on three separate occasions but none of her calls were returned. Id., at 811-12.

On September 15, 2021, Madison National sent Kamholtz a letter denying her claim. Madison National concluded that Kamholtz's “self-reported complaints are not supported by findings on ophthalmic exams.” Dkt. 11-2, at 200. Madison National concluded that Kamholtz did not submit objective medical evidence of a functional limitation, which meant that she did not meet the policy's definition of disability.

C. First administrative appeal

Kamholtz timely appealed the denial in January 2022. She sent a letter that explained her symptoms in detail, including that when she experienced the spasming sensation it made it difficult to focus her eyes and that the spasming was “excruciatingly painful.” Dkt. 11-2, at 132. Kamholtz acknowledged that she can technically see when experiencing spasms. Id. But she said that the extreme pain in her eyes prevents her from doing anything other than massaging her eyes with heating pads for long periods of time. Id., at 132-33.

Kamholtz also submitted statements from her two sisters and a close friend, an updated letter from Dr. Belsky, reference materials from the Ehlers-Danlos Society, and letters from Dr. Belsky and Dr. Alexandra Ilkevitch, a physical medicine and rehabilitation doctor. Dr. Belsky's letter...