MacNaughton v. Paul Revere Ins. Co.

663 F.Supp.3d 136

Mary MACNAUGHTON, M.D., Plaintiff, v. The PAUL REVERE INSURANCE COMPANY and Unum Group, Defendants.

CIVIL ACTION NO. 4:19-40016-TSH

United States District Court, D. Massachusetts

Signed March 22, 2023

Jonathan M. Feigenbaum, Boston, MA, Talia Ravis, Pro Hac Vice, Law Office of Talia Ravis, PA, Kansas City, MI, for Plaintiff.

J. Christopher Collins, Joseph M. Hamilton, Mirick O'Connell DeMallie & Lougee LLP, Worcester, MA, for Defendants.

ORDER AND MEMORANDUM ON PARTIES' CROSS-MOTIONS FOR SUMMARY JUDGMENT (Docket Nos. 103 & 106)

HILLMAN, Senior District Judge

Dr. Mary MacNaughton ("plaintiff") commenced this action against The Paul Revere Insurance Company ("Paul Revere") and Unum Group ("Unum") (collectively, "defendants") to recover unpaid benefits after an adverse benefits determination on her employer-sponsored long-term disability claim. In a previous order, this Court remanded the claim to ensure a "full and fair review" of Dr. MacNaughton's appeal of the adverse decision. After remand, defendants denied Dr. MacNaughton's claim a second time and both parties moved for summary judgment. For the reasons below, under the arbitrary and capricious standard of review, the defendants' decision is supported by substantial evidence and reasoned. Therefore, plaintiff's motion is denied and defendants' motion is granted.

Background

The following is taken from the parties' undisputed statements of material facts, which are based solely on the administrative record. Liston v. Unum Corp. Officer Severance Plan, 330 F.3d 19, 23-24 (1st Cir. 2003). The Court cites to the record where a fact is disputed. This summary focuses on facts relevant to the issues at summary judgment and does not repeat all the facts in the earlier summary judgment order. (Docket No. 81).

1. Claim, Denial, Appeal, Lawsuit

From 1998 to 2007 the plaintiff worked as a radiologist at Alliance Radiology in Overland Park, Kansas. Her work included reading radiographic images, including X-rays, CT scans, and MRIs. As part of her employment with Alliance, the plaintiff was offered coverage under a Long-Term Disability Plan ("the Plan") insured by the defendants. The Plan provides benefits to individuals who are "totally disabled." The Plan defines "total disability" as being "unable to perform the important duties of [one's] own occupation on a Full-time or part-time basis because of an Injury or Sickness that started while insured under this Policy." The Plan defines a physician's "own occupation" as the physician's "specialty in the practice of medicine." The Plan does not define "important duties."

In 2007, after giving birth to twins, Dr. MacNaughton submitted a disability claim based on difficulties seeing out of her left eye. From 2007 to 2010 she was examined by various doctors and diagnosed with nerve damage in her left eye causing a visual field defect and convergence insufficiency. Paul Revere initially denied the claim on the basis that a visual field defect in one eye would be "filled in" by the healthy eye. However, after objections from her then-attending physician ("AP"), Paul Revere approved her disability claim. Dr. Shatz, Paul Revere's doctor, noted that convergence insufficiency is a "binocular" disorder for which the right eye cannot correct for the left. Dr. Shatz also noted that the documented nerve damage in the left eye could render the convergence insufficiency condition permanent and non-correctable. Paul Revere paid benefits without issue until 2017. During this time Dr. MacNaughton worked part-time in a supervisory capacity, but never as a diagnostic radiologist.

In June 2017, Paul Revere contacted Dr. MacNaughton and she reported that she had "blurred vision" but that, in her supervisory, non-diagnostic position, "there are not R & Ls really" (restrictions and limitations). Her case was subsequently transferred to Disability Benefits Specialists for further review. (PRL-1840). In August 2017, at least one employee of Paul Revere working on Dr. MacNaughton's case considered whether it was feasible for diagnostic radiologists to work with one eye. (PRL-2004).

In July 2017, Paul Revere received records from Dr. MacNaughton's AP that supported the convergence insufficiency diagnosis. However, that AP retired shortly thereafter and her new AP, Dr. Pole, did not feel comfortable opining on Dr. MacNaughton's capacity to work. In August 2017 he sent Paul Revere an equivocal letter that sheds little light on her condition. (PRL-2033-34). Dr. Pole agreed it would be appropriate for Dr. MacNaughton to be examined by an independent medical examiner ("IME"). (PRL-2025).

Dr. Rosenberg, an IME, examined Dr. MacNaughton and concluded in November 2017 that any deficiencies in visual acuity were correctable, her convergence insufficiency was also correctable, that her vision was otherwise normal, and that she could go back to work. (PRL-2207-14). He did not address or test for nerve damage. Internal documents reveal that Paul Revere never sent Dr. Rosenberg the physical requirements for diagnostic radiologists. (PRL-2226). Paul Revere sent a follow up letter with those requirements to Dr. Rosenberg, (PRL-2255-56), the same day it sent its denial letter to Dr. MacNaughton, (PRL-2246-51). The denial letter was based substantially on Dr. Rosenberg's report. After receiving the physical requirements for radiologists Dr. Rosenberg did eventually respond that he found Dr. MacNaughton would be "[a]bsolutely able to perform" her duties as a diagnostic radiologist. Dr. MacNaughton appealed that decision.

During the appeal, Dr. MacNaughton submitted a report from her new AP, Dr. Warren. (PRL-2431-53) ("Dr. Warren Report #1"). Because of its importance to the case, the Court recounts that report in some detail. Dr. Warren diagnosed Dr. MacNaughton with "ischemic optic neuropathy" (nerve damage to the left eye). Dr. Warren is adamant in his report that this type of injury is permanent and can neither be corrected nor heal, comparing it to spinal damage or other nervous system injuries. As proof of the nerve damage, he identified a "pupillary abnormality," and conducted an electroretinography (ERG) that demonstrated the left eye did not conduct electricity the same way the right eye did. He insisted in the report that the pupillary abnormality was permanent. He also conducted a visual field test, which showed a visual field deficit adjacent to the optic nerve and argued that the visual field deficit caused Dr. MacNaughton to have reduced reading speeds and created "an area where she cannot see when she reads from left to right." His report concluded that this prevented her from performing her job as a diagnostic radiologist. This report also mentioned that Dr. MacNaughton's visual acuity in her left eye was 20/40, but that does not seem to be the focus of his report. Dr. Warren criticized Dr. Rosenberg's report, arguing that Dr. MacNaughton does not have convergence insufficiency and faults Dr. Rosenberg for not mentioning a pupillary examination or the nerve damage.

Paul Revere submitted all available records, including Dr. Warren Report #1, to Dr. Eisenberg, a different IME. In September 2018, Dr. Eisenberg submitted a report. (PRL-2563-67) ("Dr. Eisenberg Report #1"). Dr. Eisenberg concluded that there was evidence of nerve damage to the left eye, including a visual field abnormality, but that diagnostic radiologists with one healthy eye are not disabled because there is no evidence their job requires depth perception. He noted that convergence insufficiency was not found by Dr. Warren and that it probably predated the injury if it existed at all as it is relatively common. He also found that the presence of normal stereo vision (measured by Dr. Rosenberg and from an earlier report), normal color vision in the left eye, multiple findings of acuity in the 20/20 - 20/25 range, and the absence of optic nerve atrophy or pallor "indicates significant retention of function in [the left] eye." He also argued the eye "recovered a significant amount of function." He concluded that "[i]schemic optic neuropathy is typically a stable condition following an inciting event . . . It is unlikely to progress, and this has been borne out in the past 11 years of serial examinations."

With some equivocation, Dr. Eisenberg did not agree with Dr. Rosenberg's report other than the ultimate conclusion that Dr. MacNaughton was able to work. Contrary to Dr. Warren, the report concludes that (1) one eye is sufficient for diagnostic radiologists (2) the field defect identified by Dr. Warren can be corrected simply by using both eyes and (3) the 20/40 finding is dubious given earlier readings.

On September 20, 2018, Paul Revere denied the claim, adopting Dr. Eisenberg's conclusions. Dr. MacNaughton was never given an opportunity to rebut Dr. Eisenberg's report.

2. Remand and Cross-Motions for Summary Judgment

Dr. MacNaughton sued and prevailed on summary judgment, receiving a remand from this Court to allow her to rebut Dr. Eisenberg's report. This Court also found that the standard of review for any decision made by the defendants was "arbitrary and capricious." (Docket No. 81).

Based on examinations from 2018 to 2022, Dr. Warren submitted a second report in the form of a deposition. (PRL 3426-76) ("Dr. Warren Report #2"). Dr. Warren argued that Dr. MacNaughton suffered from poor stereo vision and depth perception, and that nerve damage caused those problems, not convergence insufficiency. Furthermore, he tested her "contrast sensitivity," and found that lacking as well. Based on these findings, Dr. Warren concluded that Dr. MacNaughton could not work. Dr. Warren also maintained that there was some loss of acuity, but did not defend his earlier 20/40 finding. He also continued to maintain that there was a visual field deficit, but did not base his finding that Dr. MacNaughton could not work on that deficit. Furthermore, Dr. Warren did not, point-by-point, rebut Dr....