Stanford v. Continental Casualty Company

455 F.Supp.2d 438

Robert R. STANFORD, Plaintiff, v. CONTINENTAL CASUALTY COMPANY, Defendant.

No. 5:05-CV-372-BR.

United States District Court, E.D. North Carolina, Western Division.

August 7, 2006.

John R. Rittelmeyer, Hartzell & Whiteman, Raleigh, NC, for Plaintiff.

Debbie Weston Harden, Katherine T. Lange, Womble Carlyle Sandridge & Rice, P.L.L.C., Charlotte, NC, for Defendant.

ORDER

BRITT, Senior District Judge.

This matter is before the court on the parties' cross-motions for summary judgment, and plaintiffs motion to file the administrative record under seal. The motions have been fully briefed, and the matter is ripe for disposition.

I. BACKGROUND

Plaintiff was employed by Beaufort Memorial Hospital ("BMH") in Beaufort, South Carolina, as a Certified Registered Nurse Anesthetist ("CRNA") from 8 April 2002 to 20 May 2004. Compl. ¶ 5. BMH provided plaintiff "long-term disability benefits pursuant to .... [a] Disability Plan ... issued by [defendant] Continental" Casualty Company ("the policy"). Id. ¶ 6. Plaintiff developed an addiction to Fentanyl, a drug used as an anesthetic and on 28 September 2003, he entered a 28-day inpatient treatment program in Wilmington, North Carolina. Id. ¶ 9. Plaintiff has also been diagnosed alternately with dysthymia and severe depression. R. at 109 (5/19/04 diagnosis of "major depression"); 116 (7/15/04 progress note stating plaintiff "fights depression" and diagnosing plaintiff with dysthymic disorder); 141 (physician's statement diagnosing plaintiff with dysthymic disorder).¹ Plaintiff relapsed, and on 24 November 2003, entered a 90-day inpatient treatment program ("Talbott") in Atlanta, Georgia. Id. at 180. On 14 January, 2004, plaintiff applied to defendant for long term disability ("LTD") benefits under the policy. Id. at 193. Defendant approved the application and paid benefits through 7 March 2004. Id. at 153. Plaintiff did not relapse again, but entered a third inpatient treatment program in St. Simons Island, Georgia, on 19 May 2004, and was released by that facility to work on 27 May 2004 "with the restriction of not having access to narcotics." Id. at 90. He reapplied for LTD benefits on 23 July 2004. Id. at 143. This application was supported by a "Functional Assessment Tool" submitted by plaintiffs treating physician (Dr. Faulk) which stated that plaintiff "suffers drowsiness as a result of his medications for depression and addiction" and "cannot be around narcotics." Id. at 130. In addition, at some point the South Carolina Board of Nursing restricted plaintiffs nursing license to prohibit him from having access to narcotics or working as a CRNA. Id. at 88 (1/31/05 letter from plaintiff appealing termination of benefits).² Defendant approved plaintiff's application on 17 August 2004. Id. at 127. Dr. Faulk noted on 20 September 2004 that plaintiff "remains at high risk in a job setting as he is being maintained on the drug Suboxone and patient care would be in jeopardy due to his potential for an impaired response while on this medication." Id. at 105.

On 20 December 2004, in a conversation with defendant, Dr. Faulk stated that plaintiff did not have any cognitive impairments or intellectual difficulties. Id. at 50. However, Dr. Faulk stated that "there is the potential" that plaintiff could experience drowsiness from his medication. Id. By that date, plaintiff had abstained from Fentanyl for approximately seven months, attended AA meetings, and was enrolled in South Carolina's Recovering Professionals Program, which is a five-year program that requires him to attend AA meetings and submit to random drug screens. Id. at 49. Defendant terminated plaintiffs benefits on 14 January 2005, "find[ing] that there is a lack of medical evidence to support that [plaintiff] [is] functionally impaired from performing the material and substantial duties of [his] regular occupation as a CRNA." Id. at 98-100.

Plaintiff appealed the denial on 31 January 2005. Id. at 88. He submitted a letter from Dr. Faulk stating that

at this time, . . . [plaintiff] will be unable to return to his regular duties as an anesthesia nurse. He cannot be subjected to controlled substances at this time.

Additionally, current medications interfere with his ability to perform many duties which might put his patients at risk.

Id. at 89. Plaintiff also submitted an article from the Associate Medical Director at Talbott which stated that anesthesiologists suffering from opiate addictions should "[n]ever return to clinical anesthesiology" if they have "[s]ignificant relapse despite adequate treatment[;]" "[l]ack[ ] confidence to return to [the] operating room and not self-administer anesthetic drugs[;]" or have a "[s]ignificant Axis I or II psychopathology[.]" Id. at 93 (emphases in original not supplied).³ Defendant denied the appeal on 21 February 2005. Id. at 85-86. Plaintiff filed this action on 27 May 2005.

II. DISCUSSION

A. Summary Judgment Standard

Summary judgment is appropriate in those cases in which there is no genuine dispute as to a material fact, and in which it appears that the moving party is entitled to judgment as a matter of law. See Fed. R.Civ.P. 56(c); Haavistola v. Community Fire Co. Of Rising Sun, Inc., 6 F.3d 211, 214 (4th Cir.1993). Summary judgment should be granted in those cases "in which it is perfectly clear that no genuine issue of material fact remains unresolved and inquiry into the facts is unnecessary to clarify the application of the law." Haavistola, 6 F.3d at 214. In making this determination, the court draws all permissible inferences from the underlying facts in the light most favorable to the party opposing the motion. See id. "[W]here the record taken as a whole could not lead to a rational trier of fact to find for the non-moving party, disposition by summary judgment is `appropriate." Teamsters Joint Council No. 83 v. Centra, Inc., 947 F.2d 115, 119 (4th Cir.1991).

B. Standard of Review under ERISA

It is undisputed that the policy is governed by the Employee Retirement Income and Security Act ("ERISA"), 29 U.S.C. § 1001 et seq. See Pl.'s Br. Supp. Mot. Summ. J. at 1; Def.'s Br. Supp. Mot. Summ. J. at 1. Plaintiff brings one claim for relief—a claim for benefits under 29 U.S.C. § 1132(a)(1)(B)—which requires the court to review the plan administrator's decision to deny benefits. See Booth v. Wal-Mart Stores, Inc., 201 F.3d 335, 341 (4th Cir.2000). The parties agree that defendant is the plan administrator, and that the terms of the policy give defendant the discretion to determine plaintiffs eligibility for benefits. See Pl.'s Br. Supp. Mot. Summ. J. at 8; Def.'s Br. Supp. Mot. Summ. J. at 10.

The parties further agree that because defendant administers its own plan, creating a financial conflict of interest, the court should review defendant's decision under the "modified abuse of discretion" standard, see Pl.'s Br. Supp. Mot. Summ. J. at 8; Def.'s Br. Supp. Mot. Summ. J. at 10, by which the court does "not act as deferentially as would otherwise be appropriate. Rather, [the court] . . . review[s] the merits of the [administrator's decision] . . . to determine whether it is consistent with an exercise of discretion by a fiduciary acting free of the interests that conflict with those of the beneficiaries[,]" Doe v. Group Hospitalization & Medical Services, 3 F.3d 80, 87 (4th Cir.1993). "[I]f the court believes the decision both reasonable and correct, it may simply affirm the decision notwithstanding the conflict. Under the sliding scale analysis, the ultimate question . . . is whether the plaintiff received a full and fair review." Conrad v. Continental Cas. Co., 232 F.Supp.2d 600, 602-03 (E.D.N.C.2002) (citations omitted).

Finally, the court examines defendant's decision under eight non-exclusive factors set out by the Fourth Circuit in Booth, 201 F.3d at 342-43. Those factors are: (1) the language of the plan; (2) the goals and purposes of the plan; (3) the adequacy of the materials used to make the decision to deny benefits; (4) consistency of interpretation of the plan; (5) whether the decision-making process was reasoned and principled; (6) consistency of the decision with ERISA requirements; (7) any external standard relevant to the exercise of discretion; and (8) the plan administrator's motives and any potential conflict of interest. See id. For the following reasons, the court concludes that these factors favor defendant, and plaintiff is not entitled to relief.

C. Booth Factors⁴

1. Language of the Plan

Under the policy, plaintiff is entitled to benefits if an

Injury or Sickness causes physical or mental impairment to such a degree of severity that You are:

1) continuously unable to perform the Material and Substantial Duties of Your Regular Occupation; and

2) not Gainfully Employed.

R. at 20 (emphases in original). The policy also provides that "loss of . . . professional license or certification does not in and of itself constitute Disability" for purposes of analyzing whether plaintiff is unable to perform the material and substantial duties of his occupation. Id. (emphasis in original). The instant dispute between the parties centers on whether plaintiff's risk of relapse renders him continuously unable to perform the material and substantial duties of a CRNA. Pl.'s Br. Supp. Mot. Summ. J. at 9-12; Def.'s Br. Supp. Mot. Summ. J. at 12-13.

Defendant has cited to several cases which hold that when a claimant's disability is addiction, the potential for relapse does not render the claimant disabled under the policy terms. See Forste v. Paul Revere Life & Accident Ins. Co., 2004 WL 3315386, * 12 (S.D.Ind. Sept.22, 2004) ("the risk that Plaintiff will relapse is [not] an `injury' or `sickness' under the Policy . . . . [because] [t]he Policy unambiguously provides that the `injury' or `sickness' must be presently-existing, and not a future potentiality"); Laucks v. Provident Cos., 1999 WL 33320463, *6 (M.D.Pa. Oct.29, 1999) ...