Audino v. Raytheon Co. Short Term Disability Plan

United States Court of Appeals
Fifth Circuit
F I L E D
IN THE UNITED STATES COURT OF APPEALS
April 13, 2005
Charles R. Fulbruge III
FOR THE FIFTH CIRCUIT Clerk
No. 04-10729
GLORIA AUDINO,
Plaintiff-Appellant,
versus
RAYTHEON COMPANY SHORT TERM DISABILITY
PLAN; RAYTHEON COMPANY LONG TERM DISABILITY
PLAN; METROPOLITAN LIFE INSURANCE COMPANY;
RAYTHEON COMPANY, ad plan administrator,
Defendants-Appellees.
Appeal from the United States District Court for
the Northern District of Texas
(USDC No. 3:03-CV-777)
_________________________________________________________
Before REAVLEY, JOLLY and PRADO, Circuit Judges.
PER CURIAM:*
Gloria Audino appeals from MetLife’s denial of her claim for disability
*
Pursuant to 5TH CIR. R. 47.5, the Court has determined that this opinion
should not be published and is not precedent except under the limited circumstances
set forth in 5TH CIR. R. 47.5.4.
benefits and the district court’s grant of summary judgment in MetLife’s favor.
Concluding that MetLife abused its discretion in evaluating Audino’s claim, we
vacate and remand.
Background. Audino worked for Raytheon Company for 17 years, most
recently as a Software Engineer Administrative Assistant. She participated in
Raytheon’s Short Term Disability (“STD”) and Long Term Disability (“LTD”)
benefits plans, paying monthly premiums for enhanced benefits. In 1999, Audino
was diagnosed with rheumatoid arthritis, an auto-immune disorder which causes
inflammation and swelling in the joints. In May 2001, she was diagnosed with optic
neuritis, which caused a partial loss of vision in her right eye. On July 9, 2002, she
filed a claim for STD benefits and a claim for LTD benefits. MetLife denied
Audino’s benefits requests.
Standard of Review. We review a district court’s grant of summary judgment
de novo, applying the same standards as the district court. Pratt v. City of Houston,
247 F.3d 601, 605-06 (5th Cir. 2001). Because the STD and LTD plans give
MetLife discretion to determine benefits eligibility, we review Met Life’s decision
to deny Audino benefits for abuse of discretion. Sweatman v. Commercial Union
Ins. Co., 39 F.3d 594, 597-98 (5th Cir. 1994). To determine whether the
administrator abused its discretion, we analyze whether it acted arbitrarily or
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capriciously. Id. at 601. A decision is arbitrary if there is no rational connection
between the known facts and the decision or between the found facts and the
evidence. Dowden v. Blue Cross & Blue Shield of Tex., Inc., 126 F.3d 641, 644
(5th Cir. 1997) (quoting Bellaire Gen. Hosp. v. Blue Cross Blue Shield, 97 F.3d
822, 828 (5th Cir. 1996)).
Analysis. MetLife denied benefits based on a purported lack of objective
medical evidence that Audino suffered from a condition or conditions rendering her
totally disabled. Under the Plan, a claimant is totally disabled if she is under the
regular care of a doctor and unable to perform all of the essential elements of her
regular job with reasonable accommodation. MetLife concluded that evidence was
lacking that Audino could not perform her job.
Audino’s employer provided MetLife with a statement listing the
occupational requirements of her job. For 1-33% of the workday, her job required:
standing; walking; climbing stairs; grasping or handling; bending, stooping, or
squatting; fine hand dexterity; forceful wrist twisting; and lifting of up to twenty
pounds. For 67-100% of the workday, the job entailed: sitting; highly repetitive
motion; fine visual attention; and precise verbal and written communication. The
employer commented that Audino was not meeting performance expectations in
areas of her job due to: (1) a decline in job accuracy after partial loss of sight; (2)
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decline in focus and alertness; (3) inability to maintain interaction with a large group
of individuals; (4) lack of responsiveness to requests; (5) poor attendance due to
illness or doctor’s appointments; and (6) limitations in assisting with meetings at
other sights “which is a job task.” In addition, in a telephone conversation with a
MetLife claims administrator, the employer stated that it “would not be able to
accommodate any restrictions or limitations.” In denying Audino’s claim, MetLife
ignored these employer comments, which show that Audino’s job performance had
declined and suggest that, at the time she filed her claim, Audino was not meeting
the minimum level of effectiveness in her job functions due to her medical
conditions.
MetLife also failed to explain why Audino’s evidence was insufficient to
show that she could not do the specific tasks listed by her employer as occupational
requirements. Audino provided MetLife with medical records showing that she has
been treated for rheumatoid arthritis for several years, and, more recently, for optic
neuritis. These records document subjective evidence of disability—her consistent
complaints of severe fatigue, pain, stiffness, and vision difficulties. They also
provided objective evidence of disability—in exams in 2001 and 2002, some of
Audino’s joints had been swollen at times and tender, she had severe arthritis
around her trapezius, her best corrected near vision in her right eye was 20/70, her
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hip muscles were tight and her back muscles sore, and blood tests indicated
inflammation. Her rheumatologist opined that Audino would benefit from more rest
and believed she should be placed on short term disability. Her opthalmologist
stated that the results of her eye exam corresponded to her complaints of having
difficulty with her near work.
MetLife based its conclusion that objective evidence that Audino could not
perform her job functions was lacking largely on the opinions of medical consultants
Tracey Schmidt (rheumatology and internal medicine) and David Turok
(opthalmology), who did not examine Audino but reviewed her records. Our review
of those records reveals several oversights in Dr. Schmidt’s analysis. Dr. Schmidt
failed to note that Audino’s SED rate1, although within the normal range at 25, was
on the high end of normal. She minimized evidence that Audino’s CRP rate2 had
been abnormal on September 17, 2002 at 0.91 mg/dL by incorrectly stating that the
record contained no prior CRP rates for comparison. In fact, between February and
September 2002, Audino’s CRP rate had been measured five times. In three tests,
her results were within the normal range of 0-0.4 mg/dL. However, the other two
tests, in June and September, were well above normal at 1.4 and 0.91 mg/dL. See
1
A blood test indicating non-specific inflammation.
2
Another test for inflammation.
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Lain v. UNUM Life Ins. Co. of Am., 279 F.3d 337, 347 (5th Cir. 2002) (faulting
disability plan administrator for characterizing test results as “essentially normal”
when they were at times abnormal and “top normal”)
Dr. Schmidt’s analysis was unsatisfactory in other aspects as well. Contrary
to her assertion that the file lacked mention of “any restricted ROM of joints other
than the right foot abnormality,” a February 2002 exam revealed that Audino’s
“wrists [were] swollen bilaterally with pain on range of motion of the left wrist” and
her “left ankle was swollen with pain [on] range of motion.” Although she noted in
summarizing the evidence that Audino’s physician had observed severe arthritis
around the trapezius in August 2002, Dr. Schmidt failed to evaluate that finding in
her analysis of whether Audino’s impairments constituted disability under the plan.
Regarding Audino’s rheumatoid arthritis and optic neuritis, Schmidt
concluded that Audino’s file lacked “objective evidence of a physical functional
capacity impairment to a full time sedentary job.” As to her optic neuritis, Dr.
Turok opined that “Ms. Audino’s current level of functionality should allow her to
maintain her job as a management assistant. The occupational requirements could
be met given her visual function.” However, Audino’s medical records show that
she has complained of and been treated for extreme fatigue, joint pain, stiffness,
swelling, and vision problems—impairments that would either prevent or make
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difficult the tasks her employer listed as requirements of her job. Neither MetLife
nor its consultants analyzed specifically how Audino’s conditions affected her
ability to engage in each of those tasks or explained why her conditions did not
prevent her from performing those tasks.
We are also troubled by MetLife’s failure to accord weight to Audino’s
consistent complaints of pain, even though those complaints were documented in
her medical records for years before she sought benefits and there is no indication
that she overstated her pain once she decided to seek benefits. We have recognized
that pain cannot always be objectively quantified and have faulted an administrator
for “focus[ing] on [] tests, rather than the pain and its effect[.]” Lain, 279 F.3d at
347.
We conclude that MetLife acted arbitrarily and capriciously in denying
Audino’s short-term disability benefits claim. The record reveals that MetLife
ignored Audino’s consistent complaints of pain as subjective, either minimized or
ignored objective evidence of disability corroborating those complaints, and
concluded that the evidence did not show an inability to do her job functions without
analyzing the effect that her conditions would have on her ability to perform her
specific job requirements. Thus, we cannot say that there is a rational connection
between the found facts and the evidence. Dowden, 126 F.3d at 644. Because
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MetLife reached its decision to deny benefits in an arbitrary manner, we vacate the
district court’s order granting summary judgment in favor of defendants, and instruct
that court to remand to MetLife to perform a satisfactory inquiry into whether
Audino can perform the essential functions of her job with reasonable
accommodation. See Quinn v. Blue Cross and Blue Shield Ass’n, 161 F.3d 472,
476-78 (7th Cir. 1998) (finding that an administrator abused its discretion by failing
to make an adequate inquiry into whether a claimant met the disability plan’s
definition of disabled and remanding to the administrator for adequate inquiry);
Schadler v. Anthem Life Ins. Co., 147 F.3d 388, 398-99 (5th Cir. 1998) (stating that
the court should not make a decision belonging to the plan administrator in the first
instance and remanding to the administrator for a new benefits eligibility
determination).
VACATED and REMANDED with instructions.
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