Corey v. Sedgwick Claims Management Services, Inc.

RECOMMENDED FOR FULL-TEXT PUBLICATION
Pursuant to Sixth Circuit I.O.P. 32.1(b)
File Name: 17a0120p.06
UNITED STATES COURT OF APPEALS
FOR THE SIXTH CIRCUIT
BRUCE COREY, ┐
Plaintiff-Appellant, │
│
> No. 16-3817
v. │
│
│
SEDGWICK CLAIMS MANAGEMENT SERVICES, INC.; │
EATON CORPORATION; EATON CORPORATION │
DISABILITY PLAN FOR U.S. EMPLOYEES; EATON │
HEALTH AND WELFARE ADMINISTRATIVE COMMITTEE, │
Defendants-Appellees. │
┘
Appeal from the United States District Court
for the Northern District of Ohio at Cleveland.
No. 1:15-cv-01736—Patricia A. Gaughan, District Judge.
Argued: March 16, 2017
Decided and Filed: June 8, 2017
Before: BOGGS, ROGERS, and COOK, Circuit Judges.
_________________
COUNSEL
ARGUED: Andrew L. Margolius, MARGOLIUS, MARGOLIUS AND ASSOCIATES,
Cleveland, Ohio, for Appellant. Maynard A. Buck, BENESCH FRIEDLANDER, COPLAN
& ARONOFF LLP, Cleveland, Ohio, for Appellees. ON BRIEF: Andrew L. Margolius,
MARGOLIUS, MARGOLIUS AND ASSOCIATES, Cleveland, Ohio, for Appellant. Maynard
A. Buck, Richard Hepp, BENESCH FRIEDLANDER, COPLAN & ARONOFF LLP, Cleveland,
Ohio, for Appellees.
No. 16-3817 Corey v. Sedgwick Claims Mgmt. Servs., et al. Page 2
_________________
OPINION
_________________
COOK, Circuit Judge. Plaintiff Bruce Corey worked as a machine operator in
Eaton Corporation’s Northern Ohio factory. Corey has long suffered from cluster headaches—
extremely painful attacks that strike several times per day for weeks on end. In 2014, Corey
applied for short-term disability benefits under Eaton’s disability plan after a bout of headaches
forced him to miss work. After granting a period of disability, the third party administering
Eaton’s disability plan (“the Administrator”) discontinued benefits because Corey failed to
provide objective findings of disability.
Under the plan, “[o]bjective findings include . . . [m]edications and/or treatment plan.”
Corey’s physicians treated his headaches by prescribing prednisone, injecting Imitrex (a
headache medication), administering oxygen therapy, and performing an occipital nerve block.
We must decide whether Corey’s medication and treatment plan satisfy the plan’s objective-
findings requirement. We hold that it does and therefore REVERSE the district court’s contrary
decision.
I.
Plan Terms. Eaton’s disability plan accords the Administrator discretion to interpret the
plan’s terms and determine benefits eligibility. Under the plan’s terms, an employee is eligible
for short-term disability benefits if he has “a covered disability,” which the plan defines as “an
occupational or non-occupational illness or injury [that] prevents [the employee] from
performing the essential duties of [the employee’s] regular position with the Company or the
duties of any suitable alternative position with the Company.”
Relevant here, the plan also requires medical documentation of a disability:
Objective findings of a disability are necessary to substantiate the period of time
your health care practitioner indicates you are unable to work because of your
disability. Objective findings are those your health care practitioner observes
through objective means, not your description of the symptoms. Objective
findings include:
No. 16-3817 Corey v. Sedgwick Claims Mgmt. Servs., et al. Page 3
 Physical examination findings (functional impairments/capacity);
 Diagnostic test results/imaging studies;
 Diagnoses;
 X-ray results;
 Observation of anatomical, physiological or psychological
abnormalities; and
 Medications and/or treatment plan.
Treatment History. In April 2014, cluster headaches forced Corey to leave work. A few
days later Corey visited a neurologist, Dr. Rorick, who noted that the headaches occurred several
times per day, typically lasted one to two hours, and were extremely painful. Dr. Rorick’s notes
reported that Corey took prednisone and injected Imitrex to treat the headaches, and explained
that supplemental oxygen therapy “can help, but makes the headaches more frequent.”
Dr. Rorick further certified that Corey could return to work on May 7 with no restrictions.
Unfortunately, Corey’s headaches persisted after May 7. Over the next few weeks, Corey
visited Dr. Rorick three times. Each time, Dr. Rorick observed that Corey’s headaches remained
“very severe and incapacitating”; the headaches made Corey nauseated, dizzy, and occasionally
rendered him unconscious. Dr. Rorick noted that Corey “is unable to drive to/from work [due to]
pain when he has headaches,” and that “[d]uring cluster headache exacerbation [periods] he
needs to be off work.” For treatment, he prescribed prednisone, lamotrigine (a prescription
anticonvulsant), and Imitrex injections.
Corey also visited a headache specialist, Dr. Baron, who reported that Corey suffered
from “chronic cluster headaches with frequent exacerbations which impair working ability,” that
the condition caused episodic flare-ups preventing Corey from working, and that it was
medically necessary for Corey to miss work during the flare-ups. Somewhat inconsistently, Dr.
Baron checked “no” in the box next to: “Is the employee unable to perform any of his/her job
functions due to the condition[?]”
Finally, in July, Corey consulted a surgeon to consider occipital nerve stimulation. The
surgeon’s report detailed Corey’s treatment history, including his use of supplemental oxygen,
Imitrex injections, and prednisone. The report related that a recent occipital nerve block
No. 16-3817 Corey v. Sedgwick Claims Mgmt. Servs., et al. Page 4
temporarily relieved Corey’s headaches. After discussing the risks, benefits, and alternatives,
Corey decided to proceed with occipital nerve stimulation.
Denial of Short-Term Benefits. The Administrator initially approved Corey’s short-term
disability application. Because Dr. Rorick certified Corey as disabled only through May 7,
however, the Administrator denied benefits after that date. Corey appealed that denial and
supplemented his application with additional doctors’ notes.
The Administrator referred Corey’s application to an independent file reviewer, who
determined that Corey was not disabled because cluster headaches do “not result in any
neurological, physical exam abnormalities.” The Administrator then denied his application due
to a lack of “objective findings contained in the medical documentation.”
When Corey appealed again, the Administrator sent his application to another
independent file reviewer, who also found “no objective evidence” of disability. The
Administrator then issued a final denial. After reciting the plan language, it concludes:
The substantial weight, [sic] of the medical documentation provided by you, your
treating health care providers and the independent physician reviewers, supports
the conclusion that for the time period from May 7, 2014 to present your
disability is not covered as required by the Plan.
The denial offers no other explanation or analysis.
II.
The Employee Retirement Income Security Act grants a plan participant the right
“to recover benefits due to him under the terms of his plan, to enforce his rights under the terms
of the plan, or to clarify his rights to future benefits under the terms of the plan.” 29 U.S.C.
§ 1132(a)(1)(B). When the plan vests the administrator with discretion to interpret the plan (as is
undisputed in this case), the court reviews the benefits denial under the “arbitrary and
capricious” standard. Spangler v. Lockheed Martin Energy Sys., Inc., 313 F.3d 356, 361 (6th
Cir. 2002) (citation omitted). The court must uphold the administrator’s decision “if it is the
result of a deliberate, principled reasoning process and if it is supported by substantial evidence.”
Glenn v. MetLife, 461 F.3d 660, 666 (6th Cir. 2006) (citation omitted). The court reviews only
No. 16-3817 Corey v. Sedgwick Claims Mgmt. Servs., et al. Page 5
the evidence available to the administrator at the time it made the final decision. Shaw v. AT&T
Umbrella Benefit Plan No. 1, 795 F.3d 538, 547 (6th Cir. 2015) (citing McClain v. Eaton Corp.
Disability Plan, 740 F.3d 1059, 1064 (6th Cir. 2014)).
III.
Corey contends that the Administrator failed to engage in a deliberate, principled
reasoning process because it disregarded his medications and treatment plan. Corey’s argument
is straightforward: the plan lists medications and treatment plan as examples of “objective
findings”; Corey furnished physician notes detailing his cluster-headache medication and
treatment plan; yet the Administrator rejected his application due to a lack of objective findings.
Neither the Administrator nor the independent examiners discussed whether Corey’s medications
and treatment plan substantiated the presence of cluster headaches (though the record is unclear
whether the Administrator provided either independent examiner with the plan’s “objective
findings” definition).
The Administrator replies that it interpreted the plan’s language to require either 1) that a
medication’s side effects cause the disability, or 2) that a medication or treatment plan
“objectively confirm that the individual is unable to work.” According to the Administrator, it is
irrelevant that Corey’s medication and treatment history verify the existence of cluster
headaches.
We agree with Corey that his medication and treatment history satisfy the plan’s
objective-findings definition. Indeed, the plan is clear and unambiguous: “Objective findings
include . . . [m]edications and/or treatment plan.” The Administrator’s additional requirement
that the medication and treatment plan either cause the disability or confirm the applicant’s
inability to work finds no support in the plan’s terms.
Furthermore, the plan’s surrounding language confirms that the prescription of
medication and a treatment plan may evidence an underlying disability. The five preceding
examples—physical-examination findings; diagnostic test results/imaging studies; diagnoses; x-
ray results; and observation of anatomical, physiological, or psychological abnormalities—are
No. 16-3817 Corey v. Sedgwick Claims Mgmt. Servs., et al. Page 6
used to verify a medical condition. None of the examples causes disability or objectively
confirms the employee’s inability to work.
An illustration from the Administrator’s brief illustrates how its interpretation here does
not fit with the plan’s other examples:
For example, a prescribed regimen of pain medication may serve to indicate the
existence of a back condition. Standing alone, however, the prescription of such
medication does not indicate that one is unable to work for a period of time
because of that condition. Indeed, some individuals experiencing back pain are
readily able to continue work.
But an x-ray showing nerve compression suffers from the same defect: it bespeaks the existence
of a back condition, but doesn’t demonstrate whether the condition prevents the employee from
working. So too with every other example in the plan.
The Administrator’s response leans heavily on the plan’s grant of interpretive discretion.
But the record leaves us guessing as to how the Administrator interpreted the plan’s objective-
findings definition. The Administrator’s denial letters simply quote the plan language and then
conclude Corey’s evidence fails to suffice. Although the Administrator enjoys interpretive
latitude, we defer only to its actual interpretations—it can’t issue a conclusory denial and then
rely on an attorney to craft a post-hoc explanation. See Univ. Hosps. of Cleveland v. Emerson
Elec. Co., 202 F.3d 839, 848 n.7 (6th Cir. 2000).
Furthermore, the Administrator relies on two cases, Scott v. Eaton Corp. Long Term
Disability Plan, 454 F. App’x 154 (4th Cir. 2011) (per curiam), and McGruder v. Eaton Corp.
Short Term Disability Plan, No. 3:06-418-CMC, 2006 WL 3042798 (D.S.C. Oct. 23, 2006),
neither of which persuades us. In both cases, the employees argued that a pain medication’s side
effects prevented them from working. Both courts denied the applicants’ claims due to
inadequate evidence corroborating their respective medication’s side effects. These cases have
little pertinence here because Corey argues that he is disabled due to his cluster headaches, not
his reaction to treatment.
In sum, the plan identifies “[m]edications and/or treatment plan” as examples of
“objective findings.” Corey’s physicians supplied evidence detailing his cluster-headache
No. 16-3817 Corey v. Sedgwick Claims Mgmt. Servs., et al. Page 7
treatment. Yet the Administrator denied Corey’s application due to a lack of objective findings.
It never explained why his medications and treatment plan failed to satisfy the plan’s objective-
findings definition. Nor did its rejection letters offer any other explanation for the benefits
denial. Accordingly, the Administrator’s decision was arbitrary and capricious.
IV.
For these reasons, we VACATE the district court’s judgment and REMAND to the
district court with instructions to remand the case to the Administrator for a full and fair review
consistent with this opinion.