Corey v. Sedgwick Claims Mgmt. Servs., Inc.

• Decision Date: 08 June 2017
• Docket Number: No. 16-3817,16-3817
• Citation: 858 F.3d 1024
• Parties: Bruce COREY, Plaintiff–Appellant, v. SEDGWICK CLAIMS MANAGEMENT SERVICES, INC.; Eaton Corporation; Eaton Corporation Disability Plan for U.S. Employees; Eaton Health and Welfare Administrative Committee, Defendants–Appellees.
• Court: U.S. Court of Appeals — Sixth Circuit

858 F.3d 1024

Bruce COREY, Plaintiff–Appellant,

v.SEDGWICK CLAIMS MANAGEMENT SERVICES, INC.; Eaton Corporation; Eaton Corporation Disability Plan for U.S. Employees; Eaton Health and Welfare Administrative Committee, Defendants–Appellees.

No. 16-3817

United States Court of Appeals, Sixth Circuit.

Argued: March 16, 2017

Decided and Filed: June 8, 2017

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.

Before: BOGGS, ROGERS, and COOK, Circuit Judges.

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:

• 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 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...