Hernandez v. Life Ins. Co. of N. Am.

• Decision Date: 01 April 2020
• Docket Number: SA-19-CV-00022-FB
• Parties: RAMON HERNANDEZ, Plaintiff, v. LIFE INSURANCE COMPANY OF NORTH AMERICA, SCHLUMBERGER GROUP WELFARE BENEFITS PLAN, Defendants.
• Court: U.S. District Court — Western District of Texas

RAMON HERNANDEZ, Plaintiff, v. LIFE INSURANCE COMPANY OF NORTH AMERICA,SCHLUMBERGER GROUP WELFARE BENEFITS PLAN, Defendants.

SA-19-CV-00022-FB

UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF TEXAS SAN ANTONIO DIVISION

April 1, 2020

REPORT AND RECOMMENDATION OF UNITED STATES MAGISTRATE JUDGE

To the Honorable United States District Judge Fred Biery:

This Report and Recommendation concerns Plaintiff's Motion for Summary Judgment and Brief in Support [#20] and Defendants' Cross Motion for Summary Judgment [#21]. All dispositive pretrial matters in this case have been referred to the undersigned for disposition pursuant to Western District of Texas Local Rule CV-72 and Appendix C [#9]. The undersigned has authority to enter this recommendation pursuant to 28 U.S.C. § 636(b)(1)(B). For the reasons set forth below, it is recommended that Plaintiff's motion be DENIED and Defendants' motion be GRANTED.

I. Procedural and Factual Background

Plaintiff Ramon Hernandez ("Hernandez") filed this action against Defendants Life Insurance Company of North America and Schlumberger Group Welfare Benefits Plan (collectively "Defendants") to secure short-term and long-term disability benefits to which Hernandez claims he is entitled under a disability insurance plan and policy governed by the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132. The ERISA plan at issue—Defendant Schlumberger Group Welfare Benefits Plan ("the Plan")—covered Hernandez by virtue of his prior employment with Schlumberger Pressure Pumping ("Schlumberger"). Defendant Life Insurance Company of North America ("LINA") is the designated claims administrator for the Plan.¹ By this action, Hernandez asserts a single cause of action for the wrongful denial of benefits under ERISA, 29 U.S.C. § 1132, and for attorney's fees and costs available under the statute. (Compl. [#1] at ¶¶ 60-64.)

The administrative record before the Court establishes that Hernandez worked as a Service Supervisor for Schlumberger from July 24, 2017 until September 28, 2017, when he ceased working based on reported mental health issues of anxiety and depression. (R. 553.) The Plan at issue provides both short-term and long-term disability benefits for eligible Schlumberger employees. (R. 668, 698.) An employee is qualified to receive short-term disability benefits if he misses more than five consecutive days of work due to a disability. (R. 668, 671, 698, 701.) These benefits will be paid retroactively from the first day of disability and continue for up to 26 weeks at 100% of an employee's "base pay." (R. 668, 671, 698, 701.) If an employee exhausts short-term disability benefits, is still unable to work, and continues to meet the requirements for short-term disability, the employee is entitled to long-term disability benefits for as long as the employee remains disabled or has reached the "maximum benefit period" under the Plan. (R. 668, 673, 680, 703.)

For purposes of short-term disability benefits and initially receiving long-term disability benefits, an employee is "disabled" if the employee is "(1) unable to perform the normal dutiesof [his] job due to an illness or injury and (2) receiving Appropriate Care and Treatment for that injury or illness." (R. 690, 720.) After receiving disability benefits for 78 weeks, an employee is "Disabled" only if the employee is "(1) unable to perform the duties of any occupation (not just [his] job at Schlumberger) for which [he is] reasonably suited due to [his] education, training or experience and (2) receiving Appropriate Care and Treatment for that injury or illness." (R. 690, 720.)

Hernandez filed a claim for short-term disability benefits based on his mental-health symptoms on November 2, 2017, and LINA began gathering medical records from Hernandez's physicians and treatment providers to determine his eligibility for benefits under the Plan. (R. 407-23.) Tammy Botello, a licensed professional counselor, provided information and records to LINA, which reflected that Hernandez first saw Ms. Botello on October 17, 2017, twenty days after he stopped working. (R. 438, 441-44.) Ms. Botello had diagnosed Hernandez with major depressive disorder and generalized anxiety disorder. (R. 438.) Ms. Botello opined that Hernandez's current mental status did not allow him "to be completely focused on his essential job functions" and recommended he be off work for 90 days, until January 31, 2018. (R. 438.)

LINA requested additional information from Ms. Botello regarding her treatment of Hernandez, as well as records related to Hernandez's treatment from Dr. Charles E. Gutierrez, a licensed psychologist to whom Ms. Botello referred Hernandez for further evaluation. (R. 469-79.) Dr. Gutierrez sent LINA his psychological assessment of Hernandez dated November 14, 2017. (R. 481-83.) Dr. Gutierrez had diagnosed Hernandez with major depressive disorder and acute stress disorder and recommended he continue with his current medication regimen and follow up with Ms. Botello for continued care. (R. 481-83.) Ms. Botello also providedsupplemental information to LINA, citing to Hernandez's panic attacks and lack of focus and noting that Hernandez had failed to appear for his last counseling appointment. (R. 487-92.)

Dr. Gitry Heydebrand, also a licensed psychologist, reviewed these medical records and the other information submitted to LINA and concluded that Hernandez was not functionally limited by his mental health symptoms or psychiatric conditions; that the treating providers' opinions were not well supported by medically acceptable clinical diagnostic techniques; that there was no indication of behavioral disturbance, cognitive dysfunction, psychotic symptomology, or a severe psychiatric disorder; and that no activity restrictions were medically necessary. (R. 484-85.) Based on this assessment, LINA denied Hernandez's claim for short-term disability benefits, concluding that none of the information provided indicated a possible impact on his day-to-day functioning. (R. 493-95.)

If a claim for benefits under the Plan is denied in whole or in part, the Plan allows a claimant to administratively appeal the determination. (R. 681-82, 711-12.) First, and as part of a claimant's mandatory administrative remedies, the determination can be appealed in writing to LINA within 180 days. (R. 681-82, 711-12.) If any part of the claim is denied on appeal, the claimant may then submit a voluntary, second appeal to the Plan's administrator—the Administrative Committee—within 180 days. (R. 682, 712.) However, this second, voluntary appeal is not part of a claimant's mandatory administrative remedies under ERISA. (R. 682, 712.)

Hernandez appealed the decision. (R. 499-504.) As part of the appeals process, LINA requested additional medical records from Ms. Botello and Sonya Jaime, a family nurse practitioner who had recently seen Hernandez. (R. 511, 598.) Ms. Jaime responded to the records request with notes from her initial visit with Hernandez on November 30, 2017, whichnoted symptoms and diagnoses of depression and anxiety and recommended treatment with a trial of an antidepressant drug, Trintellix. (R. 528-43.)

Les Kertay, licensed psychologist, reviewed Hernandez's file on appeal. (R. 518-19.) Dr. Kertay also concluded that Hernandez's medical records did not support a psychiatric functional impairment that would preclude operational functioning or require work restrictions. (R. 518-19.) Dr. Kertay explained that the records contained a single office visit note from Ms. Botello, which on its own did not document any functional evaluation of Hernandez's claimed limitations or provide other explanation for an inability to perform his occupational duties. (R. 518.) Dr. Kertay also found Dr. Gutierrez's evaluation insufficient, as it did not specify Hernandez's functional limitations. (R. 518.) LINA denied the claim on appeal on January 17, 2018. (R. 520-22.)

Hernandez submitted a new claim for long-term disability benefits based on the same mental health issues on February 13, 2018. (R. 42.) LINA requested updated medical records from Hernandez's medical providers, but no additional information was received. (R. 79-86, 333.) Hernandez's file was reviewed by Dr. Aneta Predanic, a board-certified psychiatrist, on February 26, 2018. (R. 87-88.) Dr. Predanic also determined that no restrictions were medically necessary to accommodate Hernandez's psychiatric conditions because he did not suffer from any documented functional limitations. (R. 87-88.) LINA denied Hernandez's long-term disability claim on March 7, 2018, again finding that the medical records did not demonstrate Hernandez was functionally impaired so as not to be able to perform his normal job duties. (R. 102-03.)

Hernandez filed an appeal with LINA but declined to submit any additional evidence in support of his claim. (R. 129-49.) Dr. Weiran Wu, a board-certified psychiatrist, reviewedHernandez's claim on appeal and similarly opined that the medical records did not support Hernandez's claim of functional impairments that would prevent him from performing his job. (R. 236-39.) Dr. Wu noted in his assessment that he had contacted Ms. Botello, who had indicated that she had last seen Hernandez in November 2017, ten months earlier, and could not provide any other information in support of his claim. (R. 238-39.) LINA denied the claim on appeal on September 27, 2018. (R. 242-45.) Hernandez chose not to file the second, voluntary appeal with the Schlumberger's Administrative Committee.

After exhausting his administrative remedies, Hernandez filed this suit on January 10, 2019. By this action, Hernandez alleges LINA failed to afford proper weight to the evidence in the administrative record during its administrative review and erred in its interpretation of the definition of "disability" in the Plan. (Compl. [#1] at ¶ 62.) Hernandez contends that the administrative record establishes he is totally...