Speciale v. Blue Cross and Blue Shield Ass'n

• Decision Date: 07 August 2008
• Docket Number: No. 07-1207.,07-1207.
• Citation: 538 F.3d 615
• Parties: Janet SPECIALE, Plaintiff-Appellee, v. BLUE CROSS AND BLUE SHIELD ASSOCIATION and Non-Contributory National Long Term Disability Program, Defendants-Appellants.
• Court: U.S. Court of Appeals — Seventh Circuit

538 F.3d 615

Janet SPECIALE, Plaintiff-Appellee, v. BLUE CROSS AND BLUE SHIELD ASSOCIATION and Non-Contributory National Long Term Disability Program, Defendants-Appellants.

No. 07-1207.

United States Court of Appeals, Seventh Circuit.

Argued September 7, 2007.

Decided August 7, 2008.

Mark D. DeBofsky, Marcie E. Goldbloom (argued), Daley, Debofsky & Bryant, Chicago, IL, for Plaintiff-Appellee.

Ian Hugh Morrison (argued), Seyfarth Shaw, Chicago, IL, for Defendants-Appellants.

Before BAUER, POSNER, and SYKES, Circuit Judges.

SYKES, Circuit Judge.

Janet Speciale was an employee of the Health Care Service Corporation ("HCSC") for a little over two years when she applied for long-term disability benefits under Blue Cross and Blue Shield Association's ("Blue Cross") Non-Contributory National Long Term Disability Program ("the Program"). Speciale suffered from fibromyalgia since 1986, but in 2001 claimed an exacerbation of her symptoms disabled her from working. The Program's Medical Review Committee ("MRC") denied Speciale's claim and her subsequent appeal. It found that her symptoms, although troublesome, did not rise to the level of disability because two of her treating physicians believed she could work with certain physical restrictions. Speciale filed this action in the district court, and both parties moved for summary judgment. Applying an arbitrary-and-capricious standard of review, the district court overturned the MRC's decision and granted Speciale's application for benefits. This appeal followed. Because the reasons given by the MRC for its decision were reasonable and supported by the record, we reverse the district court's judgment and remand for entry of summary judgment in favor of Blue Cross and the Program.

I. Background

Speciale worked for HCSC as a senior account executive from June 1998 through November 7, 2000. HCSC is an independent licensee of Blue Cross, and as an employee, Speciale was covered by the Program, entitling her to benefits if she should ever become disabled.¹ The Program is administered by the National Employee Benefits Committee ("NEBC") of Blue Cross. The NEBC delegated day-to-day responsibilities for the Program to the National Employee Benefits Association ("NEBA"), which in turn assigned the authority to determine claims to the Medical Review Committee.

Speciale's job was hectic; she was required to respond constantly to problems and emergencies with clients or brokers and spent nearly half of her time traveling to meetings. Her job required fine-finger movement, talking, and listening, as well as climbing stairs and lifting up to 50 pounds from either the floor or table level. She was also required to work overtime seven or more times per month.

A. Speciale's Medical History

Although her job could be considered stressful for the average person in good health, Speciale suffered from a number of medical conditions that made her position even more difficult. She was diagnosed with fibromyalgia in 1986, and her symptoms, though initially manageable, began to worsen in 2000. Dr. Kevin Snydersmith, her physician, recorded in September of 2000 that Speciale complained of severe back pain, as well as pain and numbness in her left shoulder and leg. Snydersmith did not think all of her symptoms were explained by the fibromyalgia, so he diagnosed her with chronic pain syndrome. He noted that her job is "fairly intense" and she had used most of her sick days because of her medical problems.

Dr. Snydersmith's diagnosis of chronic pain syndrome set in motion treatment and diagnostic regimes that ultimately resulted in Speciale's application for long-term disability benefits on April 18, 2001. In October 2000 Dr. Snydersmith noted that Speciale was on at least four different medications and also received shots of Toradol once or twice per month to control her pain. That same month Speciale met with rheumatologist Dr. Ann Winny, who spoke at length with Speciale and believed her symptoms were "progressively worsening." Speciale mentioned she might take time off from work to see if the stress of her job was the cause of her deterioration. Dr. Winny believed the symptoms were due to fibromyalgia and chronic pain syndrome but did not rule out the possibility of multiple sclerosis ("MS").

Speciale met with Dr. Brian O'Shaughnessy on November 1, 2000. After evaluating her symptoms and a recent MRI of the brain, he believed she was suffering from some form of demyelinating disease and wanted her to have a lumbar puncture to further investigate this possibility. Dr. O'Shaughnessy reiterated his suspicions in February 2001 when Speciale came into his office and reported that she was dizzy and tired, suffered extreme back pain, and had difficulty walking. Dr. O'Shaughnessy thought this could be explained by an exacerbation of a demyelinating disease but noted that Speciale had an appointment with Dr. Boris Vern, head of the multiple sclerosis clinic at the University of Illinois, for testing. Dr. O'Shaughnessy reported to Blue Cross on March 17 that Speciale could not work due to her severe pain and fatigue and her return to work was "indefinite pending [the] outcome of testing" by Dr. Vern. Tests conducted on March 22 indicated that Speciale's "sensory symptoms are overshadowed and probably colored by her chronic pain, which seems to [be] of myofascial origin." Dr. Vern thought that MS could be a possibility but that it was "not strongly supported by the available lab studies."

While under the care of Dr. O'Shaughnessy, Speciale continued to see Dr. Snydersmith. In mid-January 2001, he provided her with a "quad" cane to ease her walking difficulties. His notes reveal that Speciale was suffering from frequent, painful kidney stones. She was put on various medications, including Vicodin, and at one point was admitted to the emergency room for pain control and hydration. In February Snydersmith referred Speciale to physiatrist Dr. Dennis Keane. After an initial consultation, Dr. Keane wrote that Speciale's symptoms were somewhat alleviated after a vacation to Arizona; however, she still experienced a great deal of pain in her back that often radiated down her left leg. He seemed to assume that Speciale suffered from MS because she used a quad cane to help her "slightly unsteady gait from her MS." He reexamined Speciale in early June and found her to be doing "dramatically better" after being placed on oral steroids.

Despite Dr. Vern's doubts, Speciale's other doctors believed she was suffering from symptoms related to MS. Dr. O'Shaughnessy wrote on May 17 that he doubted fibromyalgia accounted for her problems because "she has had [it] for 14 years and it has not caused" the symptoms of which she was more recently complaining. Less then a month later he wrote: "I feel her clinical picture is most compatible with multiple sclerosis. I do not see her improving enough at this time to return to work." Dr. Snydersmith supported this diagnosis and found her symptoms were "likely due to developing MS." Dr. Winny agreed that Speciale "is probably disabled at this point" because her MS makes it difficult for her to walk.

Although Speciale's symptoms were serious, the tentative diagnosis of MS turned out to be inaccurate. Dr. Snydersmith told Blue Cross Nurse Sue Majewski on August 27 that the lumbar puncture did not confirm MS and the diagnosis was simply fibromyalgia that had been worsening in recent months. He could not predict how long Speciale could stand or walk each day as he no longer managed her case (Dr. Keane had taken over treatment of her pain).

Speciale's application for disability benefits was reviewed in August 2001 by Dr. E. Richard Blonsky, Blue Cross's senior medical consultant. Dr. Blonsky filled out a Physician's Recommendation Form and noted that there was no clear evidence of MS. He went on to state that Speciale suffered from fibromyalgia for 20 years and had worked, making this a "very marginal case." He also noted the lack of "confirmatory findings" and that the record contained "a lot of subjective complaints." He concluded: "I am not totally convinced of her disability. Were there any H.R., performance issues?" Dr. Blonsky reevaluated Speciale's file on September 5, this time confirming she did not have MS and reaffirming his previous finding that she was not disabled. Indeed, Dr. Keane had responded to an inquiry from the MRC by pointing out that Speciale suffered from back pain, leg spasms, weakness, and fatigue. Even so, he told the MRC that Speciale was physically capable of performing sedentary and light-duty jobs.

B. Procedural History

The MRC informed Speciale of its decision to deny her benefits application on October 30, 2001. It noted that Drs. Snydersmith, O'Shaughnessy, and Winny all believed Speciale had MS when they said she was disabled, but it was not known whether the negative lumbar puncture would change their opinions. Further, the committee noted that Dr. Keane believed she could work with some limitations (such as changing positions frequently) and his opinion carried weight because of his specialty in pain management. The letter also stated that the MRC conducted a vocational analysis, which revealed at least six career opportunities in the surrounding area that would pay a comparable salary while still accommodating Speciale's restrictions.

Speciale timely appealed the denial of benefits. She supplemented the record with new evidence, including progress notes and a functional-capacity questionnaire from Dr. Winny and progress notes from Dr. Keane. The questionnaire noted Speciale's "marked limitation" in dealing with work-related stress due to her fibromyalgia. Her physical limitations were also quite severe: she could only sit for 10 minutes and stand for 15 minutes in a 60-minute period; she had to walk every 30 minutes for at least 5 minutes at a time; she needed a job that permitted shifting positions and allowed her to take...