Daie v. Intel Corp. Long Term Disability Plan

          ORDER RE CROSS-MOTIONS FOR SUMMARY JUDGMENT

          WILLIAM ALSUP UNITED STATES DISTRICT JUDGE.

         INTRODUCTION

         In this action seeking long-term disability benefits pursuant to a plan governed by the Employee Retirement Income Security Act of 1974, both sides move for summary judgment. To the extent stated below, defendants’ motion is Granted, and plaintiff’s motion is Denied.

         STATEMENT

         Plaintiff Ed Daie, a fifty-eight year old man, worked for defendant Intel Corporation for twenty-seven years. He most recently worked as the server memory and security technology director, a sedentary but intellectually demanding position. Daie took an unpaid leave of absence beginning in September 2012. He participated in the Intel Corporation Long Term Disability Plan, which was governed by the Employee Retirement Income Security Act of 1974 (the “Plan”) and fully funded by Intel (Plan Doc. at 1-40).^[1]

         The Plan generally paid sixty-five percent of a participant’s monthly earnings if that participant proved he had a qualifying “Disability, ” which the Plan defined as “illness or injury that renders a Participant incapable of performing work. Both the illness or injury, and the inability to perform work, must be substantiated by Objective Medical Findings” (Plan Doc. at 3).

         The Plan defined an “Objective Medical Finding” as follows (Plan Doc. at 5-6):

A measurable, independently-observable abnormality which is evidenced by one or more standard medical diagnostic procedures including laboratory tests, physical examination findings, X-rays, MRI’s, EEG’s, ECG’s, “Catscans” or similar tests that support the presence of a disability or indicate a functional limitation. Not all tests or test results meet the criteria of Objective Medical Findings. For example, tests that depend on Participant self-reports, such as trigger point/tender point tests, are not considered objective and do not establish eligibility for benefits under this Plan. . . . Objective Medial Findings do not include physicians’ opinions or other third party opinions based on the acceptance of subjective complaints (e.g., headache, fatigue, pain, nausea), age, transportation, local labor market and other non-medical factors. To be considered an abnormality, the test result must be clearly recognizable as out of the range of normal for a healthy population. The significance of the abnormality must be understood and accepted by the medical community as diagnostic of the specific disabling condition asserted by the Participant.

         The Plan offered two periods of long-term disability benefits. In the first eighteen months of a claimed disability, a participant was entitled to benefits if his disability prevented him from working at his “own occupation.” Beginning in the nineteenth month, a participant was entitled to benefits only if his disability prevented him from working in “any occupation” (Plan Doc. at 3).

         The Plan delegated discretionary authority for claims handling in the first instance and first-level appeals to defendant The Reed Group, Ltd., and it delegated responsibility for final appeals to defendant Claim Appeal Fiduciary Services, Inc. (Plan Doc. at 19, 38).

         Daie took a leave of absence from his position beginning in September 2012. He told a consulting psychiatrist he was going on a one-month leave of absence due to scheduled sinus surgery, but he also stated he did not think he would return to work because he felt he was “being gradually managed out of his position as part of a restructuring of the company” (AR at 806).

         Daie applied for short-term disability benefits through an unrelated plan offered by Intel. Daie’s application for short-term benefits won approval and terminated a year later in September 2013 - the maximum period available under the short-term plan. Unlike the long-term plan, Intel’s short-term plan did not require members to provide objective medical findings to support a claim.

         Daie applied for Social Security benefits and for benefits from a private disability insurance policy from Metlife, Inc. Both applications were granted (AR at 243, 1682, 1858).

         Daie then applied for long-term benefits under the Intel Plan. In support of his claim, Daie submitted extensive medical records from numerous physicians who have treated him for eleven different conditions in three categories: upper respiratory conditions (chronic acute sinusitis, allergic rhinitis, severe asthma, and sleep apnea), psychiatric conditions (major depressive disorder, episodic mood disorder, and generalized anxiety disorder), and musculoskeletal conditions (meralgia paresthetica, lumbar spondylosis, and avascular necrosis) (AR at 489).^[2]

         1. Daie’s Medical Conditions.

         A. Upper Respiratory Conditions.

         To the Plan, Daie submitted evidence that he suffered from severe asthma, allergic rhinitis, chronic acute sinusitis, and sleep apnea, conditions that interfered with Daie’s breathing and caused allergy-related symptoms. Numerous records indicated that he had smoked cigars since 1980 and continued to do so despite instructions from his physicians to stop (AR at 1488, 1595-96, 1602).

         Test results indicated that Daie had limited lung capacity and that he underwent eight reconstructive sinus surgeries to correct his conditions, but the treatment was not effective. Daie took numerous medications, including the steroid Prednisone, to treat his conditions, and he carried an epi-pen in case of emergency. He informed one psychiatrist, Dr. Robert Bright, that he had a number of life-threatening asthma attacks (AR at 1193, 2379).

         On September 27, 2012, Daie underwent sinus surgery, performed by Dr. John Raines. Prior to that surgery, his primary care physician, Dr. Richard Settles, wrote an attending physician statement in support of Daie’s claim for short-term benefits, noting the scheduled surgery and stating that Daie “will be unable to work at all after 9/27/2012” (AR at 1733). Following the surgery, Surgeon Raines released Daie to return to work on October 11, 2012 (AR at 1721-22). On November 14, however, Physician Settles wrote an additional statement in support of Daie’s application for benefits from Metlife listing numerous conditions, and indicating “patient is unable to work at all . . . patient has had all of these conditions rapidly come on and is totally unable to work at this time” (AR at 2165-66).

         In February 2013, after a sleep study, Dr. Phillip Lyng diagnosed Daie with moderate “obstructive sleep apnea and severe upper air way resistance” (AR at 1805). Sleep-Study Physician Lyng instructed Daie to wear a continuous positive air pressure (“CPAP”) machine while he sleeps; however, Daie claimed he could not sleep while using the CPAP machine, which he attributed to his asthma and sinus problems (AR at 1194). Sleep-Study Physician Lyng informed Daie that acclimation to the CPAP machine would take some time and that he might need to go through several different masks (AR at 1184). Daie visited a sleep center, where he tried several different masks (AR at 2242-44). The record does not indicate the status of Daie’s efforts with various sleep apnea treatments.

         B. Psychiatric Conditions.

         Daie provided records of psychiatric conditions, which he attributed in part to side effects from his allergy medications, particularly the Prednisone. Two psychiatric emergencies required him to be admitted to the hospital in 2007. Daie’s psychiatrist, Dr. Leanne Kelley, diagnosed him with a mood disorder and generalized anxiety disorder. Psychiatrist Kelley stated that Daie “[s]hould not engage in usual work activities - failure to perform adequately would worsen his anxiety and depression. Poor concentration, fatigue, mood swings limit all work functions. Analytical skills are particularly impacted by depression, anxiety, medication side effects.” Psychiatrist Kelley made her diagnoses based only on “reported symptoms.” She provided no response when asked whether she had made any objective physical findings (AR at 1737-38).

         Daie also submitted records from his ear, nose, and throat specialist, Dr. Stephen Graham who opined about Daie’s cognitive conditions. In a statement written in March 2013, ENT Physician Graham indicated that Daie suffered from “inability to remain awake, think clearly, and speak while on necessary medication, ” but estimated Daie could return to work by June 2013 (AR at 1716). A later statement, written in June 2013 indicated Daie was “unable to work within his profession due to cognitive issues” and described that disability as “likely permanent” (AR at 1503). ENT Physician Graham did not attribute any disability to Daie’s sinus conditions.^[3]

         C. Musculoskeletal Conditions.

         Daie submitted records from Dr. Ibrahim Aksoy, including EMGs, x-rays, and MRIs. The records indicated that Daie suffered from several musculoskeletal conditions that caused severe chronic pain throughout his lower back, thighs, and hip (AR at 1201, 2403, 2495). In May 2012, at his only visit with Pauline Lucas, a physical therapist, Daie stated that he rated the pain a two out of ten during the visit, though he said it reached an eight out of ten “at worst” (AR at 2405). Musculoskeletal Physician Aksoy’s records from a visit in April 2012 indicated that Daie reported a range of intensity from “1 to 8 out of 10” and that he reported “4/10 pain” which he described as “an average day” (AR at 1556). The following month, Musculoskeletal Physician Aksoy indicated that Daie reported “pain ranging in intensity from 2 to 3 out of 10” (ibid.).^[4]

         Per Musculoskeletal Physician Aksoy’s recommendation, Daie went to another physical therapist in November 2012, Susan Meland, who wrote in a report that “his pain level on [that] date [was] noted to be 4 out of 10. He note[d] at the worst, in the last week is [sic] was 6 to 7 out of 10” (AR at 814). Daie attended a total of seven physical therapy sessions, but the sessions did not help (AR at 1564).

         In February 2013, Musculoskeletal Physician Aksoy noted that Daie’s pain intensity “range[d] from 0 to 8 out of 10” (ibid.). In March 2013, Daie received an injection, which he later reported to Musculoskeletal Physician Aksoy “resolved his back pain.” Nevertheless, following the injection, Daie reported that his overall pain intensity was “worse than before” (AR at 816).^[5]

         2. Defendants’ Evaluation of Daie’s Claims.

         A. Initial Review and ...