United States District Court, S.D. Texas, Houston Division
MEMORANDUM AND OPINION
Rosenthal, Chief United States District Judge
ERISA case challenges a plan administrator's denial of
benefits under an employer-funded long-term disability plan.
Samuel Heron, III sued the ExxonMobil Disability Plan,
alleging that the decision to end his long-term disability
benefits after an initial two-year period violated the
Employee Retirement Income Security Act, 29 U.S.C. §
1132(a)(1)(B). (Docket Entry No. 1). The Plan moved for
summary judgment on the grounds that the plan
administrator's decision was informed and reasonable,
made after a careful investigation with the assistance of
multiple independent third-party advisors, and is supported
by substantial evidence. The Plan seeks a summary judgment
that it did not abuse its discretion in denying Heron's
long-term disability benefits. (Docket Entry No. 24). Based
on the pleadings, the parties' arguments and submissions,
the administrative record, and the applicable law, this court
grants the Plan's motion for summary judgment. Final
judgment is entered by separate order. The reasons for the
ruling are explained below.
Heron, III is a 60-year-old man who suffers from a variety of
illnesses, including diabetes, pancreatitis, Sjogren's
Syndrome-an autoimmune-system disorder characterized by dry
eyes and dry mouth-and yawning seizures-seizures clinically
manifested in part by yawns. (Docket Entry No. 23-4 at 647).
began working in the procurement department at ExxonMobil in
1988, where he negotiated and managed worldwide material and
services agreements. (Docket Entry No. 23-4 at 685). He was
covered by the ExxonMobil Plan. Under the Plan, disability
benefits are divided into two periods the first is “the
period that begins on the last day the person was actively at
work, and ends two years later.” (§ 5.15; Docket
23-1 at 93-94). In this first period, an individual is
incapacitated “if the person is wholly and continuously
unable, by reason of a physical or mental health impairment,
to perform any work suitable to the person's
capabilities, training and experience, that the person's
employer has available during the initial period, and such
inability to perform work is expected to continue for . . .
at least six months from the date the person's ability to
perform work is determined.” (§§ 5.13(A),
5.13(C); Docket Entry No. 23-1 at 92-93). After the initial
two-year period, an individual is incapacitated “if the
person is wholly and continuously unable, by reason of a
physical or mental health impairment, to perform any work for
compensation or profit for which the person is or may become
reasonably fitted by education, training or experience, and
such inability to perform work is expected to continue for .
. . at least six months from the date the person's
ability to perform work is determined.” (§§
5.13(B), 5.13(C), Docket Entry No. 23-1 at 92-93). In the
initial period, the definition of incapacitated looks only to
the ability to perform jobs available at the individual's
current employer. After the initial period, the definition
looks to the ability to perform any work that the person can
do or reasonably could do with training.
last day of work at ExxonMobil was September 28, 2012.
(Docket Entry No. 23-4 at 678). He was granted disability
benefits for the initial two-year period under the Plan.
(Docket Entry No. 1 at ¶ 27; Docket Entry No. 23-4 at
719-21). In January 2013, an ExxonMobil physician, Dr.
Eugenia George, recommended that Heron's “work
hours [be] limited to a maximum of four (4) hours per
day.” (Docket Entry No. at 23-4 at 658). Dr. George met
with Heron in February 2013 and recommended medical
retirement from ExxonMobil. (Docket Entry No. 23-4 at 657).
ExxonMobil Disability Plan documents, ExxonMobil Benefit
Plans Common Provisions and the Summary Plan Description
govern. (Docket Entry No. 23-1 at 69-97, 99-164, 166-196).
There are two entities responsible for Plan administration:
the Third-Party Claims Administrator, the Life Insurance
Company of North America, LINA, a CIGNA subsidiary, is
responsible for reviewing claims and determining benefit
amounts for long-term disability benefits, (Docket Entry No.
23-1 at 187); and the Administrator-Benefits, Exxon Mobil
Corporation, is “vested with full and final
discretionary authority to determine eligibility for
benefits, to construe and interpret the terms of the core
benefit plans in their application to any participant or
beneficiary, and to decide any and all appeals relating to
claims by participants or beneficiaries.” (§
2.1(B)(1); Docket Entry No. at 23-1122-123).
the end of the first two years and periodically thereafter,
LINA conducts a benefits-continuation test. If LINA
determines that the beneficiary no longer meets the Plan
definition of incapacitated, the benefits are discontinued.
(Docket Entry No. 23-1 at 179). LINA began reviewing
Heron's case in April 2014, requesting medical records,
an Estimated Physical Abilities Assessment, and a Follow-Up
Medical Request Form from three of Heron's doctors: Dr.
Joel Nachimson; Dr. Nadim Zacca; and Dr. Vivian Rodriguez.
The doctors provided medical records. Dr. Zacca completed
neither of the requested forms, Dr. Nachimson completed only
the Follow-Up Medical Request Form, and Dr. Rodriguez
completed both forms. LINA used this information to perform a
Transferable Skills Analysis. Based on the review and the
results, LINA concluded that, given his current medical
limitations, Heron could perform the occupations of an
Import-Export Agent or a Management Analyst. (Docket Entry
No. 23-1 at 62-64).
Rodriguez's forms indicated that Heron was able to return
to work for four hours per day. Dr. Rodriguez noted that
Heron's medical condition limited him to nonstressful
jobs with no traveling, lifting, pushing, or pulling
required. She answered “yes” to the question,
“do you expect functional deficits to prevent your
patient from performing essential job functions?” In
response to the question, “what is your best estimate
of when your patient can return to work, ” she
answered, “unable to return” because of
“chronic pain at epigastric area and prone [to]
recurrent pancreatitis.” On the Physical Abilities
Assessment, Dr. Rodriguez noted that Heron was able to
tolerate sitting, standing, and walking during the work day,
each for up to 2.5 hours, or one-third of the work day.
(Docket Entry No. 23-4 at 597-98).
Nachimson also stated that he expected “functional
deficits to prevent [Heron] from performing essential job
functions.” He answered “yes” to the
question, “could your patient return to work at this
time if accommodations were made for the listed
restrictions?” (Docket Entry No. 23-4 at 602).
reviewing Heron's medical records and the forms received
from Drs. Nachimson and Rodriguez, LINA determined that the
“medical information received does not support
functional limitations that would prevent [Heron] from
performing the duties of any occupation.” (Docket Entry
No. 23-1 at 63-64). LINA denied the continuation of long-term
November 2014, Heron submitted his request for additional
review to LINA. Heron informed LINA that he was suffering
from “abdominal diabetic neuropathy pains  so intense
that [he] cannot sit in a ninety-degree position for a
prolonged period of time, ” and that he was having
“feelings of extreme physical tiredness and
frustration.” Heron supplied over ten exhibits from
various doctors involved in his care. (Docket Entry No. 23-1
engaged Dr. Michael Perkins to perform an independent medical
examination and produce a report. During this in-person
examination, Heron “experience[d] constant right lower
quadrant pain and right back pain, ” “numbness of
both legs” and “blurred vision.” Heron told
Dr. Perkins that he walked three to four miles a day and
attended football games, but also that spent “most of
the day lying on the couch sleeping.” Dr. Perkins
concluded that Heron “is physically functionally
impaired” and that “work activity restrictions
are medically necessary.” In response to a question
asking what activities Heron could tolerate
“[t]hroughout an 8-hour workday, to the extent that
positional changes are necessary, with rest breaks and meal
breaks at appropriate intervals, ” Dr. Perkins noted
that Heron could sit for over 5.5 hours per day and could
walk or stand for between 2.5 and 5.5 hours per day. (Docket
Entry No. 23-1 at 40-52).
letter dated March 6, 2015, LINA affirmed its decision to
deny Heron continued long-term disability benefits stating:
“We do not dispute you may have been somewhat limited
or restricted due to your subsequent diagnoses and treatment;
however, an explanation of your functionality and how your
functional capacity continuously prevented you from
performing the essential duties of any occupation from
September 29, 2014 through the present and beyond was not
clinically supported.” The letter told Heron that his
next avenue was to appeal to ...