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Heron v. Exxonmobil Disability Plan

United States District Court, S.D. Texas, Houston Division

July 28, 2017

SAMUEL HERON, III, Plaintiff,
v.
EXXONMOBIL DISABILITY PLAN, Defendant.

          MEMORANDUM AND OPINION

          Lee H. Rosenthal, Chief United States District Judge

         This 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.

         I. Background

         Samuel 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).

         Heron 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.

         Heron's 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).

         The 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).

         Near 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).

         Dr. 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).

         Dr. 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).

         After 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 disability benefits.

         In 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 at 208-12).

         LINA 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).

         In a 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 ...


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