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Keaton v. Sedwick Claims Management Services, Inc.

United States District Court, W.D. Texas, San Antonio Division

April 30, 2018




         On this date, the Court considered the status of the above captioned-cased. After careful consideration, the Court hereby GRANTS Defendant Charter Communications, Inc. (“Charter”)'s Motion for Summary Judgment (Docket no. 44) and GRANTS Defendant Sedgwick Claims Management Services, Inc. (“Sedgwick”)'s Motion for Summary Judgment (Docket no. 45).


         On March 21, 2017, Plaintiff William Keaton filed his Complaint with this Court. Docket no. 1. Plaintiff filed his First Amended Complaint on January 23, 2018.[1] Docket no. 55. Plaintiff is a former employee of Charter and brings claims against it for denial of benefits under its employee benefit plan (“the Plan”) for short-term disability (“STD”) and refusal to supply plan documents. Id. Plaintiff also brings claims against Sedgwick, the third-party administrator for the STD component of the Plan, for denial of STD benefits. Id.

         Plaintiff was employed by Time Warner Cable, Inc., with which Charter merged in 2016, as a Major Account Executive and was a participant in the Plan. Id. at 2. Plaintiff states the Plan pays STD benefits to claimants who are found to be “totally disabled, ” and under the Plan, a person is considered “totally disabled” after the Elimination Period if, “[y]ou are earning less than 20% of your pre-disability Covered Compensation due to an injury or illness (including Mental Illness, Substance Abuse and pregnancy); and [y]ou cannot perform the Essential Duties of your own occupation.” Id. at 2-3.

         Plaintiff alleges that he stopped working for Charter on April 30, 2015, “due to acute chest pain, severe fatigue, and significantly lowered exercise tolerance he suffered as a result of coronary artery disease, diabetes mellitus with neuropathy, hypertension, hyperlipidemia, obstructive sleep apnea and adjustment disorder with depression and anxiety.” Id. at 3. On May 1, 2015, Plaintiff submitted a claim for benefits under the Plan to Charter, which then submitted it to Sedgwick to determine if he qualified for STD benefits. Id. Plaintiff submitted a May 20, 2015, Attending Physician's Statement (“APS”) completed by his cardiologist Dr. Rita Friedrichs, who opined that Plaintiff was unable to return to work even in a restricted capacity. Id.

         Plaintiff alleges that Sedgwick never requested medical records that he authorized it to obtain, failed to have his claim reviewed by a physician and/or request he undergo an independent medical examination, and concluded on June 8, 2015, that he was not disabled under the Plan based only on the APS. Id. Plaintiff appealed Sedgwick's decision and alleges he requested a copy of the administrative record and all plan documents on June 30, 2015. Id. at 3- 4. Plaintiff states Defendants failed to produce the requested documents within the required thirty days. Id. at 4. Plaintiff alleges he only received a portion of the administrative record after making additional requests in October 2015. Id. Plaintiff submitted his appeal on February 11, 2016, and provided Sedgwick “with a letter supporting his disability authored by Dr. Friedrichs and his medical records from Audie L. Murphy Veteran's Administration Hospital in San Antonio.” Id.

         Plaintiff states that Dr. Friedrichs's letter included that she examined him on several occasions after his February 6, 2015, heart catheter implantation, and that during those visits, Plaintiff was “still recovering from the implantation procedure, but his diabetes had become uncontrollable, resulting in the disabling symptoms of profound fatigue and significantly lowered concentration and energy levels.” Id. Dr. Friedrichs further opined that Plaintiff suffered from “a possible adjustment disorder resulting in periods of acute anxiety and depression” and stated that Plaintiff's physical and cognitive symptoms prevented him from working beginning May 1, 2015, through the date of her letter. Id. at 4-5.

         Sedgwick upheld its decision denying Plaintiff's claim for STD benefits on April 8, 2016. Id. at 5. Plaintiff states that two physicians from whom Sedgwick sought independent opinions concluded that Plaintiff was “clinically stable” after the heart catheter implant procedure and his medical records did not provide evidence to support his disabling symptoms. Id. Plaintiff alleges that these findings were made “despite significant medical evidence to the contrary.” Id. Plaintiff alleges he then attempted to seek Plan documents related to his claim, but Defendants never acknowledged or produced the requested documents. Id.

         Plaintiff alleges he is entitled to STD under the Plan because he meets the definition of “total disability.” Id. at 6. Plaintiff brings claims against Charter and Sedgwick for breach of the Plan under 29 U.S.C. § 1132(a)(1)(B) for denying him STD benefits and failing to provide him with a full and fair review of his claim. Id. Plaintiff also brings a claim against Charter for failure to supply Plan documents under 29 U.S.C. § 1132(c)(1) after he requested specific documents. Id. at 6-7.

         Defendants state that under the STD program, a claimant is eligible to receive benefits if he is “totally disabled, ” which means he “cannot perform the Essential Duties of [his] own occupation.” Docket no. 44 at 7. Defendants allege that Sedgwick, as claims administrator for the STD program, has “sole authority to determine benefit claims under the terms of the Disability Program.” Id. Defendants state that if a claimant exercises the right to appeal a denial of coverage, that appeal is evaluated by “a person different from the person who made the initial determination” who is not a subordinate of the initial claims handler, and “[n]o deference is afforded to” the initial decision. Id. Claimants may present additional evidence, and the appellate review “take[s] into account all new information, whether or not presented or available at the initial determination.” Id. Defendants state that appellants are “provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to [their] claim for benefits.” Id.

         Defendants state that Sedgwick reviewed Dr. Friedrichs's APS, which estimated Plaintiff's duration of disability at thirty-one days. Id. at 8. Defendants allege that after reviewing the APS, and following “two unsuccessful attempts to contact Dr. Friedrichs, Sedgwick's initial assessment was to deny [Plaintiff's] claim.” Id. The claims adjuster found that “[t]here is no severity of condition” or “evidence of functional impairment, ” and that Plaintiff's “subjective” complaints are not adequately supported by his doctor's objective findings. Id. The adjuster labeled Plaintiff's employment position as “sedentary” and concluded that “[i]t is not known why [Plaintiff] cannot perform his job duties at present.” Id. Sedgwick denied Plaintiff STD benefits, noting that Dr. Friedrichs's report “failed to provide objective medical evidence of functional impairment or indicate any emergent or escalated care was required” during the requested disability period. Id.

         Defendants state that after Plaintiff appealed his denial of coverage, the file was reviewed by Dr. Robert Bryg, a Board-certified cardiologist. Id. at 9. Dr. Bryg concluded in his report that Plaintiff was not disabled from his occupation as of May 1, 2015, and noted clinical findings evidencing “fatigue and poorly controlled diabetes, ” but he observed that based on the medical records provided, Plaintiff “had no further chest pain” following his stenting procedure. Id. Dr. Bryg concluded that there was no evidence of disability. Id. Defendants state that a second report by Dr. Anu Davis, a Board-certified endocrinologist, similarly found that Plaintiff suffered from poorly-controlled diabetes and fatigue, but that there was “a lack of clinical records to support disability” because “[t]here is no mention of [shortness of breath] in the clinical records due to the claimant's heart issues.” Id. Defendants allege that Sedgwick denied Plaintiff's appeal after reviewing all of the records provided by Plaintiff, which consisted of “medical records from Timothy Dao, MD, Mithila Fadia, MD, Rita Friedrichs, MD, Son Pham, MD, Michael Phillips, MD, Andrew Slusher, MD, Tanya Gambli, RN, Preciosa Jumamil, RN, and Myocardial Perfusion Imaging dated February 06, 2015 through January 19, 2016.” Id. at 9-10. Sedgwick also allegedly relied on the evaluations conducted by Drs. Bryg and Davis. Id. at 10. Defendants allege that Sedgwick determined that “the medical information in the file [did] not support [Plaintiff]'s inability to perform [his] occupation.” Id. at 10.

         Defendants state that Plaintiff sent Sedgwick three document requests related to his STD claim on June 30, 2015, September 2, 2015, and September 24, 2015, and that Plaintiff sent another request for Plan documents on May 12, 2016. Docket no. 44 at 10. Defendants allege that Sedgwick complied with Plaintiff's requests on July 8, 2015. Id.

         On December 1, 2017, Charter moved for summary judgment, arguing that it did not violate the Plan or ERISA by denying Plaintiff STD benefits and that it did not fail to properly provide Plaintiff with copies of requested Plan documents. Docket no. 44. On the same date, Sedgwick filed its motion for summary judgment, joining and incorporating Charter's motion and memorandum in support of same, arguing that it did not violate the Plan or ERISA by denying Plaintiff STD benefits. Docket no. 45.

         I. Legal Standard

         The court shall grant summary judgment if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law. Fed.R.Civ.P. 56(a). To establish that there is no genuine issue as to any material fact, the movant must either submit evidence that negates the existence of some material element of the non-moving party's claim or defense, or, if the crucial issue is one for which the non-moving party will bear the burden of proof at trial, merely point out that the evidence in the record is insufficient to support an essential element of the non-movant's claim or defense. Lavespere v. Niagra Machine & Tool Works, Inc., 910 F.2d 167, 178 (5th Cir. 1990), cert. denied, 510 U.S. 859 (1993). Once the movant carries its initial burden, the burden shifts to the non-movant to show that summary judgment is inappropriate. See Fields v. City of S. Hous., 922 F.2d 1183, 1187 (5th Cir. 1991).

         In order for a court to conclude that there are no genuine issues of material fact, the court must be satisfied that no reasonable trier of fact could have found for the non-movant, or, in other words, that the evidence favoring the non-movant is insufficient to enable a reasonable jury to return a verdict for the non-movant. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 250 n.4 (1986). In making this determination, the court should review all the evidence in the record, giving credence to the evidence favoring the non-movant as well as the “evidence supporting the moving party that is uncontradicted and unimpeached, at least to the extent that evidence comes from disinterested witnesses.” Reeves v. Sanderson Plumbing Prods., Inc., 530 U.S. 133, 151 (2000).

         II. Application

         Defendants argue they are entitled to summary judgment on both the denial of STD benefits and the claim related to providing requested Plan documents. Plaintiff argues that Defendants' motion for summary judgment should be denied, and instead, the Court should enter summary judgment in his favor on these claims.[2]

         I. Denial of STD Benefits

         Defendants argue that they are entitled to summary judgment because Sedgwick's denial of Plaintiff's STD claim is subject to review under an abuse of discretion standard with respect to both Defendants, and there is no evidence in the administrative record to indicate Sedgwick abused its discretion. Plaintiff argues that, with respect to his claim against Charter, the Court should review the denial of STD benefits de novo because Charter did not have discretionary authority to determine the payment of STD ...

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