The opinion of the court was delivered by: Blanche M. Manning United States District Court Judge
In this ERISA case, plaintiff Gandhi Gutta seeks review of the denial of his claim for long term disability benefits under defendant Standard Select Trust Insurance's long-term disability plan. The parties' cross-motions for summary judgment are before the court. In addition, Standard Select seeks to strike a social security disability ruling in Dr. Gutta's favor because it is outside the administrative record. For the following reasons, the court grants the motion to strike. It also finds that Standard Select's denial of benefits was not arbitrary and capricious and that Standard Select is entitled to summary judgment as to its counterclaim. Thus, Dr. Gutta's motion for summary judgment is denied and Standard Select's motion is granted.
The court begins by noting that regrettably, the parties' fact statements list facts seriatim in what appears to be a largely random order. The court commends the liberal use of point headings in the future, as this practice makes it far easier to accurately summarize all of the material facts and locate facts as necessary. With that said, the following facts are undisputed unless otherwise noted. Dr. Gutta was born on December 15, 1941. He is a medical doctor and worked as a general laparoscopic surgeon until August 25, 2000. Dr. Gutta had disability insurance pursuant to a group policy underwritten by Standard Insurance.
A. Standard Select's Policy
Standard Select's group policy contains an allocation of authority provision which provides as follows:
Except for those functions which the Group Policy specifically reserves to the Policyowner or Employer, Standard has full and exclusive authority to control and manage the Group Policy, to administer claims, and to interpret the Group Policy and resolve all questions arising in its administration, interpretation, and application. Standard's authority includes, but is not limited to:
1. The right to resolve all matters when a review has been requested;
2. The right to establish and enforce rules and procedures for the administration of the Group Policy and any claim under it;
3. The right to determine:
a. Eligibility for insurance
b. Entitlement to benefits;
c. Amount of benefits payable;
d. Sufficiency and the amount of information we may reasonably require to determine a., b., or c., above.
Subject to the review procedures of the Group Policy any decision Standard makes in the exercise of our authority is conclusive and binding.
Joint Apdx., Ex. A, Group Policy, Amendment 8, p. 2.
The group policy defines "disabled" as follows:
Until LTD Benefits have been paid for 24 months, you are Disabled if, as a result of Sickness, Accidental Bodily Injury, or Pregnancy, you are either:
a. Unable to perform with reasonable continuity the material duties of your own occupation; or
b. Unable to earn more than 80% of your Indexed Predisability Earnings while working in your own occupation.
After LTD Benefits have been paid for 24 months, you are Disabled if, as a result of Sickness, Accidental Bodily Injury, or pregnancy, you are either:
a. Unable to perform with reasonable continuity the material duties of any gainful occupation for which you are reasonably fitted by education, training, and experience; or
b. Unable to earn more than 80% of your Indexed Predisability Earnings while working in your own or any other occupation.
Id., Group Policy at p. 23.
In addition, the group policy contains a provision for "Income Received From Other Sources." It defines "Income Received From Other Sources," in subsection (f), as "[t]he amount you receive or are eligible to receive because of your disability under any group insurance coverage, other than group credit insurance or group mortgage disability insurance[.]"
Aaron Weinberg, M.D., an ophthalmologist selected by Standard Select, performed an independent medical examination ("IME") of Dr. Gutta on April 8, 2001. In his IME report, Dr. Weinberg opined that he found no pupillary defect, normal peripheral and arteriole retinas, and no evidence of macular degeneration in either eye. He also found that Dr. Gutta had minimal background diabetic retinopathy changes in his right eye, a laser scar in his left eye as a result of treatment for a leaking microaneurysm associated with his diabetic retinopathy, mild cataracts in each eye, and paracentral scotoma (the loss of a small part outside the central field of vision) in his left eye. Based on these findings, he stated that "[w]ith 20/20 vision in both eyes, a normal peripheral retina, and visual field there should be no substantial limitations on [Dr. Gutta's] depth perception."
In his report, Dr. Weinberg also noted that "Dr. Gutta does not feel capable of performing surgery due to his scotoma and decreased depth perception. Certainly, the lack of confidence in his own surgical skills as well as others in the operating room with similar concerns, it may be reasonable for him to stop practicing." Dr. Weinberg's report also stated that Dr. Gutta was able to drive himself to and from Dr. Weinberg's office. Ultimately, Dr. Weinberg concluded that "the objective findings on today's examination do not correlate with his [Dr. Gutta's] complaints" and that Dr. Gutta "should have no restrictions on his physical abilities based on the eye findings described above."
Dr. F. Soroco, an endocrinologist, completed an Attending Physician's Statement ("APS"). In this statement, he stated that Dr. Gutta had blind spots in his left eye and that Dr. Gutta's vision would progressively deteriorate and eventually culminate in total blindness.
Dr. Raichland, an ophthalmologist, also completed an APS. In Dr. Raichland's APS, he recommended Dr. Gutta should stop working on August 25, 2000, due to blind spots in his left eye that cause him to be unable to perform laparoscopic surgery. Dr. Raichland also noted that Dr. Gutta had been diagnosed with drusen and vitreous bodies on March 17, 1997, and that his diabetes contributes to this condition. In addition, Dr. Raichland stated that Dr. Gutta's diagnoses include macular degeneration in both eyes and retinal artery aneurysm in his left eye.
He opined that these impairments are permanent and that the macular degeneration could lead to blindness. Finally, he indicated that Dr. Gutta's treatment was complicated by his multiple medical problems.
In late 2000, Debbie Sawyer, a nurse, contacted Dr. Raichland to discuss the outcome of Dr. Gutta's laser surgery. Dr. Raichland informed Nurse Sawyer that Dr. Gutta has 20/20 vision with corrective lenses, and that he "could not comment as to whether [his blind spot] would be significant enough to cause [Dr. Gutta] to cease work." Dr. Raichland also told Nurse Sawyer that he thought that Dr. Gutta had ceased work due to his other medical conditions, not due to any problems with his vision. He then suggested that "[Standard Select] might want [Dr. Gutta] evaluated by another ophthalmologist to determine [Dr. Gutta's] limitations."
B. Dr. Gutta's Orthopedic Condition
In January of 2001, Anthony Romeo, M.D., an orthopedic surgeon, recommended right shoulder arthroscopy, capsular release, and limited acromioplasty surgery for Dr. Gutta's shoulder pain. Later that month, he performed right shoulder arthroscopy, acromioplasty, CA-ligament release, and posterior capsular release on Dr. Gutta's right shoulder. Dr. Romeo's preoperative and postoperative diagnosis as of the date of Dr. Gutta's shoulder surgery was right shoulder impingement syndrome and right shoulder posterior capsular stiffness. He reported that Dr. Gutta has a positive impingement sign with some very mild associated bicipital tendonitis on the right side.
On April 6, 2001, Dr. Gutta returned to see Dr. Romeo for a post-operative follow up appointment. Dr. Romeo's notes state:
Dr. Gutta returns for reevaluation. He is three months following his right shoulder arthroscopy and acromioplasty. He is having no pain at night, and he is able to use his arm for all of his activities. He would like to return back to golf and I have no reservations in allowing him to do so. He will continue with his exercise program on his own. He has had some problems with his right elbow. He has a history of childhood injury to his right elbow. He has occasional mild medial elbow pain, and he is lacking approximately 5 degrees of extension. His radiographs demonstrate an old fibrous nonunion at the medical epicondyle secondary to an MCL strain during his developmental years. This is a non-operative problem. He will continue to use his arm as tolerated. I will see Dr. Gutta back either in six months or on an as-needed basis. We did briefly discuss his left shoulder, but, at this time, he is having no discomfort and would like to continue with conservative management.
Joint Apdx., Ex. D, Admin. Rec. at STND 0710.
On January 27, 2001, Standard consulted with Bradley Fancher, M.D., who opined, based on his review of the medical records, that Dr. Gutta would be unable to perform laparoscopic surgery while recovering from the capsular release, and that his shoulder condition "was likely fairly limiting prior to surgery." Id. at STND 0580-582.
On October 4, 2000, Dr. Gutta saw N.V. Joshi, M.D., a neurologist, for a neurophysiological consultation. Dr. Gutta complained of pain in deltoid, biceps, and brachioradialis muscle on the right side. Dr. Gutta's H.F. Wave study, which evaluates nerve conduction, showed an absence of 'H' Reflex on his right side. His EMG study was "mildly abnormal" with respect to the firing frequency of the motor units with "no acute denervation," normal sensory study, and normal motor study. Joint Apdx., Ex. D, Admin. Rec. at STND 0443. Dr. Joshi's final impression was very mild right C6-7 radiculopathy with a notation that "this does not explain the clinical picture." Id.
In Dr. Joshi's APS, he stated that Dr. Gutta's symptoms were weakness of the left arm and hand and his primary diagnosis was "ulnar nerve palsy left" with symptoms of weakness in his left arm and hand. Id. at STND 0402. He stated that "due to paralysis of left ulnar nerve, patient has problems performing surgery" and opined that "[p]atient cannot perform major surgical procedures." He then concluded that Dr. Gutta should stop working as a surgeon on August 25, 2000, and added Dr. Gutta will not get better, only worse and that there is no specific treatment possible. Id. On November 21, 2000, Dr. Gutta advised Standard Select that he is "not following" with Dr. Joshi. Id. at STND 0338.
Dr. Joshi referred Dr. Gutta to Vikram Gandhi, M.D., an orthopedist. Dr. Gandhi filled out an APS on September 15, 2000. As of November 21, 2000, Dr. Gutta advised Standard Select that he was "not following" with Dr. Gandhi. In Dr. Gandhi's APS, he stated that Dr. Gutta's symptoms were pain in the left thumb, an inability to tie knots, and severe pain while wearing gloves. He also noted that Dr. Gutta had degenerative changes in the carpal bones of both wrists and could not perform surgery due to pain, the inability to wear gloves, ulnar nerve palsy, blind spots in the left eye, and impaired hand function. Dr. Gandhi thus recommended that Dr. Gutta should stop performing surgery as of August 25, 2000.
Dr. Gandhi further reported that physical therapy and immobilization has not helped Dr. Gutta's pain and that Dr. Gutta cannot take medications or steroid injections for the pain because they cause stomach pain and impair his ability to manage his blood sugar. Dr. Gandhi opined that he did not expect Dr. Gutta's condition to change, Dr. Gutta's condition is progressively deteriorating, and Dr. Gutta has multiple non-correctable problems.
Dr. Luis F. Soruco, M.D., is an endocrinologist who treated Dr. Gutta's diabetes. The record contains progress notes from September of 1995 indicating that Dr. Gutta stated that he was experiencing pain and vision problems. On December 23, 2002, Dr. Soruco noted that Dr. Gutta had Type I diabetes with episodes of mild hypoglycemia and increased blood pressure.
Dr. Soruco prepared an APS which Dr. Gutta submitted to Standard Select. In his APS, which is dated October 4, 2000, Dr. Soruco noted that Dr. Gutta had been diagnosed with diabetes seven years ago. He also recommended that Dr. Gutta should stop working on August 25, 2000, because blind spots and his dislocated left thumb prevent him from performing laparoscopic surgery and tying knots, respectively. In addition, Dr. Soruco noted that these limitations are permanent and cannot be corrected. Finally, in his capacity as an endocrinologist, he opined that Dr. Gutta's vision would progressively deteriorate and that Dr. Gutta would eventually become blind.
Dr. Surender Kumar, M.D., is a cardiologist. On February 1, 1993, Dr. Kumar reported that Dr. Gutta has a history of diabetes and atypical chest pain. On January 29, 1993, and February 1, 1993, Dr. Gutta underwent a Thallium Treadmill Stress Test. The thallium studies showed reversible ischemia in the anteroseptal and a small portion of the posterolateral wall of the heart. On February 1, 1993, Dr. Gutta underwent cardiac catheterization for exertional chest pain from mild coronary artery disease in the left anterior descending branch.
On May 16, 2000, Dr. Gutta underwent a left heart catheterization, left ventricular and right and left coronary angiography followed by aortic arch angiography due to a history of chest pain. Dr. Kumar's postoperative diagnosis of Dr. Gutta was mild coronary artery disease and a normal left ventricle. Upon discharge, Dr. Kumar noted that Dr. Gutta is taking the following medications: insulin, Vasotec, Lopid, Lipitor, and baby aspirin. Dr. Kumar's records do not contain any opinions as to whether Dr. Gutta's heart problems affect his ability to work.
Dr. Hans Carlson is a physiatrist (a physician specializing in physical medicine and rehabilitation). Standard asked him to review the available medical records. On July 13, 2004, Dr. Carlson prepared a Physicians Consultant Memo which stated, in pertinent part, that:
The claimant is noted to have limitations secondary to musculoskeletal conditions and these have been described as hand and wrist pain as well as degenerative changes, bilateral ulnar neuropathies, degenerative arthritis of the knees, cervical spondylosis, and shoulder pain. These records detail some mild left shoulder tendonitis and right shoulder impingement syndrome that, as of 4/6/01, apparently were essentially resolved or not limiting in activities. We have no notes beyond Dr. Romeo's note from 4/6/01 that suggest ongoing shoulder problems. The available notes do not provide any convincing evidence of an active cervical or lumbosacral radiculopathy or any significant impairment related to the radiculopathy.
The claimant is noted to have some hand pain and imaging studies to document bilateral wrist degenerative changes, as well as left thumb degenerative changes. Records do not show any ongoing treatment with respect to the wrist or hand degenerative changes. In fact, with respect to Dr. [Vikram] Gandhi's records, we only have clinic notes from 12/3/02 and 4/9/04. These records do not provide any evidence of degenerative knee arthritis, ...