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Sandt-Mika v. SBC Disability Income Plan

September 18, 2008


The opinion of the court was delivered by: Magistrate Judge Geraldine Soat Brown


Plaintiff Laura Sandt-Mika ("Sandt-Mika"), a former quality control manager of Ameritech Services, Inc., brought this suit pursuant to § 502(a)(1)(B) of the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132(a)(1)(B), against defendant AT&T Disability Income Program, f/k/a SBC Disability Income Plan (the "Plan"). Sandt-Mika claims that the Plan improperly denied her application for short-term disability benefits. Both Sandt-Mika and the Plan have moved for judgment on the administrative record. [Dkt 27, 30.] The parties have consented to the jurisdiction of a Magistrate Judge pursuant to 28 U.S.C. § 636(c). [Dkt 16.] For the reasons set forth below, Sandt-Mika's motion is denied and the Plan's motion is granted.


A. Sandt-Mika's Employment and the Plan

Sandt-Mika was employed as a Manager-Quality/M&P/Process by Ameritech Services, Inc. (Answer ¶ 2.) [Dkt 14.] According to Ameritech's description, which Sandt-Mika does not dispute, her responsibilities included: the identification, analysis, development, and documentation of process improvements. Consults with line management on process management and improvement. Identifies and makes recommendations for process improvements. . . . (AR 85.) Her job was classified as a "sedentary" position, requiring "process implementation," sitting, typing and talking on the telephone. (AR 61.) She worked Monday through Friday, 8 a.m. to 5 p.m. (AR 61.)*fn2

As a benefit of her employment, Sandt-Mika participated in an employee welfare benefit plan providing short-term disability benefits for up to 52 weeks. (Plan Text, AR 11.) Short-term disability benefits are available to eligible employees who are partially or totally disabled as defined under the Plan. (Plan Text, AR 11.) "Partial Disability" or "Partially Disabled" is defined by the Plan as the following: that because of Illness or Injury, an Employee is unable to perform all of the essential functions of his job or another available job assigned by the Participating Company, within the same full- or part-time classification for which the Employee is qualified . . . .

(Plan Text, AR 10.)*fn3 Eligible employees may receive short-term disability benefits beginning on the eighth consecutive calendar day of an absence caused by an illness or injury. (Plan Text, AR 5 (referring to Summary Plan Description, Watts Decl., Ex. 2 at DI2, DI5).) Short-term disability benefits may be withheld under the Plan if the claimant does not provide sufficient medical information about her condition. (Plan Text, AR 14.)

AT&T Inc. ("AT&T") is the Plan Administrator with discretionary authority to determine Plan eligibility and to appoint one or more Claims Administrators. (Watts Decl. ¶¶ 2, 3.) AT&T appointed Sedgwick Claims Management Services, Inc. ("Sedgwick") as a third party Claims Administrator for the Plan. (Watts Decl. ¶ 4.) As Claims Administrator, Sedgwick has authority to administer claims without prior written approval by AT&T, to determine benefits eligibility and to interpret the terms of the Plan. (Watts Decl. ¶¶ 6, 8, 9.) The Plan provides:

[E]ach Claims Administrator and each subcommittee to whom claim determination or review authority has been delegated shall have full and exclusive authority and discretion to grant and deny claims under the Plan, including the power to interpret the Plan and determine the eligibility of any individual to participate in and receive benefits under the Plan. The decision of . . . a Claims Administrator or any subcommittee, as applicable, on any claim, in accordance with the claim procedures set forth in this Subsection 5.5, shall be final and conclusive and shall not be subject to further review. (Plan Text, AR 21.) Sedgwick receives a flat fee for its services irrespective of its claim determinations and plays no role in funding or budgeting claims for payment. (Watts Decl. ¶¶ 8, 9.)

B. Sandt-Mika's Disability Claim

On October 11, 2005, Sandt-Mika visited the office of her primary care physician, Dr. Maelen Pantano, complaining that she was "very, very fatigued," under "a lot of stress" and "not able to work." (AR 142.) According to Dr. Pantano's notes, Sandt-Mika attributed the stress to concern for her daughter who had been diagnosed with a benign tumor that was thought to be cancerous. (AR 142.) Dr. Pantano examined Sandt-Mika and prepared an internal medicine progress note in which she wrote under "Assessment and Plan":

The patient has an acute stress reaction. She was given a note to be off work until the 31st. The patient is not able to work because of inability to sleep. I gave her a referral for behavioral health, four visits, for acute stress reaction. The patient is advised to rest and to go for counseling. I gave her Ambien for nighttime. . . . I ordered a comprehensive metabolic profile, CBC, urinalysis, and a cardiac risk profile." (AR 143.) Dr. Pantano's progress note also reflects that Sandt-Mika had a temperature of 100.6E Fahrenheit. (AR 142.)

On the following day, October 12, 2005, Sandt-Mika initiated a claim for short-term disability benefits under the Plan by contacting Sedgwick's SBC Medical Absence and Accommodation Resource Team ("SMAART") by telephone. (AR 61.)*fn4 During the conversation, Sandt-Mika indicated that she was off work until October 31 due to "stress." (AR 64-65.) The SMAART representative explained SBC's disability policies and procedures, including the requirement that a claimant supply necessary medical records, and explained to Sandt-Mika that "[c]laims without medical information supporting a complete inability to perform your assigned job duties by the medical due date will be denied." (AR 61-64.)

C. SMAART's Review of Sandt-Mika's Claim

By letter dated October 12, 2005, SMAART notified Sandt-Mika that a claim had been initiated and a "determination [wa]s pending receipt of medical substantiation from [her] treatment provider." (AR 156.) SMAART further explained that "[t]o qualify for benefit payments under the SBC disability plans, your medical condition should involve a sickness or injury, supported by medical documentation that prevents you from performing the duties of your job with or without reasonable accommodations." (AR 156.) The letter stated that Sandt-Mika or her medical provider must submit all relevant medical records by October 27, 2005, and "[i]f the medical documentation received from your treatment provider does not contain information that establishes that your condition prevents you from performing the duties of your job with or without reasonable accommodations, your claim will not qualify for benefit payments under the SBC disability plans." (AR 156.)

Over the next several days, SMAART contacted Dr. Pantano by telephone and by fax, seeking information about Sandt-Mika's condition. (AR 57-60, 116.) On October 26, 2005, Dr. Pantano responded by faxing to SMAART the medical progress note she prepared from SandtMika's initial visit on October 11, 2005. (AR 139-46.)*fn5 Although Dr. Pantano's progress note states that the doctor ordered a "comprehensive metabolic profile, CBC, urinalysis, and a cardiac risk profile" for Sandt-Mika and there is an October 17, 2005 notation in SMAART's system indicating an October 19, 2005 appointment for blood work (AR 58-59), the information Dr. Pantano sent on October 26, 2005 did not include any laboratory results. (AR 139-46.)

A SMAART case manager reviewed Dr. Pantano's October 11, 2005 progress note, and entered the following notation on SMAART's system: "[I]t is unclear if very very fatigued is self reported or fatigued. Her pe [physical exam] is normal except does have slight fever. No notes from therapist recd." (AR 56.) The SMAART case manager also noted several questions to consider, including: "What are objective observables to substantiate severity and [employee] inability to work sedentary job duties?" (AR 56.)

The claim was then referred to a SMAART physician advisor, Dr. Elizabeth Henderson, a board certified psychiatrist. (AR 53-56.) According to the notes in the SMAART system, in response to a request for objective data regarding Sandt-Mika's behavior and mental status, Dr. Pantano stated on October 28, 2005 that "she did not have the correct release of information to reveal that 'type' of information," and refused to give any further detail, stating only that she had referred Sandt-Mika to a psychiatrist and extended her return to work date to November 1, 2005. (AR 53.)

Dr. Henderson concluded that the "[a]vailable information suggests fatigue and some type of medical process involving fever, but there are no objective findings to support depression or impaired psychiatric functioning." (AR 53.) Dr. Henderson concluded that the "[a]vailable information [did] not support impairment" of Sandt-Mika's ability to perform repetitive work activities or her ability to comprehend and follow instructions. (AR 53-54.) In response to the question about the objective observables that substantiate severity and an inability to work, Dr. Henderson stated that the "[a]vailable information does not contain descriptions of her mental status or behavior." (AR 54.)

D. SMAART's Initial Denial of Claim

As of November 2, 2005, Dr. Pantano's October 11, 2005 progress note was the only medical documentation Sandt-Mika had submitted to support her claim for disability. After receiving Dr. Henderson's review, SMAART denied Sandt-Mika's claim. (AR 51.) SMAART contacted SandtMika on November 2 to notify her of that decision and advise her that SMAART would re-evaluate the claim ...

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