Case Studies

Donnella Smith, Esq.
200 Main Street, Suite 3200
Any Where, Florida 96590

Re: Ms. Jane P., - Final Appeal
Dear Ms. Smith:

Claim Appeal Fiduciary Services, Inc. ("CAFS") has had the opportunity to review and consider Ms. P's final appeal for benefits under the X Corporation Long Term Disability Plan (the “ LTD Plan” or the “Plan”). CAFS is the designated independent fiduciary charged with the responsibility of processing Ms. P's final disability claim appeal under the LTD Plan, in accordance with the terms of the LTD Plan. For the reasons stated in this letter, CAFS must deny Ms. P's Appeal for benefits under the LTD Plan.

Specific Reasons for Determination and Reference to Plan Provisions

Factual Background and Claim History - The Administrative Record regarding Ms. P's claim indicates that Ms. P was employed at X's Smith City, State A facility as a machine operator.

Ms P.'s first day of absence was April 7, 1999. Ms. P applied for and received 6 months of short term disability benefits under the X STD Plan during the period from April 1999 through her transition to 1st tier long term disability benefits in February 2001. During the short term disability period, Ms. P returned to work for two short periods. Under the 1st tier of the LTD Plan, which provides for 24 months of benefits, inclusive of the aggregate 6-month short term disability period, a participant is considered "disabled" if he or she cannot perform the essential tasks of his or her own position. Ms. P received the balance of her 1st tier LTD Plan benefits from February 10, 2001 through August 31, 2002. Following the 1st tier of LTD Plan benefits, the Plan's 2nd tier of benefits requires that Ms. P demonstrate that she is disabled from performing "any occupation". After a review of the Administrative Record, the Claim Coordinator at Y Company, the LTD Plan's third party administrator, determined that Ms. P could no longer be considered "disabled" under the 2nd tier requirements of the Plan. Ms. P was informed, by letter dated August 27, 2002, of the initial denial of her benefits and of the LTD Plan's claim procedures.

By letter dated January 27, 2003, as Ms. P's attorney, you informed the Appeal Coordinator that you represented Ms. P and that your letter represented a formal appeal of the denial of benefits under the Plan. You enclosed voluminous medical records. By letter dated March 11, 2003, to you, the Appeal Coordinator informed Ms. P that the initial denial of benefits under the Plan was upheld. The letter also advised that a second appeal could be submitted within 60 days of the letter's receipt. By letter dated March 25, 2003, you submitted additional medical records. You provided additional medical records with your letters to Y Company dated April 28, 2003 and April 29, 2003. Your letter of May 1, 2003 indicated that there were no additional records forthcoming and that the administrative record was complete for X's final determination. Y Company's letters of June 10, 2003 and June 17, 2003 concerned an extension of time for X to respond. This letter is X's final determination of Ms. P's claim for LTD Plan benefits.

Plan Provisions Supporting the Denial of Benefits

Pursuant to the LTD Plan, a covered disability is defined as follows:

During the first 24 months of such disability, inclusive of any period of short term disability, you are totally and continuously unable to perform the essential duties of your employment with the Company, or the duties of any other suitable alternative position with the Company; and

During the continuation of such total disability following the first 24 months, you are totally and continuously unable to engage in any occupation or perform any work for compensation or profit for which you are, or may become, reasonably well fitted by reason of education, training or experience - at the Company or elsewhere. Page 10, LTD Plan Summary Plan Description (“LTD SPD”).

The LTD Plan grants X complete discretionary authority regarding the interpretation of the LTD Plan as follows:

The Plan Administrator shall have discretionary authority to determine eligibility for benefits and to construe any and all terms of the Plan, including, but not limited to, any disputed or doubtful terms. The Plan Administrator shall also have the power and discretion to determine all questions of fact and law arising in connection with the administration, interpretation and application of the Plan. Any and all determinations by the Plan Administrator shall be conclusive and binding on all persons... Page 13, LTD SPD.

Pursuant to the LTD Plan, X is the “Plan Administrator”. Page 25, LTD SPD.

Reasons for Denial and Application of the Plan

Ms. P's records were reviewed and analyzed by an independent physician reviewer who is a member of an independent third party review organization.

This physician is Board certified in Physical Medicine and Rehabilitation, a Diplomate of the American Academy of Physical Medicine and Rehabilitation (“AAPMR”), and a Diplomate of the American Board of Electrodiagnostic Medicine. This physician is also a member of the American Spinal Injury Association (a body of the AAPMR), a State Academy of Physical Medicine and Rehabilitation and a State Medical Society. This physician is licensed to practice in four (4) states and has been in practice since 1978.

Upon review of the extensive records submitted by Ms. P, this physician reviewer concluded that Ms. P's condition did not meet the definition of disability under the terms of the Plan. The physician reviewed the entire administrative record and culled from the documents, dating back to 1990, five (5) distinct areas of concern for Ms. P. His observations are as follows:

1. With respect to Carpal Tunnel Syndrome (“CTS”), this physician reviewer observed that Ms. P has made no complaints with regard to her hand for 5 1/2 years. She was treated for mild CTS with carpal tunnel release surgery, after which she showed improvement. During the period that Ms. P had post-surgical complaints, they were unsupported by objective findings. The reviewer noted that recent neurological examinations noted sensation intact and symmetrical two point discrimination. The physician reviewer pointed out that in any event, mild CTS might restrict Ms. P's work, but would not prevent her from performing “any occupation.
   
   
2. With respect to Cervical Disc Disease, this physician reviewer noted that the surgeon who performed the anterior cervical fusion noted good healing and good results. The reviewer noted that except for mild restriction in cervical range, all postoperative test results have been essentially normal. Again there have been no recent complaints on the part of Ms. P. Therefore, this condition cannot support a finding that Ms. P is disabled from performing "any occupation."
   
   
3. The physician reviewer noted that Ms. P has carried the diagnosis of fibromyalgia for many years, despite that fact that there have been no abnormal labs, no widespread loss of joint motion and no abnormal neuromusculoskeletal exams. In addition, the problem of tenderness and complaints of pain do not seem to be ongoing since they are not documented in the most recent clinic notes, or the numerous emergency room (ER) examinations. The lack of objective medical documentation with respect to fibromyalgia does not support Ms. P's claim of disability from "any occupation."
   
   
4. With respect to other musculoskeletal conditions including TMJ, Piriformis Syndrome and lateral epicondylitis, this physician reviewer noted that Ms. P has had no complaints over the past year. The physician noted that these various conditions do not support a disability from "any occupation."
   
   
5. Ms. P's major ongoing problem appears to be migraine headaches. The physician reviewer noted that all neurological exams were normal and that no structural reason was found to explain the headaches or their apparent increasing frequency. The reviewer noted that Ms. P has not followed up on a behavioral program recommended by examiners at the Z Hospital regarding chronic pain, nor on the diagnosis of depression and treatment plan for the same. It appears that Ms. P is instead visiting emergency rooms as well as her primary care clinic for narcotic injections. The physician reviewer observed:

The patient's visits to the clinic and ER are becoming quite frequent. She is going to two different hospitals [emergency rooms] as well as her primary care clinic. She is getting more frequent narcotic injections. It appears that the patient may at this point be dependent on the narcotics. If so, the behavioral problems (depression) and sleep problems, as well as the headaches, may be related to her narcotic usage. If so, this would require a drug detoxification program.

The physician reviewer continued by pointing out that while Ms. P complains of nausea and vomiting in connection with her headaches, no vomiting has been documented in her numerous ER visits. Lab studies, which would support reported vomiting, show normal hydration and electrolyte levels. The conclusions described above were consistent with observations made by Dr. B, a psychologist who conducted a Y Company physician review on February 27, 2003, by Dr. M, a specialist in internal medicine who conducted a Y Company physician review on February 26, 2003, by Dr. Z, a rheumatologist who conducted a Y Company physician review on May 5, 2003, by Dr. C, a neurologist who conducted a Y Company physician review on May 5, 2003, and by Dr. G, a psychiatrist who conducted a Y Company physician review on May 5, 2003.

In conclusion, the medical professionals who have reviewed the medical documentation provided by Ms. P do not support the conclusion that Ms. P is disabled from any occupation. A review of all of the medical information does not reveal a clear determination by any treating physician that she has met the Plan's standard for disability from any occupation. Her Social Security award of disability benefits was determined under a different standard that is not dispositive of a disability determination under the terms of the LTD Plan. CAFS has full discretion to determine eligibility for Plan benefits which in this instance requires medical evidence to support a disability that prevents an individual from performing any occupation. Based upon these facts, Ms. P's final appeal for benefits under the Plan must be denied.

Additional Information

Pursuant to X's Benefit Determination and Claims Appeal Procedure for the Plan, this final review by CAFS has been a “fresh” look, without deference to any prior denial decision. In addition, the final review was conducted by CAFS, which is completely independent of the plan sponsor. As such, this review was not conducted by a person involved in the prior denial decision, and CAFS is not in any way a subordinate of the prior decision maker.

Ms. P is entitled to receive, upon written request and free of charge, any documents, records and other information that he/she has not yet received and that were relied upon in making this benefit determination, or that were submitted, considered or generated in the course of making his benefit determination, or that demonstrate compliance with the Plan claims processing administrative procedure. Such information may be requested at the address stated above.

This is the last and final review of Ms. P's claim for LTD benefits. Ms. P has the right to pursue a civil action under Section 502 of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”), 29 U.S.C. §1132. A civil action must be brought within one (1) year from the date of this letter. The review of this claim applied the LTD SPD and LTD Plan terms, and facts in the administrative record of this claim. Other than the documents referred to in this letter, no other internal rule, guideline, protocol or other similar criterion was relied upon in making this determination.

Very truly yours,

CLAIM APPEAL FIDUCIARY SERVICES, INC.

By___________________________

Sheila Ninneman - Vice President Claim Appeals