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Braden v. AT&T Umbrella Benefit Pan No. 3

United States District Court, D. Minnesota

March 17, 2017

Jeremy Braden, Plaintiff,
v.
AT&T Umbrella Benefit Pan No. 3, Defendant.,

          Alesia R. Strand, Esq., Thomas J. Beedem, Esq. counsel for plaintiff.

          Noah G. Lipschultz, Esq. and Littler Mendelson, PC, counsel for defendant.

          ORDER

          David S. Doty, Judge

         This matter is before the court upon the cross-motions for summary judgment by plaintiff Jeremy Braden and defendant AT&T Umbrella Benefit Plan No. 3. Based on a review of the file, record, and proceedings herein, and for the following reasons, the court grants defendant's motion.

         BACKGROUND

         This insurance benefit dispute arises out of the Plan's denial of short-term disability benefits to Jeremy Braden. From July 14, 2008, to June 2, 2015, Braden was employed at AT&T as a Business Customer Service Specialist II. Braden's position required him to use problem solving and troubleshooting skills to assist AT&T's internal customer service representatives and business clients with a variety of cellular network and billing issues. Admin. R. at 277-78. The position was sedentary; it consisted of using a telephone and computer while sitting. Id. at 1. Braden had disability benefits through the AT&T Mobility Benefits Program (Plan). Under the Plan, AT&T delegated its discretionary authority to make all benefit determinations to Sedgwick Claims Management Services, Inc. See id. at 725, 727. A claimant filing for disability benefits under the Plan must provide Sedgwick with “satisfactory Medical Evidence of [his] Disability from [his] Physician.” Id. at 703. The Plan defines “medical evidence” as:

Objective medical information sufficient to show that the Participant is Disabled, as determined at the sole discretion of [Sedgwick]. Objective medical information includes, but is not limited to, results from diagnostic tools and examinations performed in accordance with the generally accepted principles of the health care profession. In general, a diagnosis that is based largely or entirely on self-reported symptoms will not be considered sufficient to support a finding of Disability. For example, reports of intense pain, standing alone, will be unlikely to support a finding of Disability, but reports of intense pain associated with an observable medical condition that typically produces intense pain could be sufficient.

Id. at 725 (emphasis added).

         On January 15, 2015, [1] Braden stopped working due to back pain, and, on January 23, applied for short-term disability benefits. See id. at 1, 4, 38. On January 29, Braden submitted a form completed by his physician, Dr. Thomas Kiefer. See id. at 85. Kiefer stated that Braden suffered from “pain and immobility” due to “lumbar disc syndrome.” Id. Due to this condition, Kiefer stated that Braden would need “days off work intermittently” and that his current functional restrictions were “limited lifting or bending.” Id. Based on this information, Sedgwick approved disability benefits through January 22. Id. at 92.

         On February 5, Braden sent Sedgwick a progress report from a February 3 follow-up visit with Kiefer, in which Kiefer discussed Braden's history of lumbar disc syndrome including two previous lumbar surgeries completed in December 2013 and June 2014. Id. at 94-95. Kiefer reported that Braden appeared in “moderate distress, ” had “difficulty walking, ” had a poor range of motion, and could not “bend forward very much.” Id. at 94. Kiefer also discussed the results of a February MRI, which showed that Braden had bulging discs, and that he did not know when Braden could return to work. Id. at 95.

         The Plan sought an independent review of Braden's medical records, and on February 12, Dr. Xico Garcia, a family practice physician, concluded that the evidence supported a claim for disability starting January 26 and that Braden could reasonably be expected to return to work by February 16 if his symptoms improved. Id. at 97-99. Based on Garcia's review, the Plan approved Braden's disability claim through February 16. Id. at 356.

         Braden did not return to work on February 17, and, on February 20, the Plan denied disability benefits for February 17 forward because “the medical documentation did not clearly address the severity of [Braden's] condition.” Id. at 358. The denial letter informed Braden that he needed to provide “clear documentation from [his] current treating provider(s) of why [he was] not able to perform the essential duties of [his] occupation.” Id. at 359. Further, the documentation would need to state “[his] functional impairments as they relat[ed] to [his] diagnosis and provide a treatment plan that addresses plans for [his] return to work with or without reasonable restrictions with a reasonable duration.” Id.

         In response, on March 13, Braden submitted a report from a February 25 follow-up visit with Kiefer, in which Kiefer observed that Braden experienced pain from bending forward, had difficulty sleeping because of the pain, and had a positive straight leg exam.[2] Id. at 101-02. Kiefer also stated that Braden should continue to be off work and that and Braden “knows he cannot sit or stand for very long.” Id. The Plan again denied disability benefits from February 17 forward for the same reasons provided in the previous denial letter.[3] See id. at 104-05.

         On March 27, Braden submitted a note from Kiefer stating that he had been disabled due to lumbar disc syndrome but could return to work on March 30 for 4 hours per day, 5 days per week. Id. at 125. The return-to-work note stated that Braden could not lift more than ten pounds, climb ladders, or squat, and that he may need to change positions every half-hour. Id. On April 2, Braden submitted another note dated April 1, in which Kiefer reiterated that Braden could not sit for over thirty minutes without standing or walking. Id. at 127.

         Braden returned to work on March 30, but he stopped working again on April 6 due to back pain. Id. at 406. On April 22, Braden submitted an April 21 physician statement from Kiefer stating that Braden had lumbar pain with immobility. Id. at 497.[4]On April 30, Dr. Katherine Duvall, a physician specializing in occupational medicine, spoke with Kiefer by telephone and reviewed the physician statement. Id. Kiefer informed Duvall that, based on the February MRI, Braden had mild stenosis and a bulging disc, but that “the MRI did not show a ‘terrible problem.'” Id. He also stated that Braden had a decreased range of motion but no neurological deficits and that he wanted to keep Braden off work completely until he met his physical therapy goals. Id. Based this information, Duvall concluded there was insufficient objective medical evidence to support a claim for disability. Id. at 498. On May 6, the Plan denied disability benefits from April 6 forward. See id. at 504-06. Again, the denial letter informed Braden that he should submit documentation showing how his condition rendered it impossible for him to work. See id. at 505.

         On June 1, Braden submitted physical therapy notes from Dr. Frank Wei, a physician specializing in physical medicine and rehabilitation. See id. at 522-32. Wei recommended physical therapy two days per week for four weeks. Id. at 531. After a review of this additional information, the Plan informed Braden that it would not alter its previous denial. See id. at 533. Braden then submitted a May 15 procedure report and a June 1 progress note from Wei on June 19. See id. at 209, 512. The procedure report indicated that Braden received an epidural injection in his back on May 15 and that Braden reported low back pain as “4/10" pre-procedure and “2-3/10" post-procedure. Id. at 512. In the progress note, Wei reported that Braden continued to have back and leg pain, “move[d] about the room stiffly, ” a straight leg test was positive, and was “not improving significantly with non-operative care.” Id. at 209. On June 24, the Plan informed Braden that the new information did not alter its decision. Id. at 542-43.

         Rather than appeal, on July 10, Braden submitted notes from a June 12 visit with Dr. John Mullan, a spine specialist. See id. at 135-36. Mullan stated that Braden had a history of lower back pain and that Braden felt he was disabled and unable to work. Id. at 135. Mullan observed that Braden was “in no acute distress, ” had a normal gait, his “motor strength [was] 5/5 in all muscle groups, ” he had no sensory loss in the lower extremities, and a straight leg test was negative. Id. Mullan discussed the possibility of back surgery with Braden, and Braden agreed to the surgery. Id.

         On September 14, Braden, through counsel, appealed the denial of short-term disability benefits. See id. at 145. In support of his appeal, Braden submitted: (1) Garcia's February 12 medical review; (2) Keifer's February 25 progress notes; and (3) Mullan's June 12 follow-up visit notes. Id. This information was the same information Braden had earlier submitted. See id. at 146. ...


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