In Lloyd v. Procter & Gamble Disability Benefit Plan, et al., No. 20-4329, __F.App’x__, 2021 WL 4026683 (6th Cir. Sept. 3, 2021), Plaintiff-Appellant Mark Lloyd appealed the district court’s judgment upholding the partial denial of his short-term disability benefits claim and the full denial of his long-term disability benefits claim under the Procter & Gamble Disability Benefit Plan. The Sixth Circuit affirmed.
For 17 years, Lloyd worked as an IT Systems/Solutions Manager at Procter & Gamble (P&G). Due to gastrointestinal issues eventually diagnosed as the rare condition, chronic intestinal pseudo-obstruction (CIPO), and fibromyalgia, he filed three disability benefit claims under the Plan. Plan benefits are not payable when a claimant’s employment at P&G ends. The Plan requires objective medical evidence showing that a claimant meets the definition of “Total Disability” (for long-term benefits) or “Partial Disability” (for short-term benefits).
“Partial Disability” is defined as a mental or physical condition resulting from an illness or injury because of which the Participant is receiving medical treatment and cannot perform regular duties of his or her current job but can perform other roles at the same site or other jobs outside of the Company. Thus, a condition of Partial Disability does not necessarily prevent the Participant from performing useful tasks, utilizing public or private transportation, or taking part in social or business activities outside the home.
“Total Disability” is defined as a mental or physical condition resulting from an illness or injury which is generally considered totally disabling by the medical profession and for which the Participant is receiving regular recognized treatment by a qualified medical professional. Usually, Total Disability involves a condition of such severity as to require care in a hospital or restriction to the immediate confines of the home. The Trustees reserve the right to determine what is considered as “regular” and “recognized treatment.”
A Review Board within P&G decides whether a claimant is eligible for benefits. If the Review Board denies a claim, an applicant can appeal the decision to the P&G Disability Committee. Lloyd’s January 23, 2015 claim was supported by his primary care doctor, but not his gastroenterologist or rheumatologist. The Review Board denied his claim and the Disability Committee upheld the denial after obtaining an independent review from a gastroenterologist, Dr. Sunil Sheth. Lloyd filed another claim with an onset date of November 3, 2015. The Review Board again denied his claim and the Disability Committee upheld the denial based on a second opinion from Dr. Sheth. Lloyd filed his last claim on January 27, 2017, the same day that P&G terminated his employment. The Review Board denied this claim and the Disability Committee obtained an outside review by Dr. Cristina Strahotin, a certified gastroenterologist. Dr. Strahotin opined that Lloyd had a partial and temporary impairment and that he could work with accommodations. Lloyd then filed suit seeking benefits in connection with his second 2015 and 2017 claims and seeking reinstatement of his employment status at P&G. The district court upheld the Plan’s decisions except that it found that Lloyd was entitled to partial disability benefits for 11 days in 2017.
In deciding Lloyd’s appeal, the Sixth Circuit found that the arbitrary and capricious standard of review applies because the Plan gives the Disability Committee discretion to interpret the Plan’s language and determine eligibility for benefits. Thus, the court will uphold an administrator’s decision if it is supported by substantial evidence. The parties dispute the proper interpretation of Partial Disability and Total Disability. The court found that the Plan’s interpretation was reasonable. The Disability Committee focused on whether Lloyd’s gastrointestinal issues rendered him unable to work, not whether CIPO is generally considered totally disabling in the medical profession. The Plan reasonably denied Lloyd’s claims because substantial evidence, including his treatment notes and the opinion of the independent reviewers, supported the finding that Lloyd could work at least part-time with his intermittent symptoms.
The court also determined that the Plan did not have to retain reviewers who were experts with CIPO, a rare disorder. “ERISA does not demand an examination by the narrowest of specialists.” Okuno v. Reliance Standard Life Ins. Co., 836 F.3d 600, 610 (6th Cir. 2016). Both Dr. Sheth and Dr. Strahotin were adequately qualified in the relevant field since both are board-certified gastroenterologists. The court also determined that there is nothing inherently objectionable about a file review versus an in-person examination. Lloyd also claimed that Defendants violated ERISA’s procedural safeguards but since he did not include the allegations in his complaint the court found that they were not properly before the district court. And, in any event, Defendants fairly reviewed each of Lloyd’s claims. Lastly, Lloyd was only entitled to benefits until his date of termination. Lloyd did not support his request for reinstatement of employment and never alleged that he was terminated to prevent exercising any right under the benefit plan, which would be brought under ERISA § 510.
LEAVE YOUR MESSAGE
We know how to get your insurance claim paid. Call today at: