ERISA Disability Claims

This 5th Circuit Court of Appeals opinion is a must read for ERISA attorneys. The case is styled, Burell v. Prudential Insurance. The facts will be given here. The case needs to be read to understand how the Court affirmed the findings of the lower Court in denying benefits to Burell.
In 1985, Burell began working as an entry-level technician for Methodist Healthcare Systems (“MHS”). After 26 years, he ended his career as Director of Biomedical Services for all San Antonio MHS facilities. As an employee of MHS, Burell participated in the company’s insurance plan (“the Plan”), which is provided through HCA Management Services, L.P. Prudential acts as both administrator and insurer of the Plan. In order to qualify for long-term disability benefits, a claimant must meet the following definition of “disabled”: the claimant must (1) be “unable to perform the material and substantial duties of [his or her] regular occupation due to [his or her] sickness or injury “; (2) be “under the regular care of a doctor “; and (3) suffer “a 20% or more loss in [his or her] monthly earnings due to that sickness or injury.”
Burell was diagnosed with multiple sclerosis (“MS”) in 2008. Citing worsening symptoms of MS, in September 2011, Burell went on medical leave and filed for long-term disability benefits with Prudential, claiming that he qualified for benefits under the Plan due to MS, headaches, depression, and anxiety. In January 2012, he stopped working altogether, ending his employment with MHS. In support of his claim, Burell submitted medical records from his treating physicians and a psychiatrist. Prudential hired Heidi Garcia, a registered nurse, and Dr. Alan Neuren, who is board certified in neurology, to review Burell’s claim. Dr. Neuren found that Burell’s diagnosis of MS was unsupported by his medical records. He also found it unlikely that Burell suffered any cognitive impairments, opining that job stress is “likely the source of his complaints as opposed to a neurological disorder.” Garcia focused her review on Burell’s claim of depression and anxiety, ultimately finding that any cognitive symptoms he was experiencing were not sufficient to prevent him from working. Based on their reports and the medical records submitted, Prudential denied Burell’s claim for long-term disability benefits.
Burell then appealed the decision through Prudential’s internal review process. On appeal, his claim was reviewed by Dr. Stuart Isaacson, who is board certified in psychiatry and neurology, and Dr. James Boone, who is a clinical neuropsychologist. Dr. Isaacson found that Burell did not meet the diagnostic criteria for MS and did not have “any medically necessary restrictions and/or limitations from any one condition or combination of conditions.” Dr. Boone found that Burell’s “file records do not validly support psychological and/or cognitive symptoms” and that he has no “medically necessary restrictions and/or limitations.” Based on the opinions of these physicians and Burell’s medical records, which included additional documentation submitted during the appeal process, Prudential again denied Burell’s claim.
Burell next sent Prudential a letter demanding the benefits he believed he was owed under the Plan. Prudential treated this demand letter as a second appeal and had the claim further reviewed by Dr. Omuwunmi Osinubi, who is board certified in anesthesiology and occupational medicine, and Dr. Melvyn Attfield. Dr. Osinubi found that although Burell’s medical records did in fact support a diagnosis of MS, he did not have any physical limitations due to the disease. Dr. Osinubi was unable to make a finding on Burell’s alleged cognitive impairments and suggested an additional neuropsychological review be performed. Upon Dr. Osinubi’s recommendation, Dr. Michael Chafetz, who is board certified in clinical neuropsychology, performed an independent neuropsychological evaluation, finding that Burell did not suffer any cognitive impairments. On the basis of these opinions and Burell’s medical records, which included additional documentation submitted during the second appeal process, Prudential denied Burell’s claim for a third time.
In April 2013, Burell filed suit against Prudential under 29 U.S.C. § 1132(a)(1)(B) and (a)(3), alleging that Prudential wrongfully denied his claim for long-term disability benefits. In December 2014, the district court granted summary judgment in favor of Prudential, and Burell timely appealed.