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Michaux v. Bayer Corp.

December 16, 2009


The opinion of the court was delivered by: Simandle, District Judge




This Court is asked to assess whether Defendants made an arbitrary and capricious determination with respect to whether Plaintiff was entitled to long-term disability benefits under his employee benefit plan. This matter is before the Court on Defendants' motion for summary judgment [Docket Item 12]. For the reasons explained below, the motion will be granted.


A. Plaintiff's Initial ERISA Complaint

In June 2005, Plaintiff filed a complaint with this Court alleging that Defendants violated the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132(a) by denying Plaintiff long-term disability (LTD) benefits. See Michaux v. Bayer Corp. ("Michaux I"), 05-CV-1430, 2006 WL 1843123, at *4 (D.N.J. June 30, 2006).*fn1

Plaintiff went on a leave of absence from his job as a plant engineer in August 2003, claiming that he was unable to perform his duties due to severe knee pain. Plaintiff was granted short-term disability pay under Bayer's disability plan and applied for LTD benefits on January 19, 2004. In his application, Plaintiff attributed his disability to left knee and back pain.

Under Bayer's LTD plan, a claimant must prove that he or she is "totally disabled" in order to be eligible for benefits. The term "totally disabled" is defined, for purposes of long-term disability, as being "unable to perform the essential duties of your regular occupation" for the six months of LTD eligibility and then "unable to work at any job for which you are or could become qualified by education, training or experience for any period after the first six months of LTD eligibility."*fn2 The Plan Administrator has discretion to make final determinations as to any facts necessary or appropriate for any purpose under the Plan, to interpret the terms and provisions of the Plans and to determine any and all questions arising under the Plans.

The initial LTD application was denied. Although Plaintiff offered some supporting medical opinion as to his limitations, the Review Committee credited the medical opinion of an independent doctor who disagreed with the conclusions of Plaintiff's doctors. Some time after the initial denial, Plaintiff was granted Social Security Disability Insurance (SSDI) benefits upon the Social Security Administration's determination that he was totally disabled. Plaintiff appealed his LTD denial to Bayer's ERISA Review Committee, which upheld the denial of benefits.

Reviewing the record in June 2006, this Court ruled that it could not determine whether the decision to deny Plaintiff LTD benefits on appeal was arbitrary and capricious, noting that Defendants' ERISA Review Committee failed to consider evidence related to Plaintiff's favorable determination by the Social Security Administration that he was totally disabled, and failed to have one of its reviewing physicians perform a physical examination of Plaintiff even after two of its reviewing physicians recommended such an examination be performed and Plaintiff's treating physicians had found disabling pain. The Court remanded the case back to Defendants' ERISA Review Committee for further administrative review and determination including examination of the Social Security records and either a physical examination or an explanation for why such an examination was not needed.

B. Plaintiff's Renewed ERISA Complaint

Upon remand, the Review Committee considered, along with the previous record: the information provided in Plaintiff's SSDI file; a report of a Dr. Steven Knezevich, an orthopedic surgeon who performed an independent medical evaluation (IME) of Plaintiff; a surveillance report from an investigative firm that followed Plaintiff, occasionally videotaping him; and a report from Plaintiff's chiropractor, Susan Welsh. (Joint App'x, Ex-A, at 2.)

Regarding the SSDI determination, the Review Committee examined and disagreed with the determination, finding that "the SSDI records . . . do not support the conclusion of the agency, and certainly do not persuade the Committee." (Id. at 5.) The Review Committee concluded that the only new medical evidence presented for the determination of SSDI that was not considered by the Review Committee previously - a medical examination performed by Dr. Tim Pinsky - did not support the Social Security Administration's determination. (Id. at 3.) Dr. Pinsky's report observed that there was "a paucity of objective diagnostic studies to substantiate [Plaintiff's] subjective complaints" and that "calluses on the palmar surface of each ...

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