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Jackson v. Blue Cross Blue Shield of Michigan Long Term Disability Program

United States District Court, E.D. Michigan, Southern Division

April 26, 2018

MARC JACKSON, Plaintiff,
v.
BLUE CROSS BLUE SHIELD OF MICHIGAN LONG TERM DISABILITY PROGRAM, [1] Defendant.

          MEMORANDUM AND ORDER GRANTING DEFENDANTS' MOTION FOR JUDGMENT (DOC. 11) AND DENYING PLAINTIFF'S CROSS MOTION FOR JUDGMENT (DOC. 10) AND DISMISSING CASE

          AVERN COHN UNITED STATES DISTRICT JUDGE

         TABLE OF CONTENTS

         I. Introduction 1

          II. Summary of Key Medical Evidence 1

         III. Legal Standard - ERISA Motion for Entry of Judgment 3

         IV. Standard of Review 4

         V. Findings of Fact 5

A. Overview of Jackson's Claim 5
B. Relevant Plan Provisions and Review Process 6
C. Review of Jackson's Claim 8
1. September 2015 - First MRC Decision 8
2. January 2016 - First CAC Decision 9
3. April 2016 - Second MRC Decision 10
4. October 2018 - Second CAC Decision 11
5. July 2017 - Final Decision 11

         VI. Conclusions of Law 12

A. No Conflict of Interest 12
B. Subjective Pain and Objective Medical Evidence 13
C. Full and Fair Review 16
1. Reasonable Process 16
2. Evidence Supporting Plan's Decision 17
3. Evidence Favorable to Jackson 21
4. Prior Award of Benefits 22

         VIII. Conclusion 23

         I. Introduction

         This is a benefits case under the Employment Retirement Income Security Act, 29 U.S.C. § 1001, et seq (ERISA). Plaintiff Marc Jackson worked for Blue Cross Blue Shield of Michigan for 24 years, most recently as a Customer Service Representative. As part of his employment, Jackson was covered under a long term disability plan called the Blue Cross Blue Shield Association Long Term Disability Program, which later became the Blue Cross Blue Shield Michigan Long Term Disability Program (the Plan) which is governed by ERISA. Jackson stopped working in 2014 and sought long term disability (LTD) benefits due to back pain and fibromyalgia and, secondarily, diabetes. Jackson said his back and other pain stems from a May 2006 car accident and noted he had back surgery in 2010. The Plan denied benefits essentially due to the lack of objective medical evidence to support Jackson's complaints of pain. After exhausting his administrative remedies, Jackson sued the Plan claiming a violation of 29 U.S.C. § 1132(a)(1)(B).

         Before the Court are cross motions for judgment. For the reasons that follow, Jackson's motion will be denied and the Plan's motion will be granted. In sum, the Plan considered the voluminous medical record and medical opinions and reasonably concluded that Jackson had not satisfied his burden of proof.

         II. Summary of Key Medical Evidence

         Due to the sheer volume of the administrative record, [2] which is the largest the undersigned has encountered in an ERISA denial of benefits case, it is helpful to summarize the key medical evidence in the administrative record.

         Jackson's treating physicians, Dr. Lee, a neurologist, and Dr. Sack, a primary care physician, submitted documents indicating Jackson could not work.

         The Plan had Jackson undergo an in-person Transferable Skills Analysis (TSA) in September in 2015 which concluded Jackson was “holding back” as to his ability to function and that he could complete 90% of the tasks of his job. The Plan also reversed the initial denial of benefits in order to determine if Jackson had a psychiatric disability, even though Jackson did not claim such a disability. The Plan directed Jackson to an independent in-person medical exam (IME) with a psychiatrist (Dr. Kezlarian) and with a physical medicine and rehabilitation physician (Dr. Friedman). Both opined Jackson was not disabled either psychiatrically or physically. The Plan also had Jackson undergo an updated TSA in April of 2016. Although Jackson's doctor interpreted the updated TSA as indicating he could not work, Plan physicians interpreted it otherwise. In addition to the two IMEs, the Plan had Jackson's claim examined by several physicians who reviewed the record, i.e. a file review. They are as follows:

Dr. Nicola (physical medicine and rehabilitation - found Jackson was not disabled but ordered an IME)
Dr. Hefter (psychiatrist - ordered the psychiatric exam)
Dr. Luc (neurologist - found Jackson not disabled, was unable to speak with Jackson's treating neurologist, Dr. Lee, because he did not return Dr. Luc's calls)
Dr. Williams (neurologist - found Jackson not disabled)
Dr. Yuan (anesthesiology - found Jackson's complaints of pain ...

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