The opinion of the court was delivered by: Judge Vanaskie
Plaintiff Brian Russell brings this action under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et. seq., to recover long-term disability benefits under the Employee Group Benefits Plan ("the Plan") sponsored by Defendant Alcoa, Inc. ("Alcoa"). Before the Court are cross-motions for summary judgment.*fn1 (Dkt. Entries 21, 24.) Having reviewed the administrative record of the benefits decision under a slightly heightened arbitrary and capricious standard, I have concluded that the denial of benefits must be sustained.
A. Alcoa's Disability Plan
The Employee Group Benefits Plan of Alcoa, Inc. Plan I ("the Plan") provides long-term disability ("LTD") benefits to eligible participants. The Plan designates Alcoa as the Plan Administrator and Sponsor. (Plan, Dkt. Entry 23-4, at 10.) The Plan Administrator is explicitly accorded the discretion: to determine eligibility under all provisions of the plans; correct defects, supply omissions, and reconcile inconsistencies in the plans; ensure that all benefits are paid according to the plans; interpret plan provisions for all participants and beneficiaries; and decide issues of credibility necessary to carry out and operate the plans.
(Id.) "It is undisputed that the Plan in this case gives discretionary authority to the fiduciary." (Pl.'s Br. Supp. Mot. Summ. J., Dkt. Entry 26, at 4.) The Plan is funded by Alcoa, participating subsidiaries, and employee contributions. (Plan, at 19; Aff. Frances C. Filipovits, Dkt. Entry 23-2, ¶ 5.)
Broadspire Services, Inc. ("Broadspire") is the third party Claims Administrator for the Plan.*fn2 (Id. at ¶ 6.) Broadspire investigates claims and makes initial claim determinations and first-level appeal determinations. (Id. at ¶ 7.) Broadspire receives the same compensation for its services whether long-term disability appeals are approved or denied. (Id. at ¶ 8.)
If an initial appeal decision is adverse, a Plan participant may file a second and final appeal with Alcoa's Benefits Management Committee (BMC). (Plan, at 20.) The BMC has the right to interpret the terms of the plan as they relate to benefits, benefits payments, eligibility and eligible pay, and to make a final and binding determination. (Id.) The BMC has designated a separate Benefits Appeals Committee (BAC) to decide second and final level appeals. (Aff. Frances C. Filipovits, at ¶ 9.) The BAC is made up of five current Alcoa employees who are participants in the Plan. (Id.) The members of the BAC do not participate in administration of the Plan and are paid no additional compensation for services rendered as BAC members. (Id.) As part of the final and second appeal, Alcoa contracts with Evaluation Specialists, LLC, to select physicians who provide medical reviews. (Id. at ¶ 10.) According to Frances C. Filipovits, Alcoa's Life and Disability Benefits Manager, the physicians selected by Evaluation Specialists have no financial incentive to provide reviews favorable to Alcoa. (Id.)
The Plan defines "totally disabled" as, because of injury or sickness, "for the first 24 months, you cannot perform each of the material duties of your regular job; and after the first 24 months, you cannot perform each of the material duties of any gainful occupation for which you are reasonably suited by training, education, or experience." (Plan, at 16) (emphasis added). Thus, the Plan applies a different standard to disability determinations based on the duration of an employee's incapacity -- the "regular occupation" standard for the first two years, and the much more stringent "any occupation" standard thereafter. (Def.'s Br. Supp. Mot. Summ. J, Dkt. Entry 23, at 5.; Plan, at 16.)
B. Mr. Russell's Medical History
Brian Russell, a Plan participant by virtue of his employment as a crane operator for Alcoa, injured his right knee after tripping over a rug in a grocery store on March 3, 2001. (Administrative Record "AR," Dkt. Entry 20, at 470.) At an examination on March 5, 2001, Calvin D. Stoudt, D.O., Mr. Russell's primary orthopedist, diagnosed a sprain of his right knee and "possible internal derangement." (Id.) Dr. Stoudt administered conservative treatment, referring Russell for pain management regarding complex regional pain syndrome.*fn3 (Id. at 471.)
Mr. Russell visited other physicians with regard to his knee. Dr. Robert Wilson, an osteopath, treated Mr. Russell on May 8, 2001, finding L6 radiculitis, possible neuropathic pain of the right knee, and sleep disturbance secondary to pain. He essentially ruled out early complex regional pain syndrome, and recommended an epidural steroid injection and lumbar sympathetic blocks for both diagnosis and treatment. (AR, at 389-390.) Dr. Kevin P. Black, an Associate Professor in the Department of Orthopedics and Rehabilitation at Hershey Medical Center, on September 7, 2001, performed an examination and x-ray on Mr. Russell, diagnosing him with bilateral patellar instability. (Id. at 405.) He recommended continued rehabilitation, but also expressed concern "that there is an excessive subjective component to the patient's pain complaints." (Id. at 405.) Dr. Carlos X. Villarreal, on April 5, 2001, after examining Mr. Russell's right lower extremity, reported that a Doppler study did not show evidence of deep vascular thrombosis. (Id. at 376.) Dr. Rajnish P. Chaudhry performed an EMG and MRI on Mr. Russell on April 27, 2001, finding normal EMG studies and an essentially unremarkable MRI of the spine. (Id. at 378-379.)
Ms. Russell started to show improvement, but, in November of 2002, felt a pop in his right knee as he climbed out of the bath tub. (Id. at 472.) After an examination by Dr. Stoudt a week later, he was diagnosed with resolving complex regional pain syndrome, patellofemoral syndrome of the right knee, and ambulatory dysfunction. (Id.) Mr. Russell returned for a subsequent visit to Dr. Stoudt on September 16, 2002. The diagnosis remained the same. (Id.)
Mr. Russell continued to work as a crane operator at Alcoa until August 5, 2003, when he represented that the pain he was experiencing rendered him unable to work and entitled him to LTD benefits under the Alcoa Plan. MetLife disability, which administered the Plan for Alcoa at that time, concluded that Mr. Russell was unable to perform the duties of a crane operator for Alcoa. Accordingly, he was awarded LTD benefits.
On December 30, 2003, Dr. Stoudt performed arthroscopic surgery on Mr. Russell's right knee. (AR, at 478.) Over the ensuing months after Mr. Russell's surgery his condition improved, and Dr. Stoudt allowed him to return to work on full duty as of March 15, 2004. (Id. at 479.) On April 13, 2004, Mr. Russell reported that he had fallen in his home the previous day, re-injuring his right knee. (Id. at 479.) It does not appear that he actually returned to work for Alcoa.
While being treated by Dr. Stoudt, Mr. Russell also received medical attention from Don Ko, M.D. At an examination on December 1, 2004, Dr. Ko thought there was a possibility of "reflex sympathetic dystrophy involving the right lower extremity. . . ." At that time, Mr. Russell was taking Darvocet up to six times a day, Bextra, Tylenol and Albuterol for pain relief. (AR, 024.) In the "HISTORY OF PRESENT ILLNESS" part of his report, Dr. Ko stated that Mr. Russell "used to work at the Alcoa Company, however, at this time, he was unable to work." Lumbar sympathetic blocks, a type of pain treatment, were performed on December 22, 2004, and December 1, 2004. (AR, at 032-34.)
On June 4, 2004, Mr. Russell saw his family doctor, James Langon, M.D., complaining of chest pain and shortness of breath. (AR, at 054.) After two subsequent visits on July 16, 2004, and August 20, 2004, Dr. Langon diagnosed Mr. Russell with bronchitis and emphysema. (Def.'s Answer to Pl.'s Statement of Material Facts ("SMF"), Dkt. Entry 31, at ¶ 53.)*fn4 On a follow-up visit in September 9, 2004, Dr. Langon reported that "[p]atient denies chest pain." (AR, at 062.) Dr. Langon further noted that there were no masses palpable, the extremity exam was without clubbing, cyanosis, or edema, the skin was clear, dry, and intact, and there was full range of motion at the hip, knee, ankle, shoulder, elbow, and wrist. (Id.)
On August 17, 2004, Mr. Russell underwent a Functional Capacity Evaluation (FCE) at the request of MetLife Disability. (AR, at 321-26.) The FCE concluded Mr. Russell had functional limitations in the areas of position tolerance and mobility, namely, decreased muscle strength in both upper and lower extremities, generalized de-conditioning, pain in the right knee and generalized fatigue. (Id. at 326.) The discrepancy between job/occupational demands and Mr. Russell's abilities was significant, making prognosis for return to his regular occupation guarded.*fn5 (Id.) As to his ability to work at all, the evaluation recommended: it may be reasonable to allow the client to work at the light level of work for 3 hours and 45 minutes and gradually increase the work hours to the 8 hour day as tolerated. Alternatively, if allowed to work at the sedentary level, the client is likely to tolerate the 8 hour work day. (Id.)
During the year 2004, Mr. Russell continued his regular post-surgery visits with Dr. Stoudt. At Mr. Russell's June 15, 2004 and July 27, 2004 visits, Dr. Stoudt noted post surgical stiffness and weakness in the right lower extremity, ambulatory dysfunction, and residual pain. (AR, at 315-16.) In a letter to Mr. Russell's lawyer dated October 25, 2004, Dr .Stoudt commented on Mr. Russell's condition:
Whether this is permanent or temporary, is hard to say. We have not seen the functional capacity test as of yet which would help with our determination. As far as whether he is permanent disability, that again is hard to say as well since I did not see anything inside his knee or any damage inside his knee that would cause permanent disability or dysfunction. All of the majority of his symptoms appear to be subjective. It is hard to say what his functional capacity or ability will be. (Id. at 480.)
On Mr. Russell's November 10, 2004 visit, Dr. Stoudt observed patellofemoral syndrome of the right knee, ambulatory dysfunction, and degenerative joint disease of the patellofemoral joint. (Id. at 317.) Mr. Russell was scheduled for pain management, prescribed Mobic, and allowed to work in a sedentary capacity only, avoiding excessive standing or walking, kneeling or squatting, heavy lifting or carrying. (Id.) At his next visit, on December 22, 2004, Mr. Russell was still experiencing pain and discomfort in his right knee, and having difficulty performing daily activities. (Id. at 318.) He had attended two pain management sessions and had been treated twice with ganglion blocks, but only showed minimal improvements.
Mr. Russell again visited Dr. Langon on January 5, 2005, this time for emphysema and bronchitis. (Id. at 065.) Dr. Langon noted that Mr. Russell denied any chest pain and had full movement of his knee. (Id.) The examination revealed no clubbing, cyanosis, or edema in Mr. Russell's knee and that Mr. Russell had a full range of motion. (Id.) At that time, Mr. Russell was also being treated for two pleural masses, and possibly metastatic nodules in each lung, the nodes suggesting underlying ...