Under the arbitrary and capricious standard, we uphold the
administrator’s decision “if it is the result of a deliberate, principled
reasoning process and if it is supported by substantial evidence.” . . Several lodestars guide our decision: “the
quality and quantity of the medical evidence”; the existence of any conflicts
of interest; whether the administrator considered any disability finding by the
Social Security Administration; and whether the administrator contracted with
physicians to conduct a file review as opposed to a physical examination of the
claimant.
Under the
employer’s LTD plan, an employee could not receive benefits after two years
unless he or she was “totally disabled, which means that the employee is
completely unable to work at least 25 hours per week because of a “medically-determinable
physical or functional impairment[.]”
In February 2008, the Social Security Administration
determined that [the plaintiff] was disabled and awarded him benefits
retroactive to his second back surgery [in January 2007]. [He] underwent a
third spinal surgery in February 2009, but his back problems continued. Thus,
near the two-year deadline of August 2009, [the insurer] asked Fura to prove
that he was totally disabled. Under the terms of the plan, a covered employee
can prove that he is totally disabled only through “significant objective
findings” from medical examinations, test results, and “anatomical,
physiological or psychological abnormalities which can be observed apart from
the individual’s symptoms.” [He] then submitted records from his treating
physicians. These records described [his] back problems, as well as a number of
other ailments.
The insurer
engaged a neurologist and a physician to review the plaintiff’s medical
records. They both found that the
plaintiff was capable of working at least 25 hours/week in a sedentary job.
The Court was unimpressed with their analysis and found
their conclusions to “suffer from some
serious flaws.” First, it was unclear
why they concluded that his “pain would permit him to work 25 hours per week”
because they never examined him, had no first-hand knowledge and were
contradicted by observations of the plaintiff’s treating physicians. They also failed to explain why the discounted
the opinions of the treating physicians on the issue of the plaintiff’s
pain. “Of course, we do not defer to the
opinions of treating physicians. . . . But
‘a plan may not reject summarily the opinions of a treating physician, [and]
must instead give reasons for adopting an alternative opinion.’”
More critically, the
Aetna physicians failed to address significant material evidence. First, no
reviewing physician addressed Dr. Ganley’s notes that Fura is losing sensation
in his arms. FedEx now claims that this condition is not serious, but no
medical professional submitted that opinion to Aetna. Second, no Aetna
physician addressed the evidence that Fura’s range of motion is restricted.
Even if Fura can get around with a walker, overwhelming medical evidence
indicates that he can do so only with difficulty. Drs. Ganley and Easton both
recorded numbness in Fura’s legs and difficulties with balance and stability.
Each doctor also recorded restrictions on Fura’s ability to sit, stand, and
drive—all elements of a sedentary workday. The omissions do not stop there. No
reviewing physician discussed the progressive nature of Fura’s ailments, his
impaired bowel and bladder function, or the impact of his lymphedema on his
ability to do sedentary work. And
Aetna’s decision to rely on file reviews makes these omissions all the more
troubling because a “plan’s decision to conduct a file-only review . . . [may]
raise questions about the thoroughness and accuracy of the benefits
determination.” Elliott v. Metro. Life
Ins. Co., 473 F.3d 613, 621 (6th Cir. 2006) (quotation marks omitted).
Neither Aetna nor the
reviewing physicians were required to discuss every piece of evidence in the
record. But Aetna’s decision to terminate Fura’s benefits “must be consistent
with the quantity and quality of the medical evidence that is available on the record.”
Moon v. Unum Provident Corp., 405
F.3d 373, 381–82 (6th Cir. 2005) (internal quotation marks omitted). Here,
Aetna relied on file reviews that failed to confront significant evidence of
total disability. In light of this evidence, Aetna did not give a reasoned
explanation for its decision.
The Court decided to remand the case to the insurer instead
of affirming the plaintiff’s judgment because the evidence was insufficient to
grant the plaintiff judgment as a matter of law, but the insurer’s decision was
insufficiently reasoned to warrant deferral. “When an employee-benefit plan
grants the plan administrator discretion to determine a claimant’s eligibility for
benefits, we can reverse that decision only if it is arbitrary or capricious.”
Remand to the plan
administrator is appropriate “where the problem is with the integrity of the
plan’s decision-making process, rather than that a claimant was denied benefits
to which he was clearly entitled.” Elliott,
473 F.3d at 622 (brackets and quotation marks omitted). Here, Aetna relied on
reviewing physicians’ opinions that did not address significant evidence of
total disability. Without an explanation for this evidence, we cannot find
Aetna’s decision to be reasoned. But neither can we say, on this record, that
Fura is totally disabled as a matter of law. Certain aspects of his treating
physicians’ reports, for example, appear conclusory. Remand, rather than
outright affirmance, is thus the appropriate outcome.
On remand, Fura will also be free to supplement the record
with the Social Security Administration’s decision granting him benefits as
well as the record in that case. Without the decision and record, Aetna had no
way of evaluating the reasons for the SSA’s award. Once the decision is part of
the record Aetna can evaluate its reasoning to determine whether the award is persuasive
evidence of total disability. Fura may also wish to ask his physicians to
explain more fully the medical evidence supporting their conclusions.
NOTICE: This summary is designed merely to inform and alert you of recent legal developments. It does not constitute legal advice and does not apply to any particular situation because different facts could lead to different results. Information here can change or be amended without notice. Readers should not act upon this information without legal advice. If you have any questions about anything you have read, you should consult with or retain an employment attorney.
