Maher v. Massachusetts General Hospital Long Term Disability Plan , 665 F.3d 289 ( 2011 )

United States Court of Appeals
For the First Circuit
No. 10-1321
DEBORAH MAHER,
Plaintiff, Appellant,
v.
MASSACHUSETTS GENERAL HOSPITAL LONG TERM DISABILITY PLAN,
Defendant, Appellee.
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF MASSACHUSETTS
[Hon. Rya W. Zobel, U.S. District Judge]
Before
Boudin, Lipez, and Howard,
Circuit Judges.
Robert J. Rosati with whom ERISA Law Group was on brief for
appellant.
Laurie F. Rubin with whom Prince, Lobel, Glovsky & Tye LLP was
on brief for appellee.
December 7, 2011
BOUDIN, Circuit Judge. Deborah Maher, a registered
nurse, began work at Massachusetts General Hospital ("MGH"), in
August 2001. Maher stopped working in November 2001 and, in
February 2002, began receiving disability benefits through MGH's
long-term disability plan due to chronic abdominal pain and related
symptoms.1 Her physicians--although never "entirely clear" on the
cause--attributed her symptoms to chronic pancreatitis, chronic
pain syndrome or fibromyalgia. Over time, joint pain added to her
woes, and Maher received "impressive amounts of narcotics" to
manage her pain, which caused some negative side effects.
In February 2007, Liberty Life Assurance Company of
Boston ("Liberty"), the plan's claims processor, terminated Maher's
benefits. After a June 2007 letter misquoted plan language,
Liberty concluded in a corrected September 2007 letter that Maher
was no longer "totally disabled," defined in Section 2.10 of the
"The Massachusetts General Hospital Long Term Disability Plan" (the
"primary plan document") as
such complete incapacity, resulting from a
medically determinable physical or mental
impairment, as prevents the Participant from
performing any and every duty of any
occupation or employment, for which he is
reasonably qualified by education, training or
experience.
1
We refer to the MGH Long-Term Disability Plan, technically
the defendant in this case, as the "MGH Plan." We refer to the
plan documents and terms as "the plan."
-2-
This determination was based in part on medical
assessments more fully described below but also on covert
surveillance video showing Maher driving, walking, jogging, bending
over, flying a kite, and lifting her three-year-old child. The
most comprehensive assessment was by Dr. Robert Millstein, a
medical consultant at Liberty, who based his judgment on review of
Maher's medical file. He confirmed diagnoses by Maher's personal
physicians of her fibromyalgia, osteoarthritis, and psoriasis but
determined that none prevented Maher from working.
Maher pursued administrative appeals with Liberty and
ultimately with Partners HealthCare System, Inc. ("Partners"), the
plan's administrator. She submitted supporting materials, most
notably March 2007 statements from her personal physician, Dr.
Elizabeth Cuevas, and Dr. Wolfram Goessling, her
gastroenterologist. Dr. Cuevas represented that Maher, despite her
pain medications, "remains in significant disability, both from her
chronic pain and from the side effects the pain medication cause,
such as somnolence. She is unable to reliably perform duties
because her pain can become so severe so quickly." And Dr.
Goessling stated that "I do not see any way that my patient would
be able to sit or stand for prolonged period[s] of time let alone
do physically or intellectually demanding work."
During the ensuing appeals, new doctors independently
reviewed Maher's files. Dr. Herbert Malinoff, conducting the
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independent assessment on Maher's appeal within Liberty, consulted
with Dr. Cuevas and Dr. Goessling, but ultimately found Maher's
symptoms "far out of proportion to any abnormality identified
physically"; Dr. Dean Hashimoto, conducting the independent
assessment on Maher's final appeal to Partners, agreed disability
had not been established. Broadly speaking, both, along with Dr.
Millstein, believed that the physical data did not explain the
degree of pain or other symptoms claimed by Maher and found she had
provided insufficient other evidence of completely debilitating
pain.
Partners formally denied Maher's last appeal in January
2008. Maher sought review of her benefits termination in federal
court under section 502 of the Employee Retirement Income Security
Act ("ERISA"), 29 U.S.C. § 1132(a)(1)(B) (2006). The district
court, reviewing the plan administrator's decision under a
deferential "arbitrary and capricious" standard, entered summary
judgment for the MGH Plan and upheld the termination of benefits.
Maher v. Mass. Gen. Hosp. Long Term Disability Plan, No. 08-10460
(D. Mass. Fed. 23, 2010) (unpublished order). Maher has now
appealed, challenging both the standard applied by the district
court and the substantive decision.
The standard of review presents an issue of law which we
review de novo, Smart v. Gillette Co. Long-Term Disability Plan, 70
F.3d 173, 178 (1st Cir. 1995). The denial of benefits is itself
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subject to de novo review (albeit ordinarily on the administrative
record) "unless the benefit plan gives the administrator or
fiduciary discretionary authority to determine eligibility for
benefits or to construe the terms of the plan," Firestone Tire &
Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989), in which event the
court applies a deferential "arbitrary and capricious" or "abuse of
discretion" standard, Cusson v. Liberty Life Assurance Co., 592
F.3d 215, 224 (1st Cir. 2010).
Here, section 6.1 of the primary plan document
unequivocally reserves to "the Hospital" authority "to determine
eligibility for benefits, construe the terms and conditions of the
Plan, and resolve disputes as to the interpretation of the Plan
documents"; and it explicitly precludes review unless the
Hospital's action was "arbitrary and capricious or without rational
basis." The "Hospital" is defined only as "The General Hospital
Corporation" ("GHC"), which is a Massachusetts charitable
organization whose sole member is MGH, whose sole member, in turn,
is Partners.2
Maher's argument in favor of de novo review is that the
final decision in this case was made by Partners; no proper
delegation of authority to determine benefits was ever made to
2
"Member," in this context, is more or less the same as
controlling party. See 18A Am. Jur. 2d: Corporations § 633 (2011)
("[M]embers, while not usually denominated 'stockholders,' have an
interest in the corporate property similar to that of stockholders
in ordinary corporations.").
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Partners; and therefore Partners' decision to deny benefits is not
protected by section 6.1's deferential standard of review. It is
clear enough that, absent a proper delegation, the MGH Plan could
not rely on section 6.1's standard to defend a denial by an
independent entity. See Terry v. Bayer Corp., 145 F.3d 28, 37-38
(1st Cir. 1998).
As it happens, GHC, MGH and Partners are in practice far
from independent. Partners is a framework entity embracing MGH and
Brigham--two of the major teaching hospitals in Boston--and
includes smaller nonprofit hospitals as well; the boards of
directors overlap; and Partners appears to operate in part as a
coordinating body that performs various functions for the member
hospitals including, at least so far as the MGH Plan is concerned,
administrator of the plan in question on behalf of "the Hospital."
We say "appears" because the MGH Plan has chosen to defend the case
as one of conventional delegation.
This choice of litigation strategy lends a certain air of
unreality to the situation. The affiliation may explain why some
aspects of the alleged delegation are not as clearly formalized as
one might expect. In the end, viewed as a conventional
delegation--the MGH Plan has not relied on affiliation or provided
detailed information about it--the treatment of Partners as a
proper inheritor of "the Hospital's" discretionary authority is
justified, but perhaps only by a modest margin.
-6-
The double issue is whether the plan "expressly
provide[s] for procedures" for GHC to designate Partners as a
fiduciary with discretionary authority to administer the plan, 29
U.S.C. § 1105(c)(1); Terry, 145 F.3d at 36, and, if so, whether
this had occurred. The courts have not been overly demanding in
the search for express "procedures." Wallace v. Johnson & Johnson,
585 F.3d 11, 15 (1st Cir. 2009). The district court relied on
section 6.3 of the primary plan document, which provides:
The Hospital may employ agents, including but
not limited to, a Claims Processor,
accountants, attorneys or actuaries to perform
such services and duties in connection with
the administration of the Plan as it may
direct. . . . The Hospital shall be fully
protected in acting upon the advice of any
such agent, in whole or in part, and shall not
be liable for any act or omission of any such
agent, the Hospital's only duty being to use
reasonable care in the selection of any such
agent.
Maher argues that the focus of this language is primarily
on ancillary duties to aid GHC in carrying out its own
responsibilities. Nothing expressly identifies decisional
authority to determine benefits as a power that can be delegated.
If a separate identification were required, that might be the end
of any delegation claim, but under the case law it is enough that
the language can be taken to include that delegation. E.g.,
Pettaway v. Teachers Ins. & Annuity Assoc., 644 F.3d 427, 434-35
(D.C. Cir. 2011).
-7-
Section 6.3 can be read quite broadly: the list of
agents GHC may employ is non-exhaustive, nothing limits the
services and duties GHC may direct its agents to perform, and the
attempt to relieve GHC of liability is consistent with an
allocation of responsibilities from one fiduciary to another. See
29 C.F.R. § 2509.75-8, FR-14. Lawyers are commonly charged with
fiduciary duties, and ERISA may in some circumstances treat
accountants and actuaries as fiduciaries as well, despite merely
providing "advice." See 29 C.F.R. § 2509.75-5, D-1.
Here, any uncertainty is resolved by looking to
associated documents including the trust agreement and the summary
plan description, 29 U.S.C. § 1024(b)(4), which we are entitled to
consult. Pettaway, 644 F.3d at 433-34. The summary plan
description clearly states that "Partners acts as the Plan
Administrator" of MGH's long-term disability plan and "has the
discretion to determine all matters relating to eligibility,
coverage and benefits under each Plan provided."3 And, the plan's
3
Maher argues that this document, titled "Partners HealthCare
System, Inc.: Health and Welfare Plan Document," is not a Summary
Plan Description for MGH's long-term disability plan because the
document lacks certain information and identifies the plan as an
insurance plan when it is in fact funded as a trust. But an MGH
Plan affidavit confirms that the document is the Summary Plan
Description, and the document itself describes Partners' role in
the administration of several benefits plans--MGH's plan among
them--and says that it, together with certain other materials,
"constitute[s] the summary plan description for each Plan."
-8-
trust agreement contemplates certain actions being undertaken by
GHC "or its delegate."
Thus the plan instruments not only make clear that the
plan authorized delegation of fiduciary responsibility to Partners,
but also that such delegation actually occurred. Compare
Rodriguez-Abreu v. Chase Manhattan Bank, N.A., 986 F.2d 580, 584
(1st Cir. 1993)(documents taken together failed to delegate).
Given that delegation, the denial will be upheld only "if it is
reasoned and supported by substantial evidence." Gannon v. Metro.
Life Ins. Co., 360 F.3d 211, 213 (1st Cir. 2004). Maher has the
burden of proving her disability. Orndorf v. Paul Revere Life Ins.
Co., 404 F.3d 510, 518-19 (1st Cir.), cert. denied, 546 U.S. 937(2005).
Turning then to the denial of benefits, it is common
ground that Maher suffers from significant medical afflictions and
uses narcotics to combat pain. The question is whether Maher's
chronic pain and/or narcotics use render her incapable of
performing the sedentary nursing jobs suggested by Liberty's
consultant in a "transferrable skills analysis" conducted during
the review of Maher's benefits; the jobs included full-time
sedentary work as a telephonic triage nurse, nurse case manager, or
utilization review nurse.
On Maher's side we have diagnoses of medical ailments
unchallenged by Partners and explicit statements, already quoted,
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by her own doctors who treated her--one of whom assessed
"significant disability" and the other of whom said that she could
not do "physically or intellectually demanding work." These are,
of course, fairly summary assessments; but the last, if fully
credited and not contradicted by other evidence, might appear to
rule out even the less physically demanding nurse-related positions
suggested.
Yet these assessments of disability also depended on
Maher's self-reporting as to the effects of medication and, more
importantly, the severity of her symptoms. Maher has been
plagued--among other things--by pain, nausea, vomiting, and
diarrhea. She has seen a host of doctors, attended pain clinics,
been recurrently hospitalized, treated with high doses of
narcotics, and undergone pancreatic and biliary
sphincterotomies--surgical procedures designed to relieve
pancreatitis.4 So obviously she has serious symptoms; but the
question remains whether they are disabling, and this brings us to
the heart of the problem.
In some situations, the degree of pain or other
dysfunction corresponds with what doctors knowing of the malady
would expect or at least deem within range. Dr. Millstein clearly
4
Arguably Maher would not suffer such travails merely to
strengthen the credibility of a disability claim or be able to fool
so many doctors over so many years if there were little or no
serious pain. See Carradine v. Barnhart, 360 F.3d 751, 755 (7th
Cir. 2004).
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thought that this was not true here--detecting some signs of
exaggeration and doctor shopping--and he concluded that any
negative impact of the narcotics would be alleviated by adaptation
to the dosages. He also relied on both the surveillance video and
a number of other separate pieces of evidence to which one might
attach more or less weight:
-a
September 2006 statement by Dr.
Cuevas, Maher's primary care physician,
stating that she had not placed restriction on
Maher for abdominal pain and was not aware of
restrictions from other doctors;
-a November 2006 record from Dr.
Anthony Reginato, a rheumatologist, indicating
that Maher denied chills, vomiting, and
abdominal pain, but also complained of having
such pain over the previous 10 days; and
-documentation that Maher had not seen
Dr. Wolfram Goessling, her gastroenterologist,
during 2006.
Dr. Malinoff, who conducted the first independent
assessment, found Maher's symptoms "far out of proportion to any
abnormality identified physically," and again relied on Liberty's
video surveillance. Dr. Malinoff also consulted with Dr. Cuevas
and Dr. Goessling. Dr. Malinoff highlighted Dr. Cuevas' agreement
that "there is no identifiable medical/internal medicine issue
which would prevent this woman from carrying out sedentary or light
labor on a full time basis," and emphasized his disagreement with
Dr. Goessling's focus on Maher's self-reported symptoms.
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Dr. Hashimoto, conducting the last independent
assessment, discredited Maher's pain based on her failure to submit
supporting evidence of disability from her treatment in pain
clinics; emphasized Dr. Cuevas' statement to Dr. Malinoff about
Maher's physicians' inability to pinpoint an anatomic cause of her
symptoms; discredited Dr. Goessling's opinion due to his failure to
treat Maher in 2006; and relied on the video surveillance of Maher.
He also said that there was little evidence of either evaluation or
treatment of her claims of impairment based on narcotics use.
This is a fairly impressive set of objections but there
are two aspects that concern us and, taken together, warrant remand
for further consideration.5 The first, and most important, rests
on the fact that at every stage of Maher's administrative appeal,
Liberty and Partners' reviewing doctors emphasized the
inconsistency between her self-reported limitations and the
surveillance video. It is not apparent to us that any such
inconsistency exists.
Maher reported that her activity varied based on the
extent of her pain, nausea, and opportunity to pre-medicate for
activities, but that she generally spent most of her days in bed.
5
See Buffonge v. Prudential Ins. Co., 426 F.3d 20, 31-32 (1st
Cir. 2005); Majeski v. Met. Life Ins. Co., 590 F.3d 478, 484 (7th
Cir. 2009); Leger v. Tribune Co. Long Term Disability Benefit Plan,
557 F.3d 823, 835 (7th Cir. 2009).
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In over 90 hours of surveillance, the most damning evidence the MGH
Plan can identify is 15 minutes during which Maher carried a bucket
or flower pot and 30 minutes during which Maher played with her
three-year-old son in the park. On 10 of the 19 days on which
surveillance video is available, Maher engaged in no activity. On
other days, Maher was shown sitting or standing outside her house
with her husband for about 20 minutes.
Thus most of the surveillance, far from contradicting
Maher's disability, seems to confirm her lifestyle as generally
housebound with occasional, limited activity. For the brief
periods of slightly more vigorous activity, Maher may have pre-
medicated or may have simply been having a "good day"--either of
which would be consistent with her reported limitations. Of
course, she may have been housebound by choice--that is the
critical question. But this is far from a situation in which a
video conclusively disproves the disability claim.6
This court earlier upheld a termination of benefits where
claimant's credibility was called into question by sporadic
surveillance capturing limited activity. Cusson v. Liberty Life
6
E.g., Oldrich v. Director, Office of Workers Comp. Programs,
141 F.3d 1178 (9th Cir. 1998) (unpublished table op.)(claimant
alleged disability due to shoulder injury but was seen chopping
trees and participating in competitive swim meet); see also Tsoulas
v. Liberty Life Assurance Co., 454 F.3d 69 (1st Cir. 2006)
(claimant reported complete inability to walk or stand without cane
or wheelchair and never left house more than once per week, but
surveillance video showed claimant walking without cane, going the
mall, and running other errands).
-13-
Assurance Co., 592 F.3d 215, 228-30 (1st Cir. 2010). But there the
videos showed activities that specifically contradicted claims made
by the claimant as to how she spent her time and what actions she
could tolerate. Id. at 225. We cautioned in that case that weight
given to surveillance in these sorts of cases depends both on the
amount and nature of the activity observed. Id.Apart from the video, the main objective fact relied on
by Partners was Maher's failure to provide supporting evidence of
disability from her pain clinics. But Maher explained her attempts
to obtain documentation from those clinics and offered both
releases to allow the MGH Plan to access the information and to
submit to examination by a doctor of the MGH Plan's choosing. It
also appears that two of the three pain clinics were MGH-affiliated
so the information ought to have been accessible.
In the end, the MGH Plan was entitled to be skeptical:
the claimant has a stake in the outcome; and the treating doctors
do not purport to explain the degree of pain claimed. But the
video evidence and failure to produce pain clinic information seem
overstated. We cannot say with assurance that the MGH Plan denied
Maher benefits to which she was entitled, but even according
deference we are also not confident that its analysis has fully
justified its decision.
The judgment of the district court is vacated and the
matter remanded to the district court so it may allow Partners to
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conduct such further review and provide such further explanation
and information as it sees fit, providing Maher a fair opportunity
to respond to any such supplementation of the administrative
record. We are not reinstating benefits but merely remanding to
the plan administrator for further consideration of the claim and
more adequate explanation, but we expect further proceedings by
Partners to proceed with expedition. Each party to bear its own
costs.
It is so ordered.
--Dissenting Opinion Follows--
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LIPEZ, Circuit Judge, dissenting. The majority correctly
identifies the "double issue" we face in determining the applicable
standard of review in this case: first, whether Massachusetts
General Hospital ("the Hospital" or "MGH") is expressly authorized
by the MGH Long Term Disability Plan ("the Plan") to delegate its
authority to determine benefits, and, second, whether MGH in fact
made such a delegation to the plan administrator, Partners
HealthCare System, Inc. ("Partners"). My colleagues answer "yes"
to each of those questions. In so concluding, however, they
disregard our precedent requiring a clear statement of the
authority to delegate, fail to respect the limits of the pertinent
Plan language, and uncritically accept Partners' declaration of
fiduciary authority despite that assertion's inconsistency with the
terms of the primary plan document.
In my view, the Plan does not give the Hospital authority
to delegate and, even if it did, Partners' assertion of its own
authority is insufficient evidence that a proper delegation in fact
occurred. Hence, because neither question may be answered
affirmatively, the de novo standard of review must be used to
evaluate the administrator's decision denying benefits to Maher.
Taking a fresh view of the record, I can only conclude that Maher's
symptoms render her incapable of sedentary work. I would thus
vacate the district court's judgment and remand for entry of
judgment in Maher's favor.
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I.
Maher challenged the termination of her benefits under
section 502 of the Employee Retirement Income Security Act
("ERISA"), 29 U.S.C. § 1132(a)(1)(B). ERISA does not prescribe a
standard of review for such actions. To fill this gap, the Supreme
Court has held that a denial of benefits challenged under
section 1132(a)(1)(B) should be reviewed de novo "unless the
benefit plan gives the administrator or fiduciary discretionary
authority to determine eligibility for benefits or to construe the
terms of the plan." Firestone Tire & Rubber Co. v. Bruch, 489 U.S.
101, 115 (1989). Where such authority is given, our review is more
deferential, id. at 111, and a benefits decision will be upheld
unless it is "arbitrary, capricious, or an abuse of discretion,"
Cusson v. Liberty Life Assurance Co. of Boston, 592 F.3d 215, 224
(1st Cir. 2010) (quoting Gannon v. Metro. Life Ins. Co., 360 F.3d
211, 213 (1st Cir. 2004)).
The standard of review inquiry must thus start with the
terms of the Plan, through which MGH provided Maher LTD benefits.
Article 6.1 of the Plan document states in full:
6.1. General. The processing of claims and
calculation of benefits shall be the sole
responsibility of the Claims Processor. The
Hospital shall have full discretionary
authority to administer the Plan, including
without limitation the authority to determine
eligibility for benefits, construe the terms
and conditions of the Plan, and resolve
disputes as to the interpretation of the Plan
documents. Any person having an interest
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under the Plan m[a]y request a determination
by the Hospital with respect to any matter
affecting such person, and any such
determination of the Hospital will be final
and binding, and shall not be subject to de
novo review, or be modified, amended, or set
aside by any judicial or administrative
authority in the absence of clear and
convincing evidence that the Hospital's action
was arbitrary and capricious or without
rational basis.
The Plan document defines the "Hospital" to mean The General
Hospital Corporation, a Massachusetts charitable organization
whose sole member is MGH. Because the above provision grants the
Hospital "full discretionary authority to administer the Plan,"
including "the authority to determine eligibility for benefits
[and] construe the terms and conditions of the Plan," a benefits
decision by MGH would typically be reviewed under the deferential
"arbitrary and capricious" standard. Firestone, 489 U.S. at 115;
Cusson, 592 F.3d at 224.
The benefits decision at issue here was not, however,
made by MGH. Instead, it was made by Partners, the Plan's
administrator. To be sure, Partners and the Hospital are closely
related. Partners, a nonprofit corporation, coordinates a
healthcare system made up of a number of constituent medical
institutions, including MGH, Brigham and Women's Hospital, and
various other hospitals and medical organizations. However closely
bound together, though, there is no question that Partners and the
Hospital are legally distinct entities, and the Plan does not argue
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that the discretionary authority conferred on the Hospital should
be imputed to Partners.7 Cf. Glotzer v. Metro. Life Ins. Co., 1 F.
App'x 740, 742 (9th Cir. 2001) (holding that, because successor
corporation inherited in full the rights and burdens of plan
administrator through purchase, discretion delegated to plan
administrator was imputed to successor).
Instead, the Plan contends that Partners validly
exercised discretionary authority that had been delegated to it by
the Hospital. ERISA provides that a named fiduciary may delegate
to others its responsibilities under a plan -- other than trustee
responsibilities -- where the plan expressly sets forth procedures
for doing so. 29 U.S.C. § 1105(c)(1); Rodriguez-Abreu v. Chase
Manhattan Bank, 986 F.2d 580, 584 (1st Cir. 1993). To determine
whether a valid delegation of authority took place here, we must
address the majority's "double issue": (1) whether the Plan
authorized the Hospital to delegate its authority to Partners and,
if so, (2) whether there is adequate evidence of the claimed
delegation of authority.
7
To the extent the majority is suggesting that the Plan's
argument for deferential review is strengthened by this alternative
theory -- i.e., that MGH and Partners are affiliated entities
between whom delegation is unnecessary -- the suggestion is
gratuitous given that the Plan did not offer the theory. Moreover,
if the Plan, a sophisticated litigant, thought such a view of the
entities' relationship was viable, it presumably would have made
the claim to avoid relying solely on an approach that even the
majority considers justified "perhaps only by a modest margin."
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A. Was Delegation Authorized?
A plan fiduciary may delegate its fiduciary
responsibilities to a third party only where the plan "expressly
provide[s] for procedures" for such a delegation. 29 U.S.C. §
1105(c)(1). As explained in Wallace v. Johnson & Johnson, 585 F.3d
11, 15 (1st Cir. 2009), our court has placed little emphasis on the
statute's reference to delegation "procedures." That is, we do not
require that a plan establish any procedures governing delegation
beyond a basic grant of the authority to delegate itself. See id.("Our own cases treat delegation 'authority' and delegation
'procedures' as more or less the same thing . . . ."). However,
the statute's reference to "expressly provid[ing]" delegation
procedures means that such a grant of authority to delegate must be
clearly stated. This is consonant both with the requirement that
the initial grant of discretionary authority by a plan be
unambiguous, see Terry v. Bayer Corp., 145 F.3d 28, 37 (1st Cir.
1998); Rodriguez-Abreu, 986 F.2d at 583, and with our case law
examining plan language granting authority to delegate.
In Wallace, we found a valid delegation of discretionary
authority where it was "clear" that the benefits plan at issue
"purport[ed] to allow delegation." 585 F.3d at 14. The relevant
language of the plan stated that the fiduciary "may '[d]elegate its
authority established' by the Plan, 'designate persons to assist in
carrying out fiduciary duties,' 'allocate responsibility for the
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operation and administration' of the Plan, and '[a]ppoint persons
or committees to assist it to perform its duties' under the Plan."
Id. at 14-15. We reached the same conclusion in Terry, where the
plan stated that "'[t]he Company may appoint one or more
individuals to act on its behalf, in which case every reference
herein made to the Company shall be deemed to mean or include the
individuals as to matters within their jurisdiction.'" 145 F.3d at
37-38. In each of these cases, the plan language was unambiguous
and unqualified in its grant of authority to delegate.
Here, in contrast, the Plan cannot be read to authorize
a delegation of plenary administrative authority over the Plan to
Partners. The most relevant provision of the Plan document, and
the one emphasized by the Plan,8 reads as follows:
6.3. Employment of Agents. The Hospital may
employ agents, including but not limited to, a
Claims Processor, accountants, attorneys or
actuaries to perform such services and duties
in connection with the administration of the
Plan as it may direct. . . . The Hospital
shall be fully protected in acting upon the
8
The Plan contains another potentially relevant provision,
Article 6.4, which provides authority for the Hospital to "delegate
to the Claims Processor responsibility for certifying the
information and amount necessary for the proper payment of claims
from the Fund under the provisions of the Plan." The Plan does not
contend, however, that the Hospital's authority to delegate its
discretionary authority to Partners arises from this provision.
This is because the delegation authorized in Article 6.4 is a
limited one relating to claims processing duties, and, as discussed
below, the authority that may be delegated to the Claims Processor
under the Plan falls short of the sort of administrative authority
that will trigger deferential review.
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advice of any such agent, in whole or in
part . . . .
Unlike the plan language in Terry and Wallace, the provision here
authorizes no complete devolution of the discretionary authority
granted to the Hospital under Article 6.1 of the Plan. Rather,
Article 6.3 allows the Hospital to "employ" agents, often referred
to as service providers in ERISA parlance, whose activities it may
"direct," to assist with the day-to-day operation of the Plan and
to advise the Hospital in carrying out the fiduciary duties
assigned to it in Article 6.1. In Terry, in the course of
determining whether a third-party claims processor could be sued as
a fiduciary under ERISA for its role in denying the claimant
benefits, we drew a sharp distinction between these types of "third
party service provider[s]," on the one hand, and the plan
administrator and fiduciaries, on the other. 145 F.3d at 35-36.
The reference to a "Claims Processor" as one of the
agents the Hospital may employ reflects the limited nature of the
delegation authorized by Article 6.3, and, critically, that it does
not include the ultimate authority to "determine eligibility for
benefits or to construe the terms of the plan" -- the authority
that triggers deferential review. Firestone, 489 U.S. at 115. A
claims processor generally makes the initial determination on a
benefits claim and may handle the first level of appeals, but
another entity is usually responsible for making a final
-22-
determination on appeal.9 In the typical instance, we have thus
noted that "an entity which merely processes claims 'is not a
fiduciary because such person does not have discretionary authority
or discretionary control respecting management of the plan.'"
Terry, 145 F.3d at 35-36 (quoting 29 C.F.R. § 2509.75-8, D-2
(1997)). Such is plainly the case under the Plan. Article 6.1
sets the Hospital's authority side-by-side with the Claims
Processor's. It makes clear that, though "[t]he processing of
claims and calculation of benefits shall be the sole responsibility
of the Claims Processor," it is the Hospital that has "full
discretionary authority to administer the Plan, including without
limitation the authority to determine eligibility for benefits,
construe the terms and conditions of the Plan, and resolve disputes
as to the interpretation of the Plan documents."
Accordingly, I read Article 6.3 to authorize delegation
of administrative functions short of the Hospital's core authority
to "determine eligibility for benefits" and "construe the terms and
conditions of the Plan."10 At a minimum, if this provision were
9
Here, for instance, Liberty (acting as claims processor)
made the initial benefits determination and processed Maher's first
appeal, but, upon Maher's second and final appeal, Partners made
the ultimate determination to deny.
10
In relying on Pettaway v. Teachers Insurance and Annuity
Ass'n of America, 644 F.3d 427 (D.C. Cir. 2011), for the
proposition that decisional authority to determine benefits can be
inferred from plan language, the majority fails to take seriously
the "clear statement" standard in our case law. Whether or not the
language in Pettaway would meet that standard, the language here
-23-
intended to permit the delegation of the totality of the Hospital's
discretionary authority, it lacks the requisite clarity. Cf.
Terry, 145 F.3d at 37 ("[T]he grant of discretionary authority must
be clear."). I thus conclude that Article 6.3 did not authorize
the Hospital's delegation of discretionary authority to Partners.
However, as discussed below, even if the Plan permitted such
delegation, the evidence that a delegation took place is
inadequate.
does not. The Pettaway court described the relevant plan
provisions as follows:
As stated in the Plan Document, the "Academy shall be the
Plan Administrator and the 'Named Fiduciary'" with the
"absolute power, authority and discretion to administer
the [Academy] Plan." Plan Document at 3.1, 3.2. "All
interpretations of the Plan, and questions concerning its
administration and application, shall be determined" by
the Academy, which has the authority to "appoint such
accountants, counsel, specialists, and other persons as
it deems necessary or desirable in connection with the
administration of the Plan." [Plan Document] at 3.2.
Pettaway, 644 F.3d at 434. Thus, unlike the MGH Plan, delegation
under the plan in Pettaway was not limited to "agents" whom the
administrator would "direct." See supra pp. 21-22. Instead, the
Pettaway administrator had broad authority to delegate
administrative responsibility to others whenever such a transfer of
duties was "deem[ed] necessary or desirable."
The limited language in the MGH Plan renders irrelevant the
majority's observation that lawyers, accountants and actuaries may
be assigned fiduciary duties. The issue here is not whether such
professionals are considered fiduciaries, but whether this Plan
clearly endorsed delegation of the authority to make final benefits
determinations.
-24-
B. Did a Delegation Occur?
The Plan asserts that evidence of a delegation of
authority to Partners can be found in a 2005 document entitled
"Partners HealthCare System, Inc. Health and Welfare Plan Document"
(the "Partners Plan Document"), which the Plan characterizes as a
Summary Plan Description ("SPD"). The document, published under
Partners' name, purports to be "a wrap-around plan document that
contains the definitions, participation and administration
provisions of the various Partners health and welfare plans," which
includes the Plan at issue here as well as over forty others, "and
incorporates by reference the various Benefit Contracts associated
with the Plan to form a complete plan document." The language
supposedly effecting the delegation, located in Section II, Article
IX of the Partners Plan Document, simply states, "Partners acts as
the Plan Administrator for ERISA purposes of the Plans." The
Partners Plan Document further provides that, as Plan
Administrator, Partners "has the discretion to determine all
matters relating to eligibility, coverage and benefits under each
Plan" and "has the full power to interpret each Plan and is
responsible for the operation of each Plan."
Our cases involving delegation of fiduciary authority
under ERISA do not directly address what sort of evidence will
suffice to show that delegation has been effected. To some extent,
the answer in an individual case may depend upon whether the ERISA
-25-
plan at issue sets forth particular procedures to canalize the
delegation process. However, often, as here, the plan will not
specify a mechanism for delegation. In these cases, our precedents
hint at some basic guidelines for determining whether the evidence
before the court establishes the delegation of fiduciary authority.
First, it is not enough merely to show that the putative
delegate is carrying out discretionary functions of plan
administration. In Rodriguez-Abreu, a senior executive of the
defendant employer conducted a review of the denial of plaintiff's
benefits and corresponded with the plaintiff regarding his
eligibility. 986 F.2d at 582, 584. The defendant argued that
these circumstances alone were sufficient to show that the plan
fiduciaries had delegated their discretion to the executive,
triggering a deferential standard of review. We disagreed. Noting
that there was "no expression of intent that [the executive] act as
the delegate of the Fiduciaries" in the plan documents or elsewhere
in the record, we found no valid delegation of authority and thus
employed a de novo standard of review. Id. at 584.
Second, evidence of the delegation may be provided by a
written instrument other than the plan documents themselves. In
Terry, the benefit plan at issue conferred discretionary authority
to administer the plan to the Bayer Corporation, and Bayer in turn
delegated that authority to an internal "Benefit Administration
Committee." 145 F.3d at 37-38. The only evidence of this
-26-
delegation was an internal organizational document (the
"Administrative Procedures for the Benefit Administration
Committee"), which, among other things, explained that the
Committee had been formed to "'act on behalf of [Bayer] by
assisting [Bayer] in fulfilling its administrative duties which are
set forth in the employee benefit plans.'" Id. at 35, 38. We
found this "clear and direct delegation -- by written instrument --
from the Plan Administrator to the Benefit Committee" sufficient to
justify a deferential standard of review. Id. at 38; see also
Wallace, 585 F.3d at 14-15 (holding extra-plan written instrument
transferring discretionary authority to administer plan to third
party sufficient evidence of valid delegation to trigger review
under the "arbitrary and capricious" standard).
Here, we have a written document -- the Partners Plan
Document -- that purportedly gives to Partners the discretionary
authority to administer the Plan. However, the relevant terms in
the Partners Plan Document represent nothing more than the bare
assertion by a third party of discretionary authority over
administration of the Plan. The document states simply that
"Partners acts as the Plan Administrator" for all plans listed
among its pages,11 and that Partners "has the discretion to
11
As Maher points out, the Partners Plan Document never
accurately refers to the Plan. In a table detailing the various
subsidiary plans to which it applies, the Partners Plan Document
lists an "MGH LTD Insurance Plan." The Plan is not, in fact, an
insurance plan, as it is funded through a trust, and thus the
-27-
determine all matters relating to eligibility, coverage and
benefits under each Plan" and "has the full power to interpret each
Plan and is responsible for the operation of each Plan." This is
at best corroborative evidence of a transfer of authority from the
Hospital to Partners, but insufficient on its own to establish the
delegation. The Plan has offered no evidence of an agreement
between the Hospital and Partners, a corporate resolution by the
Hospital, or other such documentation that would indicate that the
Hospital affirmatively granted discretionary authority over the
Plan to Partners.
In arguing over the effect of the Partners Plan Document,
the parties vigorously dispute whether it properly qualifies as an
SPD for the Plan.12 This is a question that need not be resolved
here, as nothing turns on it. Even if the Partners Plan Document
qualified as an SPD, there would be a direct conflict with the
primary Plan document that must be resolved in the Plan document's
favor. Each document purports to grant full discretionary
authority over the Plan, with the power to make "final and binding"
decisions, to a different entity. Where there is a conflict
reference to an "LTD Insurance Plan" is erroneous.
12
Maher argues at some length that the Partners Plan Document
fails to include all categories of information required by statute
to be present in an SPD. See 29 U.S.C. § 1022(b). The Plan
counters that the Partners Plan Document explicitly states that it
is only one of several documents that "collectively constitute the
summary plan description for each Plan," implying that those
additional documents supply the missing information.
-28-
between the plan and the SPD, the plan language will generally
control, except in situations where the beneficiary relied to her
detriment on the SPD. See Ringwald v. Prudential Ins. Co. of Am.,
609 F.3d 946, 948-49 (8th Cir. 2010) (disregarding grant of
discretionary authority that appeared only in SPD); Schwartz v.
Prudential Ins. Co. of Am., 450 F.3d 697, 699-700 (7th Cir. 2006)
(same, and explaining that SPD controls if participant
detrimentally relied on it); cf. Mauser v. Raytheon Co. Pension
Plan for Salaried Emps., 239 F.3d 51, 54-55 (1st Cir. 2001) (where
SPD conflicts with a plan's terms, the SPD will control if the
claimant demonstrates "significant or reasonable reliance" on the
SPD). Thus, to the extent that the Partners Plan Document
qualifies as an SPD, the grant of discretionary authority in the
Plan document must still be credited over the conflicting grant in
the putative SPD.13
In sum, the Plan by its terms did not authorize the
Hospital to delegate its authority, and, even if the Plan had
permitted such delegation, there is insufficient evidence that the
13
The majority fails to confront the inconsistency between the
documents and, indeed, cites the Partners Plan Document as evidence
that the Hospital was authorized to delegate its discretionary
authority. But a bare assertion of authority by the putative
delegee is even less meaningful as proof that delegation was
authorized than it is as evidence that a delegation in fact
occurred. In effect, the majority assumes that Partners' assertion
that it had authority is evidence that it was given that authority.
Such circular reasoning is both illogical and unpersuasive.
-29-
Hospital in fact delegated its authority to Partners. Partners'
denial of Maher's benefits must therefore be reviewed de novo.
II.
In a de novo review of a benefits decision, "no deference
[is given] to administrators' opinions or conclusions based on
the[] facts." Orndorf v. Paul Revere Life Ins. Co., 404 F.3d 510,
518 (1st Cir. 2005); see also Richards v. Hewlett-Packard Corp.,
592 F.3d 232, 239 (1st Cir. 2010) (same). Instead, an independent
review of the evidence in the administrative record must be
performed, Orndorf, 404 F.3d at 518; Richards, 592 F.3d at 239, and
the "guiding principle" is that the plaintiff bears the burden of
proving he is disabled, Orndorf, 404 F.3d at 518-19. To meet that
burden, the terms of the Plan require Maher to prove a "complete
incapacity" preventing her "from performing any and every duty of
any occupation or employment, for which [she] is reasonably
qualified by education, training or experience." The Plan has
narrowed the scope of the inquiry somewhat by specifying the
occupations for which it believes Maher to be qualified: telephonic
triage nurse, nurse case manager, and utilization review nurse.
Maher's arguments on the merits of the Plan's benefits
determination fall into two categories. First, Maher argues that
her use of narcotics renders her incapable of filling any of the
above-mentioned jobs for which she is qualified by "education,
training, or experience." In support of this argument she points
-30-
to state law that purportedly prohibits her from performing any
nursing duties while under the influence of narcotics.
Alternatively, she submits that, legality aside, the effects of her
medications would impair her judgment and interfere with her
ability to perform nursing duties. Second, Maher contends that the
evidence supports the disability caused by her chronic pain and
nausea, and that Partners wrongly discounted evidence of the manner
and extent to which pain affects her ability to function.
I address each of these arguments in turn.
A. Disabling Effects of Narcotics Use
Maher's medical records confirm that, for nearly a
decade, Maher has treated pain with a varying array of powerful
narcotics, and she usually has taken multiple drugs at the same
time and in significant doses. In a 2007 letter, Dr. Elizabeth
Cuevas, Maher's primary care doctor, noted that her patient is
"treated with narcotics that are prescribed at very high doses,"
and Dr. Wolfram Goessling, Maher's treating gastroenterologist, has
similarly noted that Maher "takes impressive amounts of narcotics."
Over the course of her treatment, Maher has consulted several pain
clinics and periodically changed medications, but her records
reveal no success in scaling back the use of narcotic painkillers.
According to Dr. Herbert Malinoff, one of Liberty's consulting
doctors, Maher's record of treatment supports a diagnosis of
-31-
"chemical dependency relative to opioid and Benzodiazepine use over
a long period of time."
Maher contends that her drug use, as a matter of law,
prevents her from working in any job within the field of nursing,
and thus precludes employment in the one area for which she is
qualified by education, training, or experience. As Maher notes,
Massachusetts' Standards of Conduct for licensed nurses prohibit
nurses from practicing "while impaired." 244 Mass. Code Regs.
§ 9.03(36). Maher argues that the sedentary nursing roles that
Liberty has suggested she would be capable of filling all
necessarily involve the "practice" of nursing, defined by statute
to include "coordination and management of resources for care
delivery." Mass. Gen. Laws Ann. ch. 112, § 80B. Because she is
"therapeutically addicted to narcotic medication," Maher suggests
that she is legally "impaired" and cannot serve in the above
positions.14
Though Maher tries to segregate this line of reasoning
from her alternative argument that the effects of her medications
would interfere with her ability to carry out the duties of a
nursing job, they cannot be so easily disentangled. The fact of
narcotics use does not, by itself, appear to preclude legal
14
Because I dispose of Maher's argument based on the
definition of "impaired," I do not address her contention that the
sedentary nursing roles identified by Liberty involve the
"practice" of nursing under Massachusetts law.
-32-
function as a nurse. The governing regulations define "impaired"
to mean "the inability to practice nursing with reasonable
judgment, skill, and safety by reason of alcohol or drug abuse, use
of substances, a physical or mental illness or condition, or by any
combination of the foregoing." 244 Mass. Code Regs. § 9.02. Thus,
whether Maher is "impaired" turns not on whether she is addicted to
narcotics, but on a factual determination of whether her narcotic
use is likely to interfere with her "judgment [and] skill." Id.
The evidence of the effect of Maher's narcotic use on her
ability to concentrate and function is mixed. There is, to be
sure, an intuitive logic to the notion that we should be wary of
entrusting patient care to a medical professional who takes large
amounts of narcotic medications. This is a point that Maher
emphasizes in her briefs, and it has some basis in fact. Medical
authorities warn that narcotics may cause sedation, "mental
clouding," and impaired psychomotor function. However, according
to a publication of the American Medical Association included in
the administrative record, these types of side effects "usually
dissipate with continued treatment, normally within a week with
regularly scheduled dosing, and studies have demonstrated that most
patients on chronic opioid therapy can safely drive cars." One of
Liberty's consulting physicians, Dr. Robert Millstein, makes the
same point in his February 2007 report, though he acknowledges
-33-
"very few studies have examined the effects of opioids on
selective, divided, and sustained attention."
Maher's medical records indicate that she has often
complained of the sedation brought on by her regimen of narcotics.
However, close scrutiny of these records indicates that many of her
reports of somnolence and other drug-related side effects are
correlated with a change in medication or an adjustment of dosage.
To take one example, Maher saw Dr. Goessling in March 2005 and
complained that the morphine she was taking made her "loopy and
more sleepy than usual." Her medical records reveal that she was
started on morphine only a couple of days prior, when she was
admitted to the hospital for abdominal pain and the pain clinicians
recommended that she transition from OxyContin.
Overall, I do not find convincing support in the record
for the proposition that Maher's drug use, by itself, would render
her incapable of working in one of the sedentary nursing positions
identified by Liberty. There is no clear prohibition in
Massachusetts on serving as a nurse while on a medically prescribed
regimen of narcotics, so long as the drugs do not impair the
nurse's "judgment, skill, and safety." Maher's doctors have not
suggested that her use of drugs would interfere with her judgment
or ability to make rational decisions. Indeed, Dr. Goessling and
Dr. Cuevas both identify excessive sedation to be the major side
effect associated with Maher's medication. I acknowledge that Dr.
-34-
Goessling has opined that he "cannot imagine that it would be in
[Maher's] or society's benefit to have her work as a nurse making
decisions over other people's lives," but he does not point to any
specific effect of the drugs that would render Maher incapable of
safely managing the limited nursing roles suggested for her by
Liberty.
I am not unconcerned by the possibility that narcotic-
related sedation would make it difficult for Maher to complete a
regular workday. In one instance in 2005, Maher reported that the
somnolence associated with a change from OxyContin to Palladone was
causing her to take three naps per day. Such considerable sedation
would clearly interfere with most if not all possible employment.
However, because Maher's reports of drowsiness and other adverse
effects from medication appear largely related to alterations in
her drug regimen -- which conforms to the medical evidence that
side effects are most pronounced when first starting a narcotic --
I do not see convincing evidence that Maher's ability to
concentrate and exercise judgment would be significantly
compromised by a regular and stable program of narcotic
medications.
B. Disabling Effects of Pain and Other Symptoms
I reach a different conclusion with respect to the impact
of the symptoms of Maher's maladies -- chronic pain, nausea,
vomiting, and food intolerance -- on her ability to work. After
-35-
careful review of the record, I find persuasive evidence that
Maher's symptoms would prevent her from performing the duties of
the jobs identified by Liberty.
Before evaluating the record on this issue, I note that
my concern here lies with the evidence of limitations attributable
to Maher's symptoms, and not with whether the evidence supports
Maher's underlying medical conditions. There is considerable
uncertainty regarding the etiology of Maher's abdominal pain and
other complaints, and attempting to resolve a question that has
stymied multiple doctors for the past decade is both unnecessary
and beyond my expertise.15 The diagnosis makes little difference
here. Our court has emphasized before that in dealing with hard-
to-diagnose, pain-related conditions, it is not reasonable to
expect or require objective evidence supporting the beneficiary's
claimed diagnosis. See Cook v. Liberty Life Assurance Co., 320
F.3d 11, 21 (1st Cir. 2003). Our focus instead must be on whether
evidence supports an inability to work due to "the physical
limitations imposed by the symptoms of such illnesses . . . ."
Boardman v. Prudential Ins. Co. of Am., 337 F.3d 9, 16 n.5 (1st
Cir. 2003).
15
Dr. Goessling, a trained gastroenterologist and Associate
Professor of Medicine at Harvard Medical School, continues to
believe that Maher's abdominal symptoms are most likely caused by
chronic pancreatitis. The Plan's doctors disagree, but concede
that the record supports a diagnosis of either "chronic pain
syndrome with abdominal focus," per Dr. Malinoff, or fibromyalgia,
per Dr. Millstein.
-36-
1. Evidence Relied upon by the Plan
I begin by assessing the evidence that, in the view of
the Plan, calls Maher's limitations into question, the foremost of
which is the alleged inconsistency between Maher's reported
capabilities and the level of activity confirmed by surveillance.
Liberty conducted surveillance of Maher on nineteen days between
October 2002 and October 2006, portions of which were recorded on
video.16 The Plan and its doctors highlighted a handful of examples
of increased activity by Maher captured in the surveillance. On
one occasion, Maher was observed walking to the front of her
property "carrying what appeared to be a flower / plant and a large
bucket," and, four minutes later, walking back with the same
bucket. On another, she drove herself a short distance (a four-
minute drive) to a local school, where she went inside and returned
carrying her son (then close to three years old), whom she placed
inside the car before departing for her home. On a third occasion
-- and the one on which the Plan places the most emphasis --
Maher's husband drove Maher and her son to a local soccer field on
a Saturday morning. There, Maher "was periodically observed as she
and her husband flew a kite with the young boy," as she "walked and
jogged around the soccer field," and as she "at one point lifted
16
This included six days of surveillance in 2002, three days
in 2005, and ten days in 2006.
-37-
the small boy and swung him around in her arms." The outing lasted
thirty-four minutes.
This surveillance evidence does not have the significance
that the Plan ascribes to it. In the activity questionnaires she
submitted to Liberty, Maher consistently reported that the level of
activity she can sustain is entirely dependent on her pain, nausea,
and level of medication. For example, in her latest questionnaire,
dated September 2006, Maher indicated that the amount of time she
can tolerate sitting, standing, and riding in or driving a car
depends on the presence of pain, nausea, vomiting, and diarrhea.
She also noted that she leaves the house during the week two to
three times a day (one to two times on weekend days), and that she
helps take care of her children and perform small chores when she
is able.
As the majority points out, Liberty's surveillance is not
inconsistent with Maher's own account of her activities. Over
nineteen days of surveillance, there were a number of days in which
Maher was confirmed to be at home and never left the residence. On
other days, she left the house -- either as a passenger or driving
herself -- to run a limited number of errands, mostly picking up or
dropping off her children at school, and once to go to dinner at a
restaurant. She was also observed outside on two brief occasions
involved in what could generously be described as yard chores:
carrying a flower pot and, on another occasion, sitting in the bed
-38-
of her husband's truck holding a broom or rake while her husband
appeared to be cleaning up. All of this activity is consistent
with her description of a low level of activity dependent on the
ebb and flow of her symptoms. It would be unusual for a mother of
three children to be able to avoid all activity.
With regard to the kite-flying episode, which strays the
farthest from Maher's reported limitations, Maher has indicated
that the outing was a "special event" for which she premedicated
with morphine. In other circumstances, this explanation might
strain credulity. Here, however, the notion that Maher
premedicates to prepare for activities that may trigger pain finds
support in records that predate the incident.17 In a March 2003
activity questionnaire, for example, Maher noted that she travels
by plane only with "pre-medication for pain and nausea from
increased cabin pressure on abdomen." In her September 2006
questionnaire, Maher also noted that her ability to carry out
various activities of daily life "always depend[s] on how much pain
medicine I use . . . to help myself." Moreover, the entire outing
17
The district court concluded that, assuming that Maher's
outing with her family can be explained by premedication, "it is a
reasonable inference that she could also pre-medicate to perform a
sedentary job." I cannot agree. Maher takes a large amount of
narcotics daily to address her background pain. The fact that she
can, on top of this background dosage, take additional pain
medications to ward off pain during the occasional short episodes
of increased activity does not suggest that it would be feasible
for her to regularly take extra medication to make it through an
eight-hour workday.
-39-
at the athletic fields was very brief, lasting just over half an
hour. It would be unfair to read too much into one short episode
of increased activity, given the consistency of the larger record
of surveillance with Maher's reported capabilities.
Turning to an evaluation of the medical opinions
concerning Maher's limitations, my conclusion again diverges from
that of the Plan and its doctors. Among Maher's treating doctors,
there is thin support for her capacity to return to a sedentary
job. The most direct evidence is found in a questionnaire,
completed by Dr. Gale Haydock, indicating that Maher is "OK to
perform sedentary duties." However, Dr. Haydock treated Maher only
once, in the winter of 2006, when Maher was admitted to the
hospital for several days to treat a flare-up of abdominal pain,
and thus Dr. Haydock had no opportunity to observe the course of
Maher's symptoms over time.
One could also, as the Plan has, read various statements
by Maher's primary care physician (Dr. Cuevas) to support Maher's
ability to perform sedentary work. Most notably, in a conversation
with Dr. Malinoff, Dr. Cuevas stated her agreement with Dr.
Malinoff's opinion that, "from a purely internal medicine
perspective, there is no identifiable physical exam or anatomic /
laboratory abnormality that would prevent [Maher] from working at
a very minimum at a sedentary level." This awkwardly precise
statement is technically true and is, undoubtedly, an accurate
-40-
reflection of Dr. Cuevas's medical opinion.18 It is also
transparently misleading. Maher's medical records make clear that
no doctor has been able to identify a physical or anatomic
abnormality that causes her symptoms. However, the absence of a
diagnosed medical condition says nothing about the reliability of
Maher's complaints or whether her reported symptoms prevent her
from working. On those questions, Dr. Cuevas's opinion is
unequivocal. In a letter dated March 2007, Dr. Cuevas wrote that
Maher "remains in significant disability, both from her chronic
pain and from the side effects the pain medication cause," and that
she "is unable to reliably perform duties because her pain can
become so severe so quickly."
Lastly, the record also contains opinions from the three
doctors retained by the Plan -- Dr. Millstein, Dr. Malinoff, and
Dr. Dean Hashimoto, Chief of Occupational and Environmental
Medicine at MGH -- concluding that the available evidence does not
support Maher's claimed inability to work a sedentary job. I find
the opinions rendered by these doctors unpersuasive. Each doctor
relied to a significant degree on the surveillance records in
evaluating Maher's capabilities, focusing on the episodes of
activity detailed above and finding them inconsistent with Maher's
18
Following their conversation, Dr. Malinoff mailed a letter
to Dr. Cuevas that recapitulated the substance of their
conversation and asked that she sign to verify its accuracy. She
did so and returned the letter to Dr. Malinoff.
-41-
claims. Dr. Malinoff and Dr. Hashimoto also interpreted Dr.
Cuevas's statements as supportive of Maher's ability to return to
work. For the reasons stated, I have reached contrary conclusions
based on the same evidence. Additionally, Dr. Hashimoto observed
that, even accepting the veracity of Maher's reported symptoms,
there has been no attempt to evaluate "through neuropsych testing,
scans, or other available means" the extent to which Maher's pain
and use of narcotics affect her cognition and ability to function.
This failing can be attributed, to some degree, to the Plan's
decision not to pursue an independent medical evaluation of Maher
to assist in the assessment of her claim.19 Nevertheless, as I
discuss below, I find the record evidence of Maher's limitations
sufficient even absent the sort of testing suggested by Dr.
Hashimoto.
19
Indeed, I find the Plan's failure to conduct an independent
medical examination somewhat troubling. There is no requirement
that a plan administrator arrange for a medical examination prior
to terminating benefits, see Orndorf, 404 F.3d at 526, but here the
circumstances certainly should have suggested its utility. As
early as 2004, Dr. Millstein counseled that "[i]f it is felt to be
important to ascertain whether impairment due to abdominal pain
exists, I would suggest consideration of functional assessment by
some alternative means." After her benefits had been denied, Maher
even offered to make herself available for a physical examination
by a doctor of the Plan's choice. The record reflects that the
Plan's administrators internally discussed the possibility of an
independent medical examination in September 2007, but declined to
pursue one due, in part, to concern for slowing down the process.
-42-
2. The Evidence Supports Maher's Limitations
Viewing the totality of the medical evidence in the
administrative record, I am persuaded that Maher's symptoms prevent
her from reliably performing the duties of a sedentary nursing job.
At the fore of that evidence are the opinions of Maher's treating
doctors, Dr. Cuevas and Dr. Goessling. As noted, Dr. Cuevas's
assessment as of March 2007 was that Maher "remains in significant
disability" and "is unable to reliably perform duties because her
pain can become so severe so quickly." Similarly, Dr. Goessling,
who has followed Maher since the onset of her abdominal symptoms in
late 2001, opined in a 2007 letter:
In her current status, Mrs. Maher is barely
able to provide for herself and her 3-year-old
son during the day. She is not able to stand
or walk for prolonged periods of time. She is
suffering from constant nausea that is only
partially relieved by her . . . medication.
She has intermittent diarrhea due to
malabsorption from lack of pancreatic enzymes
followed by constipation caused by her high
doses of narcotics medication. On top of her
chronic abdominal pain, she has frequent
exacerbations, [and] often this pain
prohibit[s] her completely from taking any
solid foods. . . . [¶] . . . [L]et me assure
that I do not see any way that my patient
would be able to sit or stand for prolonged
period[s] of time let alone do physically or
intellectually demanding work.
While there is some evidence that Dr. Goessling did not actively
treat Maher in 2006 and 2007, he saw her repeatedly in the
-43-
preceding years and she appears to have consulted with him prior to
his writing the letter quoted above.20
These opinions echo Maher's own assessment of her
limitations. In an affidavit, Maher stated that she "cannot be
counted on to do anything," because her symptoms come on
unpredictably and leave her in "excruciating pain" that "is so bad
that it sucks the wind out of [her]." Though pain is subjective
and thus difficult to reliably document, her characterization
appears to be borne out by the record. From late 2001, she has
consistently complained of intermittent and severe abdominal pain.
Her complaints have been credible enough to convince the numerous
doctors who have seen her that she needs serious narcotics to
relieve her pain and allow her to function. While we might suspect
drug-seeking tendencies in such circumstances, the record does not
reveal such tendencies. An early note from Dr. Goessling indicates
that Maher was "quite reluctant to take pain medications," and
there are multiple indications in later records of her desire to
move off of the painkillers.21 Even with her regular regimen of
20
The letter, addressed to Maher's case manager at Liberty,
begins, "I would like to update you on [Maher's] overall condition,
especially in light of the recent denial letter for her benefits
that she received," implicitly suggesting that Dr. Goessling had
current knowledge of Maher's condition at the time of writing.
21
Still, the record is mixed as to the sincerity of Maher's
desire to discontinue narcotic use, as she has twice started
treatment with a pain clinic and then failed to follow up. She
ascribes her reluctance to continue treatment at the clinics to
interpersonal conflict with the doctors at one clinic, and a
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heavy narcotics, Maher's abdominal pain has repeatedly brought her
to the emergency room, where she was admitted on at least two
occasions for multiple-day stays to manage her pain.
Maher's record of treatment thus bespeaks significant and
debilitating pain. Given the number of medical professionals who
have examined her and found her distress genuine, I have no reason
to question the reality of this pain. As the Seventh Circuit noted
in Carradine v. Barnhart, 360 F.3d 751 (7th Cir. 2004):
What is significant is the improbability that
[the claimant] would have undergone the
pain-treatment procedures that she did, which
included . . . heavy doses of strong drugs
. . ., merely in order to strengthen the
credibility of her complaints of pain and so
increase her chances of obtaining disability
benefits; likewise the improbability that she
is a good enough actress to fool a host of
doctors and emergency-room personnel into
thinking she suffers extreme pain; and the
(perhaps lesser) improbability that this host
of medical workers would prescribe drugs and
other treatment for her if they thought she
were faking her symptoms. Such an inference
would amount to an accusation that the medical
workers who treated [the claimant] were
behaving unprofessionally.
Id. at 755 (internal citation omitted). I therefore credit Maher's
reports of abdominal pain, and note as well that her
gastrointestinal and food intolerance symptoms -- which are more
readily verified -- find support in numerous records.
feeling that the type of program offered by the other clinic was
not appropriate for her. Her lack of follow-through in this regard
does not diminish the overall force of the evidence of her pain.
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I similarly find the evidence sufficient to corroborate
Maher's claims that these symptoms would interfere with her ability
to work. Maher's recurring acute attacks of abdominal pain would,
at a minimum, result in frequent absences from work, which would be
prohibitively disruptive of any attempt to maintain regular
employment. Surveillance also suggests that her background level
of symptoms is sufficient to keep her housebound with some
frequency, or to permit only limited levels of activity. Though
Maher may occasionally run errands, contribute to household chores,
or even recreate with her family for short periods of time, there
is a sharp "difference between a person's being able to engage in
sporadic physical activities and her being able to work eight hours
a day five consecutive days of the week." Id. On balance, I
conclude that the evidence demonstrates that Maher cannot reliably
perform the duties of a full-time sedentary nursing job.
III.
Based on a close, de novo review of the administrative
record, I am persuaded that Maher's abdominal pain and related
symptoms effectively prevent her "from performing any and every
duty of any occupation or employment, for which [she] is reasonably
qualified by education, training or experience." Hence, I believe
we must go beyond vacating the district court's grant of summary
judgment in favor of the Plan and remand for entry of judgment in
Maher's favor. I therefore dissent.
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