Chalker v. Raytheon Company , 291 F. App'x 138 ( 2008 )

FILED
United States Court of Appeals
Tenth Circuit
August 19, 2008
UNITED STATES COURT OF APPEALS
Elisabeth A. Shumaker
TENTH CIRCUIT Clerk of Court
MATHEW B. CHALKER,
Plaintiff-Appellant,
v.
RAYTHEON COMPANY; No. 07-4069
RAYTHEON COMPANY LONG- (D.C. No. 2:05-CV-00869-TS)
TERM DISABILITY PLAN; (D. Utah)
RAYTHEON EMPLOYEES
DISABILITY TRUST;
METROPOLITAN LIFE INSURANCE
COMPANY,
Defendants-Appellees.
ORDER AND JUDGMENT *
Before BRISCOE, EBEL, and MURPHY, Circuit Judges.
Plaintiff-Appellant Mathew Chalker appeals the district court’s entry of
judgment based on the administrative record in favor of Defendants-Appellees
Raytheon and Metropolitan Life Insurance Company (“MetLife”). This case
arises out of Chalker’s allegation that Defendants wrongfully terminated his long-
*
This order and judgment is not binding precedent, except under the
doctrines of law of the case, res judicata, and collateral estoppel. It may be cited,
however, for its persuasive value consistent with Fed. R. App. P. 32.1 and 10th
Cir. R. 32.1.
term disability benefits under the Employee Retirement Income Security Act
(“ERISA”), 29 U.S.C. § 1132. The district court disposed of Chalker’s claims on
two grounds: (1) Chalker’s suit was time-barred by a one-year contractual
limitations period contained in the company’s Long-Term Disability Plan (“the
Plan”), and (2) even if Chalker’s suit were not time-barred, MetLife’s decision to
terminate Chalker’s benefits was not arbitrary and capricious. Chalker now
appeals. We exercise jurisdiction pursuant to 28 U.S.C. § 1291 and AFFIRM.
I. BACKGROUND
From 1977 until 2000, Chalker was employed in Raytheon’s Human
Resources Department, eventually serving as the Department’s Senior Manager.
While with Raytheon, Chalker participated in the Plan. The Plan is sponsored and
administered by Raytheon, while MetLife is the long-term disability (“LTD”)
claims administrator. As the LTD claims administrator, MetLife determines “all
claims for [b]enefits and questions which may arise under the Plan with respect to
the payment of [b]enefits....” The Plan specifically provides that these decisions
“shall be conclusive and binding on all persons, unless a court of competent
jurisdiction determines that [MetLife’s] decision was arbitrary or capricious.”
MetLife has no financial obligations under the Plan, which is funded exclusively
by Raytheon employees.
As provided for in the Plan, an individual is considered disabled “for the
first 15 months [he] is receiving LTD benefits if [he is] unable to perform the
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essential elements of [his] job with reasonable accommodation.” Once this
15-month period has expired, an individual continues to be eligible for LTD
benefits only if he is “unable to work at any job for which [he is] reasonably
qualified by training, education or experience....” While receiving benefits, an
individual may be asked to “provide proof of [a] continued disability.”
Individuals who believe they have been wrongfully denied benefits under
the Plan may commence civil actions after exhausting a number of administrative
remedies. However,
no action at law or in equity shall be brought to recover Benefits
under the Plan prior to expiration of sixty (60) days after a claim has
been filed in accordance with the requirements of the Plan, nor shall
an action be brought at all unless within one (1) year after expiration
of the time permitted under the Plan for furnishing proof of disability
to the Claims Administrator.
This information is not contained in the Summary Plan Description (“SPD”).
In November of 2000, Chalker became unable to continue his employment
with Raytheon due to a variety of medical difficulties. Chalker thereafter
requested LTD benefits; MetLife initially approved those benefits in February of
2001. At this time, Chalker was diagnosed with major depressive disorder,
generalized anxiety disorder, and fibromyalgia.
Over the next year, Chalker’s condition showed little improvement. In May
of 2002, Katherine Thompson, Chalker’s clinical nurse specialist, asserted that
Chalker was “not anywhere [near] ready to [return to work] due to his physical
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condition….” Similarly, in December of that same year, Dr. McBride, Chalker’s
treating physician, asserted that Chalker’s “physical abilities are poor but
improving languidly. At this time, [Chalker] cannot perform any job.” Eight
months later, in August of 2003, Chalker’s condition still had not improved. To
that effect, Dr. Jepson, Chalker’s subsequent treating physician, noted that
Chalker could not “perform any activity for more than 5-10 minutes” and was to
“avoid completely” standing, sitting, or reaching, among other activities. Based
on such concerns, MetLife continued Chalker’s LTD benefits.
Some time later, in February of 2004, Chalker underwent a Facility
Capacity Evaluation (“FCE”) at MetLife’s direction. As part of the FCE, Chalker
was asked to perform 21 different physical tasks, including pushing, pulling, and
sitting. According to John Michael Orr, the FCE administrator, Chalker
“participated fully in 2 out of 21 tasks ... and demonstrated self-limiting
participation by stopping tasks early due only to reasons of pain on 19 out of 21
tasks....”
Based on Chalker’s performance during the FCE, Orr opined that Chalker
was “capable of performing physical work at the Light level, as defined by the
U.S. Department of Labor....” Orr further noted that “[t]his overall level of work
is merely a guideline, if accommodations are made based on the specific abilities
and tolerances demonstrated, other levels of work may be feasible.”
Nevertheless, Orr concluded that “[g]iven [Chalker’s] tendency toward self-
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limiting physical demands secondary to increasing pain levels and his reduced
position tolerances for sustained sitting and standing, it [was] difficult to predict
whether Mr. Chalker could maintain the Sedentary level of work for the 8-hour
day.”
Orr’s basic conclusions were supported by Dr. Tracey Schmidt, an
independent physician consultant (“IPC”) to whom MetLife provided the results
of Chalker’s FCE. According to a report prepared by Dr. Schmidt, who is Board
Certified in Internal Medicine and Rheumatology, Chalker
was given a light work capacity [on the FCE] due to significant self-
limiting behavior. Therefore, this represents a minimum, not a
maximum, work capacity.... By self-limiting on the FCE, no
maximum work capacity could be ascertained, but there was no
objective evidence [Chalker] would be unable to work in a light
capacity on a full-time basis.
On the heels of Dr. Schmidt’s report, in May of 2004, MetLife obtained an
Employability Assessment and Labor Market Analysis regarding Chalker. This
analysis concluded that “Chalker possesse[d] transferable skills and aptitudes and
temperaments for other occupations” and that “3 [such] potential occupations for
which Mr. Chalker [was] qualified” existed in his geographic area. Each of these
potential occupations required a light level of physical exertion and involved
managerial responsibilities.
In light of the Employability Assessment and Labor Market Analysis, in
June of 2004, MetLife informed Chalker that “[b]ased upon a thorough and
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extensive review and evaluation of all the medical information submitted by
[Chalker], [his] physicians, and all the documentation contained in [Chalker’s]
claim file,” Chalker no longer qualified for LTD benefits under the Plan. In
reaching this decision, MetLife cited the FCE, Dr. Schmidt’s report, and the
Employability Assessment and Labor Market Analysis. MetLife’s letter
concluded that
in view of the above, we have determined that the medical evidence
submitted does not support the existence of a totally disabling
condition preventing you from performing any and all occupations
for which you are reasonably qualified.... Therefore, under the terms
of the Plan, we have no alternative but to terminate your benefits
effective May 28, 2004.
In July of 2004, Chalker appealed MetLife’s decision. According to
Chalker, “[a] significant portion of the medical evidence was left out of [his] file
and was not considered during the first review, which led to an incorrect
conclusion about [his] disability.” Chief among this evidence according to
Chalker was a Statement of Functional Capacity (“SFC”) completed by Dr.
Jepson, asserting that Chalker was “‘totally disabled for any occupation for an
indefinite period of time.’” Chalker also offered letters from Drs. Jepson and
McBride indicating that he was totally disabled and unable to perform any job.
Dr. Jepson’s letter specifically took issue with the FCE:
With regard to [Chalker’s] functional capacity evaluation on
February 5, 2004, I think MetLife should be aware that he suffered
for several days with a post-activity spasm pain known as “after
discharge” pain. He was in bed for several days afterwards. During
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the evaluation itself he had to rest in a combination of lying down
and sitting for about 120 minutes. He was only able to perform
activities for about 60 minutes. Therefore, it seems impossible that
[Chalker] would be able to work eight hours each day, five days a
week.
Thus, Dr. Jepson opined that Chalker was “completely and permanently disabled
from any occupation....”
Following its receipt of Chalker’s appeal, in August of 2004, MetLife
obtained an additional report from another IPC, Dr. Elinor Mody (who like Dr.
Schmidt, is Board Certified in Internal Medicine and Rheumatology). According
to Dr. Mody’s report, she had a telephone conversation with Dr. McBride, in
which Dr. McBride allegedly asserted that “Chalker had no inflamed joints and all
of his disabling diagnosis were subjective. Mr. Chalker has improved quite a bit
on medication. He can now walk down the stairs without difficulty; initially he
would not even leave the bed.” In light these remarks and the additional
information contained in the various reports concerning Chalker, Dr. Mody
concluded that “[t]here is no clear medical evidence in terms of [Chalker’s]
physical health to support recommending against all work. Mr. Chalker has,
again, no abnormal joint findings and no significant cardiovascular disease that
has been documented. Therefore, there are no obvious adverse consequences that
come to mind from performing a sedentary job.” Thus, although Dr. Mody agreed
with the FCE and Dr. Schmidt that Chalker was capable of some level of work,
she believed this work could be at the sedentary level.
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In light of Dr. Mody’s conclusion that Chalker was capable of sedentary
work as opposed to light level work, in September of 2004, MetLife obtained a
new Employability Assessment and Labor Market Analysis for Chalker. This
analysis concluded that there were four available positions involving sedentary
work for which Chalker was qualified. Based on Dr. Mody’s report, as well as
the updated Employability Assessment and Labor Market Analysis, MetLife
denied Chalker’s appeal on October 5, 2004.
In denying Chalker’s appeal, MetLife was dismissive of Dr. Jepson’s SFC
because Dr. Jepson “did not provide office notes or physical exam findings. In
addition, Dr. Jepson did not comment on [Dr. Schmidt’s report]....” Additionally,
in order to support its decision, MetLife cited Dr. Mody’s report, noting that Dr.
Mody had spoken with Dr. McBride, and concluded that “there [was] no clear
medical evidence in terms of [Chalker’s] physical health to support
recommending against all work.” Lastly, MetLife cited a September 2004 report
from a psychiatrist, Dr. Reginald Givens, that concluded “there is not clear
medical evidence to support a psychiatric condition that would prevent [Chalker]
from all work.”
On October 21, 2005, over a year after MetLife denied Chalker’s appeal,
Chalker sued Defendants, asserting that he was improperly denied LTD benefits
under the Plan. Defendants filed a motion for judgment on the administrative
record. The district court granted this motion, concluding that Chalker’s claim
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was time-barred because he did not file his civil action within the one year
contractual limitations provision contained in the Plan. Alternatively, the district
court asserted that even if Chalker’s claim were not time-barred, Chalker had not
shown that MetLife’s decision to deny him LTD benefits was arbitary and
capricious. Chalker now appeals.
II. DISCUSSION
Because we believe this case can be readily decided on the merits, we need
not consider whether Chalker’s civil action is barred by the Plan’s contractual
limitations provision, and we instead focus our analysis exclusively on whether
MetLife’s decision to terminate Chalker’s benefits was arbitrary and capricious.
A. Standard of Review
The Plan grants MetLife discretionary authority to determine eligibility for
LTD benefits. 1 Therefore, we agree with the district court that MetLife’s decision
should be reviewed under the arbitrary and capricious standard. See Gaither v.
Aetna Life Ins. Co., 388 F.3d 759, 767 (10th Cir 2004). And “[b]ecause
[Chalker] has not raised the issue of a potential conflict of interest warranting an
enhanced standard of review, we assume that the pure arbitrary and capricious
standard applies.” Buckardt v. Albertson’s, Inc., 221 Fed. App’x 730, 734 (10th
1
In this regard, the Plan provides that “[t]he decisions of the Claims
Administrator shall be conclusive and binding on all persons, unless a court of
competent jurisdiction determines that such decision was arbitrary and
capricious.”
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Cir. 2007) (unpublished) (citing Fought v. UNUM Life Ins. Co. of Am., 379 F.3d
997, 1003 (10th Cir.2004)).
“The district court’s determination of whether a plan administrator’s
decision is arbitrary and capricious is a legal conclusion subject to de novo
review.” Rekstad v. U.S. Bancorp, 451 F.3d 1114, 1119 (10th Cir. 2006).
“Indicia of arbitrary and capricious decisions include lack of substantial evidence,
mistake of law, bad faith, and conflict of interest by the fiduciary.” Caldwell v.
Life Ins. Co. of N. Am., 287 F.3d 1276, 1282 (10th Cir. 2002). “Substantial
evidence is such evidence that a reasonable mind might accept as adequate to
support the conclusion reached by the decisionmaker.” Id. (alteration, quotations
omitted). “Substantial evidences requires more than a scintilla but less than a
preponderance.” Sandoval v. Aetna Life & Cas. Ins. Co., 967 F.2d 377, 382 (10th
Cir. 1992) (quotation omitted).
“When reviewing [MetLife’s decision] under the arbitrary and capricious
standard, [MetLife’s] decision need not be the only logical one nor even the best
one. It need only be sufficiently supported by facts within [its] knowledge to
counter a claim that it was arbitrary or capricious.” Kimber v. Thiokol Corp., 196
F.3d 1092, 1098 (10th Cir. 1999) (alterations, quotations omitted). With this in
mind, “[t]he decision will be upheld unless it is not grounded on any reasonable
basis.” Id. (quotation omitted).
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B. Chalker’s Arguments
Chalker briefly advances several arguments in an effort to prove that
MetLife’s decision was arbitary and capricious. We consider each in turn.
1. MetLife did not consider information provided by Chalker’s treating
physicians
Chalker’s argument that MetLife failed to consider information provided by
his treating physicians is unavailing. There is no evidence in the record
suggesting that MetLife ignored the reports of Drs. McBride and Jepson; indeed,
the evidence is to the contrary. MetLife consistently provided the reports of Drs.
McBride and Jepson to the IPCs who independently evaluated Chalker’s
condition. Although Chalker may disagree with the analysis of the IPCs, there is
simply no evidence that MetLife failed to consider the materials provided by his
treating physicians.
As the Supreme Court indicated in Black & Decker Disability Plan v. Nord,
538 U.S. 822, 834 (2003):
Plan administrators, of course, may not arbitrarily refuse to credit a
claimant’s reliable evidence, including the opinions of a treating
physician. But, we hold, courts have no warrant to require
administrators automatically to accord special weight to the opinions
of a claimant’s physician; nor may courts impose on plan
administrators a discrete burden of explanation when they credit
reliable evidence that conflicts with a treating physician’s evaluation.
Thus, it was not arbitrary and capricious for MetLife to credit the reports of the
two IPCs rather than the reports of Drs. McBride and Jepson; MetLife did not
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owe the opinions of Drs. McBride and Jepson any special deference. Meraou v.
Williams Co. Long Term Disability Plan, 221 Fed. App’x 696, 702 (10th Cir.
2007) (unpublished opinion) (asserting that “[i]n ERISA cases no special
deference is due the opinion of the claimant’s treating physician.”).
2. MetLife relied upon a flawed and inconsistent FCE
Chalker also asserts that numerous flaws with the FCE rob it of any utility
in assessing whether he ought to receive LTD benefits. In Buckardt, 221 Fed.
App’x at 736, this court considered the utility of FCEs that “contain[ed] some
contradictory findings....” At issue there were FCEs that asserted the claimant
had to change postures frequently during the evaluation, experienced
high pain levels at certain times during the testing, reported difficulty
sitting, standing, walking, and lifting, and reported pain that
prevented her from hobbies, sports, sexual relations, chores, and
work. However, despite noting these difficulties, both [FCEs]
ultimately concluded that [the claimant] was capable of modified
sedentary work.
Id. Despite these contradictory findings, this court nevertheless asserted that the
administrator could rely on the FCEs, as under the arbitrary and capricious
standard of review, “‘[t]he Administrator[’s] decision need not be the only logical
one nor even the best one. It need only be sufficiently supported by facts within
[his] knowledge to counter a claim that it was arbitrary and capricious.’” Id.(quoting Kimber, 196 F.3d at 1098.)
The same notion rings true in this case. Although there may well be some
flaws with the FCE, it is not so flawed that it could not have provided MetLife
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with any reasonable basis to terminate Chalker’s LTD benefits. That is, the
evidence is of the sort that “a reasonable mind could accept as sufficient.”
Adamson v. UNUM Life Ins. Co. of Am., 455 F.3d 1209, 1212 (10th Cir. 2006).
3. MetLife relied upon the opinions of IPCs whose qualifications with
respect to fibromyalgia were not established
Next, Chalker contends that the qualifications of Drs. Schmidt and Mody
with respect to fibromyalgia were not established. Drs. Schmidt and Mody,
however, are both Board Certified in Rheumatology; “rheumatology is the
relevant specialty for fibromyalgia.” Howell v. Astrue, 248 Fed. App’x 797, 798
(9th Cir. Sept. 19, 2007) (unpublished). Nevertheless, Chalker contends that
“[a]lthough fibromyalgia may generally be included within the field of
rheumatology, that does not mean all rheumatologists are qualified to handle
fibromyalgia cases.”
While it is no doubt true that some rheumatologists have more expertise in
fibromyalgia than others, it cannot be said that MetLife’s reliance on the opinions
of two independent, board certified rheumatologists was arbitrary and capricious.
Although MetLife may have been better served by finding rheumatologists with
fibromyalgia specialties, it cannot be concluded that doing so was required under
the arbitrary and capricious standard of review. Again, the opinions of Drs. Mody
and Schmidt, provided evidence of the sort that “a reasonable mind could accept
as sufficient.” Adamson, 455 F.3d at 1212.
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4. Defendants relied upon the opinions of IPCs who disagreed
Next, Chalker points out that Drs. Mody and Schmidt disagreed regarding
the level of work he was capable of performing. In this respect, Dr. Mody
concluded that Chalker was capable of sedentary work, while Dr. Schmidt
concluded that Chalker was capable of light level work. This disagreement,
however, is of no aid to Chalker’s claim. While Drs. Mody and Schmidt may
have disagreed about the level of work Chalker was capable of, they did not
disagree that Chalker was capable of performing some level of work. And
whether that work be at a sedentary or light level is immaterial in deciding
whether MetLife arbitrarily and capriciously denied Chalker LTD benefits.
5. Defendants failed to consider Chalker’s medication/pain/or other
circumstantial evidence in determining whether he was disabled
Finally, Chalker asserts, without elaborating, that MetLife ignored
Chalker’s medication schedule, constant pain, and “other circumstantial evidence”
in concluding that he was no longer qualified for LTD benefits. Because Chalker
does not extrapolate on these arguments, it is difficult to determine his precise
claims. In any case, the arguments are of no aid to Chalker in surmounting the
arbitrary and capricious standard of review.
Again, the question for this court is not whether MetLife made the
“correct” decision in terminating Chalker’s LTD benefits. Instead, the question is
whether MetLife had a reasonable basis for the decision that it made. We are
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confident that it did. In determining that Chalker was not qualified for LTD
benefits, MetLife relied on the evaluations of two independent, board certified
rheumatologists as well as the independent FCE, all of which suggested that
Chalker could perform some level of work. While Chalker may be able to dispute
this evidence, he cannot contradict it to such an extent that it can be said
MetLife’s decision was arbitrary and capricious.
III. CONCLUSION
Based on the foregoing, the judgment of the district court is AFFIRMED.
ENTERED FOR THE COURT
David M. Ebel
Circuit Judge
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07-4069, Chalker v. Raytheon Company, et al.
BRISCOE, J. dissenting:
I respectfully dissent. In my view, the administrative record firmly
establishes that MetLife’s decision to terminate Chalker’s disability benefits was
arbitrary and capricious because it was based, in substantial part, on a critically
flawed Functional Capacity Evaluation (FCE) summary report. Further, it is
apparent from the record on appeal that the district court erred in concluding that
Chalker’s suit was time-barred. I would reverse and remand for further
proceedings.
I.
Defendants’ termination of Chalker’s disability benefits
Although I agree with the majority’s resolution of most of the challenges
leveled by Chalker against MetLife’s decision, I disagree with the majority’s
conclusion, in Section II.B.2, that the FCE summary report was “not so flawed
that it could not have provided MetLife with any reasonable basis to terminate
Chalker’s [long-term disability] benefits.” O&J at 12-13. On this key point, I
conclude, after carefully examining the administrative record, that reasonable
minds simply could not accept as sufficient the conclusions reached in the FCE
summary report. Adamson v. Unum Life Ins. Co. of Am., 455 F.3d 1209, 1212
(10th Cir. 2006).
To begin with, the detailed findings reported in the FCE summary report
are inconsistent with, and ultimately fail to support, the conclusion reached in the
FCE summary report. In particular, the FCE summary report acknowledged that
Chalker, due to what it described as “intolerable pain” (or, alternatively, as “8” or
“8-9” on a “0-10 subjective pain scale”), was unable to complete 19 of the 21
tasks that were part of the FCE, and also “performed poorly on the sustained
sitting task due to high pain scores and a high frequency of postural adjustments .
. . .” Aplee. Supp. App. at 476. In addition, the FCE summary report
acknowledged that Chalker’s “tolerances for Light level work for the 8 hour day
[we]re difficult to predict given the extent of [his] self-limiting behavior . . . .”
Id. at 475. Nevertheless, the FCE summary report effectively criticized Chalker
for failing to “demonstrate sufficient signs of maximal physical effort on the
majority of the tasks,” id., and ultimately concluded he was “capable of
performing physical work at the Light level, as defined by the U.S. Department of
Labor in the Dictionary of Occupational Titles.” Id.
Moreover, the FCE summary report makes no mention of the fact that
Chalker, according to his own undisputed reports and those of his treating
physician, was on pain medication during the FCE and was incapacitated by pain
for several days following the FCE. That evidence, as Chalker asserts, likewise
calls into question the FCE summary report’s conclusion that he was capable of
performing “Light level” work on a full-time (8 hours per day, 40 hours per week)
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basis. 1 See Force v. Ameritech Corp., Inc., 250 Fed. Appx. 662, 669 (6th Cir.
2007) (concluding that administrator’s decision to deny benefits was arbitrary and
capricious because, in pertinent part, it was based on an internally inconsistent
FCE).
Although MetLife’s decision to terminate Chalker’s long-term disability
benefits was not based solely on the FCE summary report, the administrative
record firmly establishes that it played a significant role in MetLife’s decision.
To begin with, it is clear that it was the FCE summary report’s conclusion that
Chalker could perform full-time work at a “Light level” that led to MetLife’s
preparation of the Employability Assessment and Labor Market Analysis and, in
turn, that report’s conclusion that Chalker was capable of working full-time in
several alternative management-type roles. Further, it is clear from the
administrative record that MetLife’s consulting physicians placed significant
weight on the FCE summary report and the related Employability Assessment.
For example, Dr. Schmidt, in her April 2004 final report, opined (without having
1
In Buckardt v. Albertson’s, Inc., 221 Fed. Appx. 730, 736-37 (10th Cir.
2007), this court noted the existence of “contradictory findings” in two FCEs
performed on the plaintiff in that case, but nevertheless concluded that the
administrator’s decision to deny benefits was neither arbitrary or capricious.
Buckardt is distinguishable, however, because (a) the internal inconsistencies
cited by the plaintiff in that case were nowhere near as serious as those at issue
here, (b) there is no indication that the FCEs in Buckardt failed to account for
critical information regarding the plaintiff, as is the case here, and (c) two FCEs
were performed in Buckardt, and the two physical therapists who performed them
independently concluded that the plaintiff was capable of performing modified
sedentary work.
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personally examined Chalker) that the conclusion set forth in the FCE summary
report “represent[ed] a minimum, not a maximum, work capacity,” and that “there
was no objective evidence that [Chalker] would be unable to work in a light
capacity on a full-time basis.” Aplee. Supp. App. at 707. Similarly, Dr. Mody
noted in her written report (likewise without having personally examined Chalker)
that, according to the FCE summary report, “Chalker was found to be capable of
sedentary level activities.” Id. at 573. In turn, MetLife’s own June 3, 2004 letter
of denial noted that, according to the Employability Assessment, Chalker “ha[d]
the ability to work at a light level” and had identified “[t]hree potential
occupations for which [he was] qualified . . . .” Id. at 520. Likewise, MetLife’s
final denial letter of October 5, 2004, noted that Chalker’s benefits “were
[originally] terminated based” in part on the results of the FCE and the
Employability Assessment, id. at 611, effectively criticized Chalker for engaging
in “self-limiting” behavior during the FCE, id. at 612, and noted that, according
to the Employability Assessment, he was capable of performing other alternative
occupations, id.In summary, MetLife’s decision to terminate Chalker’s long-term disability
benefits was arbitrary and capricious due to the significant reliance that MetLife
and its consulting physicians placed on the flawed FCE summary report.
Accordingly, assuming that Chalker’s suit was timely filed, the proper route is to
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reverse the judgment of the district court and remand to MetLife for further
consideration of Chalker’s claim for long-term disability benefits.
Timeliness of Chalker’s lawsuit
As the majority notes, the district court concluded, as an alternative basis
for granting judgment in favor of defendants, that Chalker’s suit was untimely
filed. The district court’s ruling on this issue is subject to de novo review.
Wright v. Southwestern Bell Tel. Co., 925 F.2d 1288, 1290 (10th Cir. 1991) (“We
review a district court’s ruling on the applicability of a[n] [ERISA] statute of
limitations de novo.”).
ERISA contains no statute of limitations which governs claims under
section 1132(a)(1)(B) or section 1132(c). Courts therefore look to the “most
analogous” state statute of limitations, e.g., Held v. Manufacturers Hanover
Leasing Corp., 912 F.2d 1197, 1201 and n.4 (10th Cir. 1990), or if the plan itself
contains a limitations period, to the plan if the contractual limitations period is
reasonable. E.g., Northlake Reg’l Med. Ctr. v. Waffle House Sys. Employee
Benefit Plan, 160 F.3d 1301, 1303 (11th Cir. 1998); Doe v. Blue Cross & Blue
Shield United of Wis., 112 F.3d 869, 874-75 (7th Cir. 1997).
Here, it is undisputed that Section 10.10 of the Plan purports to set forth a
contractual limitations period:
Limitation of Action. In addition to the provisions of Section 10.9
[requiring exhaustion of plan remedies], no action at law or in equity
shall be brought to recover Benefits under the Plan prior to the
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expiration of sixty (60) days after a claim has been filed in
accordance with the requirements of the Plan, nor shall an action be
brought at all unless within one (1) year after expiration of the time
permitted under the Plan for furnishing proof of disability to the
Claims Administrator.
Aplee. Supp. App. at 70. Defendants argued in their motion for judgment on the
administrative record, and the district court agreed, that this one-year limitations
period was controlling, “accrued on the date that MetLife rendered its final
decision on Chalker’s administrative appeal of the termination of his benefits,”
and expired one year later, on or about October 5, 2005, approximately two weeks
before Chalker filed this action (October 21, 2005). App. at 35 (defendants’
motion for judgment on the administrative record).
a) Ambiguity of contractual limitations provision
Chalker contends that “Defendants’ contractual limitations provision is
unenforceable because it is not presented in a clear manner.” Aplt. Br. at 23. In
this regard, Chalker notes that the “contractual limitations provision . . . does not
appear within the section of the Plan dealing with claim review or appeal
procedures,” but instead “appears within the ‘General Provisions’ section of the
Plan, buried amidst legal boilerplate relating to choice of law and severability.”
Id. at 20. He also asserts that “the specific language of Defendants’ contractual
limitations provision is at best confusing, and at worst unintelligible.” Id. In
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particular, Chalker contends that the phrase “expiration of the time permitted . . .
for furnishing proof of disability,” as used in the provision, is unclear.
Addressing Chalker’s contentions in order, the positioning of the
contractual limitations provision within the Plan itself does not appear to be
problematic. To be sure, the contractual limitations provision is contained in
Article X of the Plan, which outlines the Plan’s “General Provisions,” rather than
Article VIII, which addresses the Plan’s “Claims Procedure.” That fact standing
alone, however, does not appear to render the contractual limitations provision
unenforceable.
Chalker’s contentions regarding the lack of clarity of the contractual
limitations provision, on the other hand, have merit. As noted by Chalker, the
provision states that the one-year limitations period begins running “after
expiration of the time permitted under the Plan for furnishing proof of disability
to the Claims Administrator,” Aplee. Supp. App. at 70, yet nowhere does the Plan
expressly set forth any time period for “furnishing proof of disability to the
Claims Administrator.” In the district court’s view, “[t]he ‘expiration of the time
permitted . . . for furnishing proof of disability’ clearly contemplate[d] the denial
of benefits after exhaustion of administrative remedies,” and “[t]here c[ould] be
no other reasonable interpretation for this particular provision within the Plan.”
App. at 103. The district court’s analysis on this point is suspect, however,
because the phrase “furnishing proof of disability” clearly focuses on the act of
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the claimant, i.e., submitting or furnishing documents or other evidence to the
claims administrator, and thus contemplates a point in time prior to the claims
administrator making a final determination on a claim for benefits or on the
appeal of a denial of benefits. Thus, not only does defendants’ purported
construction of the contractual limitations provision fail to comport with its
language, this critical portion of the contractual limitations provision is not
“written in a manner clearly calculated to be understood by the average plan
participant,” as required by Section 1022(a) of ERISA, 29 U.S.C. § 1132(a).
Accordingly, the consequences of defendants’ inaccurate drafting should fall
squarely on them, rather than on Chalker. See Chiles, 95 F.3d at 1518.
b) SPD’s silence as to contractual limitations period
Chalker further contends “it is undisputed that Defendants’ contractual
limitations provision does not appear within the SPD.” Aplt. Br. at 18. Thus, he
contends, “such provision is in violation of 29 U.S.C. Section 1022(a), and is
unenforceable against [him].” Id. Chalker also asserts, and correctly so, that the
district court failed to address this argument.
“Where the SPD [at issue] is silent on a provision that the plan documents
include, and plaintiff contends therefore the term cannot apply to him,” “a two-
step approach” must be used “to analyze plaintiff’s argument.” Tocker v. Philip
Morris Co., 470 F.3d 481, 488 (2d Cir. 2006). “First, relying on the statutory
language of ERISA and its implementing regulations,” the court must “look to see
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whether ERISA requires the term to be stated in the SPD.” Id. “Second,” the
court must “consider whether plaintiff was likely prejudiced by the SPD’s silence
on the term or information at issue.” Id.; see Chiles, 95 F.3d at 1519 (holding
that, where an SPD incorrectly describes Plan benefits, the claimant must
demonstrate, in order to secure relief, that he significantly relied upon, or was
possibly prejudiced by, the faulty plan description).
ERISA’s statutory language provides, in pertinent part, that “[t]he summary
plan description shall contain” information regarding “the remedies available
under the plan for the redress of claims which are denied in whole or in part . . .
.” 29 U.S.C. § 1022(b). Although this statutory language does not speak directly
to the filing of a lawsuit under ERISA or the limitations period that applies to the
filing of such a lawsuit, ERISA’s implementing regulations do. Specifically, 29
C.F.R. § 2520.102-3 outlines in substantial detail the contents that must be
included in the summary plan description. Among those requisite contents are:
The procedures governing claims for benefits . . . , applicable time
limits, and remedies available under the plan for redress of claims
which are denied in whole or in part . . . .
29 C.F.R. § 2520.102-3(s) (emphasis added). In my view, this regulatory
reference to “applicable time limits,” particularly since it is mentioned in the
same sentence as “procedures” and “remedies,” includes the applicable time
limits, after administrative appeals have been exhausted, for filing suit to
challenge a denial of benefits (especially if the time period for doing so is
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controlled by the plan at issue and is shorter than the otherwise applicable statute
of limitations).
Reviewing the SPD at issue here, it is clear that it failed to satisfy these
regulatory requirements. To be sure, the SPD outlined in detail the administrative
appeal procedures available to a claimant whose claim had been denied, including
the time limits applicable to those procedures. Aplee. Supp. App. at 25. The
SPD also contained a lengthy section entitled “YOUR RIGHTS UNDER ERISA,”
which indicated, in pertinent part, “If you have a claim for benefits that is denied
or ignored in whole or in part, you may file suit in a state or federal court.” Id. at
27. This same section also indicated, in pertinent part, that “[i]f you [the
claimant] have any questions about . . . your rights under ERISA, you should
contact the nearest office of the Pension and Welfare Benefits Administration,
U.S. Department of Labor, listed in your telephone directory, or the Division of
Technical Assistance and Inquiries [in] . . . Washington, DC . . . .” Id. Notably,
the SPD made no mention of the generally applicable time limits for filing suit
under ERISA, or of the specific time limitation for doing so that was set forth in
the Plan itself. Thus, a plan participant reviewing and relying on the SPD would
not have been aware of the Plan’s purported one-year time period for filing suit,
and, had they contacted either of the federal offices listed in the SPD to inquire
about the time for filing suit, would likely have been told only of the rule
generally applicable to ERISA law suits. In other words, the federal offices listed
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in the SPD would not have known about the unique, one-year limitations period
set forth in the Plan.
That leads to the second question in the two-part inquiry, i.e., was Chalker
“likely prejudiced” by the SPD’s silence on this matter? In other words, given
the circumstances at issue here, is it “probable” that Chalker would have filed his
action within the one-year contractual limitations period had “the SPD been
adequate”? Wilkins v. Mason Tenders Dist. Council Pension Fund, 445 F.3d 572,
585 (2d Cir. 2006). The administrative record compiled by defendants contains
nothing relevant to this inquiry (e.g., a letter from MetLife to Chalker advising
him of the one-year contractual limitations period). Nor does Chalker’s response
to defendants’ motion for judgment (e.g., an affidavit from Chalker), although
that is understandable in light of the fact that defendants’ motion was expressly
based solely on the administrative record. Given the absence of any significant
evidence on the “likely prejudice” issue, the best course in my view it to remand
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this case to the district court for further proceedings on the issue. 2 See Chiles, 95
F.3d at 1519 (“we leave it to the district court to determine the issue of reliance”).
II.
For the reasons outlined above, I would reverse the judgment of the district
court and remand for further proceedings on the issue of whether Chalker was
“likely prejudiced” by the failure of the Summary Plan Description to inform him
of the one-year contractual limitations provision. If, on remand, the district court
determines that Chalker was “likely prejudiced,” then the district court should
2
In the absence of a remand, it appears more likely than not that Chalker
was prejudiced by the SPD’s silence as to the existence of a contractual
limitations period. “[T]he SPD is an employee’s primary source of information
regarding employment benefits, and employees are entitled to rely on the
descriptions contained in the summary.” Mario v. P&C Food Mkts., Inc., 313
F.3d 758, 765 (2d Cir. 2002) (internal quotation marks omitted); see Chiles, 95
F.3d at 1519 (“the purpose of the SPD is to give employees an understanding of
the plan upon which they are entitled to rely”). An employee in Chalker’s
situation who relied exclusively on the SPD at issue in this case, including calling
one or both of the federal offices listed in the SPD, would not have been aware of
the one-year limitations period set forth in the Plan, and instead presumably
would have relied on the general principles of law applicable to ERISA claims.
Under those principles, an action seeking benefits under ERISA must comply with
the “most analogous” state statute of limitations. Held v. Manufacturers Hanover
Leasing Corp., 912 F.2d 1197 (10th Cir. 1990). In this case, which was brought
in Utah, the most analogous state statute of limitations is Utah’s three-year statute
of limitations applicable to written policies or contracts of first party insurance,
Utah Code Ann. § 31A-21-313(1). Lang v. Aetna Life Ins. Co., 196 F.3d 1102,
1104 (10th Cir. 1999) (holding that this statute was the most analogous state
statute for purposes of ERISA action filed in Utah). Thus, absent the one-year
limitations period set forth in the Plan, Chalker would have had three years in
which to file suit challenging the denial of his administrative appeal, and his
action indisputably would have been timely.
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remand the case to MetLife for further consideration of Chalker’s claim for long-
term disability benefits.
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