McClenahan v. Metropolitan Life Insurance Co ( 2011 )

FILED
United States Court of Appeals
Tenth Circuit
March 21, 2011
UNITED STATES COURT OF APPEALS
Elisabeth A. Shumaker
Clerk of Court
TENTH CIRCUIT
MARY McCLENAHAN,
Plaintiff - Appellant,
v.
No. 10-1101
METROPOLITAN LIFE INSURANCE
(D.C. No. 08-CV-00254-REB-KMT)
COMPANY, a New York insurance
(D. Colo.)
company; and KROGER CO.
HEALTH AND WELFARE BENEFIT
PLAN, an ERISA welfare benefit plan,
Defendants - Appellees.
ORDER AND JUDGMENT *
Before KELLY, EBEL, and GORSUCH, Circuit Judges.
This case requires us to answer two questions: First, whether a Colorado
statute operates retroactively, where it affects the standard of review courts use to
interpret plans governed by the Employee Retirement Income Security Act
(ERISA). Second, whether the insurer in this case abused its discretion in
denying a claimant disability benefits under the parties’ governing plan. To both
questions, the district court answered no and we agree.
*
This order and judgment is not binding precedent except under the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.
I
As an employee of the Kroger Company, Mary McClenahan was entitled to
benefits under the company’s health and welfare benefits plan. As part of this
ERISA plan, Metropolitan Life Insurance Company provided long-term disability
insurance to Kroger employees. Due to a neuromusculoskeletal condition,
radiculopathy, Ms. McClenahan eventually stopped working for Kroger, and
MetLife provided her benefits for a twenty-four month period that expired
March 13, 2006.
After that period, MetLife terminated payments to Ms. McClenahan.
Pursuant to a limitation clause in the plan, MetLife determined that Ms.
McClenahan couldn’t receive benefits past a twenty-four month period unless she
demonstrated continuing “objective evidence of . . . radiculopathies” —
radiculopathies defined in the plan as a “[d]isease of the peripheral nerve roots
supported by objective clinical findings of nerve pathology.” Aplt. App. Vol. III
at 385. In making its decision to deny Ms. McClenahan continued benefits past
the initial twenty-four month period, MetLife relied in part on Dr. R. Kevin
Smith’s independent review of her medical file and his conclusion that evidence
of radiculopathy was lacking.
Ms. McClenahan challenged this decision through MetLife’s internal appeal
procedures, disputing MetLife’s factual assessment that she could no longer show
objective evidence of radiculopathies. Ms. McClenahan forwarded to MetLife an
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electromyography test conducted on March 9, 2006 by Dr. John Stephens, who
reported that “there is some EMG evidence of what appears to be chronic
denervation likely in a left L5 pattern.” Aplt. App. Vol. III at 564. For its part,
during the claims review process MetLife consulted other in-house medical
advisors and independent physicians besides Dr. Smith, including Dr. Joseph
Monkofsy who concluded that neither the March 9 EMG report nor other medical
files demonstrated “any of the exclusionary diagnoses listed . . . including current
objective evidence of radiculopathy.” Aplt. App. Vol. III at 528. MetLife also
asked Ms. McClenahan’s physician, Dr. John Drye, to review MetLife’s findings.
Disagreeing with the other physicians consulted by MetLife, Dr. Drye believed
Ms. McClenahan’s disability had objective evidence of radiculopathies. Aplt.
App. Vol. III at 509. Based on the entire record before it, MetLife nevertheless
upheld its original determination to deny Ms. McClenahan any further benefits.
Having exhausted MetLife’s appeals process, Ms. McClenahan brought this
lawsuit, arguing that MetLife erred in its assessment of her condition and arguing
that she should be allowed to supplement the administrative record with a new
medical report dated March 19, 2008. The district court held the new medical
report inadmissible and eventually granted summary judgment in favor of
MetLife.
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II
In this appeal, Ms. McClenahan contends that a newly enacted Colorado
statute subjects MetLife’s claims decisions to de novo review, and that the district
court erred by applying a lesser, abuse of discretion standard to MetLife’s
determination. Further, even if an abuse of discretion standard does apply, Ms.
McClenahan argues that MetLife abused its discretion. Finally, Ms. McClenahan
contests the district court’s exclusion of the March 19, 2008 medical report. We
address each of these arguments in turn.
A
The United States Supreme Court has told us that the denial of benefits
under an ERISA plan is reviewed for abuse of discretion if the plan gives the plan
fiduciary — here, MetLife — discretionary authority to determine eligibility for
benefits or to construe the terms of the plan. See Firestone Tire & Rubber Co. v.
Bruch, 489 U.S. 101, 115 (1989). Before us both sides agree that the policy gives
MetLife discretion, and the district court applied the abuse of discretion standard
when conducting its review of MetLife’s disability determination.
Still, Ms. McClenahan argues the district court erred when it reviewed
MetLife’s decision for an abuse of discretion; in her view, the court should have
applied de novo standard of review. This is so, she insists, because of a relatively
recent Colorado statute requiring “de novo [review] in any court with
jurisdiction” for a disability benefits “claim [that] has been denied in whole or in
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part.” Colo. Rev. Stat. § 10-3-1116(3). Notably, neither side before us suggests
that Colorado’s statute is preempted by ERISA. Instead, they disagree only over
the application of the state statute to this suit according to its own terms. Because
we agree with MetLife that the statute doesn’t apply to this suit we have no
occasion to pass on the question whether, if applicable, the Colorado statute
might or might not be preempted by ERISA.
To apply to this case at all, the Colorado statute must operate retroactively.
That’s because § 10-3-1116 was enacted after all the events at issue had occurred,
including the plan’s formation and MetLife’s denial of benefits. See In re Estate
of Dewitt, 54 P.3d 849, 854 (Colo. 2002) (“[A] statute is presumed to operate
prospectively, meaning it operates on transactions occurring after its effective
date.”) (emphasis added). In deciding whether a statute can be applied
retroactively under Colorado law, a court must ask two questions. First, the court
must ask if the Colorado General Assembly clearly intended the statute to have
retroactive effect. Second, if the legislature did so intend, the court must then ask
if the statute is unconstitutionally retrospective. See Dewitt, 54 P.3d at 854;
Colo. Const. Art. II, § 11 (prohibiting any statute that is “retrospective in its
operation.”) (emphasis added). A statute intended to operate retroactively is
impermissibly retrospective under the Colorado constitution — and thus can’t be
applied retroactively under state law — if but only if it impairs a vested right,
creates a new obligation, imposes a new duty, or attaches a new disability. See
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Dewitt, 54 P.3d at 854; Cont’l Title Co. v. District Court, 645 P.2d 1310, 1314-15
(Colo. 1982) (allowing retroactive application of a law where its only effect was
to “provide an alternative remedy for vindication of the alleged discriminatory
and unfair employment practice”).
Conflating the terms “retroactive” and “retrospective,” Ms. McClenahan
argues that Colo. Rev. Stat. § 10-3-1116(3) can apply to this case because it
doesn’t constitute an impairment of a vested right or imposition of a new duty.
After all, she says, the statute only affects a court’s standard of review. But even
assuming without deciding that the statute before us doesn’t impair any vested
right and so isn’t retrospective, Ms. McClenahan fails to show that the legislature
clearly intended the statute to have retroactive effect — the first step of the two-
part test under Colorado law. Indeed, at oral argument Ms. McClenahan’s
counsel admitted he couldn’t discern any such intent, and neither do we. While
an express “declaration” of retroactivity isn’t required, there is no indication that
the statute before us was ever intended to apply to prior conduct. Cf. Ficarra v.
Dep’t of Regulatory Agencies, 849 P.2d 6, 12-14 (Colo. 1993) (finding
“unmistakable intent” of retroactivity, where the statute on its face would ascribe
“to certain transactions that occurred before the effective date of the [amendment]
different legal effects from that which they had under the law when they
occurred.”). So it is that under Colorado Supreme Court precedent, the statute
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here can’t be applied to MetLife’s claim determination, and the district court
properly reviewed MetLife’s decision in this case for abuse of discretion.
B
We now turn to the propriety of the district court’s holding that MetLife did
not abuse its discretion, or act arbitrarily and capriciously, when denying Ms.
McClenahan’s claim for continued benefits. In the ERISA context, the terms
“abuse of discretion” and “arbitrary and capricious” are used interchangeably, at
least in this circuit. Weber v. GE Group Life Assur. Co., 541 F.3d 1002, 1010
n.10 (10th Cir. 2008). And a decision is arbitrary and capricious if it lacks a
“reasonable basis” or is not supported by substantial evidence. See Adamson v.
Unum Life Ins. Co. of Am., 455 F.3d 1209, 1212 (10th Cir. 2006) (“[T]here is no
requirement that the basis be the only logical one or even the superlative one . . .
[only that] the administrator’s decision resides somewhere on a continuum of
reasonableness — even if on the low end.”); Sandoval v. Aetna Life & Cas. Ins.
Co., 967 F.2d 377, 382 (10th Cir. 1992). Based on the record as a whole,
evidence is substantial if a “reasonable mind might accept [it] as adequate to
support the conclusion reached by the [decisionmaker].” Sandoval, 967 F.2d at
382 (citation omitted). While the decisionmaker must take into account
“whatever in the record fairly detracts from” its determination, substantial
evidence requires “more than a scintilla but less than a preponderance.” Id.(citation omitted).
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Because MetLife suffers from a conflict of interest in this case — a conflict
created by the fact that MetLife pays benefits out of its own pocket and
determines whether an employee is eligible — we “dial back our deference,”
weighing the conflict as a “factor in determining whether there is an abuse of
discretion.” Weber, 541 F.3d at 1010; Holcomb v. Unum Life Ins. Co. of Am., 578
F.3d 1187, 1192-93 (10th Cir. 2009). The plaintiff nevertheless retains the
burden of showing abuse. See Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 116
(2008); Holcomb, 578 F.3d at 1192-93 (10th Cir. 2009) (recognizing abrogation
of Fought v. Unum Life Ins. Co. of Am., 379 F.3d 997, 1005 (10th Cir. 2004)).
We agree with the district court that Ms. McClenahan failed to carry her
burden in this case. This is because we can’t say MetLife acted unreasonably
when it denied benefits after she failed to provide evidence of radiculopathies on
or after March 13, 2006. MetLife consulted in-house nurses and doctors, as well
as independent physicians, and sought out responses from Ms. McClenahan’s own
treating physicians. Cf. Holcomb, 578 F.3d at 1193 (“Unum took steps to reduce
its inherent bias by hiring two independent physicians . . . .”). For example,
independent physician Dr. Smith concluded that “[a]s it relates to the claimant’s
neuromusculoskeletal and soft tissue disorders, the medical records do not
indicate objective clinical evidence for . . . radiculopathies . . . .” Aplt. App. Vol.
IV at 636. Moreover, Dr. Smith wrote that “[r]ecent exam findings” indicated
“no neuromuscular abnormalities or nerve root tension signs consistent with
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radiculopathies.” Id. After Ms. McClenahan challenged MetLife’s initial claim
denial, MetLife consulted another independent physician, Dr. Monkofsky. While
asked by MetLife to look for evidence of radiculopathies “beyond March 13,
2006,” Dr. Monkofsky conducted a more extensive review, examining Ms.
McClenahan’s records dating from October 2003 through October 2007 — the
date he performed his review. 1 See Aplt. App. Vol. III at 520, 527-29.
Ultimately, he concluded that “there was insufficient objective medical evidence
to support any of the exclusionary diagnoses . . . including current objective
evidence of radiculopathy.” Id. at 528. Referring specifically to the March 9,
2006 EMG report, he noted that “[o]ld diagnostic reports indicating evidence of
‘chronic denervation’ at L5 do not support current or continuing evidence of
radiculopathy.” Id.
That Ms. McClenahan’s physician, Dr. Drye, drew a contrary conclusion
doesn’t suffice to render MetLife’s decision arbitrary and capricious. After all,
MetLife has no obligation 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.” Black & Decker Disability Plan v. Nord, 538
1
Dr. Monkofsky, in his report, rephrased MetLife’s question as “Is there
any evidence of the exclusions listed below [including radiculopathy] beyond
3/16/06?” Aplt. App. Vol. III, at 527. We don’t think this typographical
inconsistency infects Dr. Monkofsky’s analysis as to render it unreliable. In any
event, Ms. McClenahan doesn’t argue otherwise.
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U.S. 822, 834 (2003). Of course, it’s equally true that insurers “may not
arbitrarily refuse to credit a claimant’s reliable evidence, including the opinions
of a treating physician.” Id. But in this case, MetLife didn’t disregard Dr. Drye’s
opinion. To the contrary, it sought out his expertise in light of inconsistent
medical conclusions from other physicians; analyzed and relied on the
conclusions of various physicians (both in-house and independent); requested the
claimant to supplement her medical file throughout the administrative appeals
process; and considered opinions from the other side. See, e.g., Holcomb, 578
F.3d at 1193 (denial of benefits was not an abuse of discretion, even though the
insurer “received a large volume of reports, letters, imaging studies, and exams
that were not entirely consistent”). MetLife’s ultimate decision may not have
been the one Ms. McClenahan sought, and it may not have been the only decision
available to the company on the record created by the parties. But neither can we
say that its decision was an unreasonable one unsupported by substantial
evidence. And more than that our precedent does not require.
In reply, Ms. McClenahan places heavy emphasis on Dr. Stephens’s
March 9 report, arguing that MetLife gave it unduly short shrift. But to establish
Ms. McClenahan’s entitlement to benefits after March 13, MetLife’s policy
required evidence establishing her continuing disability on or after that date. Dr.
Stephens’s examination establishing that she suffered from radiculopathy at an
earlier date, even a reasonably proximate earlier date, may very well suggest she
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continued to suffer from the disorder on or after March 13, but it cannot suffice to
compel such a conclusion. After all, patients sometimes do improve. Besides,
even considering the March 9 report on its own terms, it rated Ms. McClenahan’s
overall motor functions as normal and suggested that denervation near her lower
spinal column was “likely,” not certain. Aplt. App. Vol. III at 564. Given the
equivocal nature of this finding and its timing, we cannot disagree with the
district court’s conclusion that it was reasonable for MetLife to rely more heavily
on other physicians who found no evidence of radiculopathies present on or after
March 13.
To be sure, Ms. McClenahan also argues that Dr. Monkofsky’s statement —
that there was no “current or continuing evidence of radiculopathy” — suggests
he only looked for radiculopathies as of October 2007, the time he examined her
medical records. And this is a problem, Ms. McClenahan argues, because
MetLife itself indicated that it was her condition as of March 13, 2006, not some
later date, that mattered for determining her entitlement to continued disability
benefits. But reading the physician’s report as a whole, we can’t draw the
inference Ms. McClenahan suggests. Cf. Holcomb, 578 F.3d at 1194 (“Because
[claimant’s] argument overstates the significance of one sentence in a large
administrative record, it is unavailing.”). In responding to MetLife’s inquiry, Dr.
Monkofsky’s report expressly took account of Ms. McClenahan’s medical data
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available from October 2003 through October 2007 — belying any contention that
he was only concerned about the presence of radiculopathies in October 2007.
C
Finally, Ms. McClenahan argues that the district court erred by denying her
request to supplement the administrative record with a medical report dated
March 19, 2008. Again, we cannot agree. Before closing her file in November
2007, MetLife provided Ms. McClenahan with plenty of notice and time to submit
evidence of radiculopathies “beyond” March 13, 2006, but the evidence she
submitted only suggested prior radiculopathy. Aplt. App. Vol. IV at 607
(“April 6, 2007 letter”) (asking her to “include copies of all medical
documentation to support that [she] has remained disabled from any occupation
beyond March 13, 2006 due to” radiculopathies). In these circumstances, the
district court properly ruled that it was obligated to reject Ms. McClenahan’s
effort to introduce new evidence in the trial court proceedings and to limit its
review to the administrative record. Indeed, our binding precedent offered the
district court no other possible path. See Hall v. Unum Life Ins. Co. of Am., 300
F.3d 1197, 1200-01 (10th Cir. 2002); Metzger v. Unum Life Ins. Co. of Am., 476
F.3d 1161, 1166 (10th Cir. 2007) (“Permitting a claimant to receive and rebut
medical opinion reports generated in the course of an administrative appeal . . .
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would set up an unnecessary cycle of submission, review, re-submission, and re-
review.”). 2
The judgment of the district court is affirmed.
ENTERED FOR THE COURT
Neil M. Gorsuch
Circuit Judge
2
Ms. McClenahan’s unopposed motion to seal volumes three through eight
of the appendix, containing personal medical information, is granted.
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