Claude J. Stiltz v. Metropolitan Life Insurance Co ( 2007 )

[DO NOT PUBLISH]
IN THE UNITED STATES COURT OF APPEALS
FILED
FOR THE ELEVENTH CIRCUIT U.S. COURT OF APPEALS
________________________ ELEVENTH CIRCUIT
JUNE 5, 2007
THOMAS K. KAHN
No. 06-15180
CLERK
________________________
D. C. Docket No. 05-03052-CV-TWT-1
CLAUDE J. STILTZ,
Plaintiff-Appellant,
versus
METROPOLITAN LIFE INSURANCE COMPANY,
Defendant-Appellee.
________________________
Appeal from the United States District Court
for the Northern District of Georgia
_________________________
(June 5, 2007)
Before PRYOR, KRAVITCH and ALARCON,* Circuit Judges.
PER CURIAM:
*
Honorable Arthur L. Alarcon, United States Circuit Judge for the Ninth Circuit, sitting
by designation.
Claude J. Stiltz appeals the summary judgment against his suit for long-term
disability benefits under the Employment Retirement Income and Security Act of
1974 (ERISA), 29 U.S.C. §§ 1001 et seq. Stiltz argues that the plan administrator,
Metropolitan Life Insurance Company (MetLife), acted arbitrarily and
capriciously when it denied his claim for benefits. MetLife responds that its
decision to terminate Stiltz’s disability benefits based on a functional capacity
evaluation and reviews by two independent physicians was not wrong. We affirm.
I. BACKGROUND
Stiltz, a senior manager for a consulting firm, received disability insurance
through his employer, who obtained a group policy from MetLife. In November
2001, Stiltz became ill and was hospitalized after a business trip to India. In
December, Stiltz applied for and eventually received short-term and long-term
disability benefits from MetLife.
In the following months, Stiltz’s treating physician, Dr. Anthony Captain,
made diagnoses that included fibromyalgia, chronic fatigue syndrome, and
irritable bowel syndrome. By October 2002, Dr. Captain’s notes remarked that
Stiltz was “doing well,” but that same month, Dr. Captain submitted to MetLife a
statement regarding Stiltz’s claim, and stated that Stiltz could only work less than
three to four hours per day. Dr. Captain’s office notes from early 2003 reflect that
2
Stiltz was reporting complaints of chronic pain and an inability to function for
more than an hour at a time. Through 2004, Stiltz continued to see Dr. Captain
and various specialists for ongoing treatment of his various complaints.
In May 2003, MetLife referred Stiltz’s claim for an independent physician
review. Dr. Tracey Schmidt reviewed Stiltz’s medical records and concluded that
his file contained only subjective complaints of fatigue and lacked “sufficient
medical [evidence] to support objective evidence of physical functional capacity
impairment to any occupation.” Dr. Schmidt also remarked that the limitations
Stiltz reported to Dr. Captain were inconsistent with Stiltz’s statements on his
application for benefits that he regularly coached soccer, performed housework
and yardwork, and helped his teenaged daughters with their studies. In September
2003, MetLife asked Dr. Schmidt to review Stiltz’s file again. Dr. Schmidt
reviewed newly submitted medical records and again concluded that the file
lacked objective evidence of Stiltz’s physical impairment.
On October 6, 2003, Dr. Captain wrote to Dr. Schmidt and objected to her
conclusions. He asserted that Stiltz’s tender point joint tenderness was objective
evidence of his diagnosis of fibromyalgia and stated that Stiltz could not sustain
activity for more than an hour at a time. Dr. Schmidt undertook a third review of
Stiltz’s file for MetLife and concluded that her opinion had not changed. Dr.
3
Schmidt spoke with Dr. Captain on November 3 and encouraged Dr. Captain to
substantiate Stiltz’s subjective complaints of inability to work and concentrate by
submitting the results of a mental status examination and a functional capacity
evaluation.
On February 4, 2004, Stiltz underwent a functional capacity evaluation.
The report concluded, based on a series of tests evaluating Stiltz’s actual ability to
sit, stand, walk, climb stairs, stoop, reach, squat, kneel, and lift, that Stiltz was
capable of performing a light-duty occupation, as defined in the Department of
Labor’s Dictionary of Occupational Titles, for an eight-hour workday. The
evaluation reflected that, in an eight-hour day, Stiltz could sit, walk, stand, and
climb “frequently,” that is, one-third to two-thirds of the time.
On March 15, Dr. Schmidt reviewed Stiltz’s file for a fourth time. She
noted that a job description submitted by Stiltz’s employer included sitting three
hours, standing three hours, walking three hours, and occasionally lifting and
carrying up to 20 pounds. Dr. Schmidt concluded that this was a “light”
occupation and, based on the functional capacity evaluation, the file lacked
objective evidence of a physical functional capacity impairment to a full-time
light-duty occupation. On April 27, 2004, MetLife completed its review of Stiltz’s
claim and terminated benefits. Stiltz appealed.
4
During the appeal process, MetLife submitted Stiltz’s file to a second
independent physician for review. On January 4, 2005, after reviewing Stiltz’s
file, Dr. Dennis Gordan concluded that Stiltz was capable of light-duty work. Dr.
Gordan criticized Dr. Captain for “giving undue weight to symptoms,” and
concluded that “[Stiltz] has overreported symptoms and [Dr. Captain] has
overrated symptoms.” Dr. Gordan stated that the functional capacity evaluation,
with its “empiric basis,” gave a better estimate of Stiltz’s actual capabilities. On
January 5, MetLife upheld its decision to deny benefits. MetLife agreed to
conduct one further review.
On September 12, 2005, MetLife again concluded that Stiltz was not
entitled to benefits. MetLife relied on the definition in the Dictionary of
Occupational Titles to conclude that, despite Stiltz’s insistence that his actual job
requirements were more than light, his “own occupation” required only light
exertional capacity. The functional capacity evaluation supported the conclusion
that Stiltz could perform a “light” occupation, and no objective findings in the
medical file precluded this finding.
Stiltz sued MetLife in Georgia state court. After removing this action to
federal court, MetLife moved for summary judgment. The district court granted
that motion and denied Stiltz’s cross-motion for summary judgment.
5
II. STANDARD OF REVIEW
We review a summary judgment de novo, applying the same legal standards
as the district court. Williams v. Bellsouth Telecomms., Inc., 373 F.3d 1132, 1134
(11th Cir. 2004). The review of a denial of benefits in an ERISA case follows a
series of steps. “At each step, the court makes a determination that results in either
the progression to the next step or the end of the inquiry.” Tippitt v. Reliance
Standard Life Ins. Co., 457 F.3d 1227, 1232 (11th Cir. 2006). The six steps are as
follows:
(1) Apply the de novo standard to determine whether the claim
administrator’s benefits-denial decision is “wrong” ( i.e., the court
disagrees with the administrator’s decision); if it is not, then end the
inquiry and affirm the decision.
(2) If the administrator’s decision in fact is “de novo wrong,” then
determine whether he was vested with discretion in reviewing claims;
if not, end judicial inquiry and reverse the decision.
(3) If the administrator’s decision is “de novo wrong” and he was
vested with discretion in reviewing claims, then determine whether
“reasonable” grounds supported it (hence, review his decision under
the more deferential arbitrary and capricious standard).
(4) If no reasonable grounds exist, then end the inquiry and reverse
the administrator’s decision; if reasonable grounds do exist, then
determine if he operated under a conflict of interest.
(5) If there is no conflict, then end the inquiry and affirm the decision.
6
(6) If there is a conflict of interest, then apply heightened arbitrary
and capricious review to the decision to affirm or deny it.
Williams, 373 F.3d at 1138 (footnotes omitted).
III. DISCUSSION
Stiltz makes two basic arguments about MetLife’s decision to deny benefits.
First, he argues that MetLife erred when it interpreted the plan to define his “own
occupation” as a light-duty occupation. Second, he argues that MetLife erred
when it determined that he was not disabled by requiring him to present objective
medical evidence and improperly weighing the evidence in his file. Both
arguments fail; we discuss each in turn.
A. The Conclusion of MetLife That Stiltz’s “Own Occupation” Was Light-Duty
Was Not De Novo Wrong.
Stiltz argues that MetLife erred when it interpreted plan language regarding
his occupation. The plan defines disability as “unable to perform the material and
substantial duties of your Own Occupation,” and defines “own occupation” as
the activity that you regularly perform and that serves as your source
of income. It is not limited to the specific position you held with
Your Employer. It may be a similar activity that could be performed
with your Employer or any other employer.
MetLife applied this language and relied on the Dictionary of Occupational
Titles to conclude that Stiltz’s own occupation involved light-duty work. Stiltz
7
contends that his occupation in fact required him to do more than light-duty work,
including lifting 75 pounds, carrying 25 pounds, traveling to Washington, D.C.
weekly, traveling overseas occasionally, and working 60 to 70 hours a week. We
agree with MetLife that the actual requirements of Stiltz’s most recent position are
not controlling.
Unlike the plans reviewed in the decision upon which Stiltz relies, the
MetLife plan defines the term “occupation.” Cf. Shahpazian v. Reliance Standard
Life Ins. Co., 388 F. Supp. 2d 1368, 1377 (N.D. Ga. 2005). The clear plan
language allowed MetLife to look beyond the requirements of “the specific
position” Stiltz held. MetLife was entitled to rely on the Dictionary of
Occupational Titles, which defines the occupations of “manager” and “consultant”
as sedentary, and consider the job description provided by Stiltz’s employer,
which described Stiltz’s job as requiring three hours each of sitting, standing, and
walking each day. When a job involves exerting negligible force but requires a
significant amount of walking or standing, the “light” classification, rather than
“sedentary,” is appropriate. Dictionary of Occupational Titles app. C, § IV.
The functional capacity evaluation reflected that Stiltz could perform a
light-duty occupation as defined by the Dictionary of Occupational Titles, and that
definition was consistent with the general job description provided by Stiltz’s
8
employer. The functional capacity evaluation concluded that Stiltz could work an
eight-hour day and that he could sit, walk, and stand “frequently,” that is, one-
third to two-thirds of the time. The conclusion of MetLife, based on its
interpretation of the plan and the functional capacity evaluation, that Stiltz could
perform his light-duty occupation was not de novo wrong.
B. The Conclusion of MetLife That Stiltz Was Not Disabled
Was Not De Novo Wrong.
Stiltz criticizes the factual determination by MetLife on two grounds. First,
he argues that MetLife improperly required him to submit objective medical
evidence. Second, Stiltz argues that MetLife improperly considered the evidence
in Stiltz’s file, giving too much weight to the results of the functional capacity
evaluation and not enough weight to Stiltz’s reported limitations and the payment
of benefits by MetLife for nearly two years. Both arguments fail.
Stiltz asserts that the plan does not require a claimant to provide objective
medical evidence in support of his claim. We agree, but the record does not reveal
that MetLife denied benefits based on a failure to provide objective evidence of
Stiltz’s ailments. To borrow the words of our sister circuit, “MetLife’s
communications with [Stiltz] support its contention that it was requesting only
substantiation of the extent of [Stiltz]’s disability and not an impossible level of
9
objective proof that [he] suffered from fibromyalgia.” Pralutsky v. Metro. Life
Ins. Co., 435 F.3d 833, 839 (8th Cir. 2006). MetLife’s final decision considered
both the subjective and the objective evidence in Stiltz’s file, and MetLife found
that the objective evidence in the functional capacity evaluation was the more
reliable evidence of Stiltz’s ability to work.
Stiltz argues that MetLife’s determination placed too much weight on the
results of the functional capacity evaluation, but we disagree. MetLife never
discredited Stiltz’s subjective complaints of pain and fatigue. Cf. Hawkins v. First
Union Corp. Long-Term Disability Plan, 326 F.3d 914, 919 (7th Cir. 2003).
MetLife properly concerned itself with whether Stiltz could perform the material
and substantial duties of his occupation. The functional capacity evaluation
reflected that Stiltz could perform light-duty work for an eight-hour day, and it
was not the only evidence that Stiltz was not disabled. Stiltz’s reported non-work
activities, which included coaching a youth soccer team, participating on a
walking team, and performing housework and yardwork, were also inconsistent
with his reported work limitations. Stiltz did not bolster his file with the results of
a second functional capacity evaluation undertaken on a “bad day” or any other
evidence that the evaluation was not an accurate measurement of his abilities. Cf.
Donovan v. Eaton Corp., Long Term Disability Plan, 462 F.3d 321, 327-28 (4th
10
Cir. 2006); see Horton v. Reliance Standard Life Ins. Co., 141 F.3d 1038, 1040
(11th Cir. 1998) (ERISA claimant has burden of establishing disability).
Stiltz also argues that MetLife’s payment of disability benefits for nearly
two years should weigh against its decision to discontinue benefits. We have
never held that such a fact is a relevant consideration when we review the denial
of benefits under ERISA. Even if we were to consider the previous payment of
benefits by MetLife, it would not change our conclusion. The record reflects that
many of Stiltz’s wide-ranging complaints, such as irritable bowel symptoms and a
sleep disorder, were successfully treated after he first filed for disability benefits.
That MetLife allowed Stiltz so much time to produce evidence of his inability to
work and that he still failed to do so supports the determination by MetLife.
IV. CONCLUSION
The summary judgment for MetLife and against Stiltz’s complaint is
AFFIRMED.
11