Myra Ray v. Sun Life & Health Insurance Company ( 2011 )

[DO NOT PUBLISH]
IN THE UNITED STATES COURT OF APPEALS
FOR THE ELEVENTH CIRCUIT
________________________ FILED
U.S. COURT OF APPEALS
ELEVENTH CIRCUIT
No. 10-14693 OCTOBER 21, 2011
Non-Argument Calendar JOHN LEY
________________________ CLERK
D.C. Docket No. 4:09-cv-00238-KOB
MYRA RAY,
Plaintiff -
Counter-Defendant -
Appellant,
versus
SUN LIFE & HEALTH INSURANCE COMPANY,
Defendant -
Counter-Claimant -
Appellee.
________________________
Appeal from the United States District Court
for the Northern District of Alabama
________________________
(October 21, 2011)
Before EDMONDSON, HULL, and MARTIN, Circuit Judges.
PER CURIAM:
Plaintiff-Appellant Myra Ray appeals the district court’s decision affirming
the termination of her long-term disability benefits. No reversible error has been
shown; we affirm.
Through her employer, Ray was covered under a long-term group disability
plan insured by Defendant-Appellee Sun Life and Health Insurance Company
(“Sun Life”). The ERISA plan document provided that GE Group Life Assurance
Company1 was the claims fiduciary and broadly granted the claims fiduciary
discretionary authority to make all claim, eligibility and other administrative
decisions. The claims fiduciary was granted sole and exclusive discretion and
authority to carry out all acts involving claims, and its findings and decisions on
claims were not to be disturbed unless the claims fiduciary acted in an arbitrary
and capricious manner.2
Before claiming disability, Ray was a senior executive with a long-time
work history with her employer. In September 2005, Ray claimed that she had
1
The policy was issued by GE Group Life Assurance Company. GE Group Life
Assurance Company changed its name to Phoenix Life Insurance Company and Phoenix Life
Insurance Company changed its name to Genworth Life and Health Insurance Company.
Genworth Life and Health Insurance Company changed its name to that of the Defendant, Sun
Life and Health Insurance Company.
2
Ray disputes that Sun Life was granted discretion under the plan. Ray argues that a
change of ownership of Genworth Life and Health Insurance Company accompanied the latter’s
change of name to that of Sun Life. But Ray offers nothing to dispute that the entity first known
as GE Group Life Assurance Company is the same entity now known as Sun Life. The district
court concluded correctly that Sun Life has discretion under the plan.
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become disabled as a result of a heart condition. In support of her claim, Ray
submitted a statement from her treating cardiologist, Dr. Bourge, that indicated her
heart condition limited completely her ability to work. Ray’s claim for long-term
disability benefits was approved, but she was advised that periodic medical
updates would be required to verify that she remained totally disabled.
Dr. Bourge confirmed Ray’s disability in statements sent to Sun Life in
2006 through 2008. But, as the district court set out in its opinion, Dr. Bourge’s
office notes often were inconsistent with the disability statements submitted to Sun
Life; the office notes suggested that Ray’s condition was much improved, that she
suffered far fewer symptoms than was represented to Sun Life, and that she was
capable of -- and engaged in -- much more activity than the disability statements
disclosed. Sun Life ordered surveillance of Ray’s activities on two dates in the
spring of 2008. The surveillance videos showed Ray engaged in activities with a
fluidity of movement, without need of assistance, and without apparent effort. The
video contradicted Dr. Bourge’s representations of Ray’s limitations in the
disability statements he submitted to Sun Life.
Sun Life engaged Dr. Eaton, an independent medical consultant with
credentials comparable to those of Dr. Bourge, to evaluate Ray’s medical records
and the surveillance information. On the basis of those medical records (including
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Dr. Bourge’s office notes) and the surveillance tapes, Dr. Eaton concluded that
Ray was capable of returning to her own occupation. Dr. Eaton performed no
physical examination of Ray.
Based on Ray’s medical records, the surveillance tapes, and Dr. Eaton’s
independent evaluation, Sun Life notified Ray that her disability benefits would be
discontinued 31 May 2008. Ray appealed that determination. While Ray’s
disability termination was on administrative appeal, the Social Security
Administration (“SSA”) awarded Ray social security benefits. Dr. Anderson, a
heart specialist and SSA consultant, testified at the SSA hearing that her treating
physician classified her condition as incompatible with gainful employment.
According to the SSA benefits award letter, Ray’s medical records support and
confirm Dr. Anderson’s testimony. Ray submitted the SSA award information to
Sun Life for consideration during the appeal process. Ray also submitted a SSA
questionnaire completed by Dr. Bourge stating that Ray was permanently disabled.
During the pendency of the administrative appeal, Sun Life engaged a
second independent non-examining medical reviewer, Dr. Rosenberg, to assess
Ray’s claim. Based on Rays medical records (which included the results of certain
clinical tests) and the surveillance videos, Dr. Rosenberg disagreed with Dr.
Bourge’s categorization of Ray’s functional limitations. Instead, Dr. Rosenberg
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concluded that Ray was capable of light and sedentary work; she was capable of
returning to work at her own occupation. Sun Life provided Ray with a copy of
Dr. Rosenberg’s report and offered her additional time to submit information to
counter Dr. Rosenberg’s conclusion. No additional information was submitted.
Upon review of Ray’s entire claim file, Sun Life determined that Ray “has
the capacity to perform a sedentary to light occupation” and that she is not totally
disabled from the position she held with her employer before she filed for
disability, a position that falls within the sedentary to light category. Sun Life
acknowledged its receipt and consideration of the SSA’s decision to grant
disability but advised that it was not bound by that decision, that the SSA may not
have had all of the information Sun Life had, and that eligibility under the plan
was dependant on the specific terms of the policy. Ray brought this ERISA action
to challenge Sun Life’s termination of her disability benefits.
ERISA itself provides no standard for review of the benefits decision of
plan administrators. Firestone Tire and Rubber Co., v. Bruch, 109 S. Ct. 948, 953
(1989). Based on Supreme Court guidance in Firestone and Metropolitan Life Ins.
Co. v. Glenn, 128 S. Ct. 2343 (2008), we have established a multi-step framework
for review of ERISA benefit decisions:
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(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 admininstrator’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) If there is a conflict, the conflict should merely be a factor for the
court to take into account when determining whether an
administrator’s decision was arbitrary and capricious.
Blankenship v. Metropolitan Life Insur. Co., 644 F.3d 1350, 1355 (11th Cir. 2011).
The district court applied properly this framework.
The district court first concluded that Sun Life’s decision to terminate
benefits was not de novo wrong. The terms of the plan define totally disabled as
“unable to perform all the material and substantial duties of your regular
occupation.” Ray argues the medical records and opinions of her treating physician
(confirmed by her social security benefits award) establish her disability. But, as
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the district court fully set out, other documents in the record contradict Dr.
Bourge’s assessment; and, in fact, Dr. Bourge’s own office records and opinions
are inconsistent internally and inconsistent with his conclusion that Ray is
permanently disabled. These inconsistencies cast doubt upon the reliability of Dr.
Bourge’s assessment of the severity of Ray’s condition. Dr. Bourge’s conclusion
of total disability was contrary to the assessments of the two non-examining
medical experts who reviewed Ray’s medical history and the surveillance tapes;
these experts both opined that Ray was capable of returning to her own occupation.
No special weight is to be accorded the opinion of a treating physician. See
Black & Decker Disability Plan v. Nord, 123 S. Ct. 1965, 1970-72 (2003). And
while approval of social security benefits may be considered, it is not conclusive on
whether a claimant is also disabled under the terms of an ERISA plan. See
Whatley v. CNA Ins. Companies, 189 F.3d 1310, 1314 n.8 (11th Cir. 1999). Based
on the administrative record available to Sun Life when it made its decision, see
Blankenship, 644 F.3d at 1354 (review of benefits denial is limited to consideration
of the material available to the administrator at the time it made its decision), we
can not say that Sun Life’s denial of benefits was de novo wrong.
That we conclude that Sun Life’s decision was not de novo wrong should
end the inquiry under our multi-step framework. The district court also considered
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the reasonableness of Sun Life’s decision as if the decision was de novo wrong and
still concluded the termination was due to be affirmed after considering all steps of
the multi-step framework. In short, the district court concluded that Sun Life did
not abuse its discretion; its decision was not arbitrary and capricious; and, after
consideration of the entire record, termination was a reasonable determination.
Ray argues conflict of interest tainted Sun Life’s decision: Sun Life made
eligibility decisions and paid awarded benefits out of its own funds. But the
district court -- notwithstanding Ray’s protestations to the contrary -- did consider
Sun Life’s conflict as a factor in its assessment; it concluded that the conflict of
interest -- considered in the light of the evidence of record -- did not cause Sun Life
to abuse its discretion. It was Ray’s burden, as the claimant, to show the decision
was arbitrary; it was not Sun Life’s burden to prove its decision was not tainted by
self-interest. See id. at 1355. And even where a conflict exists, deference is owed
to the plan administrator’s discretionary decision-making. Id.
Even assuming the decision of Sun Life was de novo wrong (an assumption
we do not accept), the administrative record shows a reasonable basis existed for
Sun Life’s benefit decision; and Sun Life’s conflict of interest did not so taint its
decision so as to render the decision arbitrary and capricious.
AFFIRMED.
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