Ellis v. Metropolitan Life ( 1997 )

PUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
ELLEN V. ELLIS,
Plaintiff-Appellant,
v.
No. 96-2711
METROPOLITAN LIFE INSURANCE
COMPANY,
Defendant-Appellee.
Appeal from the United States District Court
for the Eastern District of Virginia, at Norfolk.
Robert G. Doumar, Senior District Judge.
(CA-95-1003-2)
Argued: July 18, 1997
Decided: September 10, 1997
Before ERVIN, Circuit Judge, and BUTZNER and
PHILLIPS, Senior Circuit Judges.
_________________________________________________________________
Affirmed by published opinion. Judge Ervin wrote the opinion, in
which Senior Judge Butzner and Senior Judge Phillips joined.
_________________________________________________________________
COUNSEL
ARGUED: John Bertram Mann, LEVIT & MANN, Richmond, Vir-
ginia, for Appellant. Alvin Pasternak, New York, New York, for
Appellee. ON BRIEF: Gregory D. Zahs, New York, New York, for
Appellee.
_________________________________________________________________
OPINION
ERVIN, Circuit Judge:
Plaintiff-Appellant Ellen V. Ellis (Ellis) appeals from an order
granting Defendant-Appellee Metropolitan Life Insurance Company's
(MetLife) cross-motion for summary judgment and denying her own.
Ellis had sought review in district court of MetLife's final determina-
tion that she was ineligible for long-term disability benefits under an
employee welfare benefit plan governed by the Employee Retirement
Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001 et seq. Ellis
alleged that MetLife had improperly denied her her benefits and
engaged in procedural errors in contravention of the statutory and reg-
ulatory requirements of ERISA. We affirm.
I.
Ellis was a branch manager for NationsBank Corporation whose
principal duties related to originating mortgage loans. She partici-
pated in NationsBank's Long Term Disability Plan (Plan). The Plan
is an employee welfare benefit plan governed by ERISA, and it is
funded by MetLife.
The Plan vests MetLife, a fiduciary under the Plan, with
discretionary authority to interpret the terms of the plan and
to determine eligibility for and entitlement to plan benefits
in accordance with the terms of the plan.
Any interpretation or determination made pursuant to
such discretionary authority shall be given full force and
effect, unless it can be shown that the determination was
arbitrary and capricious.
J.A. at 101. The terms of the Plan provide, in pertinent part, that a
participant is "disabled" if
due to an Injury or Sickness, [the participant] require[s] the
regular care and attendance of a Doctor . . . and:
2
(1) [the participant is] unable to perform each of the material
duties of [her] regular job . . . .
J.A. at 92.
In August 1993, Ellis submitted a long-term disability claim form
in which she declared that she suffered from blurred vision, balance
problems, and chronic pain which precluded her from driving, read-
ing, sitting, or standing for any length of time without rest. She indi-
cated that she believed her disability arose from a dental visit
procedure that occurred in April 1992, five days after which she
admitted herself to a hospital. MetLife subsequently initiated its
review procedure.
At MetLife's request, Ellis's health care providers submitted medi-
cal information relating to her claim. Her primary treating provider,
Michael Porvaznik, D.O., informed MetLife that, in his opinion, Ellis
was disabled, and he diagnosed her difficulties as being due to
somatic dysfunction. Records submitted by other health care provid-
ers, however, indicated that the etiology of her problems was undeter-
mined, that the results of a neurological examination were normal,
and that there were no known limitations on her return to work.
In November 1993, MetLife referred Ellis's claim file to the Inde-
pendent Board Certified Physicians Roundtable (Roundtable), an
independent medical consulting group, for an assessment of Ellis's
condition. The Roundtable members who reviewed Ellis's file con-
sisted of an internal medicine and neurology specialist, an internal
medicine and cardiology specialist, and an orthopedic surgeon. This
panel concluded that no medical diagnosis for her condition could be
confirmed. The panel suggested the possibility of an underlying psy-
chiatric disorder, but no such evidence had been submitted to them.
Functional ability on the basis of a psychiatric disorder could not be
assessed. Nonetheless, assuming that each of Ellis's symptoms were
present, the panel concluded that Ellis ought to be able to lift various
weights, to walk or stand for three to four hours a day in divided peri-
ods, and to sit for eight to ten hours a day.
Based on the Roundtable's findings, MetLife denied Ellis's claim
in a letter dated December 9, 1993. MetLife explained why her claim
3
was denied, informed her of the Roundtable's conclusions, notified
her that she could request further review within 60 days, and
explained that additional documentation could be submitted for
review.
Ellis did seek further review, and Porvaznik compiled additional
medical reports and information. Porvaznik himself characterized
Ellis's problem as severe and disabling but admitted that the etiology
remained unclear. Reports by other providers, however, were again
inconclusive. A neurobehavioral profile revealed that Ellis possessed
"considerable strengths in the majority of skills assessed, including
sensory-perceptual abilities, general intellectual abilities, and execu-
tive functioning skills." J.A. at 167. That report concluded that
"[a]lthough her symptoms are very real, and do apparently preclude
her resumption of her previous lifestyle, it is difficult to pinpoint eti-
ology of symptoms with any degree of certainty." J.A. at 168. A fur-
ther head and neck examination, MRI, audiogram, and otoscopic
examination yielded normal results. A physical therapist reported that
Ellis's performance on one test was consistent with a patient who has
sensory organization dysfunction. Another report suggested that Ellis
appears to have a predisposition to fibromyalgia and recommended a
treatment of progressive aerobic exercise. And yet another report
could find no evidence of neurological disease but admitted that the
reported symptoms were incapacitating.
MetLife submitted this new material to the Roundtable, which
added a psychiatrist to the panel of the original three members. Based
on all the information supplied, the Roundtable, in a May 16, 1994,
report, suggested that there was a reasonable basis for a probable
diagnosis of fibrositis or fibromyalgia but that it could not be confirmed.1
Still, assuming that fibrositis or fibromyalgia was present, as well as
a memory deficit, a peripheral vestibular disorder, and some element
of depression or dysthymia,2 the Roundtable determined that there
_________________________________________________________________
1 Fibrositis or fibromyalgia is a"group of common nonspecific ill-
nesses characterized by pain, tenderness, and stiffness of joints, capsules,
and adjacent structures." Taber's Cyclopedic Medical Dictionary (16th
ed. 1989).
2 Dysthymia is a "morbid anxiety and depression accompanied by
obsession." Webster's Third New International Dictionary 712 (1993).
4
was no incompatibility between Ellis's functional capacity and her
work requirements, even though her functional limitations could have
been over-estimated.
Rather than continue to deny Ellis's claim based on this report,
MetLife instead provided copies of the report to Ellis's health care
providers to seek their comments. In particular, MetLife requested
that they address whether Ellis was totally disabled with respect to her
occupation of bank branch manager and to submit objective medical
evidence of her continuing disability. Only a few of the health care
providers responded. Additional testing of Ellis was arranged, how-
ever, and MetLife continued to accept and consider evidence through
January 1995. The new reports continued to give a wide variety of
assessments. One neuro-psychologist, for example, suggested that the
environment of the banking industry, especially NationsBank's
merger with Sovran Bank and its attendant layoffs, created the poten-
tial for "secondary gain" because of Ellis's access to long-term dis-
ability benefits. See J.A. at 238. A clinical social worker, however,
discounted that hypothesis, believing that Ellis had been earning more
than $100,000 annually whereas her disability payments would
amount to only $28,000 annually. See J.A. at 245. A statement by
NationsBank placed Ellis's annual earnings at approximately
$38,700. See J.A. at 107.
MetLife submitted all of this data for a third time to the Round-
table. In place of the specialist in internal medicine and cardiology,
a specialist in internal medicine and rheumatology was substituted;
the three other panel members remained the same as on the second
panel. In a report of February 4, 1995, the panel concluded that a
diagnosis of fibrositis remained probable. But again, assuming that
diagnosis, as well as symptoms of muscle tightness, pain, and ocular
convergence, the panel determined that Ellis ought to be able to lift
even greater weights than indicated before, walk and stand six to eight
hours a day, and sit for eight to ten hours a day. This functional
capacity was yet again found not to be medically incompatible with
Ellis's work requirements.
Following this review of its earlier denial, MetLife informed Ellis
on March 28, 1995, that its decision remained the same and that her
file was closed.
5
Ellis filed this action on October 12, 1995, alleging (1) that
MetLife had failed to give her adequate written notice of the reasons
for its denial of her claim, (2) that she was not given a full and fair
review, and (3) that the denial violated the terms of the Plan and
ERISA. Following cross-motions for summary judgment, the district
court granted MetLife's motion and denied Ellis's. The court deter-
mined that, considering the inconclusive evidence of the conflicting
reports of Ellis's own health care providers as well as the three deter-
minations of the Roundtable, substantial evidence supported
MetLife's denial decision. MetLife, therefore, had not abused the dis-
cretion vested in it by the Plan, notwithstanding the slight possibility
of a financial conflict of interest. The court also concluded that
MetLife had substantially complied with the applicable regulations
interpreting ERISA in its denial letters and that, because MetLife had
done more than was required to permit Ellis to present her claim,
there was no question that she had received a full and fair review.
This appeal followed.
II.
Over the last few years, we have developed a well-settled frame-
work for review of the denial of benefits under ERISA plans. Where
a plaintiff is appealing the grant of summary judgment, we engage in
a de novo review, applying the same standards that the district court
employed. See Brogan v. Holland, 105 F.3d 158, 161 (4th Cir. 1997).
In cases where the benefit plan grants the administrator or fiduciary
discretionary authority to determine eligibility or to construe the
terms of the plan, the denial decision must be reviewed for abuse of
discretion. See Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101,
111, 115 (1989); Brogan, 105 F.3d at 161; Bedrick v. Travelers Ins.
Co., 93 F.3d 149, 152 (4th Cir. 1996); Bernstein v. CapitalCare, Inc.,
70 F.3d 783, 787 (4th Cir. 1995); Doe v. Group Hospitalization &
Medical Servs., 3 F.3d 80, 85 (4th Cir. 1993). Under this deferential
standard, the administrator or fiduciary's decision will not be dis-
turbed if it is reasonable, even if this court would have come to a dif-
ferent conclusion independently. See Bruch, 489 U.S. at 115; Brogan,
105 F.3d at 161; Haley v. Paul Revere Life Ins. Co., 77 F.3d 84, 89
(4th Cir. 1996); Bernstein, 70 F.3d at 787; Fagan v. National Stabili-
zation Agreement of the Sheet Metal Indus. Trust Fund, 60 F.3d 175,
6
180 (4th Cir. 1995); Doe, 3 F.3d at 85. Such a decision is reasonable
if it is "the result of a deliberate, principled reasoning process and if
it is supported by substantial evidence." Brogan, 105 F.3d at 161(quoting Bernstein, 70 F.3d at 788).
As an initial matter, a reviewing court determines de novo whether
the ERISA plan confers discretionary authority on the administrator
or fiduciary and, if so, whether the administrator or fiduciary acted
within that discretion. See Haley, 77 F.3d at 89. In the instant case,
there is really no question that MetLife possessed discretionary
authority to determine Ellis's entitlement to benefits and that
MetLife's denial was plainly within that scope. The parties do not dis-
pute this and the Plan's language is crystal clear. See supra part I.
(quoting Plan language). We must therefore review MetLife's denial
decision for an abuse of that discretion vested in MetLife.
Ellis argues, however, that we should determine her eligibility for
benefits de novo because MetLife, as both fiduciary of the Plan's ben-
eficiaries and the Plan's insurer, suffers from a conflict of interest.
Again, we have established a well-developed framework for consider-
ing such conflicts of interest in a court's reviewing calculus. The
Supreme Court has recognized that where a plan administrator or
fiduciary is vested with discretionary authority and is "operating
under a conflict of interest, that conflict must be weighed as a ``fac-
tor[ ] in determining whether there is an abuse of discretion.'" Bruch,
489 U.S. at 115 (quoting Restatement (Second) of Trusts § 187 cmt.
d (1959)). Because ERISA plans are governed by trust principles, this
factor is just one of several that a court should consider in determin-
ing whether an administrator or fiduciary has abused the discretion
vested in it. We have recently stated that a reviewing court should
consider, to the extent relevant,
(1) the scope of the discretion conferred; (2) the purpose of
the plan provision in which the discretion is granted; (3) any
external standard relevant to the exercise of that discretion;
(4) the administrator's motives; and (5) any conflict of inter-
est under which the administrator operates in making its
decision.
Haley, 77 F.3d at 89 (citing Restatement (Second) of Trusts § 187
cmt. d (1959)). As we recently explained in Bedrick v. Travelers
7
Insurance Company, the court applies the conflict of interest factor,
on a case by case basis, to lessen the deference normally given under
this standard of review only to the extent necessary to counteract any
influence unduly resulting from the conflict:
[W]hen a fiduciary exercises discretion in interpreting a dis-
puted term of the contract where one interpretation will fur-
ther the financial interests of the fiduciary, we will not act
as deferentially as would otherwise be appropriate. Rather,
we will review the merits of the interpretation to determine
whether it is consistent with an exercise of discretion by a
fiduciary acting free of the interests that conflict with those
of the beneficiaries. In short, the fiduciary decision will be
entitled to some deference, but this deference will be less-
ened to the degree necessary to neutralize any untoward
influence resulting from the conflict.
Bedrick, 93 F.3d at 152 (harmonizing Bruch and circuit law and quot-
ing Bailey v. Blue Cross & Blue Shield, 67 F.3d 53, 56 (4th Cir. 1995)
(quoting Doe, 3 F.3d at 87), cert. denied, 116 S. Ct. 1043 (1996)); see
also Martin v. Blue Cross & Blue Shield of Va., Inc. , 115 F.3d 1201,
1206 (4th Cir. 1997).
It therefore appears that in no case does the court deviate from the
abuse of discretion standard. Instead, the court modifies that abuse of
discretion standard according to a sliding scale. The more incentive
for the administrator or fiduciary to benefit itself by a certain interpre-
tation of benefit eligibility or other plan terms, the more objectively
reasonable the administrator or fiduciary's decision must be and the
more substantial the evidence must be to support it.
In the instant case, it is clear that an administrator or fiduciary, free
of MetLife's conflict of interest, would have been more than reason-
able in exercising its discretion to deny Ellis benefits under the cir-
cumstances of this case. The decision maker had before it three
separate reports of the independent Roundtable. 3 Each of these reports
_________________________________________________________________
3 It is worth noting that Ellis presented no evidence that the Roundtable
is not independent of MetLife or that MetLife somehow unduly influ-
ences the Roundtable's evaluation.
8
concluded that there was no conclusive diagnosis of Ellis's condition.
Each also assessed her functional limitations, even assuming her
symptoms and certain possible diagnoses. The first report implicitly,
and the second two explicitly, found no incompatibility between her
functional capabilities and the physical requirements of her job as a
bank branch manager. These reports constitute a substantial basis on
which an objectively reasonable decision maker could determine that
Ellis was not disabled within the terms of the Plan.
But MetLife had before it not just these reports by the Roundtable
specialists but also all the data submitted by Ellis and her health care
providers. Although Ellis's osteopath, Porvaznik, as well as several
other health care providers, opined that Ellis was, in fact, disabled,
there was no consensus on a diagnosis of Ellis's condition or even on
whether there was a medical cause for her symptoms. Indeed, a num-
ber of her examiners indicated that she retained"executive function-
ing skills," that she could engage in various forms of physical
exercise, and that she could return to work on a reduced schedule.
One report even suggested that the possibility that Ellis was embel-
lishing her symptoms for potential secondary gain warranted serious
consideration. Based on this conflicting data, but supported by the
independent medical assessment of the Roundtable, MetLife deter-
mined that Ellis was not "unable to perform each of the material
duties of [her] regular job" "due to an injury or sickness" and thus that
she was not disabled within the meaning of the Plan. 4 Despite
MetLife's conflict of interest, which, as the district court noted, was
greatly mitigated by its substantial reliance on the evaluations of the
independent Roundtable, we conclude that MetLife did not abuse its
discretion in denying Ellis benefits. MetLife's decision was based on
substantial evidence, and its lengthy and thorough review evinces a
deliberate, principled reasoning process.
_________________________________________________________________
4 Ellis argues that the Roundtable's evaluation of her functional capac-
ity should be discounted in light of her health care providers' determina-
tion of her disability. That is, the treating provider's conclusion should
trump that of the reviewing physician, since the former had the opportu-
nity to examine the patient while the latter had only the cold paper record
to go by. We need not, and do not, reach this issue, as it is evident that
Ellis's own providers had not reached a consensus that she was disabled
in any sense of the word (vis-a-vis the meaning within the Plan), let
alone that she could not perform the material duties of her job.
9
As fiduciary, MetLife must serve the best interests of all Plan bene-
ficiaries, not just the best interest of one potential beneficiary. Faced
with conflicting evaluations by the claimant's own health care provid-
ers, no conclusive diagnosis, and three separate reports of an indepen-
dent panel of medical specialists finding no incompatibility between
her functional limitations and her job requirements, a fiduciary free
of any conflict of interest would have been more than reasonable in
rejecting Ellis's claim and preserving the Plan's funds for those bene-
ficiaries who satisfy the Plan's definition of "disabled."
III.
In addition to challenging MetLife's denial of benefits, Ellis also
alleged procedural errors in contravention of ERISA's statutory law
and its applicable regulations. Section 503 of ERISA requires that an
adequate notice, "setting forth the specific reasons for [the] denial,
written in a manner calculated to be understood by the participant,"
as well as the opportunity for a full and fair review, must be given to
any participant whose claim is denied. 29 U.S.C.§ 1133. Ellis claims
both that her notice was deficient and that her review was not full and
fair.
A.
ERISA regulations elaborate specifically what a denial notice must
contain:
(1) The specific reason or reasons for the denial;
(2) Specific reference to pertinent plan provisions on which
the denial is based;
(3) A description of any additional material or information
necessary for the claimant to perfect the claim and an expla-
nation of why such material or information is necessary; and
(4) Appropriate information as to the steps to be taken if the
participant or beneficiary wishes to submit his or her claim
for review.
10
29 C.F.R. § 2560.503-1(f). Whether MetLife's denial notice complied
with this regulation is a question of law subject to de novo review. See
Brogan v. Holland, 105 F.3d 158, 165 (4th Cir. 1997). As we recently
re-emphasized in Brogan, substantial compliance with the spirit of the
regulation will suffice, for "[n]ot all procedural defects will invalidate
a plan administrator's decision." Id.; see also Sheppard & Enoch
Pratt Hosp., Inc. v. Travelers Ins. Co., 32 F.3d 120, 127 (4th Cir.
1994). Substantial compliance exists where the claimant is provided
with "a statement of reasons that, under the circumstances of the case,
permitted a sufficiently clear understanding of the administrator's
position to permit effective review." Brogan , 105 F.3d at 165 (internal
quotation marks and citations omitted).
In the instant case, MetLife's denial letter of December 9, 1993,
explained that Ellis's claim was denied because her functional limita-
tions did not adversely impact her ability to perform the duties of her
job, quoted the relevant Plan language defining"totally disabled,"
informed her of the Roundtable's conclusions, notified her that she
could request further review within 60 days, and explained that addi-
tional documentation could be submitted for review. 5 In all material
_________________________________________________________________
5 The denial letter states in pertinent part:
The policy states:
"Total Disability" or "Totally Disabled" means the Employee:
- is completely and continuously unable to do each of the
material duties of his job; and
- requires the regular care and attendance of a Physician.
[. . .]
We have reviewed the extensive medical information submitted
by your physicians, Michael Porvaznik, M.D. [sic], Francis
Hunter, M.D., and Robert Allen, M.D. and subsequently,
referred their reports to a Board Certified Physicians Roundtable.
This Roundtable was unable to support your claim of inability to
perform the duties of your own occupation. This is based entirely
on the physicians' evidence submitted on the restric-
tions/limitations you claim to have from headaches, vertigo, and
syncopal spells.
According to the medical records available, no specific cause of
continued syncopal spells exists. These records indicate the prior
11
respects, MetLife substantially complied with each of the ERISA reg-
ulation's requirements.
Ellis argues that the denial notice was deficient because it failed to
inform her of the information she needed to provide in order to per-
fect her claim. In particular, she asserts that the Roundtable's report,
which was not provided to her with the denial letter, but which she
later obtained, apparently during discovery, states that "additional
diagnosis and evaluations would be of merit or merit consideration."
Br. of Appellant at 41. Her argument is that, had she known this infor-
mation, she would have known what medical proof she needed in
order to prove her disability. Ellis's argument is fundamentally flawed
in two respects.
_________________________________________________________________
relatively good relief of dizziness and nausea by meclizine, the
absence of any balance, coordination or vestibular abnormalities
on clinical exam, the absence of any neurologic abnormalities of
the facial or trigeminal nerve on clinical exam, and the lack of
any medical indication of loss of higher cognitive function.
Based on the above information, we are unable to give this claim
favorable consideration from the claim effective date of August
31, 1993.
We want you to understand that our decision in this matter has
been based solely upon information contained in our file. As
such, we are willing to answer any questions or to review any
further material you would care to submit which may have an
effect upon consideration given to this claim.
[. . .]
You may request a review of the claim within 60 days of the
denial date by writing directly to Group Insurance Claims
Review, Metropolitan Life Insurance Company, at the address
indicated in this letter. . . . When requesting this review, you
should state the reason you believe the claim was improperly
denied and you may submit any data, questions or comments to
Metropolitan you deem appropriate. Metropolitan will reevaluate
all the data and you will be informed in a timely manner of our
findings.
J.A. at 159-60 (bold and underlining in original).
12
First, Ellis entirely misconstrues what the Roundtable report says.
That report actually states:
The above functional capacities do not assume that any
major improvement has occurred with treatment. However,
such might be obtainable with additional diagnosis. As
noted above, the fluctuating visual field loss may be due to
migraine phenomena, which have specific treatments for
prevention that have not been used. Evaluation for signifi-
cant postural hypotension, and its treatment if found, may
also be of merit. The other alternative, of psychiatric cause,
also may merit consideration.
J.A. at 146. The report does not say that if Ellis were diagnosed or
evaluated for certain conditions that such conditions would prove her
disability. Instead, the report states that, were her diagnosis known,
then improvement in her functional capacities might be obtained
through appropriate, directed treatment. What Ellis fails to understand
is that, even without such diagnosis, treatment, or improvement, her
functional capacities are such that she was deemed able to perform
her job duties.
Second, and more importantly, MetLife, in its denial letter,
informed Ellis of what she needed to do in order to obtain a review
of her claim pursuant to 29 C.F.R. § 2560.503-1(f)(4). MetLife was
not requiring any further information from Ellis to perfect her claim
under 29 C.F.R. § 2560.503-1(f)(3). Her claim was already complete
and perfected; no additional information was necessary for MetLife
to process it and render a decision in her case. These two provisions
of the content of notice regulation are distinct and operate indepen-
dently. Subsection (f)(3) is only implicated when there remain unre-
solved, material factual questions about which a plan administrator or
fiduciary must have information in order to review the denial of a
claim. See Brehmer v. Inland Steel Indus. Pension Plan, 114 F.3d
656, 661-62 (7th Cir. 1997). Ellis has somehow conflated these pur-
poses and come to the erroneous belief that MetLife is under an obli-
gation to inform her of what she needs to tell MetLife in order to
obtain disability benefits. That is not MetLife's role as a fiduciary.
MetLife must treat each claimant with procedural fairness, but,
because it must also guard against improper claims, it is not its duty
13
to affirmatively aid claimants in proving their claims. MetLife's
denial letter of December 9, 1993, substantially complies with the
applicable ERISA regulations in all material respects.
B.
Ellis also alleged that the review she obtained was not full and fair.
The applicable regulation provides that every ERISA plan must estab-
lish procedures under which a full and fair review may be obtained.
These procedures must, at a minimum, permit the claimant to
(i) Request a review upon written application to the plan;
(ii) Review pertinent documents; and
(iii) Submit issues and comments in writing.
29 C.F.R. § 2560.503-1(g)(1). Once a decision on review is reached,
the regulations further require that
[t]he decision on review shall be in writing and shall include
specific reasons for the decision, written in a manner calcu-
lated to be understood by the claimant, as well as specific
references to the pertinent plan provisions on which the
decision is based.
29 C.F.R. § 2560.503-1(h)(3).
It appears that neither party really comprehends what these regula-
tions require. MetLife argues, and the district court agreed, that the
review of Ellis's claim that it provided was more than eminently full
and fair. MetLife, for example, sent the Roundtable's second report
to Ellis's health care providers and allowed them the opportunity to
critique it. It subsequently repeatedly extended the deadline for Ellis's
providers to submit evidence on her behalf, and then submitted all the
data to the Roundtable yet a third time before it finally decided to
uphold its original denial and close Ellis's case. Ellis for her part
argues that she never received any of the Roundtable's reports and
that the third report in particular was crucial since she claims the
14
Roundtable specifically requested that Ellis be psychiatrically evalu-
ated according to a list of questions it prepared. Both miss the point.
The full and fair review procedural requirements serve two com-
plementary purposes. They are designed to permit a plan's adminis-
trators to resolve disputes in an efficient, streamlined, non-adversarial
manner. At the same time, the procedures ensure that a plan partici-
pant is protected from arbitrary or unprincipled decision-making. See
Weaver v. Phoenix Home Life Mut. Ins. Co., 990 F.2d 154, 157 (4th
Cir. 1993). Both the specific minimum procedural review require-
ments of subsection (g)(1) and the notice requirements of the decision
on review of subsection (h)(3) have been read as ensuring that a full
and fair review is conducted by the administrator, that a claimant is
enabled to prepare an appeal for further administrative review or
recourse to the federal courts, and that the courts can perform the task,
entrusted to them by ERISA, of reviewing a claim denial. See
Wilczynski v. Lumbermens Mut. Cas. Co., 93 F.3d 397, 402 n.3 (7th
Cir. 1996) (interpreting 29 C.F.R. § 2560.503-1(g)(1)(ii)); Halpin v.
W.W. Grainger, Inc., 962 F.2d 685, 693 (7th Cir. 1992) (interpreting
29 C.F.R. § 2560.503-1(h)(3)). Compliance that substantially fulfills
these goals suffices.
What Ellis fails to understand is that the initial decisional process
and the subsequent review process are distinct. While it appears that
Ellis did request a review in writing and submit her disputed issues
in writing in accordance with 29 C.F.R. § 2560.530-1(g)(1)(i) & (iii),
it is unclear from the record before us whether she ever requested,
either in writing or in verba, to review the pertinent documents pursu-
ant to 29 C.F.R. § 2560.530-1(g)(1)(ii). On the other hand, MetLife
did not provide these documents on its own initiative, in particular the
first report of the Roundtable on which it so heavily relied in its initial
denial of Ellis's claim. The opportunity to review the pertinent docu-
ments is critical to a full and fair review, for by that mechanism the
claimant has access to the evidence upon which the decision-maker
relied in denying the claim and thus the opportunity to challenge its
accuracy and reliability. See Wilczynski, 93 F.3d at 402; Halpin, 962
F.2d at 689. Again, although the initial denial letter and the subse-
quent review process are distinct, there is some support for the view
that, by informing a claimant of the steps to be taken to initiate the
review process, in accordance with 29 C.F.R. § 2560.530-1(f)(4),
15
there is an implicit obligation on the part of the administrator to
inform a claimant that she may review pertinent documents. See
Grossmuller v. International Union, United Auto. Aerospace and
Agric. Implement Workers of America, Local 813, 715 F.2d 853, 858
& n.5 (3d Cir. 1983) (stating, in the context of analyzing the statutory
and regulatory meaning of "full and fair review," that the "fiduciary
must also inform the participant of what evidence he relied upon and
provide him with an opportunity to examine that evidence and to sub-
mit written comments or rebuttal documentary evidence"). This
MetLife did not do. What is implicit in the ERISA regulations we
now make explicit: A plan administrator or fiduciary must inform a
claimant that, should she desire to submit her claim for review follow-
ing an initial denial, she is entitled to review the pertinent documents
upon which the initial denial decision was predicated.
The notice requirement for the decision on review must be every
bit as explicit as an initial denial notice in terms of providing specific
reasons for the continued denial and specific references to the perti-
nent plan provisions. Compare 29 C.F.R.§ 2560.503-1(h)(3) with id.
§ 2560.503-1(f)(1) & (2). What is not required, because not relevant
at this stage of the administrative review, is notice regarding how to
perfect a claim or how to seek review. Cf. 29 C.F.R. § 2560.503-
1(f)(3) & (4).
MetLife's "decision on review" letter of March 28, 1995, states in
toto:
Your request for a subsequent review of your Long Term
Disability termination of benefits has been completed.
This reply constitutes our final response in your ERISA
appeal.
Review of your claim under ERISA has previously been
completed and our decision remains the same.
Your Long Term Disability file remains closed.
Should you have any questions or concerns, you may con-
tact us at the listed number.
16
J.A. at 269. On its face, this letter is baldly deficient in specific refer-
ences to the reasons for the decision and contains no references to the
pertinent Plan provisions.
It is plain that MetLife has not followed the letter of the applicable
ERISA regulations concerning its review of Ellis's claim denial. In
the first place, MetLife ought to have informed Ellis that she could
review the documentary evidence that MetLife relied upon in reach-
ing its initial decision. In this particular case, the most critical docu-
ment was the Roundtable's first report. In the second place, MetLife
also failed to provide its rationale for its continued denial with the
requisite specificity. On the other hand, Ellis also complains that she
was never provided with the second and third Roundtable reports.
Although it was incumbent upon MetLife to describe the Round-
table's analysis to the extent MetLife based its decision on that analy-
sis, MetLife was under no duty to provide these latter two reports to
Ellis as part of the review procedures.
Were the regulations to be strictly construed as written, then, due
to these procedural defects, Ellis did not receive a full and fair review.
What is not written, however, but what is implicit in their nature, is
that there must be a causal connection between these defects and the
final denial of a claim. Although Ellis did not review the first Round-
table report, she informs us that what is important about that docu-
ment is that the Roundtable believed that certain diagnoses would
have merited consideration. However, as explained above, Ellis
entirely misconstrues what that report says. It is apparent that had
Ellis had the report, the data she could have submitted to MetLife
would not have materially affected the Roundtable's subsequent anal-
yses. Two additional factors, beyond her misunderstanding of the
report's contents, make this plain. First, Ellis was, in fact, examined
by a variety of different specialists who sought to make diagnoses of
her condition, including psychologists and psychiatrists. By her (mis)-
understanding, the Roundtable sought evaluations by psychologists or
psychiatrists, and she acquired that evidence independently. Evi-
dently, she was not prejudiced by not reviewing the report. Second,
MetLife provided a copy of the Roundtable's second report to Ellis's
health care providers. This second report was even more detailed than
the first, and it made clear that the available data on her functional
limitations did not preclude her from engaging in the physical tasks
17
of her profession. By providing this second report for critique and
permitting Ellis and her health care providers to submit additional
data in response, MetLife, in effect, neutralized any harm it may have
caused by not informing Ellis that she could have reviewed the first
report. We can see no causal link between MetLife's failure to inform
Ellis that she could review pertinent documents and the ultimate
denial of her claim.
Similarly, although MetLife's "decision on review" letter appears
woefully deficient on its face, it does state that the "decision remains
the same." We note that the purpose of the specificity requirements
in the notice provision is to permit the claimant to adequately prepare
an appeal to the federal courts and for those courts to properly review
the decision. See Wilczynski, 93 F.3d at 402 n.3; Collins v. Central
States, Southeast and Southwest Areas Health and Welfare Fund, 18
F.3d 556, 561 (8th Cir. 1994); Halpin, 962 F.2d at 693. Because the
record before us, as before the lower court, contains all of the docu-
mentary evidence that MetLife relied upon in reaching its decision,
and it is clear, as discussed above, that MetLife did not abuse its dis-
cretion in denying Ellis's claim based upon that evidence, Ellis has
in no way been prejudiced by the deficiencies in MetLife's "decision
on review" letter. Indeed, the district court interpreted the conclusion
that MetLife's "decision remain[ed] the same" as making it plain to
Ellis that the lack of medical documentation of her affliction was the
cause of the denial. Whether this be so, these deficiencies obviously
are not causally related to MetLife's ultimate denial, and Ellis has
been able to effectively prosecute her appeal in the federal courts.
Moreover, it would be pointless for us to vacate the decision below
and remand with instructions to the lower court that it should, in turn,
remand this matter to MetLife with instructions that it provide Ellis
with the specific reasons for its continued denial, since those reasons
are now apparent to all. Lex non praecipit inutilia, quia inutilis labor
stultus.
We do not believe that this disposition makes the review proce-
dures of 29 C.F.R. § 2560.503-1(g)(1) or the notice provisions of 29
C.F.R. § 2560.503-1(h)(3) toothless. We emphasize that MetLife is
saved in this instance only because the substance of the review that
MetLife did provide to Ellis was full and fair, even though it did not
technically comply with all of ERISA's procedural requirements.
18
Although we do not say that MetLife substantially complied with the
requirements, we do conclude that MetLife substantively complied
with the spirit and intent of a full and fair review in this particular
case. Ellis was not subject to an arbitrary or unprincipled decision-
making process. Hereafter, MetLife, as well as other plan administra-
tors and fiduciaries, would be well advised to ascertain their compli-
ance with these ERISA procedural requirements.
IV.
Based on the foregoing analysis of Ellis's three allegations, we
affirm the grant of summary judgment to MetLife and its denial to
Ellis.
AFFIRMED
19