Jones v. Unum Life Insurance Co. of America , 57 F. App'x 159 ( 2003 )

UNPUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
PEGGY C. JONES, 
Plaintiff-Appellant,
v.
 No. 02-1263
UNUM LIFE INSURANCE COMPANY OF
AMERICA,
Defendant-Appellee.

Appeal from the United States District Court
for the Western District of Virginia, at Roanoke.
James C. Turk, District Judge.
(CA-99-672-7)
Submitted: January 29, 2003
Decided: February 10, 2003
Before WILKINSON, Chief Judge, and TRAXLER and
GREGORY, Circuit Judges.
Affirmed by unpublished per curiam opinion.
COUNSEL
Roger W. Rutherford, David S. Bary, WOLFE, WILLIAMS &
RUTHERFORD, Norton, Virginia, for Appellant. Powell M. Leitch,
III, FLIPPIN, DENSMORE, MORSE & JESSEE, Roanoke, Virginia,
for Appellee.
2 JONES v. UNUM LIFE INSURANCE CO.
Unpublished opinions are not binding precedent in this circuit. See
Local Rule 36(c).
OPINION
PER CURIAM:
Peggy Jones appeals the district court’s order granting summary
judgment to defendant UNUM Life Insurance Co. (UNUM) on her
claim under the Employee Retirement Income Security Act of 1974,
29 U.S.C. § 1001 et seq. (2000) (ERISA). Jones claimed that UNUM
abused its discretion as insurance plan administrator in denying her
claim for long term disability benefits. We affirm.
Jones worked in food operations at Virginia Tech for more than
twenty years before she stopped working because of back pain. She
filed a claim for disability benefits with her insurer, UNUM. Her pol-
icy has a two-part definition of disability. For the first twenty-four
months the claimant is not working, the claimant is disabled if she
cannot perform her regular duties. After twenty-four months, the
claimant is disabled only if she cannot perform any gainful occupa-
tion for which she is qualified. UNUM eventually paid benefits for
the initial two-year period, but denied further benefits to Jones upon
a finding that her condition did not satisfy the more restrictive defini-
tion of disability that is applicable after twenty-four months.
This court has developed a well-settled framework for review of
the denial of benefits under ERISA plans. Where a plaintiff is appeal-
ing the grant of summary judgment, this court engages 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 discretion-
ary authority to determine eligibility for benefits or to construe the
terms of the plan, the denial decision must be reviewed for abuse of
discretion. See Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101,
115 (1989); Brogan, 105 F.3d at 161. Under this deferential standard,
the administrator or fiduciary’s decision will not be disturbed if it is
reasonable, even if this court would have come to a different conclu-
JONES v. UNUM LIFE INSURANCE CO. 3
sion independently. See Bruch, 489 U.S. at 115; Brogan, 105 F.3d at
161. Such a decision is reasonable if it is "the result of a deliberate,
principled reasoning process and if it is supported by substantial evi-
dence." Brogan, 105 F.3d at 161 (internal quotation omitted).
In cases like this one, when the plan administrator is also the plan’s
insurer, a conflict of interest exists. To safeguard against the potential
for bias on the part of the insurer, a reviewing court must shift the
standard of review to the extent necessary to counteract evidence of
undue influence. Elliot v. Sara Lee Corp., 190 F.3d 601, 605 (4th Cir.
1999); Ellis v. Metropolitan Life Ins. Co., 126 F.3d 228, 233 (4th Cir.
1997) (characterizing this shifting as a "sliding scale"); Hines v.
UNUM Life Ins. Co., 110 F. Supp. 2d 458, 461 (W.D. Va. 2000)
("[T]he amount of deference given to an administrator’s denial of
benefits is inversely proportional to the degree of self-dealing evident
in the record."). We find virtually no evidence of self-dealing in the
record, and therefore agree with the district court that the appropriate
standard of review remains abuse of discretion, albeit with a concomi-
tant skepticism of unsupported statements of UNUM representatives.
Given this deferential standard of review, we find that substantial
evidence supports UNUM’s decision to deny benefits. UNUM based
its decision on restrictions proposed by Jones’s own doctor. The doc-
tor changed his recommendations, but only after UNUM announced
its decision to deny additional benefits under the disability definition
applicable after twenty-four months, and he did not cite any medical
evidence of a change in Jones’s condition warranting stricter occupa-
tional limitations. In addition, the results of Jones’s functional capac-
ity examination were not consistent with an inability to perform any
gainful occupation.
Because we find UNUM’s decision reasonable, we affirm the order
of the district court. We dispense with oral argument because the facts
and legal contentions are adequately presented in the materials before
the court and argument would not aid the decisional process.
AFFIRMED