Frankton v. Metropolitan Life Insurance Company , 432 F. App'x 210 ( 2011 )

UNPUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
No. 09-2184
GEORGIA FRANKTON,
Plaintiff - Appellant,
v.
METROPOLITAN LIFE INSURANCE COMPANY,
Defendant - Appellee.
Appeal from the United States District Court for the District of
Maryland, at Baltimore. J. Frederick Motz, District Judge.
(1:08-cv-02209-JFM)
Argued: January 26, 2011 Decided: May 23, 2011
Before WILKINSON and KEENAN, Circuit Judges, and Irene C.
BERGER, United States District Judge for the Southern District
of West Virginia, sitting by designation.
Affirmed by unpublished per curiam opinion.
ARGUED: Jason Ehrenberg, BAILEY & EHRENBERG, PLLC, Washington,
D.C., for Appellant. Clifford Russell Scott, METROPOLITAN LIFE
INSURANCE COMPANY, New York, New York, for Appellee. ON BRIEF:
Adam H. Garner, MCGUIREWOODS LLP, Baltimore, Maryland, for
Appellee.
Unpublished opinions are not binding precedent in this circuit.
PER CURIAM:
Georgia Frankton, a former employee of Constellation Energy
Group, Inc. (Constellation), brought this action against
Metropolitan Life Insurance Company (MetLife), the administrator
of Constellation’s long-term disability plan. Frankton alleges
that Metropolitan violated the Employee Retirement Income
Security Act of 1974 (ERISA), 29 U.S.C. §§ 1001 et seq., by
terminating Frankton’s long-term disability benefits. The
district court awarded summary judgment in favor of Metropolitan
and, upon our review, we affirm the district court’s judgment.
I.
In 1976, Frankton began her employment with Baltimore Gas &
Electric Company, now a subsidiary of Constellation. As a
“financial reconciler” for Constellation, Frankton participated
in the Constellation Energy Group Long Term Disability Plan (the
Plan), which is an employee benefits plan governed by ERISA.
MetLife, the Plan’s claim administrator, has discretion and
authority to make benefits determinations under the Plan.
In November 2002, after Frankton stopped working for
Constellation due to multiple medical diagnoses, she timely
2
filed an application for long-term disability benefits. 1 To
support her benefits claim, Frankton included a “personal
profile,” in which she described having to lie down “a good part
of [the] day” to take pressure off her spine. Her “personal
profile” also stated that she only drives when necessary and
performs light housework in short increments.
MetLife initially denied Frankton’s disability benefits
claim. After Frankton timely appealed the decision, MetLife
approved her claim retroactive to June 1, 2003.
On December 1, 2004, as part of MetLife’s ongoing
obligation to review claims under the Plan, MetLife requested
additional documentation from Frankton to evaluate whether she
continued to qualify as “disabled” under the Plan. MetLife
explained in a letter to Frankton that the Plan’s definition for
“disabled” changes after a participant receives benefits for
twenty-four months. 2 As relevant to this appeal, after twenty-
1
At the time Frankton applied for disability benefits, she
had been diagnosed with thoracic outlet syndrome, disk
instability, cervical radiculopathy, cervical and lumbar facet
syndrome, hyperthyroidism, coccydynia, and “TMJ.”
2
The relevant language of the Plan states:
‘Disability’ or ‘Disabled’ means that, due to an
Injury or Sickness, you require the regular care
and attendance of a Doctor and:
1. you are unable to perform each of the
material duties of your job, as set forth in the
(Continued)
3
four months, the determination whether a claimant is “disabled”
shifts from an evaluation of the claimant’s ability to perform
her “regular job,” to an evaluation of the claimant’s ability to
perform “any occupation.”
In response to MetLife’s request for additional
information, Frankton sent several documents to MetLife,
including medical records from Frankton’s treating physician,
Dr. Nelson Hendler. According to a letter written by Dr.
Hendler, Frankton was “temporarily totally disabled.”
MetLife reviewed the claim file, including the documents
submitted by Dr. Hendler. Based on conflicting medical reports
in the file, MetLife concluded that Frankton should undergo an
independent medical examination.
On March 14, 2005, Dr. John Parkerson conducted an
independent medical examination of Frankton. Based on this
examination and on Dr. Parkerson’s review of Frankton’s claim
Employee’s job description that is maintained by
the Employer; and
2. after the first 24 months of Monthly Benefit
payments, you must also be unable to perform each
of the material duties of any occupation for
which you are reasonably or may reasonably become
qualified taking into consideration your prior
training or training available through a
rehabilitation program offered to you and
approved by us, your education, your experience
and your past earnings. (MET 1037-38).
4
file, Dr. Parkerson created a report for MetLife. MetLife sent
a copy of the report to Dr. Hendler and asked that he indicate
any disagreement with Dr. Parkerson’s findings and provide
MetLife with objective evidence supporting such disagreement.
Dr. Parkerson’s report included a description of Frankton’s
medical history and symptoms, and a list of the various medical
records that Dr. Parkerson reviewed before examining Frankton.
The report indicated that three of Frankton’s treating
physicians had opined that her symptoms had a significant
psychiatric component. The report listed Dr. Parkerson’s
diagnoses of Frankton, including “[s]tatus post instrumented
cervical fusion C4-6,” possible vascular thoracic outlet
syndrome, lumbar degenerative disc disease, and “depressive
disorder vs. somatoform disorder.”
Despite these various diagnoses, Dr. Parkerson’s report
stated that Frankton “could return to work at her regular job
without any specific restrictions,” and that “[t]he restrictions
provided by the attending physician are not fully supported by
the physical examination.” The report stated that Frankton was
not “temporarily totally disabled on a physical basis,” and that
her limitations “either have a primary psychiatric basis . . .
or possibly a consciously self-limiting condition.” The report
stated that her “objective examination” was “not consistent with
her reported functional status.”
5
MetLife also hired a private investigator, who conducted
video surveillance of Frankton both on the day of her
examination and on the two days following that examination. The
investigator observed Frankton walking with an “obvious limp”
while entering the office for her medical examination, but later
walking with a normal gait without any apparent discomfort. The
investigator observed Frankton bending at the waist several
times, loading groceries into her vehicle, pushing a grocery
cart, carrying clothing to a dry cleaner, retrieving packages
from her vehicle, and entering and exiting her vehicle without
any assistance.
A few weeks after Dr. Parkerson’s examination, Frankton
informed MetLife that she had been awarded Social Security
disability insurance benefits by the Social Security
Administration (Agency). MetLife instructed Frankton to send
MetLife a copy of the award letter.
MetLife never received a copy of the letter. After
reviewing Frankton’s claim file, MetLife determined that
Frankton was no longer “disabled” within the meaning of the
Plan. Accordingly, MetLife terminated Frankton’s long-term
disability benefits.
MetLife sent a letter to Frankton that explained the basis
for MetLife’s decision terminating her benefits. The letter
listed the various documents that MetLife reviewed before
6
terminating Frankton’s benefits, including the medical documents
submitted by Dr. Hendler and a statement and personal health
profile completed by Frankton. The letter explained that
MetLife had concluded that the independent medical examination
was inconsistent with Frankton’s self-described physical
limitations. The letter also indicated that Dr. Hendler had not
responded to Dr. Parkerson’s report.
Frankton appealed the decision terminating her benefits
under the Plan’s provisions. After Frankton submitted her
appeal, Dr. Hendler sent MetLife a letter dated May 4, 2005. In
the letter, Dr. Hendler indicated that he agreed with Dr.
Parkerson’s diagnoses, but that he disagreed with Dr.
Parkerson’s conclusion that Frankton’s diagnoses did not
preclude her from returning to work.
In October 2005, MetLife submitted Frankton’s claim file,
including her medical records and the May 2005 submission from
Dr. Hendler, to Dr. Dennis Gordan, an independent physician
consultant. After submitting the claim file to Dr. Gordan,
MetLife received additional documents from Dr. Hendler. MetLife
determined that these documents were largely duplicative of
other documents in Frankton’s claim file and, for that reason,
did not send them to Dr. Gordan. Based on a review of the
documents that MetLife submitted in the claim file, Dr. Gordan
concluded that many of Frankton’s complaints lacked any
7
psychological basis, and that the medical documentation was
insufficient to support Frankton’s claim that that she was
unable to function in a sedentary job.
In November 2005, MetLife upheld its decision terminating
Frankton’s benefits. In a letter to Frankton, MetLife explained
that Frankton’s claim file lacked sufficient medical
documentation to support an impairment that would have prevented
Frankton from working in her most recent position, or at a
position that required “sedentary type work.”
In her complaint filed in the district court, Frankton
alleged that MetLife failed to consider relevant medical
information when reviewing Frankton’s claim for benefits. After
the parties filed cross-motions for summary judgment, the
district court awarded summary judgment in favor of MetLife.
The district court held that MetLife used a “full and fair
reasoning process” in reviewing Frankton’s claim by collecting
medical reports from Frankton’s numerous health care providers,
by seeking independent evaluations of Frankton’s medical records
and physical condition, by considering non-medical evidence, and
by considering documents prepared by Frankton describing her
symptoms. The district court also held that MetLife’s decision
was supported by substantial evidence, including the reports of
an independent medical examiner, an independent physician
8
consultant, and a private investigator. Frankton timely
appealed to this Court.
II.
In an appeal under ERISA, we review a district court's
decision de novo, employing the same standards governing the
district court's review of the plan administrator's decision.
Williams v. Metro. Life Ins., Co., 609 F.3d 622, 629 (4th Cir.
2010). When, as here, an ERISA benefit plan vests with the plan
administrator the discretionary authority to make eligibility
determinations for beneficiaries, a reviewing court evaluates
the plan administrator's decision for abuse of discretion. Id.
at 629-30.
Under the abuse-of-discretion standard, we will not disturb
a plan administrator's decision if the decision is reasonable,
even if we would have come to a contrary conclusion
independently. Id. at 630. Thus, we may not substitute our own
judgment in place of the judgment of the plan administrator.
Id. To be deemed reasonable, the administrator's decision must
result from a “deliberate, principled reasoning process” and be
supported by substantial evidence. Id. (quoting Guthrie v.
Nat’l Rural Elec. Coop. Assoc. Long-term Disability Plan, 509
F.3d 644, 651 (4th Cir. 2007)).
9
In our decision in Booth v. Wal-Mart Stores, Inc.
Associates Health & Welfare Plan, 201 F.3d 335, 342-48 (4th Cir.
2000), we set forth eight nonexclusive factors that courts
should consider in reviewing the reasonableness of a plan
administrator's decision. These factors include:
(1) the language of the plan; (2) the purposes and
goals of the plan; (3) the adequacy of the materials
considered to make the decision and the degree to
which they support it; (4) whether the fiduciary's
interpretation was consistent with other provisions in
the plan and with earlier interpretations of the plan;
(5) whether the decisionmaking process was reasoned
and principled; (6) whether the decision was
consistent with the procedural and substantive
requirements of ERISA; (7) any external standard
relevant to the exercise of discretion; and (8) the
fiduciary's motives and any conflict of interest it
may have.
Id. A reviewing court’s assessment of the reasonableness of an
administrator’s decision is limited to a review of the documents
in the administrative record. Sheppard & Enoch Pratt Hosp.,
Inc. v. Travelers Ins., Co., 32 F.3d 120, 125 (4th Cir. 1994).
III.
A.
On appeal, Frankton raises three arguments concerning the
reasonableness of certain actions taken by MetLife. The
district court addressed each argument in its summary judgment
10
order. 3 Upon considering the district court’s analysis described
below, we agree with the district court’s disposition on these
issues.
According to Frankton, MetLife acted unreasonably in
failing to send Dr. Hendler’s most recent medical records to Dr.
Gordan. However, as the district court explained, MetLife did
not receive the medical records until after MerLife had sent the
claim file to Dr. Gordan. Even though MetLife did not later
send these documents to Dr. Gordan, the documents were included
in Frankton’s claim file when MetLife conducted its final
administrative review.
According to the district court, the documents were
duplicative of other documents in Frankton’s claim file. The
district court found that the only document that contained new
information was Dr. Hendler’s most recent “office note.” The
district court observed that Frankton did not indicate what
substantive information that the note would have added to the
3
In the district court, Frankton argued that MetLife failed
to take into consideration Frankton’s job description that
entailed “a significant amount of standing and lifting over ten
pounds, as well as pushing and pulling carts and bending over.”
Frankton now argues that the district court failed to consider
the sitting requirements of the position. Because Frankton did
not challenge MetLife’s failure to consider those sitting
requirements in the proceedings before the district court, the
argument is waived. See United States v. Evans, 404 F.3d 227,
236 n.5 (4th Cir. 2005).
11
record. Therefore, the district court held, and we agree, that
MetLife’s failure to forward the “office note” was a “minor
procedural violation [] not sufficient to undermine the
reasonableness of MetLife’s conclusions.”
Next, Frankton argued in the district court that MetLife
erred in failing to consider the fact that she had been awarded
Social Security disability insurance. However, as found by
district court, there was no evidence in the administrative
record indicating that MetLife had received the letter from the
Agency confirming the award of these benefits to Frankton.
Therefore, the district court properly held that it would not
consider the award letter in determining the reasonableness of
MetLife’s denial of benefits decision. See Sheppard, 32 F.3d at
125.
Although MetLife conceded that it was aware that the Agency
had awarded benefits to Frankton, the district court concluded
that MetLife did not abuse its discretion by reaching a
different decision than the Agency’s decision, because the
Agency’s standard for awarding disability differs from the
Plan’s definition of “disability.” As the district court
explained, MetLife is not obligated to weigh the Agency’s
disability determination more favorably than the other evidence
in the record. See Gallagher v. Reliance Std. Life Ins., Co.,
305 F.3d 264, 275 (4th Cir. 2002).
12
Frankton also argued in the district court that MetLife
failed to accord the proper weight to Dr. Hendler’s medical
reports. However, as the district court explained, although
plan administrators may not arbitrarily ignore reliable
evidence, ERISA does not require that administrators accord
special deference to the opinions of treating physicians. See
Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834
(2003). Upon reviewing the medical reports, the district court
stated that the reports of Dr. Parkerson and Dr. Gordan are
“replete with references to and criticism of Dr. Hendler’s
records and diagnoses.” Accordingly, the district court held
that MetLife acted reasonably in relying on the reports of Dr.
Parkerson and Dr. Gordan and in rejecting the opinion of Dr.
Hendler. For the same reason given by the district court, we
conclude that the court did not abuse its discretion in making
this determination.
B.
Finally, we address one additional argument raised by
Frankton on appeal. According to Frankton, the district court
erred by failing to consider MetLife’s conflict of interest in
determining whether MetLife acted reasonably.
The presence of a conflict of interest is one fact, among
many, that a reviewing court may consider in evaluating the
reasonableness of a plan administrator’s decision. Williams,
13
609 F.3d at 630. A conflict of interest exists in this case
because MetLife, as the plan administrator, has authority both
to evaluate benefit eligibility and to pay benefit claims. Id.
at 630-31. In reviewing the reasonableness of an
administrator’s decision, we consider an administrator’s
conflict of interest because of the administrator’s financial
incentive to deny coverage in its claims processing.
Metropolitan Life Ins., Co. v. Glenn, 554 U.S. 105, 114-15
(2008).
The record shows that MetLife attempted to make an accurate
claim assessment by hiring an independent medical examiner and
an independent physician consultant to review Frankton’s entire
claim file. According to the district court, those physicians
reached “reasoned and principled conclusions.” Both physicians
prepared detailed reports and justified their conclusions in
light of contrary reports from Dr. Hendler. Thus, we conclude
that Frankton has failed to show that MetLife’s conflict of
interest is sufficient to outweigh the evidence of MetLife’s
effort in assuring an accurate claim assessment.
IV.
In conclusion, we agree with the analysis of the district
court and hold that Frankton failed to raise a genuine issue of
material fact regarding the reasonableness of MetLife’s decision
14
to terminate Frankton’s long-term disability benefits.
Accordingly, we affirm the district court’s judgment.
AFFIRMED
15