Dudley v. Sedgwick Claims Management Services Inc. , 495 F. App'x 470 ( 2012 )

Case: 11-11165 Document: 00512032958 Page: 1 Date Filed: 10/25/2012
IN THE UNITED STATES COURT OF APPEALS
FOR THE FIFTH CIRCUIT United States Court of Appeals
Fifth Circuit
FILED
October 25, 2012
No. 11-11165
Lyle W. Cayce
Clerk
LINDA DUDLEY,
Plaintiff-Appellant,
versus
SEDGWICK CLAIMS MANAGEMENT SERVICES INCORPORATED,
Defendant-Appellee.
Appeal from the United States District Court
for the Northern District of Texas
USDC No. 3:11-CV-28
Before KING, SMITH, and BARKSDALE, Circuit Judges.
JERRY E. SMITH, Circuit Judge:*
Linda Dudley sought short-term disability benefits under her employer-
sponsored benefit plan for claims of incapacitating knee pain. The plan’s admin-
*
Pursuant to 5TH CIR. R. 47.5, the court has determined that this opinion should not
be published and is not precedent except under the limited circumstances set forth in 5TH CIR.
R. 47.5.4.
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istrator, Sedgwick Claims Management Services, Inc. (“Sedgwick”), granted
disability benefits immediately following two knee surgeries but denied the
remainder of the request. After an unsuccessful administrative appeal, Dudley
sued for wrongful denial of benefits under the Employee Retirement Income
Security Act of 1974 (“ERISA”), § 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B). The
district court granted summary judgment for Sedgwick, see Dudley v. Sedgwick
Claims Mgmt. Servs., Inc., 2011 WL 5080739 (N.D. Tex. 2011), and Dudley
appeals. We find no error and affirm.
I.
Working in a clerical position as a Directory Composer for a subsidiary of
AT&T, Dudley participated in the AT&T Disability Income Program (“DIP”)
administered by Sedgwick.1 After undergoing arthroscopic knee surgery on
December 15, 2009, Dudley received twenty days of disability. Sedgwick advised
that she would have to submit additional documentation if benefits were needed
beyond January 3, 2010.
On December 29, Dudley had a follow-up visit with her surgeon, who noted
that the “[w]ound looks good. Stitches were removed.” He wrote that Dudley
was to start physical therapy and would be seen again in a month, and “[s]o far
1
Both parties refer to the DIP, a “component program” under the AT&T Umbrella Ben-
efit Plan No. 1, as the governing document. The DIP states that “[t]his [summary plan
description] along with the AT&T Umbrella Benefit Plan No. 1 is the official document for the
benefits offered under the AT&T Disability Income Program . . . . It will govern and be the
final authority on the terms of the program.” Summary plan descriptions (“SPD”) are required
by ERISA, 29 U.S.C. § 1022, and are often a separate document, used to “apprise [the plan’s]
participants and beneficiaries of their rights and obligations under the plan,” § 1022(a). The
distinction between an SPD and a plan matters; the Supreme Court recently clarified that
§ 1132(a)(1)(B) allows beneficiaries to enforce the terms of a plan but not an SPD. CIGNA
Corp. v. Amara, 131 S. Ct. 1866, 1877 (2011). Because neither party points to an alternative
plan document in the record, both parties rely on the DIP as the governing text, and only a
plan can be enforced under § 1132(a)(1)(B), we treat the DIP as the plan. Cf. Koehler v. Aetna
Health Inc., 683 F.3d 182, 185 (5th Cir. 2012) (treating SPD language as the plan where the
two share identical text).
2
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so good.”
Dudley requested that her benefits continue. On January 4, Sedgwick
received records from the December 29 visit and a “Physical Capacities Evalua-
tion” completed by Dudley’s surgeon. Based on the December 29 visit, her sur-
geon wrote on the evaluation form, “no standing, stooping, lifting, or pushing
until further notice”; he also indicated that she was incapable of sitting, stand-
ing, walking, speaking, looking at a computer screen, or moving a computer
mouse. A large portion of the form, asking questions about Dudley’s functional-
ity, remained blank. The surgeon concluded that Dudley was to remain off work
until further notice.
Sedgwick sent Dudley’s records to a physician advisor, who determined
there was insufficient objective information to substantiate Dudley’s incapacity
to perform her occupational duties; as a result, Sedgwick denied Dudley’s claim
for coverage beginning January 4. With the denial letter, Sedgwick included
information on the Quality Review Unit Appeal Procedures, which required “[a]
description of how your level of functionality impacts your ability to work and
perform your daily activities . . . [and] [c]linical documentation that supports the
treatment provider’s rationale.”
Dudley, her surgeon, her physical therapists, and Sedgwick exchanged
several communications over the following months. Sedgwick continued to deny
the post-January 4 claim for a lack of clinical evidence, each time including the
same information on the appeals process. For example, on January 22, Dudley’s
surgeon transcribed a letter to Sedgwick describing Dudley’s history of care. As
to her current status, he wrote, “I have advised her to stay off her leg as much
as possible, and I have changed her pain medication to Norco and prescribed a
Licoderm Pain Patch. She is to remain off work and is to follow up with me in
1 week.” Sedgwick responded that the additional information “does not provide
clinical evidence to support disability from January 4, 2010 through your return
3
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to work and does not alter our previous denial decision.”
Dudley underwent full knee replacement surgery on March 4. Sedgwick
eventually approved leave from March 4 until April 14, covering the six weeks
following that surgery. Records from that period were submitted to Sedgwick
as justification for extending the benefits beyond April 14.
On March 23, Dudley’s surgeon noted she was “coming along well” and
“[a]s far as work she is still to stay off until further notice.” On March 25,
Dudley’s physical therapist documented some numbness, hypersensitivity, and
“burning pain” around the knee. As for Dudley’s functionality, Dudley “used a
walker for about a week and a half and then has been using the cane. The
patient states that she has been driving just short distances to the grocery store;
however to come to physical therapy, she is having somebody drive her.” The
physical therapist commented that Dudley “is going to New York on 04/29/10,
and another goal is for her to be able to walk around and sightsee. The patient
states that if she has to, she may take more rest breaks than her girlfriends.”
On April 1 and 6, Dudley visited with her surgeon again. He acknowl-
edged she was using a cane, her knee was stable, and “[h]opefully she is able to
do at least a sit down job now.” He also recorded his concerns with her returning
to work “due to her leg being in constant pain and swelling,” along with the
“requirement to use cryotherapy . . . thirty minutes every two hours and we also
understand patient was on medication for pain, which is not safe to drive under
medication effects.”
On April 12, Dudley initiated the formal appeal process, and Sedgwick for-
warded her file to two physician advisors for review. By May 25, both doctors
reviewed the file and made their initial determination that there was no clinical
evidence to demonstrate inability to function in a sedentary job. On June 17,
based on her medical records and the physician advisors’ reports, Sedgwick
denied Dudley’s appeal for benefits from January 4 to March 3 and from April 15
4
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to her return to work on April 26.2 The denial letter stated that “[a]lthough
some findings are referenced, none are documented to be so severe as to prevent
you from performing the duties of your job as a Directory Composer, with or
without reasonable accommodations . . . .”
After the denial, Dudley sued Sedgwick in state court for wrongful denial
of benefits under ERISA, 29 U.S.C. § 1132(a)(1)(B). Sedgwick removed to federal
court, and both parties moved for summary judgment. The district court granted
Sedgwick’s motion, finding that Sedgwick had not abused its discretion in its fac-
tual determinations and that its interpretation of the DIP was legally sound.
Dudley, 2011 WL 5080739, at *7, 9.
II.
We review a summary judgment de novo, applying the standard of review
of the district court. Dutka ex rel. Estate of T.M. v. AIG Life Ins. Co., 573 F.3d
210, 213 (5th Cir. 2009). Summary judgment is appropriate where, viewing the
evidence in the light most favorable to the non-moving party, “there is no genu-
ine dispute as to any material fact and the movant is entitled to judgment as a
matter of law.” FED. R. CIV. P. 56(a); Koehler, 683 F.3d at 184.
This appeal involves reviewing the administrator’s factual determination
and interpretation of the plan. Factual determinations made by an administra-
tor are reviewed by a district court for abuse of discretion. Dutka, 573 F.3d at
212. Similarly, where the plan grants the administrator “discretionary authority
to determine eligibility for benefits or to construe the terms of the plan,” Herring
v. Campbell, 690 F.3d 413, 415 (5th Cir. 2012), courts review the administrator’s
interpretation for abuse of discretion. See also Metro. Life Ins. Co. v. Glenn, 554
2
Sedgwick did grant Dudley additional benefits for May 6 to May 23, 2010, for knee
manipulations. She returned to work with restrictions against pushing and pulling and was
provided time to heat and ice her knee.
5
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U.S. 105, 111 (2008).
It is undisputed that the terms of the plan grant Sedgwick the necessary
discretionary authority. The DIP states that the plan administrator “will have
sole discretion to interpret the Program, including, but not limited to, interpreta-
tion of the terms of the Program, determinations of coverage and eligibility for
benefits, and determination of all relevant factual matters.”3
In the ERISA context, abuse of discretion is the “functional equivalent of
arbitrary and capricious review.” Anderson v. Cytec Indus., Inc., 619 F.3d 505,
512 (5th Cir. 2010) (per curiam). An arbitrary and capricious decision is one
“made without a rational connection between the known facts and the decision.”4
This deferential review does not require a complex inquiry into the decision: “[I]t
need only assure that the administrator’s decision fall somewhere on a contin-
uum of reasonablenessSSeven if on the low end.”5
A.
We first consider whether Sedgwick abused its discretion in interpreting
the plan. Dudley asserts that the DIP requires only “medical documentation”
and that Sedgwick’s rejection for a lack of objective findings of functional limita-
tions is an abuse of discretion.6
3
See also Duhon v. Texaco, Inc., 15 F.3d 1302, 1305S06 (5th Cir. 1994) (“This court has
not imposed a linguistic template to satisfy this requirement, but in this case the plan’s plain
language provides that the administrator may make an independent and final determination
of eligibility.”).
4
Meditrust Fin. Servs. Corp. v. Sterling Chems. Inc., 168 F.3d 211, 215 (5th Cir. 1999)
(quoting Bellaire Gen. Hosp. v. Blue Cross Blue Shield, 97 F.3d 822, 828 (5th Cir. 1996)).
5
Holland v. Int’l Paper Co. Ret. Plan, 576 F.3d 240, 247 (5th Cir. 2009) (quoting Corry
v. Liberty Life Assurance Co., 499 F.3d 389, 398 (5th Cir. 2007)).
6
Sedgwick maintains that the plan’s terms are not ambiguous. Even assuming the
plan is ambiguous however, Sedgwick’s interpretation was not an abuse of discretion.
6
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This court often applies a two-step analysis to review an administrator’s
interpretation of a plan:
A court first determines the legally correct interpretation of the
plan, and whether the administrator’s interpretation accords with
the proper legal determination. If the administrator’s construction
is legally sound, then no abuse of discretion occurred and the
inquiry ends. But if the court concludes that the administrator has
not given the plan the legally correct interpretation, the court must
then determine whether the administrator’s interpretation consti-
tutes an abuse of discretion.[7]
For the first step, the court asks whether the interpretation is legally cor-
rect. ERISA plans are “governed in the first instance by the plain meaning of
the plan language.”8 Typically, the question whether an interpretation was
legally correct is governed by three factors: “(1) whether the administrator has
given the plan a uniform construction, (2) whether the interpretation is consis-
tent with a fair reading of the plan, and (3) any unanticipated costs resulting
from different interpretations of the plan.”9 If the administrator’s interpretation
is determined to be legally correct, there is no abuse of discretion, and the
inquiry is complete. Rhorer, 181 F.3d at 639S40.
The second step asks whether the administrator’s interpretation was an
abuse of discretion. This step is reached if that interpretation is legally incor-
rect. Alternatively, the first step can be skipped “if we can more readily deter-
mine that the decision was not an abuse of discretion.” Holland, 576 F.3d at 246
n.2. This court often considers three factors in determining whether the admin-
7
Rhorer v. Raytheon Eng’rs & Constructors, Inc., 181 F.3d 634, 639S40 (5th Cir. 1999)
(citations omitted), abrogated on other grounds by Amara. But see Duhon, 15 F.3d at 1307 n.3
(stating that “the reviewing court is not rigidly confined to this two-step analysis in every
case”).
8
Tucker v. Shreveport Transit Mgmt. Inc., 226 F.3d 394, 398 (5th Cir. 2000) (quoting
Threadgill v. Prudential Sec. Grp., Inc., 145 F.3d 286, 292 (5th Cir. 1998)).
9
Ellis v. Liberty Life Assurance Co., 394 F.3d 262, 270 (5th Cir. 2005); Wildbur v.
ARCO Chem. Co., 974 F.2d 631, 638 (5th Cir. 1992).
7
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istrator abused its discretion: “(1) the internal consistency of the plan under the
administrator’s interpretation, (2) any relevant regulations formulated by the
appropriate administrative agencies, and (3) the factual background of the deter-
mination and any inferences of lack of good faith.” Wildbur, 974 F.2d at 638.
Here we choose to bypass the legal correctness of the interpretation,
because we conclude that it was not an abuse of discretion. See Holland, 576
F.3d at 246 n.2; High v. E-Systems Inc., 459 F.3d 573, 577 (5th Cir. 2006). Look-
ing to the three-factor test, the first is the internal consistency of the plan under
the interpretation. Wildbur, 974 F.2d at 638.10 Sedgwick’s requirement of objec-
tive evidence of functional occupational limitations is consistent with the DIP’s
requirement of medical documentation of disability, defined as being unable to
perform the functions of one’s job. As Sedgwick argues, the DIP’s failure specifi-
cally to include the word “objective” is not automatically inconsistent.
Similarly, in Anderson, 619 F.3d at 509, the plan provided disability bene-
fits if a participant was unable “to perform any and every duty pertaining to his
occupation.” The beneficiary’s physician provided records concluding that he
was unable to do his job because of intensified symptoms of post-traumatic stress
disorder. Id. The plan’s reviewing physicians, and eventually the administrator,
determined there was a lack of documentation to support an occupational
impairment that would prevent the claimant from working. Id. at 510. This
court found that a “plan administrator does not abuse its discretion by making
a reasonable request for some objective verification of the functional limitations
imposed by a medical . . . condition.” Id. at 514.
10
Dudley argues that this factor is irrelevant, citing Rhorer, 181 F.3d at 643, for the
proposition that when an SPD is involved, the internal-consistency factor does not matter.
More accurately, Rhorer rejected reliance on consistencies between an interpretation and a
plan document to determine whether the interpretation of an SPD was an abuse of discretion.
Id. In this case, there is only one document. More importantly, Rhorer used the factors to liti-
gate the interpretation of an SPD under § 1132(a)(1)(B). In the wake of Amara, Dudley cannot
pursue a similar claim.
8
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Here, the DIP defined disability as being “unable to perform all of the
essential functions of your job or another available job assigned by the Partici-
pating Company with the same full-time or part-time classification for which you
are qualified.” As with Anderson, the interpretation requiring objective verifica-
tion of functional limitations is not inconsistent with the plan’s text.
Addressing the second factor, we consider relevant regulations. Wildbur,
974 F.2d at 638. On appeal, Dudley presents only regulations governing SPDs,
but “CIGNA does not disturb our prior holdings that (1) ambiguous plan lan-
guage be given a meaning as close as possible to what is said in the plan sum-
mary, and (2) plan summaries be interpreted in light of the applicable statutes
and regulations.”11 For this reason, we consider the regulations Dudley relies on.
Dudley asserts that Sedgwick’s interpretation is an abuse of discretion
because SPDs must include “a statement clearly identifying circumstances which
may result in . . . loss, forfeiture, [or ]suspension . . . of any benefits that a parti-
cipant or beneficiary might otherwise reasonably expect the plan to provide on
the basis of the description of benefits.” 29 C.F.R. § 2520.102-3(l). Sedgwick’s
interpretation satisfies that regulation.
Under “Discontinuance of Benefits,” the DIP states that benefits will ter-
minate if “[y]ou no longer meet the requirements for Partial Disability or Total
Disability as determined in the sole discretion of the Claims Administrator.” The
definitions of disability, illness, and injury refer to the ability to perform “the
essential functions of your job” and the “duties of any job assigned.” Further-
more, participants are notified that benefits will be denied if they “fail to provide
Medical documentation or other information reasonably required by the Claims
Administrator for purposes of administering [the] claim.” For the same reasons,
Dudley’s argument under 29 C.F.R. § 2520.102-2(b) also fails, that “[t]he format
11
Koehler, 683 F.3d at 189 (referring to Amara, holding that terms of a summary plan
description cannot be enforced through § 1132(a)(1)(B)).
9
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of the summary plan description must not have the effect to misleading, misin-
forming or failing to inform participants.” Relevant regulations do not demon-
strate that Sedgwick’s interpretation was an abuse of discretion.
The third factor considers “the factual background of the determination
and any inferences of lack of good faith.” Wildbur, 974 F.2d at 638. Dudley
claims that this factor points to an abuse of discretion, because Sedgwick, in
alleging bad faith and violation of its guidelines, posed conclusional questions
to the consulting physicians. Even assuming, for purposes of summary judg-
ment, some of the questions were inappropriate is not sufficient to say that Sedg-
wick’s interpretation was an abuse of discretion. Sedgwick also asked the physi-
cians more appropriate questions, such as “What are the clinical findings con-
tained in the medical record and how would it impact the employee’s ability to
function?”
The factual background instead demonstrates Sedgwick’s good faith. First,
it granted Dudley benefits following her two knee surgeries and for later proce-
dures. Second, immediately upon becoming aware of Dudley’s condition, it com-
municated, in a letter dated December 8, 2009, that “to qualify for benefit pay-
ments under the AT&T disability plans, your medical condition should involve
a sickness or injury, supported by medical documentation that prevents you from
performing the duties of your job.” That letter also stated,“[i]t is critical that
your physician demonstrate by his/her observations and clinical findings that
you are unable to perform your work”; and “[i]f the medical documentation does
not contain information that establishes that your condition prevents you from
performing the duties of your job with or without accommodations, your claim
will not qualify for benefit payments under AT&T disability plans.”
Sedgwick also contacted Dudley after each denial or submission of insuffi-
cient documentation. With each denial letter, Sedgwick included the appeal pro-
cedure, specifically noting that the provider must submit “a clear outline of your
10
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level of functionality, a description of how your level of functionality impacts
your ability to work and perform your daily activities, a detailed description of
the treatment provider’s rationale for your level of functionality, clinical docu-
mentation that supports the treatment provider’s rationale.” Sedgwick also com-
municated with Dudley’s provider: “Please provide us with the specific func-
tional limitations preventing your patient from working at this time,” and it
asked for specific evaluations on various tasks. Further demonstrating Sedg-
wick’s good faith, all three of the reviewing physicians attempted to contact Dud-
ley’s treating physician, but their calls were never returned.
Considering these three factors, Sedgwick did not abuse its discretion
interpreting the DIP to require objective medical evidence demonstrating Dud-
ley’s occupational limitations. Sedgwick’s interpretation was reasonable and far
from arbitrary. See Holland, 576 F.3d at 247.
B.
The district court and this court on de novo review consider a plan admin-
istrator’s factual determinations for abuse of discretion. Vercher v. Alexander &
Alexander Inc., 379 F.3d 222, 226 (5th Cir. 2004). Deference is given to the
administrator’s decisions “that reflect a reasonable and impartial judgment.” Id.at 231 (citing Pierre v. Conn. Gen. Life Ins. Co., 932 F.2d 1552, 1562 (5th Cir.
1991)). The abuse-of-discretion standard examines whether the administrator’s
factual determination was arbitrary and capricious. Meditrust, 168 F.3d at 214.
An administrator’s determinations are affirmed when supported by substantial
evidence. Ellis, 394 F.3d at 273. “A decision is arbitrary only if made without
a rational connection between the known facts and the decision or between the
found facts and the evidence.” Holland, 576 F.3d at 246 (quoting Meditrust, 168
F.3d at 215).
Dudley contends that Sedgwick’s determination that she was not disabled
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was an abuse of discretion. First, Dudley argues that there was no concrete or
substantial evidence to support Sedgwick’s denial, because (1) she showed evi-
dence to support her claim, (2) Sedgwick ignored clinical evidence from her treat-
ing physician, and (3) Sedgwick did not focus on her pain.
Dudley asserts that because she can show evidence to support her claim
of disability, Sedgwick’s determination must be wrong. The amount of evidence
Dudley presents is irrelevant: “This argument misapprehends the burden of
proof under ERISA. The law requires only that substantial evidence support a
plan fiduciary’s decisions, including those to deny or to terminate benefits, not
that substantial evidence (or, for that matter, even a preponderance) exists to
support the employee’s claim of disability.” Ellis 394 F.3d at 273.
Next, Dudley argues that the denial was not based on concrete evidence,
because Sedgwick allegedly ignored and disregarded clinical evidence from the
treating physician. The record refutes that claim. In Meditrust, 168 F.3d at 215,
this court held that the administrator “fully and adequately reviewed [the bene-
ficiary’s] claim,” because the denial letters expressly contained the basis for
denial, the plan reviewed all of the relevant medical documentation, and physi-
cians reviewed the hospital records. Sedgwick did all of those things.
Furthermore, Sedgwick does not have to defer to the treating physician.
“[P]lan administrators are not obliged to accord special deference to the opinions
of treating physicians.”12 Choosing not to defer to the treating doctor is not the
equivalent of ignoring his opinion. “[T]he experts here were not required to
accept the opinion of [the] treating physician that his symptoms rendered him
incapable of performing his job. This was neither arbitrary nor an abuse of dis-
cretion. . . .” Anderson, 619 F.3d at 513. Dudley’s surgeon reported her “debili-
tating pain” and concluded she should remain off work. Sedgwick did not abuse
12
Gothard v. Metro. Life Ins. Co., 491 F.3d 246, 249 (5th Cir. 2007) (quoting Black &
Decker Disability Plan v. Nord, 538 U.S. 822, 831 (2003)); Vercher, 379 F.3d at 233.
12
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its discretion in deferring to its medical experts instead of to Dudley’s surgeon’s
conclusions. “[T]he administrator, under the established standard of review that
restricts the courts, was not obliged to accept the opinion of [the] physicians. In
this ‘battle of the experts’ the administrator is vested with the discretion to
choose one side over another.” Id. (quoting Corry, 499 F.3d at 401).
Relatedly, Dudley also contends that because Sedgwick did not focus on
her pain, the denial was not based on substantial evidence. In Corry, 499 F.3d
at 399S400, this court held that the administrator had sufficiently considered the
beneficiary’s subjective complaints, because it cited the complaints in its denial
letter and physician reports. “Thus, although it is certainly true that [the
administrator’s] references [to the beneficiary’s] subjective complaints were less
prominent than [the administrator’s] emphasis on the lack of objective medical
evidence of a disability, it is clear that [the administrator’s] analysis considered
[the] subject complaints of disability.” Id. at 400. In its final denial letter, Sedg-
wick acknowledged Dudley’s complaints of pain, as did the consulting physicians
in their reports.
Despite Dudley’s claims to the contrary, Sedgwick’s factual determination
was based on substantial evidence. Sedgwick only needs to present evidence
such that a reasonable person could find it adequate to support the conclusion.
Ellis, 394 F.3d at 273. In Corry, 499 F.3d at 402, the insurance company relied
on the medical opinions of three consulting physicians, who found a lack of objec-
tive evidence that the beneficiary was disabled. We responded that “[i]t seems
indisputable that the medical opinions of [the administrator’s] three consulting
physicians, each of whom are [sic] specialists and qualified experts in their fields
specifically related to [the claimant’s] symptoms, constitute substantial evidence
supporting [the administrator’s] determination that [the claimant] has no disa-
bility that would preclude her from performing sedentary work.” Id. Similarly
in Anderson, 619 F.3d at 513, this court concluded that “[the administrator] did
13
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not abuse its discretion by relying on the independent experts’ opinion that [the
claimant] had not offered clinical objective proof showing the functional effect of
his PTSD.”
Sedgwick’s determination was supported by its medical experts, who
included a family-practice physician, an orthopedic surgeon, and a physical-
medicine and rehabilitation specialist. The experts’ conclusions that there was
a lack of objective evidence supporting an occupational limitation serve as sub-
stantial evidence.
Dudley also asserts that the physicians’ reports that Sedgwick relied on
have no rational connection to the evidence and did not give full force to her
symptoms.13 Because the reports relied on facts not in Dudley’s favor and did
not accept all of her surgeon’s conclusions, she argues there was no rational
connection to the evidence. She relies on Martin v. SBC Disability Income Plan,
257 F. App’x 751 (5th Cir. 2007), which can be distinguished from the instant
case. There the reports from the treating physicians were more detailed, regard-
ing functionality, than were Dudley’s medical records:
[The claimant] has outbursts of anger and difficulty concentrating,
is barely able to function and only able to perform the most basic
activities of daily living. . . . [She] is unable to work because the
basic functions of her job, interacting with the public, driving a com-
pany vehicle . . . would be difficult for [her] to perform because of
her inability to concentrate.
Id. at 754.
Though Dudley’s medical records state that she suffered major knee prob-
lems with resulting pain, her records do not state how her knee injuries affected
her ability to function in a sedentary job. Furthermore, the physicians’ reviews
13
See Holland, 576 F.3d at 246 (“A decision is arbitrary only if made without a rational
connection between the known facts and the decision or between the found facts and the evi-
dence.” (quoting Meditrust, 168 F.3d at 215)).
14
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were based on a full record, and their reports cited to Dudley’s medical reports.14
Sedgwick’s determination of Dudley’s disability was not an abuse of discre-
tion. The decision requires evidence that is “more than a scintilla, less than a
preponderance, and is such relevant evidence as a reasonable mind might accept
as adequate to support a conclusion.” Ellis, 394 F.3d at 273 (quoting Deters v.
Sec’y of Health, Educ. & Welfare, 789 F.2d 1181, 1185 (5th Cir. 1986)). Because
Sedgwick’s decision was rationally related to the facts and based on substantial
evidence, gathered from Dudley’s physician and physical therapists, along with
independent experts, the district court correctly granted summary judgment for
Sedgwick. See Holland, 576 F.3d at 246.
The summary judgment is AFFIRMED.
14
See Meditrust, 168 F.3d at 215 (“Our review of the record supports the district court’s
finding that the Plan fully and adequately reviewed [the] claim. The denial letters expressly
contain the basis for the denial . . . . Moreover, the Plan’s review was based on a full record.
In fact, a collection agency retained by [the administrator] forwarded to the Plan ‘all of the
medical records and supporting documentation.’”).
15