Seiser v. Unum Provident Corp. ( 2005 )

NOT RECOMMENDED FOR FULL-TEXT PUBLICATION
File Name: 05a0309n.06
Filed: April 22, 2005
No. 04-1177
UNITED STATES COURT OF APPEALS
FOR THE SIXTH CIRCUIT
CAROL SEISER, )
)
Plaintiff - Appellant, )
) ON APPEAL FROM THE
v. ) UNITED STATES DISTRICT
) COURT FOR THE WESTERN
UNUM PROVIDENT CORP., ) DISTRICT OF MICHIGAN
)
Defendant - Appellee. )
) OPINION
_______________________________________)
Before: MOORE and SUTTON, Circuit Judges and CARMAN, Judge.*
CARMAN, Judge. Plaintiff-Appellant Carol Seiser (“Seiser”) appeals the district court’s
denials of her motion for judgment on the administrative record and motion to expand the
administrative record and judgment in favor of Defendant-Appellee UNUM Provident Corporation
(“UNUM”). On December 31, 2003, the district court: (1) denied Seiser’s motion for judgment on
the administrative record; (2) denied Seiser’s motion to expand the administrative record to include
the Social Security Administration’s (“SSA”) determination to award Seiser disability benefits; and
(3) entered judgment on the administrative record in favor of UNUM. Seiser filed a timely notice
of appeal to this court. Upon review, we hold that the district court properly denied the motion for
*
The Honorable Gregory W. Carman, United States Court of International Trade, sitting
by designation.
judgment on the administrative record, properly denied the motion to expand the administrative
record, and properly entered judgment in favor of UNUM.
I. BACKGROUND
Seiser was employed as a nurse by Borgess Medical Center until 1995, when she filed a
claim for long term disability due to orthopedic lower back problems. Seiser was covered by a long
term disability policy (“policy”) issued by UNUM. Under its policy, UNUM paid disability benefits
from the beginning of 1995 until September 2001, when UNUM terminated Seiser’s disability
benefits pursuant to the terms of its disability policy.1 J.A. at 633-35. Upon review of Seiser’s
medical statements and applying her medical limitations to its Transferable Skills Analysis
(“TSA”),2 UNUM concluded that Seiser was capable of performing several sedentary occupations
and thus ineligible for continued disability benefits.3
1
UNUM’s disability policy states:
“Disability” and “disabled” mean that because of injury or sickness:
1. the insured cannot perform each of the material duties of his regular
occupation; and
2. after benefits have been paid for 36 months, the insured cannot
perform each of the material duties of any gainful occupation for
which he is reasonably fitted by training, education or experience.
J.A. at 633.
2
The TSA was performed by a vocational specialist, who determined that Seiser was able
to perform sedentary jobs within the community based on her educational background and
professional experience. J.A. at 646-49.
3
UNUM apparently based its original denial decision upon a review of Attending
Physician Statements from Seiser’s treating physicians, Dr. Dall, an orthopedic specialist, and
Dr. Brush, a pulmonary specialist. Dr. Dall’s statement of March 14, 2001, listed Seiser’s
restrictions as “no lifting over ten pounds, no bending, twisting, pushing or pulling... sitting,
standing and walking as tolerated.” J.A. at 622. Dr. Brush’s statement of March 12, 2001, listed
Seiser’s limitation as only “no physical exertion.” J.A. at 624. UNUM hired a board certified
internal medicine physician, Dr. Hashway, to conduct a review of Seiser’s medical statements.
On August 1, 2001, Dr. Hashway’s review concluded that Seiser “appears capable of sedentary
occupational activities.” J.A. at 680.
2
In support of her administrative appeal, Seiser submitted a note from Dr. Dall dated
September 12, 2001.4 J.A. at 621. Two days later, UNUM notified Seiser that Dr. Dall’s note was
insufficient as support for continued disability but informed Seiser that her entire file would be sent
to UNUM’s Quality Performance Support Unit (“Support Unit”) for final determination. J.A. at 616.
On October 26, 2001, the Support Unit sent Seiser a letter upholding UNUM’s denial of benefits but
invited her to submit additional medical information. J.A. at 601-05. On November 30, 2001, Seiser
submitted subsequent notes from Dr. Dall and Dr. Brush besides a letter from a third physician, Dr.
Fabi, a nuerosurgeon. Dr. Dall’s note essentially parroted his September note, again offering no
explanatory analysis. J.A. at 585 (“permanently totally disabled from any useful work including
sedentary work”). Dr. Fabi’s letter concurred that Seiser was “totally disabled from any type of
sedentary or gainful employment of any sort” but deferred to Dr. Brush’s evaluations regarding
pulmonary limitations on sedentary work. J.A. at 587 (“pulmonary status limits her ability to
perform even sedentary work, and I leave this up to Dr. Brush and his evalutions”). Dr. Brush,
however, again only limited Seiser from physical activity. J.A. at 586 (“disabled from any
employment where any physical activity is required”). These additional materials were reviewed
by UNUM’s consulting physicians, Dr. Hashway and Dr. Martin,5 both of whom determined that
Seiser was capable of sedentary work. J.A. at 583, 576-77. On March 13, 2002, after this series of
submissions and reviews, UNUM informed Seiser of its final determination to deny disability
4
Dr. Dall’s note stated that Seiser was “totally disabled from any useful work including
sedentary work,” but did not provide any underlying explanation or clinical data. J.A. at 621.
5
Dr. Martin is a board certified occupational medicine physician.
3
benefits. J.A. at 573-74. On September 23, 2002, the SSA awarded Seiser disability benefits. J.A.
at 36.
II. ANALYSIS
A. Standard of Review
The issue before us is whether Seiser is entitled to disability benefits under UNUM’s
disability policy. We generally review an administrator’s denial of benefits de novo. See Wilkins
v. Baptist Healthcare Sys., Inc., 150 F.3d 609, 613 (6th Cir. 1998). However, when the ERISA plan
expressly provides discretion to the administrator in making eligibility decisions, the reviewing court
employs the arbitrary and capricious standard of review. See Williams v. Int’l Paper Co., 227 F.3d
706, 711 (6th Cir. 2000) (citing Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 110-12
(1989)). The arbitrary and capricious standard is the “least demanding form of judicial review of
administrative action.” McDonald v. Western-Southern Life Ins. Co., 347 F.3d 161, 169 (6th Cir.
2003) (internal citations and quotations omitted). A decision is not arbitrary and capricious “when
it is possible to offer a reasoned explanation, based on the evidence, for a particular outcome.”
Williams, 227 F.3d at 712 (internal quotation omitted). This standard requires that we defer to the
administrator’s construction when the policy vests the administrator with the discretion to interpret
that policy. Davis v. Ky. Fin. Cos. Ret. Plan, 887 F.2d 689, 695 (6th Cir. 1989). Upon review of
UNUM’s policy provisions, the district court concluded that the policy sufficiently granted “UNUM
the discretionary authority to interpret the [policy] and to determine eligibility for benefits required
to support application of the arbitrary and capricious standard.”6 J.A. at 35. We agree.
6
The “Certificate Section” of UNUM’s policy states that “[w]hen making a benefit
determination under the policy, UNUM has discretionary authority to determine [the insured’s]
eligibility for benefits and to interpret the terms and provisions of the policy.” J.A. at 495.
4
B. Motion for Judgment on the Administrative Record
The district court concluded that UNUM’s determination was not arbitrary and capricious
based upon review of the administrative record. J.A. at 36. The district court correctly notes that
Seiser bore the burden to prove eligibility for disability under the terms of the policy.7 Id. To
support her case for disability, Seiser submitted six doctors’ statements and notes on at least three
separate occasions between March 2001 and November 2001. The record also reflects that UNUM
provided ample notice and opportunity for Seiser to provide medical support and supplement her
record with additional medical information.8 UNUM then re-submitted all of Seiser’s supplemental
documents not only to the original consulting physician, Dr. Hashway, but also to a second
consulting physician, Dr. Martin. Both drew the same conclusion upon review of the totality of
Seiser’s documents; the doctors’ statements and notes submitted on behalf of Seiser did not provide
sufficient clinical findings that Seiser could not perform sedentary work.9
Although Seiser contends that UNUM’s consulting physicians engaged in “cherry picking”
of medical evidence and the TSA analysis was flawed (Pl.-Appellant’s Final Br. on Appeal at 17),
we find that the record does not support these contentions. We agree with the district court that the
7
The district court read the second provision of the policy – “the insured cannot perform
each of the material duties of any gainful occupation for which he is reasonably fitted by
training, education or experience” – as laying the onus on the insured to prove eligibility for
disability. We have upheld such readings. See, e.g., Miller v. Metro Life Ins. Co., 925 F.2d 979,
985 (6th Cir. 1991).
8
After initial insufficient submissions of medical information, UNUM invited Seiser to
submit additional information on September 14, 2001, and October 26, 2001, via letter. See
supra, J.A. at 616.
9
UNUM’s consulting physicians conceded that Seiser’s submissions supported that she
was disabled from physical work; however, these reviewing physicians concluded that the
clinical data did not support that Seiser was disabled from sedentary work. J.A. at 577, 583.
5
administrative record does not support Seiser’s contention that UNUM’s consulting physicians
failed to properly consider Seiser’s combination impairment condition in the same manner as her
treating physicians. J.A. at 37. The record reflects that the consulting physicians’ opinions and
conclusions “incorporated the same medical restrictions and limitations prescribed by Seiser’s
treating physicians.” J.A. at 37. During oral argument, Seiser implored us to give more weight to
her treating physicians’ conclusions rather than UNUM’s consulting physicians’ conclusions in our
analysis. However, the Supreme Court has held, and Seiser conceded at oral argument, that the
treating physician rule applicable to an SSA analysis is not binding in ERISA cases. See Black &
Decker Disability Plan v. Nord, 538 U.S. 822, 825 (2003) (holding that ERISA plan administrators
are not obligated to accord special deference to the opinions of treating physicians). We have
recently adopted this principle in Whitaker v. Hartford Life & Accident Ins. Co., No. 03-6682, _ F.3d
_, 2005 U.S. App. LEXIS 3492, at *4 (6th Cir. Jan. 24, 2005) (affirming the proposition that the
treating physician rule does not apply in ERISA cases).10 Accordingly, we find that UNUM’s
administrators were not arbitrary and capricious by not according special deference to the opinions
of Seiser’s treating physicians. Further, when an administrator exercises his discretionary power
“to rely upon the medical opinion of one doctor over that of another in determining whether a
claimant is entitled to ERISA benefits, the plan administrator’s decision cannot be said to have been
arbitrary and capricious.” McDonald, 347 F.3d at 169.
Upon review of the record, we find that UNUM offered sufficient reasoned explanation,
based on the substantial evidence of Seiser’s own submissions, for its decision to deny her disability
10
This decision is designated for full-text publication.
6
benefits. Therefore, we hold that the district court properly denied Seiser’s motion for judgment on
the administrative record and properly entered judgment in favor of UNUM.
C. Motion to Expand the Administrative Record
It is well-established that the district court is strictly limited to the record of the administrator
in its review. See Killian v. Healthsource Provident Adm’r, Inc., 152 F.3d 514, 522 (6th Cir. 1998)
(“in an ERISA claim contesting a denial of benefits, the district court is strictly limited to a
consideration of the information actually considered by the administrator”); see also Wilkins, 150
F.3d at 615 (finding that an affidavit dated over one month after final decision denying benefits was
not part of the administrative record). Since the SSA’s disability determination was awarded six
months subsequent to UNUM’s final decision to deny benefits, the SSA’s determination was clearly
not a part of the administrative record. The SSA determination was not, nor should it have been,
a part of the record before the district court.
In her appeal, Seiser also argues that we should remand the case to UNUM so that it can
reconsider its decision in light of the SSA determination. In support of this argument, Seiser cites
to an unpublished district court opinion in which the court remanded a similar case to “enable the
SSA decision to become part of the Administrative Record, thereby properly enabling the Court to
consider both the SSA decision and the [administrator]’s treatment of such decision.” Quast v.
Square D Co., No. 02:01-CV-1135, 2003 U.S. Dist. LEXIS 19644, at *10 (S.D. Ohio July 15, 2003).
The district court reasoned that “[w]hen faced with the task of determining whether the
[administrator]’s denial of [the claimant]’s benefits was arbitrary and capricious, the Court needs
this information in order to conduct a complete and meaningful review.” Id. Respectfully, we
disagree.
7
Under the arbitrary and capricious standard, a reviewing court must simply determine
whether there exists “a reasoned explanation, based on the evidence, for a particular outcome.”
Williams, 227 F.3d at 712 (internal quotation omitted). The district court’s explanation in Quast that
a remand is required to consider new evidence before a court can determine whether an outcome is
reasonably reached based on the old evidence is illogical. Moreover, we recently held that “an
ERISA plan administrator is not bound by an SSA disability determination when reviewing a claim
for benefits under an ERISA plan.” Whitaker, 2005 U.S. App. LEXIS 3492, at *4-5; see also Black
& Decker, 538 U.S. at 832-33 (noting the “critical differences between the Social Security disability
program and ERISA benefit plans”); Wagner-Harding v. Farmland Indus. Inc. Employee Ret. Plan,
No. 01-3085, 2001 U.S. App. LEXIS 26408, at *15 (10th Cir. Dec. 10, 2001) (holding that SSA
“proceedings are entirely different and separate from a claim under ERISA, with different parties,
different evidentiary standards, and different bodies of law governing their outcomes”). Therefore,
we decline Seiser’s invitation to adopt the Quast approach. Instead, we hold that where a plan
administrator has denied a disability claim, a remand to the administrator to consider a contrary SSA
determination issued after the administrative decision is unwarranted.
III. CONCLUSION
For the foregoing reasons, we affirm the decision of the district court to deny Plaintiff-
Appellant’s motion for judgment on the administrative record and the motion to expand the
administrative record. Judgment in favor of Defendant-Appellee is affirmed.
8