Nancy Love v. National City Corporation Welf ( 2009 )

In the
United States Court of Appeals
For the Seventh Circuit
No. 08-1722
N ANCY L OVE,
Plaintiff-Appellant,
v.
N ATIONAL C ITY C ORPORATION
W ELFARE B ENEFITS P LAN,
Defendant-Appellee.
Appeal from the United States District Court
for the Northern District of Illinois, Western Division.
No. 07 C 50048—Frederick J. Kapala, Judge.
A RGUED O CTOBER 21, 2008—D ECIDED JULY 23, 2009
Before R IPPLE, E VANS, and S YKES, Circuit Judges.
S YKES, Circuit Judge. Nancy Love worked for National
City Corporation for twenty years before leaving due to
health problems. After her physician diagnosed her with
multiple sclerosis, Love applied for and received short-
term disability benefits—and subsequently long-term
disability benefits—through National City’s Welfare
Benefits Plan (“the Plan”). Three years after Love began
2 No. 08-1722
receiving disability benefits, the Plan administrator
terminated her benefits, stating that she no longer fit
the Plan’s definition of “disabled.” Love appealed the
benefits-termination decision and the Plan denied her
appeal. Love then sued the Plan under the Employment
Retirement Income Security Act (“ERISA”), 29 U.S.C.
§§ 1001 et seq., alleging that her disability benefits
were terminated without sufficient explanation or
medical support. The district court granted summary
judgment for the Plan. Because the Plan did not ade-
quately explain why it concluded Love was no longer
disabled, we reverse the judgment of the district court
with instructions to remand to the Plan administrator
for further proceedings.
I. Background
Nancy Love worked for National City for more than
twenty years in a variety of positions including bank teller,
teller supervisor, and technical-support analyst. She
stopped working in August 2001 when she began experi-
encing fatigue, dizziness, and blurred vision. After her
physician diagnosed her with multiple sclerosis, Love
applied for and received short-term disability benefits
for 26 weeks, the maximum period permitted under the
Plan. When her short-term benefits ran out, Love
applied for and received long-term disability benefits. She
continued to receive long-term disability benefits from
February 2002 until December 2005, when Liberty
Mutual, the claims administrator for the Plan, informed her
that she no longer met the Plan’s definition of “disabled.”
No. 08-1722 3
To receive disability benefits, claimants must meet the
Plan’s definition of “disabled.” The Plan sets out two
separate definitions of “disabled.” One definition
controls benefits for the first two years of disability,
and the second, more stringent definition covers any
remaining period of disability:
The definition of disabled during the 26-week [short-
term disability] period and the first 18 months you
receive [long-term disability] benefits is that you
cannot perform the duties of your particular job with
National City or a job with equivalent duties and
responsibilities . . . . After you have been disabled
for two years (that is, you have received six months
of short-term disability benefits plus 18 months of
[long-term disability] benefits), the definition of
disabled changes. The Plan Administrator must deter-
mine that your condition makes you unable to
perform the duties of any other occupation for which
you are, or could become, qualified by education,
training or experience.
Phrased another way, a claimant is disabled under the
first definition if she cannot perform her particular job; she
is disabled under the second definition if she cannot
perform any job—including one for which she could
become qualified by additional education or training. If
the recipient fails to meet the applicable definition, dis-
ability benefits terminate.
Liberty Mutual initially determined that Love qualified
as “disabled” under the first definition. That definition
controlled for the 26 weeks that Love received short-term
4 No. 08-1722
disability benefits and the first 18 months that she received
long-term disability benefits. In August 2003, two years
after Love began receiving benefits, the second definition
of “disability” kicked in under the Plan. Liberty Mutual
continued to pay Love benefits but did not reassess her
eligibility under the new definition until 2005. At that
time, it enlisted Dr. Jonathan Sands, its medical con-
sultant, to assess Love’s status under the second, more
stringent definition of “disability.” Dr. Sands reviewed
Love’s medical file, which contained reports and records
from several treating physicians. He observed that while
Love probably suffered from multiple sclerosis, she
never suffered a documented clinical attack nor ex-
hibited any documented clinical signs. He also noted
that her neurologic examination was normal. Based on
this information, Dr. Sands concluded that Love was not
“disabled” under the Plan’s second definition and that
“no objective limitations in functional ability or capacity
are noted.” Liberty Mutual sent Dr. Sands’s report to
Dr. Regina Bielkus, Love’s primary physician, and asked
her to explain whether she disagreed with any portion
of Dr. Sands’s report. Dr. Bielkus did not respond to
Liberty Mutual’s inquiries. On December 14, 2005,
Liberty Mutual informed Love that she no longer
qualified for long-term disability benefits. The letter
explained that Dr. Sands had reviewed her medical file
and had found no objective data supporting Love’s asser-
tion that she had limited functional ability.
Love appealed the decision to the Claims Appeal Com-
mittee. As support for her continued eligibility, she
submitted various new reports purporting to show ob-
No. 08-1722 5
jective limitations on her functional capacity to work. For
example, she submitted a physical-therapy evaluation, a
functional-capacity evaluation, and a vocational evalua-
tion. Each report was prepared by a different doctor, and
each report concluded that Love had limited functional
ability. The Committee turned this new informa-
tion, along with Love’s complete medical file, over to
Dr. Gerald Winkler for review. Dr. Winkler agreed with
Dr. Sands’s conclusion that Love was not totally dis-
abled. Specifically, he concluded that Love remained able
to “do a job that can be performed either seated or stand-
ing, that entails the use of a telephone, that entails
the intermittent reference to a computer display or
printed material without requirements of speed, and
that requires conversation with members of the general
public.” The Committee denied Love’s appeal, citing
Dr. Winkler’s conclusion that Love could perform a job
with the listed functional limitations. Love subsequently
sued the Plan under ERISA, claiming that the Plan did not
consider all the relevant medical evidence and did not
sufficiently explain its termination decision. The district
court granted summary judgment in favor of the Plan,
holding that the Plan both considered all the relevant
evidence and sufficiently justified its termination decision.
II. Analysis
A. Standard of Review
We review a district court’s grant of summary judg-
ment de novo and view all facts in favor of the nonmoving
party. Tate v. Long Term Disability Plan Salaried Employees,
6 No. 08-1722
545 F.3d 555, 559 (7th Cir. 2008). Because the Plan has
discretion to determine an individual’s eligibility for
benefits, we review the Plan’s decision to terminate
Love’s benefits under an arbitrary and capricious
standard.1 Hackett v. Xerox Corp. Long-Term Disability
Income Plan, 315 F.3d 771, 773 (7th Cir. 2003). While this
standard of review is deferential, it is not a rubber
stamp, and “we will not uphold a termination [of benefits]
where there is an absence of reasoning in the record to
support it.” Id. at 774-75. Furthermore, ERISA requires
plan administrators to communicate specific reasons for
a denial of benefits to the claimant and address any
reliable evidence of eligibility put forward by the claim-
ant. See 29 U.S.C. § 1133; Black & Decker Disability Plan v.
Nord, 538 U.S. 822, 834 (2003). We will reverse a Plan’s
determination as arbitrary and capricious if it fails to
1
We reject Love’s suggestion that the Supreme Court’s
decision in Metropolitan Life Insurance Co. v. Glenn, 128 S. Ct. 2343(2008), “fundamentally altered the paradigm for adjudicating
ERISA claims” by requiring us to conduct a more searching
review. The Supreme Court in Glenn merely held that courts
reviewing benefits determinations under ERISA should
consider any conflict of interest that exists when a plan ad-
ministrator both evaluates claims for benefits and pays those
benefits. Id. at 2348. The Court explicitly disavowed any
suggestion that it was altering the standard of review. Id. at
2350 (“We do not believe that Firestone’s statement implies a
change in the standard of review . . . .”). We continue to apply
an arbitrary-and-capricious standard to denial-of-benefits
claims after Glenn. See Jenkins v. Price Waterhouse Long Term
Disability Plan, 564 F.3d 856, 861 (7th Cir. 2009).
No. 08-1722 7
substantially comply with these requirements. Nord,
538 U.S. at 834; Tate, 545 F.3d at 559.
B. Sufficiency of Explanation
ERISA requires employee benefit plans that deny dis-
ability benefits to “set[] forth the specific reasons for
such denial, written in a manner calculated to be under-
stood by the participant.” 29 U.S.C. § 1133. The accompa-
nying regulations further require the plan to describe
“any additional material or information necessary for
the claimant to perfect the claim and an explanation of
why such material or information is necessary.” 29 C.F.R.
§ 2560.503-1(g)(iii). These requirements are designed
both to allow the claimant to address the determinative
issues on appeal and to ensure meaningful review of the
denial. Halpin v. W.W. Grainger, Inc., 962 F.2d 685, 689
(7th Cir. 1992). We will reverse any denial of benefits
that does not substantially comply with these regulations.
Id. at 693-94.
In this case neither the initial termination letter nor
the subsequent letter denying Love’s appeal sufficiently
explained the denial. Both letters asserted that all
relevant medical evidence had been considered, but
neither letter explained why the reviewer chose to dis-
credit the evaluations and conclusions of Love’s treating
physicians. See id. at 694. Liberty Mutual conducted the
initial review, retaining Dr. Sands as an independent
medical consultant. After reviewing Love’s medical file,
Dr. Sands concluded that Love was not totally disabled
because there was no “objective” evidence that Love
8 No. 08-1722
suffered any functional limitations. However, Love’s file
contained numerous test reports indicating a reduced
functional capacity, such as an MRI of her spine, evoked-
response tests, several physical-capacity reports, and
various lab reports. The file also contained several evalua-
tions by Dr. Bielkus, Love’s primary physician, opining
that Love’s functional limitations stemming from her
multiple sclerosis made her unable to work. She con-
cluded that Love was “medically disabled on a
permanent basis from any form of gainful occupation.” In
fact, every doctor that personally examined Love con-
cluded that she was unable to work more than a few
hours a day and that she could not stand, sit, or walk
for more than an hour at a time. Dr. Sands did not
address any of these reports in his cursory report, which
dedicated less than half a page to its analysis and recom-
mendation. Liberty Mutual’s termination letter merely
recited the various items in Love’s medical file in a
bulleted list, stated that Dr. Sands had found no ob-
jective limitations in Love’s functional ability, and termi-
nated her benefits without any further discussion or
explanation. We are troubled by the fact that neither
Dr. Sands’s report nor Liberty Mutual’s letter addressed
the contrary findings of Love’s treating physicians or
explained why Liberty Mutual chose to discredit them.
On appeal, Love submitted additional reports demon-
strating her functional incapacity to the Plan’s internal
appeals committee. These reports showed that Love had
significant impairments: She could not walk, sit, or
stand for more than an hour at a time; she could only
lift light items occasionally; she had limited flexibility,
No. 08-1722 9
serious vision impairments, and diminished muscular
strength; and she experienced frequent spells of
dizziness, vertigo, and fatigue. Dr. Winkler, who was
retained by the Plan to review Love’s file on appeal,
noted these problems but concluded that Love could
perform a job “either seated or standing, that entails
the use of a telephone, that entails the intermittent refer-
ence to a computer display or printed material without
requirements of speed, and that requires conversation
with members of the general public.” While acknowl-
edging that Love could not perform her current job,
Dr. Winkler concluded that Love was not totally disabled
but did not adequately explain his conclusion. For exam-
ple, Dr. Winkler noted Love’s chronic fatigue but dis-
missed it by asserting that “there are medications that
are used to treat fatigue.” Additionally, Dr. Winkler
noted that Love was limited to a six-hour workday. In
fact, however, only one physical therapist had concluded
that Love would be able to work for up to six hours; the
rest of Love’s treating physicians had concluded that
she was limited to, at most, two or three hours of work
each day. Dr. Winkler did not address the opinions of
these other physicians.
These explanations are insufficient to meet ERISA’s
requirement that specific and understandable reasons
for a denial be communicated to the claimant. Halpin,
962 F.2d at 688-89. As we have noted, “[b]are conclusions
are not a rationale.” Id. at 693. The Plan must provide
a reasonable explanation for its determination and
must address any reliable, contrary evidence presented
by the claimant. Nord, 538 U.S. at 834 (“Plan administra-
10 No. 08-1722
tors, of course, may not arbitrarily refuse to credit a claim-
ant’s reliable evidence, including the opinions of a
treating physician.”); see also Kalish v. Liberty Mut./Liberty
Life Assurance Co., 419 F.3d 501, 510 (6th Cir. 2005) (holding
that a plan acted arbitrarily in denying disability benefits
when its medical consultant failed to rebut the con-
trary medical conclusions of the claimant’s primary
physician). The Plan did not explain why it chose to
discount the near-unanimous opinions of Love’s treating
physicians. While plan administrators do not owe any
special deference to the opinions of treating physicians,
see Nord, 538 U.S. at 834, they may not simply ignore
their medical conclusions or dismiss those conclusions
without explanation. We do not hold that the evidence
here requires a finding that Love is totally disabled, only
that ERISA requires the Plan to provide a more thorough
explanation for its determination than it has here. The
Plan acted arbitrarily by terminating Love’s benefits
without sufficiently explaining its basis for doing so.
One final point bears a brief word. Love complains that
the Plan’s determination is suspect given the Social Secu-
rity Administration’s (“SSA”) determination that she
qualified for disability benefits. In 2002 the SSA deter-
mined that Love met its definition of “disabled” because
of her multiple sclerosis and awarded her retroactive
disability benefits from August 2001—the date she
stopped working at National City. We note, however, that
the Plan’s definition of “disabled” is different from—and
arguably more stringent than—the SSA’s definition. See
42 U.S.C. § 423(d)(1)(A) (defining disability as the “inabil-
ity to engage in any substantial gainful activity by
No. 08-1722 11
reason of any . . . physical or mental impairment which . . .
has lasted or can be expected to last for a contin-
uous period of not less than 12 months”). But see Diaz v.
Prudential Ins. Co. of Am., 499 F.3d 640, 644 (7th Cir.
2007) (suggesting that the differences between the
Plan’s definition and the SSA definition are minor). In
addition, we have repeatedly emphasized that the SSA’s
determination of disability is not binding on employers
under ERISA. See Mote v. Aetna Life Ins. Co., 502 F.3d
601, 610 (7th Cir. 2007). SSA determinations are often
instructive, but they are not determinative. Id. Because we
are remanding, the Plan will have an opportunity to
consider the SSA’s determination when it reevaluates
Love’s eligibility.
C. Remedy
We conclude that the Plan acted arbitrarily in terminat-
ing Love’s disability benefits without giving a sufficient
explanation of its reasons. Love wants us to award her
retroactive benefits, but we decline to do so. Retroactive
reinstatement of benefits is a proper remedy in cases
where the evidence is “so clear cut that it would be unrea-
sonable for the plan administrator to deny the applica-
tion for benefits on any ground.” Gallo v. Amoco Corp., 102
F.3d 918, 923 (7th Cir. 1996). Here, the evidence is not so
clear. “[W]hen a court or agency fails to make adequate
findings or fails to provide an adequate reasoning, the
proper remedy in an ERISA case . . . is to remand for
further findings or explanations . . . .” Quinn v. Blue Cross
& Blue Shield Assoc., 161 F.3d 472, 477 (7th Cir. 1998). On
12 No. 08-1722
remand, the Plan should conduct a more thorough
inquiry into whether Love meets the Plan’s definition of
“disabled.” If it concludes that she does not meet that
definition, it must adequately explain the reasons sup-
porting its decision, including at a minimum an explana-
tion of why it is discounting the medical opinions of
Love’s treating physicians.
Accordingly, we R EVERSE the district court’s entry of
summary judgment and R EMAND with instructions to
remand to the Plan administrator for further proceedings
consistent with this opinion.
7-23-09