Elliott v. Sara Lee Corporation

PUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
BRENDA ELLIOTT,
Plaintiff-Appellant,
v. No. 98-2346
SARA LEE CORPORATION,
Defendant-Appellee.
Appeal from the United States District Court
for the Western District of North Carolina, at Statesville.
Lacy H. Thornburg, District Judge.
(CA-96-96-5-T)
Argued: May 5, 1999
Decided: September 14, 1999
Before MURNAGHAN, LUTTIG, and WILLIAMS,
Circuit Judges.
_________________________________________________________________
Affirmed by published opinion. Judge Murnaghan wrote the opinion,
in which Judge Luttig and Judge Williams joined.
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COUNSEL
ARGUED: Donald Joseph Willey, Jefferson, North Carolina, for
Appellant. W. R. Loftis, Jr., CONSTANGY, BROOKS & SMITH,
L.L.C., Winston-Salem, North Carolina, for Appellee. ON BRIEF:
Virginia A. Piekarski, CONSTANGY, BROOKS & SMITH, L.L.C.,
Winston-Salem, North Carolina, for Appellee.
_________________________________________________________________
OPINION
MURNAGHAN, Circuit Judge:
Under the long-term disability plan of the Sara Lee Corporation,
Brenda Elliott received benefits for a year due to her obesity and
degenerative disc disease. After the first year of disability, Sara Lee
terminated Elliott's benefits, upon a finding that she could perform
some sedentary work. Elliott disagreed with the finding and instituted
the instant action, alleging that Sara Lee breached its contract with her
in violation of the Employee Retirement Income Security Act of 1974
("ERISA"), as amended, 29 U.S.C.A. §§ 1001-1461 (West 1999). The
district court judge affirmed Sara Lee's denial of benefits, granting
the company's motion for summary judgment. Elliott now appeals.
Finding no error, we affirm the district court's decision.
I.
Brenda Elliott ("Elliott") worked as a sewing machine operator at
a products plant of the Sara Lee Corporation ("Sara Lee") in Jeffer-
son, North Carolina. She worked at the plant until June 1991, when
she took a medical leave of absence due to obesity and degenerative
disc disease. Initially, while on leave, Elliott received either her salary
or sick pay. On October 31, 1991, she applied for long-term disability
benefits.
Sara Lee administers and insures its own long-term disability plan,
the Hourly Piece Rate Long Term Disability Plan of Sara Lee Corpo-
ration Consumer Personal Products Group (the "Plan"). Under the
Plan, the employee is entitled to benefits in her first year of disability
if she is unable to perform her regular job.1 Elliott was unable to work
_________________________________________________________________
1 Subsection 2.5 of the Plan provides as follows:
2.5. Total Disability. During the first year of disability, an
employee shall be deemed totally disabled while he or she is
unable to perform each and all of the duties pertaining to his or
her occupation and not engaged in any occupation or employ-
ment for wage or profit for which he or she is reasonably quali-
fied by education, training or experience. After the expiration of
the period set forth above, "total disability" means the continu-
ous inability of the employee to engage in each and every occu-
pation or employment for wage or profit for which he or she is
reasonably qualified by education, training or experience.
2
as a sewing machine operator, so she received benefits pursuant to the
Plan beginning November 16, 1991.
After the first year of disability, the definition of "totally disabled"
changes. After that first year, the employee is entitled to benefits only
if she is unable to engage in "each and every occupation or employ-
ment for wage or profit for which ... she is reasonably qualified by
education, training or experience." The burden of proving the disabil-
ity is on the employee. Moreover, the Plan Administrator has the dis-
cretion to request that the employee submit conclusive medical
evidence of the continuance of her disability and to direct the
employee to submit to an independent medical examination.2
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2 Subsection 2.7 of the Plan provides as follows:
2.7. Entitlement to Benefits. Entitlement to monthly disability
benefits under the plan is subject to the following:
(a) A covered employee must support his or her initial enti-
tlement to benefits by submitting, on a form provided
by the administrator, written proof covering the occur-
rence, character and extent of disability within the six-
week period which ends with the expiration of the
fourteen-week period immediately following the occur-
rence of disability. As requested by the administrator,
it may require the employee to submit conclusive medi-
cal evidence of the continuance of his or her disability.
In connection therewith, the administrator shall have
the right to direct such employee to submit to an inde-
pendent medical examination by a physician designated
by the administrator.
(b) A covered employee must be under the continuous care
of a physician legally licensed to practice medicine
with a defined course of treatment appropriate for the
employee's disability. If an employee's disability is a
mental or nervous disorder, his or her treatment must
include care by a Board certified, licensed physician
who specializes in psychiatric medicine.
All proof submitted pursuant to this subsection must be accept-
able to the administrator, which shall have sole discretion in
determining the acceptability of such proof.
3
On May 14, 1992, a representative of the John Hancock Mutual
Life Insurance Company ("John Hancock"), on behalf of the Plan
Administrator, informed Elliott by letter of the stricter definition of
"totally disabled" that would take effect once her first year of disabil-
ity expired. The letter also indicated that the Plan Administrator was
reevaluating Elliott's condition in light of the changed definition.
Toward this end, John Hancock requested updated information on
Elliott's condition from her treating physician, Dr. Glen Liesegang.
Dr. Liesegang completed an Attending Physician's Statement in
which he classified Elliott's physical impairment as moderate. He
found that her degree of impairment was 35 to 55 percent and that she
was capable of clerical or administrative activity. He indicated that he
did not expect a marked improvement in Elliott's condition in the
future.
Elliott's other treating physicians -- Drs. John Wolfe, William M.
Smith, and Lowell Furman -- also submitted statements. Dr. Wolfe
also classified Elliott as capable of clerical or administrative activity
and indicated that he expected her condition to improve markedly in
the future. Dr. Smith found Elliott's degree of impairment to be 60
to 70 percent. He also indicated that he expected a marked improve-
ment in the future and believed that Elliott would be a suitable candi-
date for trial employment. Finally, Dr. Furman, who had not seen
Elliott since August 1991, found that she had only a slight physical
limitation, with a degree of impairment of only 15 to 30 percent. He
concluded that she was capable of performing light manual activity.
Based on these physician statements, the Plan Administrator deter-
mined that Elliott was no longer "totally disabled" under the terms of
the Plan and, therefore, not entitled to benefits.
Elliott appealed the decision. In an appeal, the employee is entitled
to submit additional medical evidence. Elliott submitted documenta-
tion that had previously been submitted to the Social Security Admin-
istration ("SSA") in support of her claim for Social Security Disability
benefits. Included among the documentation was Dr. Liesegang's
Disability Determination Evaluation in which he concluded that
Elliott's "condition is disabling to 25-50% in light of her difficulty
squatting and rising, sitting for prolonged periods of time, fatigue, and
intense muscle tightening when doing repetitive activities." He further
found that "[h]er obesity does limit her ability to stand for prolonged
4
periods of time, and probably contributes to her sense of fatigue and
inability to exercise." The SSA determined that Elliott was totally
disabled3 and awarded her benefits effective December 1991.
Sara Lee arranged for Elliott to be evaluated by independent medi-
cal and psychological examiners. Dr. Earl K. Wilson, who performed
the medical evaluation, found that Elliott could not perform her previ-
ous work as a sewing machine operator but indicated that she should
be able to do some sedentary activity. He suggested that she would
be a good candidate for vocational rehabilitation. The psychologist,
Alan Galloway of the Piedmont Treatment Center in Hickory, North
Carolina, also found that Elliott was capable of performing sedentary
work.
Finally, Sara Lee again requested updated information from Dr.
Liesegang, Elliott's treating physician. Dr. Liesegang, by letter dated
August 23, 1993, stated the following:
Mrs. Elliott's prognosis is difficult as her condition fluctu-
ates. It is also difficult to judge when she will be able to
return to full time employment. However, she may be able
to perform desk work/receptionist type employment. She
should avoid lifting more than 10 lbs., bending and squat-
ting.
Sara Lee's corporate medical director at the time, Dr. Donald
Hayes, reviewed the independent evaluations and the updated infor-
mation from Dr. Liesegang. Dr. Hayes noted that he agreed with the
conclusions of the other medical providers that Elliott could perform
sedentary work. The Appeal Committee met on October 8, 1993 to
review Elliott's claim and upheld the Plan Administrator's determina-
tion that Elliott was not "totally disabled" within the meaning of the
Plan.
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3 The SSA found that Elliott's condition qualified as a total disability
under its Listing of Impairments, which awards disability benefits for
obesity based upon a history of pain and limitation of motion in any
weight-bearing joint or the lumbosacral spine. 20 C.F.R. § 404, Subpart
P, App. 1, § 9.09(A).
5
Elliott instituted the instant action on July 2, 1996 in Ashe County,
North Carolina, Superior Court, alleging that Sara Lee breached its
contract with her in violation of ERISA. Sara Lee removed the action
to the United States District Court for the Western District of North
Carolina. Upon the conclusion of discovery, both Sara Lee and Elliott
moved for summary judgment. The magistrate judge hearing the case
recommended that the parties' cross-motions for summary judgment
be denied. Sara Lee filed objections to the magistrate's recommenda-
tion, and, on August 14, 1998, the district court judge denied Elliott's
motion for summary judgment and granted Sara Lee's motion.
Elliott now appeals that decision. Because we find no error in the
district court's determination, we affirm.
II.
In reviewing a district court's grant of summary judgment, we
examine the decision de novo, employing the same legal standards
applied by the district court. See Brogan v. Holland, 105 F.3d 158,
161 (4th Cir. 1997). A federal court's ability to review a discretionary
decision of the administrator of an employee benefits plan is signifi-
cantly limited. If "the benefit plan gives the administrator or fiduciary
discretionary authority to determine eligibility for benefits or to con-
strue the terms of the plan," Firestone Tire & Rubber Co. v. Bruch,
489 U.S. 101, 115 (1989), a reviewing court may reverse the denial
of benefits only upon a finding of abuse of discretion. See id. at 111;
see also Ellis v. Metropolitan Life Insurance Co. , 126 F.3d 228, 232
(4th Cir. 1997). Under the abuse of discretion standard, the adminis-
trator's decision will not be disturbed if it "``is the result of a deliber-
ate, principled reasoning process and if it is supported by substantial
evidence.'" Brogan, 105 F.3d at 161. In the present case, both parties
agree that the Plan gives to Sara Lee discretionary authority to make
eligibility determinations,4 thus triggering an abuse of discretion stan-
dard.
_________________________________________________________________
4 Subsection 2.7 of the Plan expressly gives the Plan Administrator sole
discretion in determining whether the employee has presented sufficient
proof of disability: "All proof submitted pursuant to this subsection must
be acceptable to the administrator, which shall have sole discretion in
determining the acceptability of such proof."
6
Even under this deferential standard, however, "evidence of admin-
istrative bias remains relevant." De Nobel v. Vitro Corp., 885 F.2d
1180, 1191 (4th Cir. 1989). The Supreme Court has recognized that
where "a benefit plan gives discretion to an administrator or fiduciary
who is operating under a conflict of interest, that conflict must be
weighed as a ``facto[r] in determining whether there is an abuse of dis-
cretion.'" Bruch, 489 U.S. at 115. Since Sara Lee is both fiduciary of
the Plan's beneficiaries and the Plan's insurer, the abuse of discretion
standard must be modified to reflect the potential conflict of interest.
The Fourth Circuit applies this modified standard on a case-by-case
basis, deviating from the usual abuse of discretion standard of review
"only to the extent necessary to counteract any influence unduly
resulting from the conflict." Ellis, 126 F.3d at 233. "The more incen-
tive for the administrator or fiduciary to benefit itself by a certain
interpretation of benefit eligibility or other plan terms, the more
objectively reasonable the administrator or fiduciary's decision must
be and the more substantial the evidence must be to support it." Id.
III.
Under Sara Lee's long-term disability plan, an employee receives
benefits during the first year of disability if she is unable to perform
all the duties of her usual occupation. After the first year, in order to
continue to receive benefits, the employee must show that she is
unable to perform the duties of any occupation for which she is rea-
sonably qualified. In accordance with the Plan, Elliott received bene-
fits during her first year of disability, since she was unable to return
to her job as a sewing machine operator. After the first year, however,
Sara Lee determined that Elliott could perform some other work and
was, thus, ineligible for continued benefits. Elliott maintains that Sara
Lee's decision to deny her benefits is unreasonable and not supported
by substantial evidence. The district court disagreed, granting Sara
Lee summary judgment. Elliott contends that the judgment was
improper because there remain material issues of fact in dispute.
In making its decision, Sara Lee relied in part on the opinion of
Elliott's treating physician, Dr. Liesegang, that she was capable of
performing sedentary work. Elliott argues that the company's findings
mischaracterize the doctor's opinion. While in a letter, dated August
23, 1993, Dr. Liesegang indicated that "Ms. Elliott may be able to
7
perform deskwork/receptionist-type employment," he stated in that
same letter that "[i]t is also difficult to judge when she will be able
to return to full time employment." Elliott maintains that it was an
abuse of discretion for Sara Lee to rely on Dr. Liesegang's single sen-
tence regarding Elliott's ability to perform deskwork, to the exclusion
of other statements that raise doubts about Elliott's capacity to work.
To the contrary, Sara Lee based its decision on a combination of
medical opinion evidence, not just Dr. Liesegang's statements, indi-
cating that Elliott was not "totally disabled" under the terms of the
Plan. The medical opinions are virtually unanimous. A total of four
physicians who had treated Elliott determined that she could perform
some work, including occupations that involved the performance of
clerical or administrative tasks. The Appeal Committee also received
independent medical and psychological evaluations, which also con-
cluded that Elliott was able to perform sedentary activities. Further-
more, on at least two separate occasions, Dr. Liesegang himself
indicated that Elliott could perform some type of sedentary work. So,
while Dr. Liesegang expressed some uncertainty about the timing of
Elliott's return to full-time employment, that uncertainty is offset by
his own assertion that she could do sedentary work and the similar
assessment of other medical experts.
Even if Dr. Liesegang's report suggested that Elliott could perform
no work at all, that fact would not preclude the Plan Administrator
from denying benefits. The Fourth Circuit has held that it is not an
abuse of discretion for a plan fiduciary to deny disability pension ben-
efits where conflicting medical reports were presented. See Ellis, 126
F.3d at 234 (finding no abuse of discretion in fiduciary's denial of
benefits where claimant's primary medical provider's finding of dis-
ability conflicted with reports of independent panel of medical spe-
cialists); Brogan, 105 F.3d at 162-63 (affirming district court's grant
of summary judgment for trustees where medical evidence was con-
flicting as to whether plaintiff's stroke occurred during course of
employment). We, therefore, conclude that Sara Lee did not mis-
characterize Dr. Liesegang's opinion and that, in any event, the com-
pany's determination that Elliott is no longer disabled is otherwise
supported by substantial evidence in the record.
Notwithstanding the overwhelming evidence in support of Sara
Lee's finding of no disability, Elliott maintains that her position is
8
vindicated by the SSA's finding that she is, in fact, disabled. See
Brogan, 105 F.3d at 163 & n.6 (noting that determination of adminis-
trative law judge in state workers' compensation proceeding may be
considered evidence when awarding disability retirement benefits).
Recognizing that the Social Security regulatory scheme is not binding
on Sara Lee, Elliott argues that the Administrator should have
accorded the federal agency's disability determination greater, if not
controlling, weight.
Despite our willingness in Brogan to consider as evidence the find-
ings by an administrative law judge (ALJ) in a workers' compensa-
tion proceeding, id., our consideration here of the SSA's finding
should depend, in part, on the presentation of some evidence that the
"disability" definitions of the agency and Plan are similar. In Brogan,
the parties disputed the timing of the claimant's disability. Id. The
claimant insisted that he suffered a disabling stroke while lifting
heavy oxygen tanks at work, while the trustees of the pension plan
maintained that it could not be established that the stroke was work-
related. Id. In its effort to ascertain whether the stroke was precipi-
tated by a specific work event or by the claimant's other health prob-
lems, the district court relied on the ALJ's finding that the claimant
had not suffered a "definite, isolated, fortuitous event." Id. The
administrative finding directly addressed the contested issue in that
case, so the court's reliance on it as additional evidence to support the
trustees' decision was warranted. Id.
Here, however, the SSA disability determination does not necessar-
ily directly address the contested issue before us. There is no indica-
tion that the definition of "total disability" under the Plan in any way
mirrors the relevant definition under the regulations of the SSA.5 See
Boyd v. Trustees of the United Mine Workers Health & Retirement
Funds, 873 F.2d 57, 58, 59 (4th Cir. 1989) (noting that Social Secur-
ity disability award conclusively established medical disability under
pension plan that expressly stated that employee was considered
_________________________________________________________________
5 Under the SSA's regulations,"disability" is defined as "the inability
to do any substantial gainful activity by reason of any medically deter-
minable physical or mental impairment which can be expected to result
in death or which has lasted or can be expected to last for a continuous
period of not less than 12 months." 20 C.F.R.§ 404.1505(a) (1999).
9
totally disabled "only if ... subsequently determined to be eligible for
Social Security Disability Insurance Benefits"). In fact, Sara Lee's
Director of Employee Benefits, James Clousing, indicated in his
sworn affidavit that "[t]here [had] been cases in which an employee
was denied Social Security Disability benefits but the Appeal Com-
mittee found that the employee was entitled to Sara Lee disability
benefits." Since Social Security determinations are not binding on the
Appeal Committee and there is no indication that the disability stan-
dards are analogous, the Plan Administrator was under no obligation
to weigh the agency's disability determination more favorably than
other evidence.
We made clear in Brogan that, while the ALJ's finding could be
considered as evidence, it was not determinative. 105 F.3d at 163 &
n.6. In the case at bar, the Appeal Committee reviewed all the mate-
rial submitted on appeal, including Elliott's award of Social Security
benefits. It decided, based on the overwhelming medical evidence that
Elliott could perform sedentary work, to uphold the Plan Administra-
tor's determination of no disability. Perceiving no abuse of discretion,
we cannot say that Fourth Circuit law requires anything more of Sara
Lee.
Additionally, Elliott urges us to adopt the "treating physician rule"
employed in evaluating Social Security Administration disability
cases. The rule requires that the fact-finder give greater deference to
the expert judgment of a physician who has observed the patient's
medical condition over a prolonged period of time. Even if we were
to apply the rule to the ERISA claim before us, which we are not per-
suaded to do, it only requires an award of benefits based upon a treat-
ing doctor's opinion of disability absent persuasive contradictory
evidence. See Foster v. Heckler, 780 F.2d 1125, 1130 (4th Cir. 1986)
(noting, in review of Social Security disability determination, that a
treating physician's testimony is "``entitled to great weight'" and that
it "is ignored only if there is persuasive contradictory evidence.").
Here, such contradictory evidence exists -- namely, the indisputable
professional opinions of five physicians that Elliott could perform
some type of sedentary work.
Finally, Elliott maintains that the fact that the Committee made no
findings as to whether or not Elliott has hand numbness, fatigue, pos-
10
tural limitations, or any functional limitations makes review of its
decision impossible and remand necessary. Elliott suggests that Sara
Lee had an obligation to secure evidence from a vocational consultant
to determine what jobs, if any, she could perform. We disagree. Given
the extensive medical record before the Appeal Committee, Sara Lee
was under no obligation to secure additional vocational evidence. See
Berry v. Ciba-Geigy Corp., 761 F.2d 1003, 1008 (4th Cir. 1985)
(finding that plan trustees had no duty to secure evidence supporting
a claim for disability benefits where they possessed reliable evidence
that claimant was not disabled).
Elliott, however, was free to supplement the record. By letter dated
July 16, 1992, a representative of John Hancock, on behalf of Sara
Lee, informed Elliott that she could augment her claim file with addi-
tional information in order to have the decision reconsidered. Indeed,
it would have behooved Elliott to do so, since, under the Plan, she
bears the burden of proving her disability. Having failed to submit
supplemental vocational information, Elliott cannot now prevail on an
argument that Sara Lee had insufficient evidence to make a reasoned
decision.
Under the circumstances, we find that an administrator, free of Sara
Lee's apparent financial conflict of interest in serving as both fidu-
ciary and insurer, would have been justified in denying Elliott bene-
fits. Sara Lee's decision was, therefore, a reasonable exercise of its
discretion. See Bruch, 489 U.S. at 111 (holding that trustee's interpre-
tation of plan terms "will not be disturbed if reasonable"); see also
Sheppard & Enoch Pratt Hospital, Inc. v. Travelers Insurance Co.,
32 F.3d 120, 125 (4th Cir. 1994) (noting that "the district court should
not disturb a benefits determination by a trustee authorized to exercise
its discretion unless the decision was unreasonable").
IV.
Elliott maintains that the district court erred in failing to consider
the affidavit of Dr. Gary Sigmon, a vocational consultant, even
though that information was not available to the Appeal Committee.
Elliott submits that the evidence from Dr. Sigmon was introduced for
the purpose of demonstrating the insufficiency of the evidence before
the Plan Administrator and the failure of the Administrator to conduct
11
a proper review of her claim. The court, Elliott insists, should have
considered the additional evidence for that limited purpose.
When a district court reviews a plan administrator's decision under
the abuse of discretion standard, "an assessment of the reasonableness
of the administrator's decision must be based on the facts known to
it at the time."6 Sheppard & Enoch Pratt Hospital, 32 F.3d at 125; see
also Bernstein v. CapitalCare, Inc., 70 F.3d 783, 788 (4th Cir. 1995).
If the court believes the administrator lacked adequate evidence on
which to base a decision, "the proper course[is] to ``remand to the
trustees for a new determination,' not to bring additional evidence
before the district court." Berry, 761 F.2d at 1007 (internal citations
omitted); see also Sheppard & Enoch Pratt Hospital, 32 F.3d at 125.
As we have previously indicated, however, "remand should be used
sparingly." Berry, 761 F.2d at 1008. Remand is most appropriate
"where the plan itself commits the trustees to consider relevant infor-
mation which they failed to consider or where [the] decision involves
``records that were readily available and records that trustees had
agreed that they would verify.'" Berry, 761 F.2d at 1008. The district
court may also exercise its discretion to remand a claim "where there
are multiple issues and little evidentiary record to review."
Quesinberry, 987 F.2d at 1025 n.6.
We find no basis to conclude that there was insufficient evidence
before the Appeal Committee. As explained above, a plan administra-
tor is under no duty to secure specific forms of evidence. Granted, the
_________________________________________________________________
6 In contrast, when a district court conducts a de novo review of ERISA
benefits claims, i.e., where the benefit plan does not give the administra-
tor or fiduciary discretionary authority to determine eligibility for bene-
fits, it may in its discretion consider evidence that was not before the
plan administrator. See Quesinberry v. Life Insurance Co. of North
America, 987 F.2d 1017, 1025 (4th Cir. 1993) (en banc). "The district
court should exercise its discretion, however, only when circumstances
clearly establish that additional evidence is necessary to conduct an ade-
quate de novo review of the benefit decision." Id. Admission of such evi-
dence may be warranted "[i]f administrative procedures do not allow for
or permit the introduction of the evidence" but not where it is merely
"cumulative of what was presented to the plan administrator, or is simply
better evidence than the claimant mustered for the claim review." Id. at
1027.
12
Appeal Committee's fiduciary obligations and Sara Lee's promise to
pay monthly benefits to those employees deemed totally disabled
under the Plan preclude the Committee from denying benefits without
any evidentiary basis. See Berry, 761 F.2d at 1008. The Committee
is not required, however, to secure the specific testimony of a voca-
tional expert like Dr. Sigmon, especially where the record already
contains ample and reliable medical documentation. 7 Having
reviewed the unanimous evidence from both Elliott's treating physi-
cians and independent medical examiners indicating that she is able
to perform some sedentary work, the Appeal Committee rendered a
reasoned decision supported by substantial evidence in the record.
Since there was sufficient evidence before the Appeal Committee to
make a rational decision and an adequate evidentiary record for a
court to conduct a meaningful review of that decision, the district
court was correct in its refusal to consider additional evidence that
was not presented to the Committee. We, therefore, find no error.
V.
For the foregoing reasons, the district court's grant of summary
judgment in favor of Sara Lee is
AFFIRMED.
_________________________________________________________________
7 Of course, Elliott had the right to supplement the record. She should
have known about the vocational evidence she now seeks to introduce
through Dr. Sigmon's affidavit and, if she believed consideration of it
was necessary to make a correct determination, should have presented it
to the Appeal Committee.
13