Joe D. Ratliff v. Guarantee Life Ins.

United States Court of Appeals
FOR THE EIGHTH CIRCUIT
___________
No. 06-2327
___________
Joe D. Ratliff, *
*
Appellant, *
* Appeal from the United States
v. * District Court for the Eastern
* District of Arkansas.
Jefferson Pilot Financial Insurance *
Company1 *
*
*
Appellee. *
___________
Submitted: December 14, 2006
Filed: July 6, 2007
___________
Before WOLLMAN, RILEY and SHEPHERD, Circuit Judges.
___________
SHEPHERD, Circuit Judge.
1
Appellant's employer provided disability benefits through Guarantee Life
Insurance Company which was merged into Jefferson Pilot Financial Insurance
Company (“Jefferson Pilot”) in 2000. The district court improperly identified
Guarantee Life Insurance Company as defendant in the style of this case, an error
which we now correct.
Appellant, Joe D. Ratliff, appeals the district court’s2 judgment denying and
dismissing his complaint against Jefferson Pilot Financial Insurance Company
(“Jefferson Pilot”) filed pursuant to the Employment Retirement Income Security Act
(“ERISA”), 29 U.S.C. §§ 1104, 1132(a)(1)(B). We affirm.
I.
Ratliff was a partner in the accounting firm of Baird, Kurtz and Dopson, LLP
(“BKD”). In 1990, Ratliff was diagnosed with coronary artery disease. In March of
2001, Ratliff developed unstable angina and subsequently underwent a triple coronary
artery bypass operation and received two stents. Ratliff was also diagnosed with
obesity, diabetes mellitus, and high cholesterol.
On August 5, 2002, Ratliff’s cardiologist, Dr. David Hicks, found Ratliff to be
stable and estimated that he should return to work in six months. On January 3, 2003,
Ratliff’s general practitioner, Dr. J. William Nuckolls, completed a form noting
Ratliff’s diagnoses and recommending that Ratliff diet, exercise, and decrease his
stress. With respect to physical restrictions, Dr. Nuckolls stated that other than diet,
exercise, and decreasing stress, “[t]here is nothing [Ratliff] should or should not do.”
Dr. Nuckolls further stated that Ratliff is capable of sitting, standing and walking eight
hours out of an eight hour work day. Likewise, no restrictions were placed on the
amount of weight that Ratliff was able to lift.
Three days later, Dr. Nuckolls drafted a letter wherein he stated that “Mr.
Ratliff is not disabled.” In the same letter, Dr. Nuckolls noted that Ratliff’s schedule
as a CPA was very stressful and that if he continued his current schedule then it was
likely that Ratliff would have another, potentially fatal, coronary event within the next
2
The late Honorable George Howard, Jr., United States District Judge for the
Eastern District of Arkansas.
-2-
several years. Dr. Nuckolls also noted that “if [Ratliff] were limited to forty hours [of
work] per week, he would be able to better take care of himself, exercise, check his
sugars, pay more attention to his diet, and have less stress.” Lastly, Dr. Nuckolls’s
letter noted that Dr. Hicks placed no restrictions or limitations on Ratliff.
Partners at BKD are required to work 2700 hours per year or approximately
fifty-two hours per week. Ratliff presented Dr. Nuckoll’s recommendations to BKD
and elected to limit his working hours to forty hours per week, or 2,080 hours per
year. Because of the reduction in the number of hours worked by Ratliff, BKD
terminated Ratliff as a partner. However, Ratliff continued to work for BKD as an
employee accountant working forty hours per week. On January 16, 2003, following
the termination of his partnership position, Ratliff submitted a claim for long term
disability benefits with BKD’s disability benefit insurer and claims administrator,
Jefferson Pilot. Jefferson Pilot denied Ratliff’s claim on April 25, 2003. Ratliff
appealed to Jefferson Pilot’s Appeals Council modifying his claim to one for partial
disability benefits. This appeal was denied as to long term and partial disability
benefits, and Ratliff filed suit in district court limiting his claim to partial disability
benefits. The parties submitted a stipulated record and briefs. The district court
dismissed Ratliff’s complaint. From that ruling, Ratliff appeals.
II.
ERISA provides a plan beneficiary with the right to judicial review of a benefits
determination. See 29 U.S.C. § 1132(a)(1)(B). “[A] denial of benefits challenged
under [ERISA] is to be reviewed under a de novo standard unless the benefit plan
gives the administrator or fiduciary discretionary authority to determine eligibility for
benefits or to construe the terms of the plan.” Firestone Tire & Rubber Co. v. Bruch,
489 U.S. 101, 115 (1989). Where the plan expressly gives the administrator discretion
to determine eligibility for benefits and to construe the terms of the plan, an abuse of
discretion standard applies. Heaser v. Toro Co., 247 F.3d 826, 833 (8th Cir. 2001).
-3-
The district court determined that an abuse of discretion standard applies here. We
review de novo the district court’s determination of the standard of review in ERISA
cases. Rittenhouse v. UnitedHealth Group Long Term Disability Ins. Plan, 476 F.3d
626, 628 (8th Cir. 2007).
The parties agree that under the terms of the Plan, Jefferson Pilot had the
authority to determine eligibility for benefits. However, Ratliff asserts that because
Jefferson Pilot reviewed his medical records in interpreting the terms of the Plan, a de
novo standard of review should apply. Ratliff analogizes Jefferson Pilot’s review of
Ratliff’s medical records to a plan administrator’s review of matters extraneous to the
plan which triggers a de novo standard of review. See Hogan v. Raytheon Co., 302
F.3d 854 (8th Cir. 2002) (construction of divorce decree); Meyer v. Duluth Bldg.
Trades Welfare Fund, 299 F.3d 686 (8th Cir. 2002) (construction of statute). We
reject Ratliff’s contention as we have repeatedly applied the abuse of discretion
standard in cases involving the plan administrator’s review of medical records. See
Dillard’s, Inc. v. Liberty Life Assur. Co. of Boston, 456 F.3d 894, 897-99 (8th Cir.
2006); McGee v. Reliance Standard Life Ins. Co., 360 F.3d 921, 924-925 (8th Cir.
2004); Shipley v. Ark. Blue Cross & Blue Shield, 333 F.3d 898, 900-02 (8th Cir.
2003); Coker v. Metro. Life Ins. Co., 281 F.3d 793, 797 (8th Cir. 2002). Thus,
reviewing de novo the district court’s determination of the appropriate standard of
review, we find that the proper standard of review of the claims administrator’s
decision is abuse of discretion. See Rittenhouse, 476 F.3d at 628 (this court conducts
de novo review of the district court’s determination of the standard of review in
ERISA cases).
Applying an abuse of discretion standard, the “administrator’s decision to deny
benefits will stand if a reasonable person could have reached a similar decision.”
Hillery v. Metro. Life Ins. Co., 453 F.3d 1087, 1090 (8th Cir. 2006) (quoting Woo v.
Deluxe Corp., 144 F.3d 1157, 1162 (8th Cir. 1998). “A reasonable decision is one
supported by substantial evidence, which is more than a scintilla but less than a
-4-
preponderance.” Id. “Substantial evidence ‘means such relevant evidence as a
reasonable mind might accept as adequate to support a conclusion.’” McGee, 360
F.3d at 924 (quoting Consol. Edison Co. v. N.L.R.B., 305 U.S. 197, 229 (1938)).
As an alternative argument, Ratliff contends that the plan administrator,
Jefferson Pilot, abused its discretion in denying his claim for partial disability benefits
because he can no longer perform his occupation on a full-time basis.
The Plan defines “Partially Disabled or Partial Disability” as:
1. During the Elimination Period and Own Occupation Period, it
means that due to an Injury or Sickness the Insured Employee:
(a) is unable to perform one or more of the material and
substantial duties of his or her regular occupation, or is
unable to perform such duties full-time; and
(b) is engaged in Partial Disability Employment.
“Full-Time” is defined by the Plan as:
[T]he average number of hours the insured employee was regularly
scheduled to work, at his or her regular occupation, during the month just
prior to:
1. The date the Elimination Period begins; or
2. The date an approved leave of absence begins, if the Elimination
Period begins while the Insured Employee is continuing coverage
during a leave of absence.
“Main duties” or “material and substantial duties” are defined as:
[T]hose job duties which:
1. are normally required to perform the Insured person’s regular
occupation; and
2. cannot reasonably be modified or omitted.
It includes those main duties as performed in the general workforce; not
as performed for a certain firm or at a certain work site.
-5-
“Partial Disability Employment” occurs when:
[T]he Insured Employee is working at his or her own or any other
occupation; but because of a Partial Disability:
1. The Insured Employee’s hours or production is reduced:
2. One or more main duties of the job are reassigned; or
3. The Insured Employee is working in a lower-paid occupation.
his or her current earnings must be at least 20% of Predisability income,
and may not exceed the percentage specified in the Partial Disability
Benefit section.
Ratliff argues that his situation fits squarely within the definition of “Partially
Disabled” because due to his illness he is unable to perform one or more of the duties
of his “Regular Occupation,” partner-accountant at BKD, “Full-Time,” that is 2700
hours per year as required of BKD’s partners. Jefferson Pilot argues that Ratliff chose
to reduce his hours in response to the suggestion of his physician that he adopt a
healthier and less stressful lifestyle but that, as verified by his doctors, he is not
disabled. Jefferson Pilot further asserts that Ratliff does not qualify for partial
disability benefits because he maintains the ability to perform the “material and
substantial duties” of his regular occupation as demonstrated by his continued
performance of forty hours per week of work as a BKD accountant.
The plain language of the Plan provides that, in order to be found “Partially
Disabled” the claimant must be “unable to perform one or more of the material and
substantial duties of his or her regular occupation, or . . . unable to perform such duties
full-time.” In denying Ratliff’s second appeal, Jefferson Pilot noted that Ratliff”s
medical records reflected no medical treatment after November 8, 2002, and
adequately considered Dr. Nuckoll’s statements that Ratliff is not disabled as well as
the doctor’s recommendations that Ratliff adopt a healthier lifestyle in order to
“modify his risk factors.” However, as cogently stated by the district court:
[a] person is not disabled based on what might happen in the future . . .
[t]here was no medical event that triggered plaintiff’s application for
-6-
LTD benefits; rather plaintiff was responding to his physician’s advice
to reduce his stress and other factors that put plaintiff at risk of another
heart attack. Plaintiff voluntarily reduced his hours which caused his
employer to terminate his position.
We cannot say that Jefferson Pilot abused its discretion in denying benefits.
When a plan administrator offers a reasonable explanation for its decision, supported
by substantial evidence, “it should not be disturbed.” Fletcher-Merrit v. NorAm
Energy Corp., 250 F.3d 1174, 1180-81 (8th Cir. 2001). The discretionary decision of
a plan administrator is not unreasonable merely because a “different, reasonable
interpretation could have been made.” Parkman v. Prudential Ins. Co. of Am., 439
F.3d 767, 773 (8th Cir. 2006)(per curiam)(citation omitted); Chronister v. Baptist
Health, 442 F.3d 648, 654 (8th Cir. 2006) (“[T]he plan administrator’s decision will
be upheld if it was reasonable, that is, if it was supported by substantial evidence. If
the decision satisfies this standard, it should not be disturbed even if another
reasonable, but different, interpretation may be made.”) (quoting McGarrah v.
Hartford Life Ins. Co., 234 F.3d 1026, 1031 (8th Cir. 2000)).
Finally, Ratliff argues that Jefferson Pilot abused its discretion in that he was
treated differently than a similarly situated BKD partner who was granted benefits
due to her disability from Rocky Mountain Spotted Fever. The determination of the
eligibility for benefits under a plan is an individualized matter with each claim to be
considered on its own merits. Parke v. First Reliance Standard Life Ins. Co., 368 F.3d
999, 1005 (8th Cir. 2004) (question of whether plan administrator has breached its
obligations must be answered on a case-by-case basis) (citing Holmes v. Pension Plan
of Bethlehem Steel Corp., 213 F.3d 124, 137-38 (3d Cir. 2000) (“The issue of liability
itself requires an individualized inquiry into the equities of each claim.”)). However,
even if the circumstances of another former claimant were relevant to the
determination of Ratliff’s claim, the medical and other records with respect to the
allegedly similarly situated BKD partner are not a part of the record in this case, and
Ratliff concedes that he has no information as to the specifics of her condition.
Absent such information, it is impossible to discern whether she was in fact similarly
-7-
situated to Ratliff and treated differently by Jefferson Pilot. Therefore, we reject this
argument.
III.
Accordingly, we affirm the judgment of the district court.
-8-