Summary
analyzing the administrator's benefits decision under a pre-existing condition clause similar to the present clause
Summary of this case from Kennard v. Unum Life Insurance CompanyOpinion
CIVIL ACTION NO: 00-940 SECTION: "R".
October 17, 2000.
ORDER AND REASONS
This is an action for review of the denial of disability benefits by the administrator of an employee welfare benefit plan governed by the Employee Retirement Income Security Act of 1974. Plaintiff alleges that defendant, Reliance Standard Life Insurance Company (RSL), denied her claim for disability benefits in violation of 29 U.S.C. § 1132 (a)(1)(B). Defendant moves for summary judgment pursuant to Rule 56. For the reasons stated below, summary judgment is GRANTED.
I. BACKGROUND
Plaintiff Mary Marlene Moore began working for CFG/Cross Equipment on November 16, 1998. As an employee, she was covered by her employer's group long-term disability plan provided under a policy issued by defendant RSL. The disability plan is an employee welfare benefit plan that is subject to and governed by ERISA. 29 U.S.C. § 1001, et seq. Plaintiff continued to work for CFG/Cross until July 14, 1999, when she claimed that she was unable to work because of her psychological status. ( See Def.'s Mem Supp. Summ. J. Ex. B.)
Moore submitted a disability claim form stating that she suffered from panic attacks in public places. Before she submitted her claim, plaintiff sought treatment for anxiety from Dr. Jerry Levine, who prescribed the tranquilizer Diazepam on December 9, 1999. Plaintiff was hospitalized at Terrebonne General Medical Center until July 23, 1999 for her condition. During this time, Dr. Harold Conrad, a psychiatrist, treated plaintiff and stated in his physician's report that plaintiff suffered from frequent panic attacks. In addition, the discharge summary from the hospital also states that plaintiff was severely depressed and anxious and that she had panic attacks during her hospital stay. ( See id. at Ex. I.) The diagnosis on discharge included both major depression and panic attacks.
Plaintiff was again hospitalized in August of 1999 for psychiatric reasons. On the treatment plan dated August 11, 1999, plaintiff stated that she was feeling suicidal due to "stressors and anxiety reasons." ( See id. at Ex. K.)
Because of her disability, plaintiff submitted a claim under the long-term disability policy provided by RSL. On November 15, 1999, RSL found plaintiff's claim barred by the pre-existing condition provision in its disability policy. RSL denied plaintiff's claim because plaintiff sought treatment for her anxiety in December of 1998, during the three months prior to the time her insurance became effective. Plaintiff appealed this decision on or about December 1, 1999. On March 6, 2000, RSL affirmed its previous decision to deny plaintiff's claim based on the pre-existing condition exclusion. Plaintiff responded by filing this lawsuit.
II. DISCUSSION
A. Summary Judgment Standard
Summary judgment is appropriate when there are no genuine issues as to any material facts, and the moving party is entitled to judgment as a matter of law. See FED. R. Civ. P. 56(c); see also Celotex Corp. v. Catrett, 477 U.S. 317, 322-23, 106 S.Ct. 2548, 2552 (1986). A court must be satisfied that no reasonable trier of fact could find for the nonmoving party or, in other words "that the evidence favoring the nonmoving party is insufficient to enable a reasonable jury to return a verdict in her favor." Lavespere v. Niagara Mach. Tool Works, Inc., 910 F.2d 167, 178 (5th Cir. 1990), abrogated on other grounds by Little v. Liquid Air Corp., 37 F.3d 1069 (5th Cir. 1994) ( citing Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 249, 106 S.Ct. 2505, 2511 (1986)). The moving party bears the burden of establishing that there are no genuine issues of material fact.
If the dispositive issue is one for which the nonmoving party will bear the burden of proof at trial, the moving party may satisfy its burden by merely pointing out that the evidence in the record contains insufficient proof concerning an essential element of the nonmoving party's claim. See Celotex, 477 U.S. at 325, 106 S.Ct. at 2554; see also Lavespere, 910 F.2d at 178. The burden then shifts to the nonmoving party, who must, by submitting or referring to evidence, set out specific facts showing that a genuine issue exists. See Celotex, 477 U.S. at 324, 106 S.Ct. at 2553. The nonmovant may not rest upon the pleadings, but must identify specific facts that establish a genuine issue exists for trial. See id. at 325, 106 S.Ct. at 2553-54; Little v. Liquid Air Corp., 37 F.3d 1069, 1075 (5th Cir. 1996).
B. Legal Standard
ERISA does not expressly delineate a standard of review for actions challenging benefit determinations. The Supreme Court and the Fifth Circuit have provided the appropriate standards in case law. The appropriate standard depends upon whether the district court is asked to review an issue of plan interpretation or a factual determination by the plan administrator. In Firestone Tire Rubber Co. v. Bruch, the Supreme Court held that an administrator's denial of benefits is reviewed de novo, unless the benefit plan gives the administrator "discretionary authority to determine eligibility for benefits or to construe the terms of the plan." 489 U.S. 101, 115, 109 S.Ct. 948, 956-57 (1989). If the plan grants such discretion, a court will reverse an administrator's decision only for abuse of that discretion. See id. Regardless of the discretion granted an administrator, however, the Fifth Circuit has held that all factual determinations under ERISA plans are to be reviewed under an abuse of discretion standard. See Meditrust Fin. Servs. Corp. v. The Sterling Chemicals, Inc., 168 F.3d 211, 215 (5th Cir. 1999) ( citing Pierre v. Connecticut Gen. Life Ins. Co., 932 F.2d 1552, 1562 (5th Cir.), cert. denied, 112 S.Ct. 453 (1991)). See also Chabert v. Provident Life Accident Co., 1994 WL 374213, at *4-5 (E.D. La. July 11, 1994) (reviewing factual determinations for abuse of discretion even when plan did not confer discretion on administrator).
Under the abuse of discretion standard, the Court considers whether the plan administrator's actions were arbitrary and capricious. See Meditrust, 168 F.3d at 215; Sweatman v. Commercial Union Ins. Co., 39 F.3d 594, 601 (5th Cir. 1994) ( quoting Salley v. E.I. DuPont de Nemours Co., 966 F.2d 1011, 1014 (5th Cir. 1992)). The Court must determine if substantial evidence exists in the record to support the decision. See Meditrust, 168 F.3d at 215. Substantial evidence "is more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Girling Health Care, Inc. v. Shalala, 85 F.3d 211, 215 (5th Cir. 1996) ( quoting Richardson v. Perales, 402 U.S. 389, 401, 91 S.Ct. 1420, 1427 (1971)); accord Rhodes v. Panhandle Eastern Corp., 1993 WL 346188, at *8 (E.D. La. Aug. 31, 1993) (substantial evidence requires more than a scintilla but less than a preponderance) (internal quotations omitted) ( quoting Sandoval v. Aetna Life and Cas. Ins. Co., 967 F.2d 377, 381 (10th Cir. 1992)). The court charged with reviewing the denial of benefits under an ERISA plan may not substitute its judgment for that of the plan administrator. See Rigby v. Bayer Corp., 933 F. Supp. 628, 633 (E.D. Tex. 1996) ( citing Denton v. First Nat'l Bank of Waco, 765 F.2d 1295 (5th Cir. 1985)). See also Pierre, 932 F.2d at 1559 ("[t]he Courts simply cannot supplant plan administrators, through de novo review, as resolvers of mundane and routine fact disputes") (citation omitted); Kolodzaike v. Occidental Chem. Corp., 88 F. Supp.2d 745, 749 (S.D. Tex. 2000) ("just because this court may have conducted the investigation differently . . . does not mean that the Administrator abused her discretion"). Rather, the Court "need only assure that the administrator's determination fall somewhere on a continuum of reasonableness — even if on the low end." Vega, 188 F.3d at 297.
Here, the policy grants defendant discretionary authority. The plan states:
Reliance Standard Life Insurance Company shall serve as the claims review fiduciary with respect to the insurance policy and the Plan. The claims review fiduciary has the discretion to interpret the terms of the Plan and the insurance policy and to determine eligibility for benefits. Decisions of the claims review fiduciary shall be complete, final and binding on all parties.
( See Def.'s Mem. Supp. Summ. J. Ex. A.) Therefore, the Court will review RSL's decision to deny plaintiff's disability claim for abuse of discretion. The Court will determine whether a genuine issue of fact exists as to whether defendant acted arbitrarily and capriciously when it decided to deny plaintiff's claim and whether such a decision was supported by substantial evidence.
C. Scope of Review
The Court's review of whether an administrator abused its discretion in making factual determinations is limited to the administrative record before the administrator. See Vega, 188 F.3d at 299 (collecting cases); Wildbur v. ARCO Chemical Co., 974 F.2d 631, 639 (5th Cir. 1992). Exceptions to this general rule exist when the Court reviews the administrator's interpretation of plan terms for abuse of discretion or investigates inferences of self-interest and good faith. See Wildbur, 974 F.2d at 639. In those circumstances, the reviewing court may consider evidence outside of the administrative record. See id. The Fifth Circuit held in Vega v. National Life Ins. Servs., Inc. that a district court reviewing the denial of benefits by an ERISA plan administrator is limited to a review of the administrative record, namely, "relevant information made available to the administrator prior to the complainant's filing of a lawsuit and in a manner that gives the administrator a fair opportunity to consider it." Vega v. National Life Ins. Servs., Inc., 188 F.3d 287, 300 (5th Cir. 1999) (en banc) (emphasis added). The purpose of confining the district court to the evidence presented to the plan administrator is to promote ERISA's goal of prompt and efficient claims resolution by plan fiduciaries. See Wildbur, 974 F.2d at 639. See also Perry v. Simplicity Eng'g, 900 F.2d 963, 967 (6th Cir. 1990) (primary goal of ERISA is to resolve disputes over benefits inexpensively and expeditiously; permitting district courts to consider evidence not presented to the plan administrator would not serve this goal). Thus, the Vega court declined to remand an ERISA claim to the plan administrator for additional evidentiary findings, reasoning as follows:
We want to encourage each of the parties to make its record before the case comes to federal court, and to allow the administrator another opportunity to make a record discourages this effort. Second, allowing the case to oscillate between the courts and the administrative process prolongs a relatively small matter that, in the interest of both parties, should be quickly decided.
Id. at 302 n. 13; accord Jourdan v. Domino Sugar Corp. Chalmette Refinery Pension Plan, 2000 WL 245859, at *8 (E.D. La. March 1, 2000).
In her opposition to summary judgment, plaintiff offers the following evidence: (1) a letter and affidavit from Dr. Harold Conrad from September of 2000, and (2) a document from an unidentified source containing medical diagnostic criteria for anxiety disorder and major depression. Plaintiff presents this evidence to support her claim that anxiety and depression are separate illnesses with distinct diagnostic criteria. This evidence was not available to the administrator at the time plaintiff's claim was denied. Considering the Fifth Circuit's caution against allowing parties to supplement the administrative record after an ERISA case is filed in federal court, as well as ERISA's goal of promoting expeditious resolutions of employee benefit claims by plan administrators, the Court cannot consider this evidence in reviewing the summary judgment motion.
D. Application
At issue is whether plaintiff's disability was a pre-existing condition and therefore not covered under the plan. Under the plan, if an employee has not been employed for one year or more, he or she is subject to a pre-existing condition limitation on coverage. The limitation provides:
Applicable employees hired on or after August 1, 1997: benefits will not be paid for a total disability: 1. Caused by; 2. Contributed to by; or 3. Resulting from; A pre-existing condition unless the insured has been actively at work for one (1) full day following the end of twelve consecutive months from the date he/she became an insured.
( See Def.'s Mem. Supp. Summ. J., Ex. A at 9.) The plan also defines pre-existing condition as follows:
"Pre-existing Condition" means any Sickness or Injury for which the Insured received medical treatment, consultation, care or services, including diagnostic procedures, or took prescribed drugs or medicines, during the 3 months immediately prior to the insured's effective date of insurance.
( See id. Ex. A at 2.) It is undisputed that plaintiff had been employed for less than a year at the time she was first insured and is therefore subject to the pre-existing condition provision. It is also undisputed that the effective date for plaintiff's insurance was February 1, 1999 and that the three month pre-existing condition exclusion period ran from November 1, 1998 through February 1, 1999. Plaintiff admits that Dr. Jerry Levine treated her on December 9, 1998, during the pre-existing limitation period, for "minor anxiety." (See Pl.'s Mem. Opp'n Summ. J., Statement of Uncontested Material Facts.) It is also undisputed that on December 9, 1998, Dr. Levine prescribed the drug Diazepam to plaintiff for anxiety, as he had on September 10, 1998 and as he did again on May 20, 1999. ( See Def.'s Mem. Supp. Summ. J. Ex. C; Pl.'s Mem. Opp'n Summ. J. Ex. A). The parties also do not dispute that in July of 1999, plaintiff suffered from a disability that rendered her unable to work. The key issue in dispute is whether plaintiff's disability resulted from her pre-existing anxiety or whether the anxiety contributed to or caused plaintiff's disability in July.
Plaintiff contends that her disability is the result of major depression that is unrelated in any manner to her pre-existing anxiety. Plaintiff also argues that depression and anxiety are distinct illnesses with separate diagnoses. Defendant argues that plaintiff's disability resulted from her anxiety or that the anxiety contributed or caused her depression and the resulting disability.
The plaintiff relies on evidence that was not available to the administrator at the time plaintiff's claim was denied and that cannot be considered by the Court here. As it stands, the administrative record consistently demonstrates that plaintiff suffered from both depression and anxiety which resulted in her hospitalization and inability to work.
First, plaintiff's self-authored disability claim form, which she completed after she ceased working, belies her claim that anxiety was not a factor in her disability. In the form, plaintiff reveals that she first started noticing the symptoms of her disability in January of 1999, during the period that she was being treated for anxiety. ( See Def.'s Mem. Supp. Summ. J., Ex. B.) In this form, plaintiff does not mention depression as the reason for not being able to work, but rather cites panic attacks in public as the reason. In addition, she identifies Dr. Levine, who had treated her for anxiety in November 1998, as one of the doctors she consulted for the condition resulting in her disability. ( See id.)
Defendant has presented evidence that anxiety and depression are often related. In a letter to plaintiff's attorney, defendant cites the DIAGNOSTIC STATISTICS MANUAL OF MENTAL DISORDERS — FOURTH EDITION OF THE AMERICAN PSYCHIATRIC ASSOCIATION to support the proposition that there "may be a blurred line between the diagnoses of depression and anxiety" and that anxiety disorder frequently occurs with mood disorders such as major depressive disorder. ( See id., Ex. E at 3.)
Defendant also provides several medical evaluations that state that anxiety was an element of plaintiff's disability. First, on July 23, 1999, Dr. Harold Conrad completed a discharge summary describing plaintiff's condition upon release from Terrebonne General Medical Center. She was at the Center from July 14, 1999, the day she left work, until July 23, 1999. In this report, Dr. Conrad explains that plaintiff was withdrawn, suicidal, refused to eat, and had difficulty sleeping. In addition, Dr. Conrad states that plaintiff suffered from:
frequent panic attacks, sometimes two or three times a day during which she has tachycardia, palpitation, sweats, shortness of breath, tingling in her fingers, toes and around her mouth, nausea and vomiting, and fear of impending death. She feels like she is having a heart attack, but examinations have proven in the past that there is no cardiac pathology and she is having panic attacks. She obsessively worries about why she can't help her son more and she constantly paces and cries. She feels paranoid at work and feels that people are talking about her.
( See id. Ex. I at 1). In this same report, Dr. Conrad also indicates that plaintiff suffered "panic attacks along with depression" on her second day at the hospital. ( See id. at 4). The report also indicates that her diagnosis on discharge included both major depression and panic attacks. ( See id.)
Plaintiff was hospitalized again in August of 1999 at Terrebonne General Medical Center/Bayou Oaks. At her psychiatric evaluation dated August 11, 1999, plaintiff stated that the reason for her admission was that she was "thinking about killing herself due to stressors and anxiety feelings." ( See id. Ex. K at 1.) At this time, plaintiff also stated that her present illness was "stressors and anxiety" and that she was having "anxiety attacks." ( See id.)
In addition, in a psychiatric report submitted to RSL by Dr. Conrad on October 25, 1999, the doctor noted that plaintiff had no ability to function outside of highly structured settings and that she suffered from "frequent panic attacks." ( See id. Ex. G at 3.) Also, in a physician's note dated October 22, 1999, Dr. Conrad states that plaintiff could not sleep and was having anxiety attacks. ( See id. Ex. H.)
The evidence presented to the Court overwhelmingly indicates that plaintiff complained of anxiety attacks after she stopped working and that these attacks at least contributed to her disability. Under the plan, a pre-existing condition need only contribute to the disability; it need not be the sole cause of the disability. ( See id. Ex. A at 9.) After reviewing the evidence before the administrator, the Court concludes that the administrator did not abuse its discretion in denying plaintiff's claim for disability benefits and that the plan had substantial evidence to support its decision.
III. CONCLUSION
Because defendant did not act arbitrarily and capriciously in denying plaintiff's disability claim, defendant's motion for summary judgment is GRANTED.
New Orleans, Louisiana, this 17th day of October, 2000.