Opinion
Civil Action No. 04-0633, Section: I/4.
November 5, 2004
ORDER AND REASONS
Before the Court is the motion of plaintiff, Kimberly Miller Moe Barnickel ("Barnickel"), to supplement the administrative record. On October 15, 2004, Barnickel filed a supplemental memorandum in support of her motion. Defendant, UNUM Life Insurance Company of America ("UNUM"), filed oppositions to plaintiff's memoranda. After considering the motion, the memoranda, and the applicable law, plaintiff's motion is DENIED.
Rec. Doc. No. 18.
Rec. Doc. No. 28.
Rec. Doc. Nos. 22 and 26.
The Standard for Supplementing the Administrative Record
The UNUM policy that is the basis of plaintiff's lawsuit is an employee welfare benefit plan sponsored by plaintiff's employer, the American Cancer Society, and covered by the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001, et seq.
Rec. Doc. No. 4.
UNUM contends that the threshold issue to be considered by the Court is whether plaintiff is contesting a factual determination or a plan determination with respect to her short term disability policy. Generally, an ERISA plan administrator's benefit interpretation can be divided into two categories: the determination of facts underlying the claim for benefits ("factual determination") and the determination of whether the administrator properly interpreted the terms of the plan ("plan interpretation"). Chapman v. Prudential Life Ins. Co., 267 F. Supp. 2d 569, 576 (E.D. La. 2003).
A factual determination usually consists of an administrator's finding that the claimant's condition meets a definition in the policy. See Gooden v. Provident Life Accident Ins. Co., 250 F.3d 329, 331 (5th Cir. 2001). Courts generally find that an individual's reported medical progress is a factual determination. See Meditrust Fin. Serv. Corp. v. Sterling Chemicals, Inc., 168 F.3d 211, 214 (5th Cir. 1999).
Classifying a plan administrator's determination establishes the proper standard of review. However, plaintiff's motion is solely to supplement the administrative record. The Court finds the issue of the proper standard of review for plaintiff's claim to be premature. The only issue before the Court is whether plaintiff is entitled to supplement the administrative record with evidence not considered by the plan administrator.
A de novo standard of review is applied to an administrator's denial of benefits under an ERISA plan unless the administrator has discretion to determine eligibility or to construe the terms of the plan, in which case an abuse of discretion standard is applied. Lain v. Unum Life Ins. Co., 279 F.3d 337, 342 (5th Cir. 2002). The abuse of discretion standard is also applied to factual determinations made by a plan administrator and a court may not open the administrative record and conduct discovery as to these determinations. Chapman, 267 F. Supp. 2d at 576 (citing Gooden, 250 F.3d at 333).
The Fifth Circuit has defined the administrative record as "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. Nat'l Life Ins. Services, 188 F.3d 287, 300 (5th Cir. 1999). The administrator has the obligation to identify the evidence in the administrative record and the claimant must be afforded a reasonable opportunity to contest the completeness of the administrative record. Id. at 295-99.
A district court considering a denial of benefits pursuant to ERISA is limited, with few exceptions, to the evidence contained in the administrative record. Estate of Bratton v. Nat'l Union Fire Ins. Co., 215 F.3d 516, 521 (5th Cir. 2000). The exceptions to the general rule barring supplementing the administrative record include: the "admission of evidence related to how an administrator has interpreted terms of the plan in other instances, and evidence, including expert opinion, that assists the district court in understanding the medical terminology or practice related to a claim." Id. Based on the court's language in Estate of Bratton, plaintiff contends that she should be allowed to supplement the administrative record with various evidence pursuant to three distinct exceptions.
In Estate of Bratton, the court stated in pertinent part:
Once the administrative record has been determined, the district court may not stray from it but for certain limited exceptions, such as the admission of evidence related to how an administrator has interpreted terms of the plan in other instances, and evidence, including expert opinion, that assists the district court in understanding the medical terminology or practice related to a claim.Estate of Bratton v. Nat'l Union Fire Ins. Co., 215 F.3d 516, 521 (5th Cir. 2000) (citing Vega v. Nat'l Life Ins. Servs., 188 F.3d 287 (5th Cir. 1999)).
Plaintiff's Exception One — Interpretation of Plan Terms
Plaintiff moves to supplement the administrative record with a transcript from a segment of CBS's "60 MINUTES" that allegedly shows UNUM's widespread practice of denying or revoking claims based on financial targets set by management. Plaintiff asserts that the "60 MINUTES" exposé reveals that UNUM administrators' interpreted disability plans such that no claimant fits within the plan's definition of disabled.
Rec. Doc. No. 18, exhibit A. Plaintiff's exhibit A appears to be the transcript from a news story located at http://www. cbsnews.com and authored by Ed Bradley that originally aired on the CBS network news-program, 60 MINUTES.
A court is allowed to admit evidence which is not in the administrative record when the evidence relates to how an administrator has interpreted plan terms in other instances. See Gooden v. Provident Life Accident Ins. Co., 250 F.3d 329, 333 (5th Cir. 2001); see generally Schultz v. Metropolitan Life Ins. Co., 872 F.2d 676, 680 (5th Cir. 1989) (implicitly approving the district court's use of affidavit evidence offered to show inconsistent treatment of other similar claims by the plan administrator).
Plaintiff has not identified any evidence that relates to how an administrator interpreted a plan term in another instance. The "60 MINUTES" transcript may suggest impropriety by UNUM, but the transcript does not demonstrate how an administrator interpreted a term of plaintiff's short term disability plan or any other similar plan. Therefore, this evidence is not within the scope of this limited exception for supplementing the administrative record.
Plaintiff's Exception Two — Expert Opinion to Clarify Terminology
Plaintiff also desires to supplement the administrative record with the deposition of Dr. Bravo in order to assist the Court in understanding "medical terminology." A court will generally deny extraneous evidence dealing with medical terminology if the court finds that the treatment and medical notes in the record sufficiently explain the plaintiff's condition and enable the court to determine whether the administrator has abused his discretion. See Chapman v. Prudential Life Ins. Co., 267 F. Supp. 2d 569, 577 (E.D. La. 2003).
Plaintiff's argument for supplementation focuses not on the medical definition of her alleged disability, i.e., fibromyalgia, but on a vocational/workplace assessment.
The Fifth Circuit has described fibromyalgia as: "an elusive but debilitating affliction." Black v. Food Lion, Inc., 171 F.3d 308, 309 (5th Cir. 1999). Fibromyalgia "is characterized by complaints of generalized pain, poor sleep, an inability to concentrate, and chronic fatigue." Id.; see also Vargas v. Lee, 317 F.3d 498, 500 n. 2 (5th Cir. 2003) (citing STEDMAN'S MEDICAL DICTIONARY 671 (27th ed. 2000)).
The Physical Capacities Evaluation ("PCE") is located in the administrative record at UACL 0397.
Generally, when deciding whether to supplement the administrative record with evidence relating to a functional assessment, a court is limited to the information included within the record. See Vega v. Nat'l Life Ins. Services, 188 F.3d 287, 299 (5th Cir. 1999) (citing a long line of Fifth Circuit cases which stand for the proposition that a district court is limited to the record with respect to factual assessments). Plaintiff identifies documents in the record which evidence conflicting understandings of Dr. Bravo's opinion that plaintiff could sit/walk/stand for three hours, alternating.
See Record UACL 00372, 00152, 00063. Plaintiff contends that the medical reviews of Susan Grover, RN, CRRN, Ann Marie J. Caron, PT, and Jan Settele, RN MS CCM, support her allegation that the deposition of Dr. Bravo would assist the Court in defining what Dr. Bravo meant. Rec. Doc. No. 18. Plaintiff also asserts that the medical evaluation form was a UNUM provided medical form which constitutes the interpretation of a "plan term" and, therefore, Dr. Bravo's deposition would assist the Court in understanding the conflicting medical terminology. Rec. Doc. No. 28. The Court finds that this evidence is not within the scope of exceptions set forth in Estate of Bratton.
The Court finds that the plaintiff's capacity to sit, stand, and walk does not fall within even the broadest definition of "medical terminology," and that supplementing the administrative record would not assist the Court in reviewing the plan administrator's determination. Whether the plan administrator properly interpreted the evidence within the record will be determined by the Court at a later date. Accordingly, plaintiff may not supplement the administrative record with Dr. Bravo's deposition.
Plaintiff's Exception Three — Miscellaneous Evidence
Finally, plaintiff asserts that Estate of Bratton creates a third exception which would allow the record to be supplemented with evidence that relates to UNUM's standard practice of denying disability claims. Specifically, plaintiff contends that a "record may be supplemented with evidence that would assist the court in analyzing how a company's particular practice could have impacted its decision in this claim." Plaintiff contends that the following materials fall within this exception: 1) the aforementioned 60 MINUTES transcript; 2) depositions of unidentified UNUM employees who would allegedly testify that UNUM had a policy requiring its administrators to deny legitimate disability claims; and 3) medical documents that are of "vital importance" to plaintiff's case that UNUM allegedly failed to consider.
Rec. Doc. No. 18.
Rec. Doc. No. 18. If plaintiff wanted additional information in the administrative record, she could have submitted the evidence to the administrator prior to filing this lawsuit. See Vega v. Nat'l Life Ins. Servs., Inc., 188 F.3d 287, 300 (5th Cir. 1999). Furthermore, plaintiff has not submitted a single document related to her claim that the administrator allegedly failed to consider or omitted from review.
In her articulation of this third exception, plaintiff misconstrues Fifth Circuit jurisprudence. Estate of Bratton provides "certain limited exceptions" when a district court may stray from a determined and finite administrative record. 215 F.3d at 521. The Estate of Bratton court's language, "[evidence] that assists the district court in understanding the medical terminology and practice related to a claim," refers to medical practices, and not, as plaintiff suggests, to any and all "practices" related to her claim. Furthermore, while plaintiff argues that the Fifth Circuit created an illustrative list by using the words "such as," plaintiff provides no authority, other than Estate of Bratton, for the Court to stray from the administrative record "but for certain limited exceptions." See Estate of Bratton, 215 F.3d at 521. In light of the absence of authority favoring supplementation, the Court finds the evidence that plaintiff wishes to add to the record outside the scope of the limited exceptions. Accordingly,
IT IS ORDERED that plaintiff's motion to supplement the administrative record is DENIED.