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explaining that administrator did not abuse discretion where evidence showed that claimant “was not totally disabled as the result of a purely physical condition”
Summary of this case from George v. Reliance Standard Life Ins. Co.Opinion
No. 13-6247
07-10-2014
SHERRY EASTIN, Plaintiff-Appellant, v. RELIANCE STANDARD LIFE INSURANCE COMPANY, Defendant-Appellee.
NOT RECOMMENDED FOR FULL-TEXT PUBLICATION ON APPEAL FROM THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF KENTUCKY
ORDER
Before: MOORE, COLE, and GIBBONS, Circuit Judges.
Sherry Eastin appeals an adverse judgment on her claim for long-term disability benefits brought under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. § 1001 et seq. The parties have waived oral argument, and this panel unanimously agrees that oral argument is not needed. Fed. R. App. P. 34(a).
Eastin was employed for several years as an "MIS Manager" but stopped working in February 2008 because she was unable to perform her material job duties as the result of fibromyalgia, trigeminal neuralgia, depression, and anxiety. In August 2008, she began receiving long-term disability benefits under an ERISA plan administered by defendant Reliance Standard Life Insurance Company. According to the plan, after a 180-day elimination period, benefits were payable for thirty-six months if the insured was unable to perform the material duties of her regular occupation. The plan specified that after the thirty-six-month period, benefits would terminate at the earliest of (1) the date the insured ceased to be totally disabled, (2) the date the insured died, (3) the maximum duration of benefits was reached, as shown by the schedule of benefits, or (4) the date the insured failed to furnish the required proof of total disability. The plan included a limitation if a mental or nervous disorder contributed to the insured's total disability: "Monthly Benefits for Total Disability caused by or contributed to by mental or nervous disorders will not be payable beyond an aggregate lifetime maximum duration of twenty-four (24) months unless the Insured is in a Hospital or Institution at the end of the twenty-four (24) month period." The definition of mental or nervous disorder included among other things, depression, anxiety, and somatoform disorders.
In July 2011, Reliance informed Eastin that it would be cancelling her benefits in August because the thirty-six-month limit would be reached and that to continue receiving benefits, she would need to prove that she was totally disabled as the result of a purely physical condition, which Reliance did not believe was supported by her existing medical records. Eastin asked Reliance to reconsider that decision. During the review period, Reliance had two independent medical examiners (IME) examine Eastin: one doctor performed a neuropsychological evaluation, and the other performed an examination of Eastin's physical complaints. At the conclusion of her physical evaluation, Eastin was found not to be totally disabled as the result of a purely physical condition. In April 2012, Reliance affirmed its decision. Eastin filed suit in state court, seeking continued long-term disability benefits. Reliance removed the action because it presented a federal question, see 28 U.S.C. §§ 1331, 1441(a), and moved for judgment on the administrative record. The district court entered judgment in favor of Reliance and dismissed the action, finding that Reliance's decision to terminate benefits was not arbitrary or capricious because one of the independent medical examiners concluded that she was physically capable of performing sedentary work.
Eastin challenges that judgment. She argues that Reliance acted arbitrarily by requiring objective proof that she suffers from fibromyalgia and disregarding her objective proof that she has physical limitations caused by fibromyalgia. She also maintains that until May 2011, Reliance did not consider her depression as contributing to her disability, and therefore, even if she is physically able to perform sedentary work, she is entitled to receive benefits for her mental disorder for twenty-four months beginning in May 2011. The parties have waived oral argument.
We review the district court's disposition of an ERISA action based on the administrative record de novo and apply the same legal standard as the district court. See Cooper v. Life Ins. Co. of N. Am, 486 F.3d 157, 164 (6th Cir. 2007). Here, the district court properly applied the arbitrary-and-capricious standard because the plan granted the plan administrator discretion to interpret its terms and determine benefits. Id. at 164-65. This is the least demanding form of judicial review. Williams v. Int'l Paper Co., 227 F.3d 706, 712 (6th Cir. 2000). Under this standard, the plan administrator's decision will be upheld if it is the result of a deliberate, principled reasoning process that is rational in light of the plan's provisions. Cooper, 486 F.3d at 165. When the plan authorizes the administrator to decide whether an employee is eligible for benefits and to pay those benefits, it creates a conflict of interest that must be taken into consideration when deciding whether the administrator's decision was arbitrary and capricious. Id.
To the extent that Eastin argues that Reliance acted arbitrarily by penalizing her for failing to submit objective proof that she suffers from fibromyalgia, her argument lacks merit. The administrative record establishes that Reliance has not disputed - and does not dispute - that Eastin suffers from fibromyalgia. Reliance terminated Eastin's benefits because, from a "physical standpoint, in the absence of a psychiatric contribution," Eastin was capable of sedentary work. Therefore, any finding that she was totally disabled was the result of a contributing mental or nervous disorder, and Eastin could not collect any further benefits under the plan. Eastin does not contend that she was totally disabled as the result of a purely physical condition, and Eastin's medical records support a finding that her depression and anxiety contributed to her condition. Reliance upheld its decision to terminate Eastin's benefits after two IMEs examined Eastin and determined that she was not totally disabled as the result of a purely physical condition. That decision was the result of a deliberate, principled reasoning process. See id.
Eastin argues that the district court erred when it placed too much emphasis on the absence of a functional capacity evaluation (FCE) in support of her claim. Eastin's argument is not relevant to this court's review. This court reviews the plan administrator's decision. Id. And in any event, the district court did not rule that a person who suffers from fibromyalgia needs to submit an FCE to establish a disability. Rather, the district court noted that an FCE is one method by which a claimant can demonstrate the physical limitations caused by fibromyalgia. See Huffaker v. Metro. Life Ins. Co., 271 F. App'x 493, 500 (6th Cir. 2008).
Eastin argues that she is entitled to recover an additional twenty-four months of benefits from May 2011 forward for her depression because Reliance did not consider it to be a contributing factor until "just before" August 2011. This argument is not supported by the record. Eastin collected benefits for thirty-seven months from August 2008 through September 2011. According to Reliance's September 2008 medical review of Eastin's file, Eastin was diagnosed with fibromyalgia, depression, and anxiety. Eastin's medical records indicate that she was being treated for depression in April 2008 and that depression and anxiety were comorbid conditions throughout 2008, 2009, 2010, and 2011. The plan provided for a lifetime, aggregate maximum of twenty-four months of benefit payments when mental or nervous disorders contributed to an insured's total disability. See Williams, 227 F.3d at 711 (stating that ERISA plans are interpreted consistent with contract principles and words are given their plain and ordinary meaning). Because the medical records support Reliance's determination that depression contributed to Eastin's total disability and the plain language of the plan provided for a lifetime maximum benefit of twenty-four months when a mental disorder contributed to a disability, Eastin is not entitled to any additional benefits.
Accordingly, we affirm the district court's judgment.
ENTERED BY ORDER OF THE COURT
/s/_________
Deborah S. Hunt, Clerk