Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alnd-2_13-cv-00685/USCOURTS-alnd-2_13-cv-00685-0/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 29:1132 E.R.I.S.A.-Employee Benefits

---

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

KAREN CRISS,

Plaintiff,

v.

UNION SECURITY INSURANCE

COMPANY,

Defendant.

}

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CIVIL ACTION NO.

2:13-cv-0685-WMA

MEMORANDUM OPINION AND ORDER

Prologue

This court devoutly wishes that the Supreme Court of the

United States had not blindly stumbled off on the wrong foot and in

the wrong direction when it handed down Firestone Tire & Rubber Co.

v. Bruch, 49 U.S. 101 (1989), the case in which it invented a

strange quasi-administrative regime for court review of denials of

ERISA benefits claims. It inexplicably substituted a procedure

borrowed from administrative law for the clear congressional

mandate that the filing of a “civil action” (a simple, straightforward, garden-variety suit for breach of contract) is the only

means for challenging such denial decisions. In the amicus curiae

brief filed by the Solicitor General in Bruch, he did his best to

keep the Supreme Court from wandering off track and ignoring

Congress. The Solicitor General, who was representing both

Congress and the persons whom Congress intended to benefit from

ERISA, failed to talk the Supreme Court out of its misguided step,

FILED

 2014 Jun-11 PM 01:36

U.S. DISTRICT COURT

N.D. OF ALABAMA

Case 2:13-cv-00685-WMA Document 29 Filed 06/11/14 Page 1 of 22
a misstep that has led to a series of further judicial glosses,

distillations, penumbras, and emanations, eventuating in the sad

state of affairs now faced by ERISA claimants and by the courts who

have to deal with ERISA benefits claims.

If Congress itself had enacted the weird scheme created by the

Bruch court out of whole cloth, ERISA would have been promptly and

successfully attacked for its patent unconstitutionality as a

violation of “due process”. A quick application of the universally

recognized legal maxim, nemo judex in causa sua, would have kept

any such statute off the statute books. Chief Justice Sir Edward

Coke in Dr. Bonham’s Case, 8 Co. Rep. 107a, 77 Eng. Rep. 638 (C.P.

1610), carved in granite for all time this fundamental

jurisprudential principle when he said, using the vernacular: “No

man should be a judge in his own case.”

The justices of the Supreme Court, including some who decided

Bruch, routinely recuse themselves when there is even the slightest

hint of any possible self-interest by the recusing justice. And

yet, today, clearly conflicted ERISA plan administrators and

insurers, when granted by the plan document that they drafted full

discretion to interpret their plans and to decide the ultimate

issue of entitlement, are routinely allowed, even required, to rule

on their own cases. Not surprisingly, this court has not found a

single case in which an insurance company has recused itself in an

ERISA case under the rule of nemo judex in causa sua. There is no

2

Case 2:13-cv-00685-WMA Document 29 Filed 06/11/14 Page 2 of 22
scheme remotely like the one created by Bruch in the annals of

Anglo-American jurisprudence. Chief Justice Coke is uncomfortable

in his crypt.

While in the above three paragraphs this court has been

indulging in wishful thinking, the court is now brought back to

earth by the knowledge that it cannot alter or ignore the actual

state of ERISA jurisprudence, as it has evolved from Bruch. 

Especially, this court cannot alter or ignore what the Eleventh

Circuit has done to produce its own sui generis brand of fruit from

the poisoned tree.

In Brown v. Blue Cross & Blue Shield of Alabama, Inc., 898

F.2d 556 (1990), the Eleventh Circuit acknowledged the binding

effect of the Bruch-created “arbitrary and capricious” standard for

reviewing the decisions of ERISA decision-makers who have granted

themselves Bruch discretion. But, in Brown, the Eleventh Circuit

also recognized that the Bruch regime could lead to the

Frankenstein that it has come to be. The Eleventh Circuit issued

its warning to itself and to others, in the following remarkable,

but unmistakable language:

Because we have restated the standard as arbitrary and

capricious, the temptation exists to consult precedent

regarding the use of that standard to review

administrative agency decisions. See e.g., Jett, 890

F.2d at 1141-42 (Johnson. J., concurring and dissenting)

(citing and quoting from Motor Vehicle Mfrs. Ass’n v.

State Farm Auto Ins. Co., 463 U.S. 29, 103 S.Ct. 2856, 77

L.Ed.2d 443 (1983)). In some instances an overlap is

evident. Compare, e.g., id. (extracting duty to

3

Case 2:13-cv-00685-WMA Document 29 Filed 06/11/14 Page 3 of 22
investigate from Motor Vehicle Mfrs. Ass’n) with Jader,

723 F.Supp. at 1342-43; Slover, 714 F.Supp. at 832-33;

Teeter v. Supplemental Pension Plan, 705 F.Supp. 1089,

1095 (E.D. Pa.1989) (fiduciary has affirmative duty to

gather information bearing on beneficiary’s claim that is

reasonably obtainable). We express caution, however, at

wholesale importation of administrative agency concepts

into the review of ERISA fiduciary decisions. Use of the

administrative agency analogy may, ironically, give too

much deference to ERISA fiduciaries. Decisions in the

ERISA context involve the interpretation of contractual

entitlements; they “are not discretionary in the sense,

familiar from administrative law, of decisions that make

policy under a broad grant of delegated powers.” Van

Boxel, 836 F.2d at 1050. Moreover, the individuals who

occupy the position of ERISA fiduciaries are less wellinsulated from outside pressures than are decisionmakers

at government agencies. See Maggard, 671 F.2d at 571. 

We therefore concentrate on the common law trust

principles to evaluate the application of the arbitrary

and capricious standard. Of course, the common law we

consider includes the cases decided under the Labor

Management Relations Act. See, e.g., Sharron v.

Amalgamated Ins. Agency Servs., Inc., 704 F.2d 562 (11th

Cir.1983) (decided under LMRA, not ERISA, but

subsequently applied to ERISA situations).

Brown, 898 F.2d at 564 n.7. This ominous footnote did not slow

down the Eleventh Circuit in its march toward achieving the

reputation as the circuit court of appeals least likely to rule

against a plan administrator or an insurer.

In response to Bruch, an increasing number of states have

adopted a statute or insurance industry rule that precludes the

inclusion of the so-called “discretionary clause” in a disability

insurance policy. These states have wisely slipped the embrace of

Bruch and have accomplished in their states what Congress intended,

namely, trials de novo for beneficiaries after they have been

4

Case 2:13-cv-00685-WMA Document 29 Filed 06/11/14 Page 4 of 22
denied and unsuccessfully exhausted their internal plan remedies. 

Alabama, Georgia, and Florida have not seen fit to take advantage

of this means for escaping Bruch. Meanwhile, the Eleventh Circuit

has created its “six-step” analysis, which puts plan administrators

and insurers firmly in the driver’s seat, and invites them to sit

in judgment on their own denial decisions, and to ignore, as if

meaningless, their fiduciary obligations of strict loyalty to their

plan beneficiaries.

So, What About the Above-Captioned Case?

Plaintiff, Karen Criss (“Criss” or “plaintiff”), brings this

action seeking benefits she claims are owed her under a long-term

disability insurance plan provided by her employer, HeartSouth

Cardiovascular Group (“HeartSouth”), and insured by defendant,

Union Security Insurance Company (“Union Security” or “defendant”).

Before the court are cross-motions for summary judgment and 1

supporting memoranda. This court has in earlier opinions made

known its belief that Rule 56 does not fit ERISA cases as long as

Bruch provides the method for review, but this court “goes along to

get along.”

Defendant’s motion is styled as a “motion for judgment on the 1

pleadings.” (Doc. 15). Because defendant relies on materials

outside the pleadings, the court construes the motion as a motion

for summary judgment. See Fed. R. Civ. Pro. 12(c)-(d).

5

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Factual Background

Plaintiff is 57 years old. From January, 2003 to February,

2008, she worked as a financial clerk for HeartSouth. R. at 139. 

As part of her employment package, she was insured under the

disability insurance policy that is at issue in the instant action

and that covered physicians, administrators, and clerks. Id.

As early as 1993, Criss was diagnosed with fibromyalgia, a

disorder of unknown cause that causes widespread and severe pain,

fatigue, sleep loss, and mood swings. R. at 502. Criss’s medical

records deal mostly with treatment she received after 2006. These

records reflect that she saw no fewer than six doctors in 2006 and

2007 for her fibromyalgia and other medical conditions, including

neuropathy (a disease similar to fibromyalgia that involves general

pain and weakness in the extremities). The doctors achieved only

partial success in treating Criss’s various ailments by increasing

or reducing her medications. See, e.g., R. at 1107. A November,

2007 doctor’s report noted that “[s]he has quit all vitamins, antidepressants, Synthroid in the last 3 weeks and now ‘I feel better

than I have before’”. Id. But, her above-mentioned symptoms were

never eliminated or ameliorated to the point of a release from pain

or from treatment.

On an afternoon in February, 2008, Criss suddenly left work in

the middle of the day in what would turn out to be a permanent

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Case 2:13-cv-00685-WMA Document 29 Filed 06/11/14 Page 6 of 22
departure. A claims agent for Union Security interviewed her in

the following month and summarized what she found as follows:

There was an incident and build up of exhausting her self

[sic] at work, new computer system at work, not

sufficient training, they had to stop what they were

doing, go out to the internet and get the training as

they needed, she couldn’t get the training she needed,

“hands on” kind of person, she couldn’t understand these

foreigner people that she couldn’t understand, she had

deadlines, she had a panic attack, she felt she was going

to explode, she ran into her bosses [sic] office, she

told the boss she had to go and she ran out of the

building.

R. at 1090. Criss tried to return to work, but upon doing so, she

had “panic attacks, [would] break out in hot sweat, her chest

[would have a] screw where the screwdriver keeps tightening it up

to about 100 pound weight, [and] she [would have] palpitations . .

. .” Id.

In the wake of what can only be described as a nervous

breakdown, Criss continued to see her treating doctors, and added

a host of new doctors, both for treatment and for evaluation of her

possible disability status. These medical consultations included

partial hospitalization in an “Intensive Outpatient Program,”

during which she was treated for “major depression, panic attacks

and work stress.” R. at 1016. She continued to receive treatment

for her pain-related illnesses such as fibromyalgia and neuropathy. 

See, e.g., R. at 779-80 (April 2008 treatment notes indicating

“very symptomatic” fibromyalgia).

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Criss filed her disability claim with Union Security in April,

2008, citing “anxiety, panic disorder, depression, severe pain,

fibromyalgia, neuropathy, [and] carpal tunnel.” R. at 1096

(emphasis added). Defendant happily approved the claim, and began

paying Criss benefits. R. at 165-69. However, defendant explained

in its approval letter that Criss was required to file a disability

claim with the Social Security Administration (“SSA”), so that

defendant could offset its payments to Criss by any amounts awarded

by the SSA. R. at 166. Criss complied with defendant’s demand,

and the SSA granted her application for benefits in May, 2009, R.

at 940-41, whereupon Criss refunded to defendant a significant

amount of money, R. at 916-17.

In 2010, defendant cut off plaintiff’s benefits. In

accordance with the plan’s procedures, Criss appealed defendant’s

decision. Defendant finally denied Criss’s appeal on November 30,

2010. R. at 470-76. It is this denial that plaintiff challenges

in the above-styled quasi-administrative proceeding.

The Six-Part Test

The first step in the Eleventh Circuit’s super-unique six-step

test requires the court to apply “the de novo standard to determine

whether the claim administrator's benefits-denial decision is

‘wrong’ (i.e., the court disagrees with the administrator's

decision)”. Blankenship v. MetLife Ins. Co., 644 F.3d 1350, 1355

(11th Cir. 2011). Only if the court determines that the decision

8

Case 2:13-cv-00685-WMA Document 29 Filed 06/11/14 Page 8 of 22
was de novo correct does the court go to “step two”, or beyond. 

This court is stymied, finding it impossible to make the

determination required by “step one”, because the record does not

provide evidence upon which this court can reasonably and fairly

reach a de novo decision.

Procedural Correctness Required

No matter whether it is ultimately determined that defendant’s

denial decision was “correct”, that determination can come only

after the plan administrator has fulfilled the “fundamental

requirement that [its] decision to deny benefits [is] based on a

complete administrative record that is the product of a fair

claim-evaluation process.” Melech v. Life Ins. Co. of N. Am., 739

F.3d 663, 676 (11th Cir. 2014) (emphasis added). Thus, if Union

Security, the plan administrator, has made a decision without a

complete administrative record, or without a fair claim-evaluation

process, “the proper course of action [for a court] is to remand

[to the plan administrator].” Id. at 675 (emphasis added).

This court detects at least two procedural shortcomings that

require a remand of this dispute to the plan administrator as

required by Melech.

9

Case 2:13-cv-00685-WMA Document 29 Filed 06/11/14 Page 9 of 22
I

Drawing the Line Between Disabling

Physical Ailments and a Disabling

Combination of Physical and Mental Ailments

The following plan language is crucial to a resolution of this

dispute:

We pay only a limited benefit for a period of disability

due to alcoholism, drug addiction, chemical dependency

and mental illness. The Maximum Benefit Period for all

such periods of disability is 24 months. . . .

Your period of disability will be considered due to

alcoholism, drug addiction, chemical dependency or mental

illness if:

- you are limited by one or more of the stated

conditions; and

- you do not have other conditions which, in the

absence of the stated conditions, would continue to

exist, limit your activities, and lead us to conclude

that you were disabled.

R. at 24 (emphasis added). This language, drafted by defendant,

creates a very difficult fact-finding regime. Whether the factfinder is the structurally conflicted payor, or is this court upon

de novo consideration (as required by “step one”), the inquiry is

whether plaintiff’s serious physical problems, divorced from her

mental problems that are largely symptomatic of her physical

problems, render her unemployable. The parties did not recognize

or adequately address this factual and semantic problem, either

during Criss’s 24-month period of mental illness, during which

plaintiff was admittedly entitled to disability benefits, or

thereafter.

10

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It does not take the dean of Johns Hopkins School of Medicine

to know that there is a link between the functioning of the human

brain and the well-being of the rest of the body, although that

connection is not easy to explain or describe. Any person who is

in constant pain becomes, at least to some extent, “anxious” (the

word from which the word “anxiety” derives). An overly anxious

person has a mental problem. In circumstances involving a myriad

of medical problems like those in this case, it may be impossible

to draw the line contemplated by this policy language. No

physician, with the possible exception of the hereinafter mentioned

Dr. Fleeson, has been asked a question that elicits his opinion as

to whether he has the tools to even answer the ultimate question,

and, if so, to give the right answer. The ultimate question of

whether Criss’s physical ailments alone disabled her becomes close

to being an academic, theoretical, hypothetical question. 

Plaintiff, who has never been called a charlatan, obviously

believes that her physical ailments alone act to prevent her from

working at any job, sedentary or not. Except for Dr. Fleeson, the

doctor who was hired by defendant during Criss’s first appeal,

nobody has attempted to distinguish the period of time, if any,

during which plaintiff’s physical disabilities alone rendered her

“disabled”, and the period during which a combination of her mental

and physical disabilities rendered her “disabled”. Dr. Fleeson

concluded that for 38 days during the 24 months of plaintiff’s

11

Case 2:13-cv-00685-WMA Document 29 Filed 06/11/14 Page 11 of 22
conceded mental illness, she was so physically disabled that she

was “disabled”, without regard to the fact that she was at the same

time mentally disabled. The court expressly asked counsel for

defendant to explain Dr. Fleeson’s rationale for this conclusion. 

In response to the court’s inquiry, defendant undertook to explain

these 38 days as follows:

Certain acute conditions constituted a separate

disability for a limited period of time.

During the first appeal, Union Security obtained an

independent medical review from William P. Fleeson, M.D.,

M.P.H. (US000529-US000556). During that review, Dr.

Fleeson identified a total of 38 days during which he

believed Plaintiff would have been physically disabled

from sedentary work due to three different acute

conditions: (1) 14 days for carpal tunnel syndrome in

September 2008; (2) 21 days for thoracic and lumbar spine

degenerative disc disease in July and August 2008; and

(3) 3 days for shoulder impingement syndrome in January

2009. (US000540-41, US000544). Dr. Fleeson based these

determinations on his evaluation of the medical records

and by referencing The Medical Disability Advisor, which

Dr. Fleeson states is a nationally-recognized and peerreviewed authority on medical conditions and their

associated recovery period and time away from work. 

(US000539).

Based on Dr. Fleeson’s finding of 38 days of complete

disability due to physical conditions, Union Security

paid Plaintiff an additional 38 days of disability

benefits. The 24-month mental illness limitation does

not apply to any periods in which Plaintiff also was

completely disabled due to physical conditions. 

Therefore, the 24 month limitation did not apply to the

prior 38 days in which Union Security found that

Plaintiff was physically disabled. Accordingly,

Plaintiff’s benefits period was extended by 38 days, from

May 27, 2010 through July 4, 2010. (US000517).

12

Case 2:13-cv-00685-WMA Document 29 Filed 06/11/14 Page 12 of 22
Apparently Dr. Fleeson was specifically asked to employ the

policy language as to whether Criss had any “other conditions

which, in the absence of the stated condition [mental illness],

would . . . limit [her] activities and lead us to conclude that

[she was] disabled”. He apparently understood the importance of

this policy language. No other physician, whether hired by

defendant or hired by plaintiff, has been asked, much less

attempted to answer, this question.

Dr. Fleeson, whose credibility is in question, discounts and

downplays Criss’s “fibromyalgia” and “neuropathy” as non-acute

conditions, apparently unlike “carpal tunnel,” or “spine

degenerative disease”, or “shoulder impingement”, which, in and of

themselves, or in combination, according to him, rendered Criss

totally unemployable. The record does not reflect whether Criss

still has carpal tunnel, and/or degeneration of her thoracic and

lumber discs, and/or shoulder impingement. Has she totally

recovered from these “acute”, disabling physical ailments? Neither

a non-treating physician, nor a treating physician, nor a

vocational expert has provided opinion evidence upon which this

court, as a de novo fact-finder, can conclude that a 57-year-old

woman with severe fibromyalgia and neuropathy, carpal tunnel,

degenerative disc disease and shoulder impingement, can find

gainful employment and fulfill the duties of an available job. 

Incidentally, while Dr. Fleeson was discussing the clinical

13

Case 2:13-cv-00685-WMA Document 29 Filed 06/11/14 Page 13 of 22
presentation of fibromyalgia, he noted that “[a]t least 17 other

medical and psychiatric conditions have considerable clinical and

symptomatic overlap with [fibromyalgia].” R. at 542 (emphasis

added). In other words, even Dr. Fleeson may find it difficult to

draw a line between fibromyalgia and mental illness. According to

him, one may imply the other. Is this a Catch-22?

II

Do Plaintiff’s Physical Problems Alone Meet

the Plan’s Definition of “Disability”?

Central to this or to any other ERISA disability claim is the

plan’s definition of “disability”. The court has already discussed

that portion of Union Security’s insurance policy that would

preclude liability for “mental illness” after 24 months. The terms

of this policy that define “disability” are complicated, but

understanding them is necessary to a decision. The pertinent

language is as follows:

DEFINITIONS FOR LONG TERM DISABILITY INSURANCE

* * * * *

Disability or disabled means that in a particular month,

you satisfy one or more of the three Tests, as described

below.

* * * * *

Occupation Test (For each All other Employees)

• during the first 24 months of a period of

disability (including the qualifying period),

an injury, sickness, or pregnancy requires

14

Case 2:13-cv-00685-WMA Document 29 Filed 06/11/14 Page 14 of 22
that you be under the regular care and

attendance of a doctor, and prevents you from

performing at least one of the material duties

of your regular occupation; and

• after 24 months of disability, an injury,

sickness, or pregnancy prevents you from

performing at least one of the material duties

of each gainful occupation for which your

education, training, and experience qualifies

you.

If during the first 24 months of a period of disability

(including the qualifying period), you can perform the

material duties of your regular occupation with

reasonable accommodation(s), you will not be considered

disabled. If, after 24 months of a period of disability,

you can perform a gainful occupation for which your

education, training, and experience qualifies you, with

reasonable accommodation(s), you will not be considered

disabled. The inability to perform a material duty

because of the discontinuance of reasonable

accommodation(s) on the part of the employer does not, in

itself, constitute disability.

* * * * *

Gainful occupation means an occupation in which you could

reasonably be expected to earn at least as much as your

Schedule Amount within 12 months of your return to work.

* * * * *

Schedule Amount: 60% of monthly pay subject to a maximum

Schedule Amount of $15,000 per month, except as stated in

Proof of Loss provision.

(italics in original, bolding added). R. at 5-7.

This language raises the following questions, as yet

unanswered:

(1) Assuming with Dr. Fleeson “that in a particular month”

(in fact, four months, September of 2008, July of 2008, August of

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Case 2:13-cv-00685-WMA Document 29 Filed 06/11/14 Page 15 of 22
2008, and January of 2009), Criss satisfied one of Union Security’s

tests, without regard to her mental condition, was she “disabled”

for each of those entire four months or just for the few days found

by Dr. Fleeson?

(2) Does contra proferentem apply to assist in the resolution

of the ambiguities in this plan language? See White v. Coca-Cola

Co., 542 F.3d 848 (11th Cir. 2008).

(3) After the first 24 months expired, did any of Criss’s

“sicknesses” prevent her from performing a “gainful occupation” for

which her “education, training and experience” qualified her?

(4) What was Criss’s education, training and experience?

(5) Can Criss perform any occupation for which she could

reasonably expect to earn “at least as much as [her] Schedule

Amount within 12 months of [her] return to work” when Criss is not

returning to work?

(6) What was Criss’s salary when she was working?

(7) What is the job market for a 57-year-old woman with

severe pain, fibromyalgia, neuropathy, carpal tunnel, disc disease,

and shoulder impingement?

(8) Can witnesses other than Dr. Fleeson, including Criss

herself, express opinions as to what particular days in what

particular months Criss was totally disabled by physical ailments

divorced from mental illness?

16

Case 2:13-cv-00685-WMA Document 29 Filed 06/11/14 Page 16 of 22
Despite the fact that the Eleventh Circuit routinely gives

plan administrators the benefit of the doubt, the Eleventh Circuit

is literally the leader in recognizing that a disability claimant

does not have to be a blind paraplegic in order to be “disabled”

within the meaning of that word in a benefits plan. The totality

of circumstances must be considered. In Helms v. Monsanto Co.,

Inc., 728 F.2d 1416 (11th Cir. 1984), the Eleventh Circuit

addressed the question which at that time was one of first

impression. What the Eleventh Circuit there held deserves a

quotation at length:

Dr. Skalka’s deposition was taken in November, 1982, in 

preparation for trial. He was asked by appellant’s

counsel to explain his reasoning as to why he concluded

that Mr. Helms was not totally and permanently disabled. 

He responded:

Well, I felt that Mr. Helms was certainly disabled, but,

according to that definition, with that word, ‘any

occupation or employment for remuneration or profit,’ I

really couldn’t think of any disability compatible with

conscious life that would allow me to say anybody was

‘disabled within the definition set out above,’ so I had

to sign it, ‘Not disabled within the definition.’

Skalka’s Deposition at 21-22.

The district court concluded that Dr. Skalka did not act

arbitrarily and capriciously in reaching his decision and

therefore Monsanto had properly denied Mr. Helms the

benefits. The sole issue before this court is whether

the arbitrator was arbitrary and capricious in finding

that appellant was not disabled because permanent total

disability is inconsistent with conscious human life. We

find that the arbitrator applied the wrong standard to

determine permanent total disability and therefore

reverse and remand for further proceedings consistent

with this opinion.

17

Case 2:13-cv-00685-WMA Document 29 Filed 06/11/14 Page 17 of 22
* * * * *

There is no particular provision in ERISA nor could we

find any federal case which specifically dealt with the

issue presented here. However, under ERISA’s legislative

scheme, this court is empowered to formulate rules of law

to govern various aspects of the employee benefit field. 

As Congress pointed out, “[I]t is also intended that a

body of law will be developed by the courts to deal with

issues involving rights and obligations under private

welfare and pension plans.” 120 Cong.Rec. 515, 751

(daily ed. August 22, 1974). Yet, in formulating these

laws courts must be guided by the general policies

underlying ERISA. The general objective of this Act is

to increase the number of individuals in employerfinanced benefit plans. Congress wanted to assure that

those who participate in the plans actually receive the

benefits they are entitled to and do not lose these as a

result of unduly restrictive provisions or lack of

sufficient funds. H.R.Rep. No. 93-807, 93rd Cong., 2nd

Sess. 3, reprinted in 1974 U.S. Code Cong. & Ad.News

4639, 4670, 4676-77.

Total disability under this type of provision is not

considered to exist if the insured can follow any

remunerative occupation, whether in his present vocation

or another. The phrase should not be given an absolute

and literal interpretation. It should not mean that the

affected individual must be utterly helpless to be

considered disabled. It must be a relative term which

means that the individual is unable to engage in a

remunerative occupation or to do work in some profitable

employment or enterprise. Permanent disability is a

question of fact that depends upon all the circumstances

of a particular case. Bearing in mind, we turn to the

arbitrator’s construction of the clause in this case.

Dr. Skalka’s decision must be upheld on review unless it

is arbitrary and capricious. (citations omitted). Dr.

Skalka’s interpretation of the DIP was arbitrary and

capricious. By his own words, a finding of permanent

disability would only be possible if the individual had

no “conscious life.” Such a standard would render the

entire Monsanto DIP totally meaningless. Recognizing

this is a difficult area, we will set forth the

appropriate standard.

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Case 2:13-cv-00685-WMA Document 29 Filed 06/11/14 Page 18 of 22
In order to determine when a Monsanto employee will be

considered to be totally and permanently disabled under

the provisions of the DIP we must define the phrase any

occupation or employment for remuneration or profit.” It

is difficult to do this because a person would almost

never be deprived of the ability to earn a nominal sum

unless he is rendered completely immobile and without

cognitive ability. In order to establish a reasonable

interpretation of this phrase we turned for guidance to

insurance policies with similar provisions and to cases

construing the Social Security disability provisions.

Analogous insurance cases consistently agree that the

term “total disability” does not mean absolute

helplessness on the part of the insured. The insured can

recover benefits if he is unable to perform all the

substantial and material acts necessary to the

prosecution of some gainful business or occupation. 

Gainful has been defined by these courts as profitable,

advantageous or lucrative. Therefore, the remuneration 

must be something reasonably substantial rather than a

mere nominal profit. (citations omitted).

* * * * *

Common knowledge of the occupations in the lives of men

and women teach us that there is scarcely any kind of

disability that prevents them from following some

vocation or other, except in cases of complete mental

incapacity. Although the achievements of disabled

persons have been remarkable, we will not adopt a strict,

literal construction of such a provision which would deny

benefits to the disabled if he should engage in some

minimal occupation, such as selling peanuts or pencils,

which would yield on a pittance. The insured is not to

be deemed “able” merely because it is shown that he could

perform some task.

Neither will we adopt the definition used by the

arbitrator in this case. He believed that anyone alive

and conscious would not qualify for benefits under the

Monsanto plan. The word disability is not ordinarily

used to describe death, although death is undeniably the

ultimate disability.

To bar recovery, under the provisions of the DIP, the

earnings possible must approach the dignity of a

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livelihood. Mr. Helms is required to show physical

inability to follow any occupation from which he could

earn a reasonably substantial income rising to the

dignity of a income or livelihood, even though the income

is not as much as he earned before the disability. See,

e.g., Mutual Life Ins. Co. v. Bryant, 296 Ky. 815, 177

S.W..2d 588 (1943). The arbitrator in this case applied

the wrong standard. We reverse and remand so that the

arbitrator can allow development of all appropriate

evidence for consideration under the correct standard.

Id. at 1419-22 (emphasis added).

Other courts have taken up the Eleventh Circuit’s theme. In

Torix v. Ball Corp., 862 F.2d 1428, 1429 (10th Cir. 1988), the

Tenth Circuit responded to a plaintiff’s argument that the ERISA

plan decision-makers had acted arbitrarily and capriciously in

determining that he was not totally disabled, without “taking into

account his age, limited educational background, and the

unavailability of suitable employment in the area.” The Tenth

Circuit responded as follows:

We believe that the policy concerns which underlie ERISA

would be severely undermined if we endorsed a literal

reading of the plan’s terms. Thus we join the reasoning

of the Eleventh Circuit and hold that a reasonable

interpretation of a claimant’s entitlement to payments

based on a claims of “total disability” must consider the

claimant’s ability to pursue gainful employment in light

of all the circumstances.

Id. (emphasis added). In Demirovic v. Building Service 32 B-J

Pension Fund, 467 F.3d 208, 212-13 (2nd Cir. 2006), the Second

Circuit found:

[T]he Fund’s Review of Demirovic’s claim suffers from a

more fundamental flaw. The Fund’s determination that

Demirovic is physically capable of performing some kind

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of sedentary work may be supported by substantial

evidence; but the Fund appears to have given no

consideration whatsoever to whether Demirovic could, in

fact, find such sedentary work.

The Second Circuit cited Helms in support of this proposition,

which makes overwhelmingly good sense.

If there is evidence in this record upon which an unbiased

arbiter can find that a 57-year-old female, with all of the

physical ailments described by her treating physicians, can expect

to obtain gainful employment, particularly employment in which she

can “reasonably be expected to earn at least as much as her

Schedule Amount”, this court has not been able to find it. In

today’s job market, employers are not eager to hire sedentary

workers 57 years of age who are in pain and have pervasive physical

ailments. 

Remand

This case is peculiarly appropriate for mediation. In light

of the foregoing, unless within two (2) weeks, the parties agree to

mediation in accordance with this court’s Alternative Dispute

Resolution Plan, the court will remand the dispute to the plan

administrator, who will be charged with obtaining answers to the

questions hereinabove outlined, and who shall provide a full and

fair administrative review. All witnesses shall be furnished a

copy of this opinion. The court shall expect this new review to be

completed and a final decision rendered within ninety (90) days.

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DONE this 11th day of June, 2014.

_____________________________

WILLIAM M. ACKER, JR.

UNITED STATES DISTRICT JUDGE

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