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Nature of Suit Code: 190
Nature of Suit: Other Contract Actions
Cause of Action: 

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United States Court of Appeals

For the Eighth Circuit

___________________________

No. 15-1524

___________________________

Gwendolyn Whitley

lllllllllllllllllllll Plaintiff - Appellee

v.

Standard Insurance Company

lllllllllllllllllllll Defendant - Appellant

____________

Appeal from United States District Court 

for the District of Minnesota - Minneapolis

____________

 Submitted: October 21, 2015

 Filed: March 4, 2016 

____________

Before LOKEN, MURPHY, and COLLOTON, Circuit Judges.

____________

LOKEN, Circuit Judge.

In February 2011, Dr. Gwendolyn Whitley was involved in a roll-over car

accident, suffering a serious head injury. Board certified in family medicine, Dr.

Whitley had worked as an emergency room physician at Lake Region Hospital (“Lake

Region”) in Fergus Falls, Minnesota, in the twenty-four months preceding the

accident. She returned to work full-time from March 16 through March 24, but

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fatigue and short-term memory issues forced her to stop. On June 28, she filed a

claim for long-term disability (“LTD”) benefits under Lake Region’s Group Long

Term Disability Insurance Policy issued by Standard Insurance Company

(“Standard”). Standard, serving as administrator of the Policy, approved Whitley’s

claim and paid LTD benefits beginning May 22, 2011. 

In August 2012, Standard determined that Whitley was no longer disabled,

discontinued benefits effective July 31, 2012, and rejected Whitley’s internal appeal

of that decision. She then commenced this action in state court, asserting various

claims against Standard and Lake Region. After Standard removed the case to federal

court, Whitley filed an amended complaint asserting, as relevant here, a claim under

ERISA that Standard’s denial of continuing disability benefits was contrary to the

terms of its Policy. See 29 U.S.C. § 1132(a)(1)(B). The district court granted

summary judgment for Whitley, concluding that Standard abused its discretion in

discontinuing LTD benefits. Standard appeals. Reviewing the grant of summary

judgment de novo and Standard’s decision for abuse of discretion, we reverse. See

Manning v. Am. Republic Ins. Co., 604 F.3d 1030, 1038 (8th Cir.), cert. denied, 562

U.S. 1062 (2010) (standard of review).

I. Background.

For physician members of the insured group, such as the 57-year-old Whitley,

the Policy provided “Own Occupation” disability benefits up to retirement age, if the

disability persisted: 

[Y]ou are required to be Disabled only from your Own Occupation.

You are Disabled from your Own Occupation if, as a result of Physical

Disease, Injury, Pregnancy or Mental Disorder:

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1. You are unable to perform with reasonable continuity the 

 Material Duties of your Own Occupation; and

2. You suffer a loss of at least 20% in your Indexed Predisability 

 Earnings when working in your Own Occupation.

* * * * *

Material Duties means the essential tasks, functions and operations, and

the skills, abilities, knowledge, training and experience, generally

required by employers from those engaged in a particular occupation that

cannot be reasonably modified or omitted. 

Whitley’s June 2011 claim stated that she was unable to perform her Own

Occupation due to post-concussive syndrome, C5 disc rupture, back pain, headaches,

and memory problems. She submitted an Attending Physician Statement from her

primary care physician, Dr. Patricia Lindholm, who diagnosed Whitley with “postconcussive syndrome.” Dr. Lindholm noted Whitley’s failed attempt to return to

work, and recommended that she not return to work until cleared by treating

neuropsychologist Dr. Paula Bergloff. In an April 7 neuropsychological evaluation,

Dr. Bergloff concluded that Whitley suffered from “[m]ild traumatic brain injury with

persistent postconcussion symptoms.” Dr. James Andrews examined Whitley on

April 26 and concluded that Whitley should not be working because her

postconcussive syndrome was “significantly affecting her memory.” 

In August 2011, Whitley submitted Attending Physician Statements from Dr.

Bergloff and Dr. Tanya Harlow. Dr. Bergloff recommended that Whitley not be

working and opined that she would need a “reduction in work hours” when able to

return to work. Dr. Harlow diagnosed Whitley as suffering from postconcussive

syndrome and noted she was “gradually improving” but unable to work because of

“cognitive difficulties.” Dr. Harlow opined that Whitley was likely to improve in

three to six months and might be ready for a trial return to work within two months. 

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In September, Dr. Andrews took MRIs of Whitley’s spine, found no significant

problems, and noted “excellent gains from a postconcussive standpoint.” 

Psychologist Dr. Elaine Greif, an independent consultant, reviewed the claim

at Standard’s request and agreed that Whitley was disabled due to her “mild traumatic

brain injury with persistent postconcussive symptoms and a history of multiple

concussions.” Dr. Greif predicted that Whitley would be able to return to work within

three to six months and recommended that work restrictions be lifted based on future

neuropsychological re-evaluations. On September 27, Standard approved Whitley’s

claim effective May 22 (the end of the Policy’s ninety-day waiting period). The letter

advised that Standard would require Attending Physician Statements “to monitor and

document your continued eligibility for LTD Benefits,” and asked Whitley to notify

Standard “of any change in your medical or employment status.”

On August 30, 2011, Whitley told Dr. Harlow that “she is ready to go back to

work in the next month.” In January 2012, Whitley told Dr. Lindholm she was “doing

well” and was “currently asymptomatic.” That month, Dr. Bergloff concluded

Whitley was doing “fairly well” and recommended a part-time return to work. In a

February 2012 letter to Lake Region, Whitley stated that she was ready to return to

“perform the full scope of emergency medicine duties.” She reported that her

“medical team has approved my return to work in the Emergency Department” and

requested that she be allowed to return “for two 4 hour shifts a week with double

coverage for the first weeks.” Lake Region responded that it could not accommodate

that request but was open to alternative work possibilities. 

After a March neuropsychological re-evaluation, Dr. Bergloff found that

Whitley was “performing within the high average range for overall intellectual

abilities . . . [with] no cognitive impairments in any area.” Dr. Bergloff recommended

return to work on a part-time basis with hours gradually increasing. In April, Whitley

told Dr. Lindholm she felt “back to normal,” did not have headaches or attention span

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problems, had completed eighty hours of Continuing Medical Education (CME), and

was “very eager to get back to work and have some purpose in her life.” In June

2012, Whitley provided Standard an Attending Physician Statement in which Dr.

Lindholm noted Whitley’s improved condition, stated no further treatment was

planned, and recommended “a transitional return to work starting with [a] 4 hours/day

limitation.” Dr. Lindholm wrote to Lake Region that Whitley had “no physical

limitations or restrictions in regard to work.”

In July 2012, Standard asked Dr. Bradley Fancher, an independent consultant,

to review Whitley’s medical records. Evaluating Whitley’s ability to return to work

as a family practice physician, her board certified specialty, Dr. Fancher determined

she could return to work, concluding that a gradual return to work was not “an

imperative requirement.” Standard advised Whitley it was discontinuing benefits

effective July 31. In the lengthy August 5 letter, Standard explained that Lake Region

“was not able to provide record of your professional service codes” documenting that

sixty percent of Whitley’s income was earned in an emergency medicine subspecialty, and therefore her Own Occupation as defined in the Policy was “as broad

as the scope of your [family] medicine license.” The letter reviewed the medical

records and opinions in some detail and concluded, “the records do not support that

you have residual physical or cognitive limitations and restrictions that would

preclude you from working with reasonable continuity in your Own Occupation at this

time.” 

On August 23, Whitley appealed Standard’s decision. She wrote: “I am

improved; I am happy to be better. I do want to return to full-time work as an

emergency medicine physician. I am not ready to return to work full-time yet.” In

support, Whitley submitted letters from Drs. Lindholm and Bergloff and speechlanguage pathologist Nan Kennelly opining that Whitley should not initially return to

work full-time. Kennelly noted that Whitley could have “difficulty executing with

[the] distraction, time pressure, interruptions and multi-tasking” of an emergency

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room. Dr. Bergloff reported that sustained activity increased Whitley’s “pain

symptoms.” Dr. Lindholm suggested a trial return to work, but noted that Whitley

“has no physical limitations” and “[h]er cognitive abilities are back to baseline.”

In considering Whitley’s appeal, Standard consulted Dr. Thomas Morgan, a

neurologist. He reviewed all of Whitley’s records and found that she “does not have

any restrictions or limitations with respect to her work as a family practice physician

in an emergency room setting . . . based on the nature of her mild concussion postconcussion syndrome and the normalization of her neuropsychological testing.” Mark

Williams, Ph.D., conducted an independent neuropsychological review of the claim

at Standard’s request. In preparing an extensive report, Dr. Williams considered

Whitley’s medical records, spoke to Dr. Bergloff, and reviewed “actual raw test data”

from Whitley’s cognitive tests. Explicitly considering “the unique demands of

emergency room practice” as described by a vocational consultant, Dr. Williams

found no “objective or even compelling subjective” indication that Whitley’s “mental

endurance” was not “intact,” especially considering her 80 hours of continuing

medical education and ability to read for four to five hours in a sitting. Dr. Williams

concluded, “based on my consideration of the full set of information that has been

provided to me, it is my opinion that Dr. Bergloff’s recommendations [of a gradual

return to work] are overly restrictive.” Drs. Morgan and Williams agreed that Whitley

was able to work on a full-time basis as of July 31, 2012. Dr. Greif again reviewed

Whitley’s claim at Standard’s request. She noted that Whitley’s history of head

injuries suggested “a return-to-work plan that involves monitoring adequacy of her

work” but agreed that while a “gradual return would be ideal . . . it is reasonable to try

a full-time return.”

Whitley underwent left knee arthroscopy in November 2012 and right total knee

arthroplasty the following month due to a fall that aggravated degenerative joint

disease that pre-dated the auto accident. Following the surgeries, Whitley markedly

changed her disability claim. In a December 4 letter to Standard, Whitley wrote that,

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due to physical problems and constant pain, “I have begun to despair that I will ever

be able to return to work and support myself again.” In a January 16, 2013, letter to

Standard, Dr. Lindholm wrote that Whitley’s “disability is multifactorial and is a

result of pre-existing spine and joint disease and the traumatic brain injury sustained

in March 2011,” and opined that Whitley “is permanently disabled and not able to

pursue gainful employment.” On January 26, Whitley wrote Standard explaining why

extensive medical records supported her claim that she is disabled by “chronic pain.”

In response, Standard asked Dr. Morgan to consider whether these additional

reports affected his prior opinion that Whitley had the “ability to return to work as a

Board Certified Family Practice Physician working in the Emergency Room setting.” 

On February 19, Dr. Morgan submitted an Addendum report. He found Whitley’s

claim of pain and fatigue to be “complaints . . . of tolerance.” Addressing Dr.

Lindholm’s January opinion, Dr. Morgan wrote: “It is understandable that Dr.

Lindholm wants to advocate for her patient . . . based on pain tolerance but this does

not restrict or limit her ability to work . . . . Whitley had a minor concussion at best,

these conditions heal within days to weeks.” Standard also asked Dr. Donald Lambe,

an independent orthopedic surgeon, to consider Whitley’s disability claim. In a

lengthy report dated February 28, 2013, Dr. Lambe opined that Whitley “was able to

work on a full-time basis from 7/31/12, up until the time of her left knee arthroscopy

of 10/22/12, and her subsequent total knee of 12/11/12, and she will again be able to

work full-time after her recuperation from the total knee arthroplasty as of 3/11/13,

and beyond.” He wrote: “From an orthopedic viewpoint her bilateral hip and knee

conditions do not preclude the standing and walking required of an ER physician, nor

does her degenerative disc disease preclude the other light physical demands of that

profession.” 

On March 28, Standard affirmed its decision to discontinue Whitley’s benefits. 

In a twenty-two-page letter to Whitley’s counsel, Standard concluded:

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- “[B]ecause we were unsure whether Dr. Whitley would be able to provide

[CPT code information showing her Own Occupation was emergency medicine]

during the independent review process, we conducted our review to include the

physical demands and Material Duties of an[] Emergency Room Physician as well [as

Family Practitioner].”

- When Whitley originally requested a review of the decision to close her claim,

she stated she wanted to return to full time work but was not ready to do so. As the

review process continued, Whitley indicated she may be unable to return to work, and

Dr. Lindholm “stated she is totally disabled,” in contradiction to Dr. Lindholm’s

statements before the claim was closed.

- “No specific ongoing cognitive deficits have been identified that would affect

her ability to safely perform all of the Material Duties of her Own Occupation of

Family Practitioner (or even an Emergency Room Physician . . .), either on a part time

or on a full time basis.”

- No “physical limitations or restrictions from her motor vehicle accident . . .

would have precluded her from working on a full time basis with reasonable

continuity as of July 31, 2012.” While Whitley has ongoing complaints of pain from

her orthopedic conditions, “our review of the medical records available and the

opinions of the Physician Consultants does not find that her chronic pain or orthopedic

conditions are significant enough to preclude work activities.”

- “Because Dr. Whitley’s limitations and restrictions prior to the claim closure

on July 31, 2012, were not related to her knees, but instead due to her cognitive

inefficiencies,” any impairment due to knee surgeries after the claim was closed is not

covered under the terms of the Policy. 

This lawsuit followed. Whitley claims that Standard abused its discretion in

determining that her Own Occupation was family medicine, rather than emergency

medicine, and in discontinuing her long term disability benefits. The district court

granted Whitley summary judgment, agreeing with both contentions. The court

granted disability benefits from August 1, 2012, “to the present” and until Whitley is

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no longer disabled from her Own Occupation as emergency medicine physician, and

awarded her attorney’s fees and costs in a stipulated amount.

II. Discussion.

A. If an ERISA plan expressly grants discretionary authority to the plan

administrator, as in this case, we review the administrator’s benefits determination for

abuse of discretion. Waldoch v. Medtronic, Inc., 757 F.3d 822, 829 (8th Cir. 2014). 

“Under the abuse of discretion standard of review, we must uphold a plan

administrator’s decision so long as it is based on a reasonable interpretation of the

Plan and is supported by substantial evidence. A decision is reasonable if a reasonable

person could have reached a similar decision, given the evidence before him, not that

a reasonable person would have reached that decision. We review [the] final claims

decision, not the initial denial letter, to ensure development of a complete record.” 

Ingram v. Terminal R.R. Ass’n of St. Louis Pension Plan for Nonschedule Emps., No.

14-3589, slip op. at 9, --- F.3d ---- (8th Cir. Jan. 29, 2016) (citations and quotations

omitted).

When the plan administrator is an insurer that is responsible for paying benefit

claims, such as Standard, it has a financial conflict of interest that a reviewing court

must take into account in determining whether the administrator, “substantively or

procedurally, has abused [its] discretion.” Metro. Life Ins. Co. v. Glenn, 554 U.S.

105, 115 (2008). Citing nothing more than Standard’s “pecuniary interest in denying

claims,” Whitley urges us to “conduct a more searching review of Standard’s decision

to terminate Whitley’s claim.” But altering the standard of review solely for this

reason would be contrary to the case-specific test adopted in Glenn. An insurer’s

structural conflict of interest “should prove less important (perhaps to the vanishing

point) where the administrator has taken active steps to reduce potential bias and to

promote accuracy.” Id. at 117, and at 126 (Kennedy, J., concurring). Here, Whitley

presented no evidence that Standard’s thorough claims review process was biased, and

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the record established that the medical professionals who peer reviewed Whitley’s

claim at Standard’s request were independent consultants, not Standard employees,

and that their compensation was not based on their findings. See Carrow v. Standard

Ins. Co., 664 F.3d 1254, 1259 (8th Cir. 2012). In these circumstances, the financial

conflict factor was reduced “to the vanishing point.”

B. Standard’s decision to discontinue LTD benefits effective July 31, 2012 --

the only decision here at issue -- was based on its determination that the disabling

cognitive impairments suffered by Whitley in the February 2011 car accident had

improved to the point that she could return full-time to her Own Occupation. The

district court first ruled that Standard abused its discretion in determining that

Whitley’s Own Occupation was family medicine, not emergency medicine. Though

the parties argue this point at length on appeal, we conclude it is almost entirely a

straw man. Standard’s initial decision was based in part on a determination that

Whitley’s Own Occupation was her board-certified specialty as a family medicine

physician. But the final decision expressly stated that Standard “conducted our review

to include the physical demands and Material Duties of an[] Emergency Room

Physician as well [as Family Practitioner].” Because exhaustion of an ERISA plan’s

appeal procedures serves many important purposes, “the reviewing court reviews the

claim administrator’s final decision to deny a claim, rather than the initial denial that

was reconsidered during the internal appeal.” Galman v. Prudential Ins. Co. of Am.,

254 F.3d 768, 770-71 (8th Cir. 2001). 

Although it failed to acknowledge this principle, the district court went on to

conclude that “Standard’s consulting physician reports contain only unsupported and

conclusory assertions regarding Whitley’s ability to generally perform work in an

emergency setting.” That issue is part of the judicial review of Standard’s final

decision, but the district court’s conclusion is inconsistent with abuse of discretion

review. During the appeal process, all of Standard’s consulting physicians addressed

this issue. Dr. Morgan found that Whitley “does not have any restrictions or

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limitations with respect to her work as a family practice physician in an emergency

room setting . . . based on the nature of her mild concussion post-concussion

syndrome and the normalization of her neuropsychological testing.” Dr. Williams

considered “the unique demands of emergency room practice” as described by a

vocational consultant and opined that a gradual return to work was “overly

restrictive.” Dr. Greif noted that Whitley would need to be monitored when first

working in an emergency room but opined that “it is reasonable to try a full-time

return [to work].” Dr. Fancher was consulted again and noted “that in emergency

medicine more than other disciplines, one’s work is more closely scrutinized.” Dr.

Lambe opined that Whitley’s hip, knee, and degenerative disc disease “do not

preclude the standing and walking required of an ER physician,” nor the other light

physical demands of that profession. The administrative record more than adequately

supports the manner in which Standard addressed the Own Occupation issue in its

final decision.

C. Turning to the main issue, the district court concluded that Standard abused

its discretion in discontinuing benefits because its “consulting physicians totally

dismiss, without support, the recommendation of Whitley’s treating physicians that

she should return to work on a part-time basis, with supervision, to determine whether

or not she can perform her job duties.” That is the pivotal issue, and it is not free from

doubt. When she appealed Standard’s adverse initial decision, Whitley wanted to

return to work and felt she had recovered the cognitive ability to perform her work as

an emergency room physician, but wished to return to Lake Region on a part-time

basis. Her treating physicians all agreed she had recovered her cognitive and other

abilities but opined that she should initially return to work on a part-time basis. 

Standard’s independent medical experts agreed that Whitley had regained the ability

to perform the material duties of her Own Occupation but disagreed that a part-time

return to work was necessary. Lake Region brought this issue to the forefront when

it could not (or would not) accommodate a part-time return to work on the terms

Whitley requested. 

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On this record, we conclude that substantial evidence supported Standard’s

decision to discontinue benefits because Whitley had recovered the ability to return

to her Own Occupation on a full-time basis. Standard provided Whitley the “full and

fair review” ERISA required before denying her appeal from the initial decision to

discontinue LTD benefits. See Prezioso v. Prudential Ins. Co. of Am., 748 F.3d 797,

805-06 (8th Cir. 2014). At the end of this process, Standard was faced with

conflicting expert opinions on an issue the objective medical evidence could not

definitively resolve -- whether Whitley had recovered from the car accident

sufficiently to work on a full-time basis, or only on a part-time basis. In resolving this

conflict, Standard was not required to give special deference to the opinions of

Whitley’s treating physicians. Black & Decker Disability Plan v. Nord, 538 U.S. 822,

825 (2003). 

Both the treating physicians and the consulting physicians agreed that Whitley

could return to work on July 31, 2012, but disagreed whether she was able to return

on a full-time basis initially. The clinical neuropsychologist, Dr. Williams, reviewed

Whitley’s medical records, spoke with Dr. Bergloff, and reviewed “actual raw test

data” from her cognitive tests. The neurologist, Dr. Morgan, concluded that Whitley’s

complaints of pain and mental fatigue were “complaints . . . of tolerance,” not

objective evidence. The orthopedic surgeon, Dr. Lambe, considered the effects of

knee surgeries and degenerative disc disease and found that Whitley could withstand

the “light physical demands” of work as an emergency room physician. Dr. Greif

recommended a gradual return to work but agreed “it is reasonable to try a full-time

return.” All the independent consultants expressly considered the contrary

recommendations of Whitley’s treating physicians and opined that Whitley was able

to go back to work full-time, even in the somewhat more demanding emergency room

environment. 

“When there is a conflict of opinion between a claimant’s treating physicians

and the plan administrator’s reviewing physicians, the plan administrator has

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discretion to deny benefits unless the record does not support denial.” Johnson v.

Metro. Life Ins. Co., 437 F.3d 809, 814 (8th Cir. 2006); see also Carrow, 664 F.3d at

1259; Bolling v. Eli Lilly & Co., 990 F.2d 1028, 1029-30 (8th Cir. 1993). Only when

the evidence relied on is “overwhelmed by contrary evidence” may the court find an

abuse of discretion. Coker v. Metro. Life Ins. Co., 281 F.3d 793, 799 (8th Cir. 2002)

(quotation omitted). In view of the conflicting opinions contained in the voluminous

administrative record, Standard’s decision to deny Whitley’s claim based on the

opinions of its independent consultants was not an abuse of discretion. Hunt v. Metro.

Life Ins. Co., 425 F.3d 489, 490-91 (8th Cir. 2005) (per curiam).

III. Conclusion.

Paragraphs 1-4 and 7-8 of the district court’s Amended Judgment in a Civil

Case dated February 27, 2015, are reversed and the case is remanded for entry of an

amended final judgment consistent with this opinion. See Johnson v. United of

Omaha Life Ins. Co., 775 F.3d 983, 989 (8th Cir. 2014).

______________________________

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