Pursuant to 5 T H C IR . R. 47.5, the court has determined that thi s opinio n should not * be publishe d an d is not precedent except under the limited circu mstance s set forth in 5 T H C IR . R. 47.5 .4. 

### INTHE UNI TED S TATESCOU RT OFAPPEALS

FORTHE FIFTH CIRCU IT

N o. 09- 30381
DA RL ENE L MCDONA L D P l a i n ti ff - A p p ell a n t v. HAR T F OR D L I F E GR OUP I NS URA NCE C OMPA NY D efen da n t- A pp el l ee

A pp ealf

rom t h e U n i t ed S t ates D i st ri ctC ou rt f o rt he Eas t e r n Di s t r i c to f Lo ui s i ana N o. 2: 06- C V

- 3015
B ef ore K IN G , G A R Z A , an d H AY N E S , C i rcui tJu dg es . P E R C U R I A M: * D arl en e M cD on al d, an of f i ce m an ager, su ffer s f rom degen erat ive di sc di sease i n he rs pi ne . Fo l l o w i ng a s ur gi c alpr o c e dur e i nt e nde d t o a l l e vi at e her b a ck pai n, s he c eas ed w or ki ng and appl i ed f orl ong- t er m di sa bi l i t y be nef i ts und erherem pl oye r ’ s E R I SApl an w i t h H ar t f o r dLif e Gr o up I ns ur a nc e Co m p any. Af t e rr e vi e w i ng M c D on al d’ s m e di c alr e c o r ds a nd i nt e r vi e w i ng he rt r e at i ng phy s i c i ans , H ar t f

o r d d e ni e d b e ne f

i t s , f i ndi ng t hats he w as c ap ab l e o f pe r f o r m i ng s e d e n ta r yw o r ka n d t h e r e fo r e d idn o t m e e t t h e p la n ’ s d e fin itio n o f “d is a b le d .” United States Court of App eals

Fifth Circuit 

### F I L E D Janua ry 19, 2010 Cha rl es R. F ulb ru g e II I Clerk Case: 09-30381 Document: 00511007186 Page: 1 Date Filed: 01/19/2010N o. 09- 30381

2 M c D o nal d b r o ugh tt w o a dm i ni s t r at ive a ppe al s , b o t h o f w hi c h H ar t f

o r d d e ni e d. M cD on al d brou gh tsui t , al l egi n g H art f ord abu sed i t s d i scr et i on b y den yi n g h er c l ai m . The di s t r i c tc o ur tg r ant e d s um m ar y j udg m e ntf o rH ar t f

o r d, a nd M c D o n a ld a p p e a ls
. W e a ffir m . I . B A CK GRO UND A
. McD on ald’

s Job R equ i rem ents& L ong T erm D i sabil i ty Pol i cy D arl en e M cD on al d (M cD o n al d) w orked as an off i ce m an ager, bu si n ess m a n a g e r , a n d p r o p e r t yman a g e r a t t h e l a w f i r m o f Br u n o & Br u n o , L LC ( B&B) st art i n g i n F ebru ary 200 2. H er j ob requ i red f requ en t com pu t er u se, prol on ged si t t i n g, st an di n g, an d w al king. S h e al so had t o f requ en t l y ben d, st oop, an d reach
w h i l e f i l i n g em pl oyee i n f

orm ati on . A n y l i f

t i n g requ i red w as norm al l y u n der t en p o u n d s , b u t o c c a s io n a llyit m ig h t e x c e e dth is a m o u n t. B& B of fe r e d l o ng t e r m di s ab i l i t y i ns ur anc e c o ve r ag e f o ri t s em pl oyees th ro u g h C N AG ro u p L ife A ss u ra n ce C o m p a n y(n o w k n o w n a s H a rtfo rd L ife G r oup I nsur ance C om pa n y, orH ar t f or d)
. U nderB & B ’ s pol i c y, an i ndi vi dual qu al i f i es f or l on g t erm di sabi l i t y ben ef i t s i f t h e i n di vi du al i s si ck o r i nj u red du ri n g a 90

- da y el i m i n ati on peri od (beginn in go n t h e date of t h e onset of di s ab i l i t y) a nd f

o ra no t he r2 4 m o nt hs f o l l o w i ng t he end o f

t he e l i m i nat i o n pe r i o d. The po l i c y r e fe r s t o t hi s i ni t i alt i m e pe r i o d (t he 9 0- da y e l i m i nat i o n per i o d p l us 24 m o nt hs ) a s t he “ O c c upa t i o n Qual i f i e r” pe r i o d, b uti ti s a l s o known i n t he i n suran ce i n du st ry as t h e “ O w n O ccupa t i on ” p eri od. T o rec eive ben ef i t s un der th e p o lic y d u r in g th e O w n O c c u p a tio n p e r io d , th e in d iv id u a l m u s t c o n tin u o u s ly
m eett h e def

i n i t i on of

“ di sabl ed” f

o r th e enti re peri od. Th e pol i cy def i n es “disab l ed ” as “[i]nju ryor [s] i ck n ess ca u s[i n g] p h ys i ca lo r m en tal i m p a i rm en t t o su ch a d eg ree of sev erity tha t [th e ind ivid u a l is ] 1) con ti n u ou sly u n a b l e to pe r f o r m t he [ m ] at e r i ala nd [ s ] ubs t ant i al[ d] ut i e s of [ he r ] [ r ] e gul ar[ o ] c c upa t i o n; Case: 09-30381 Document: 00511007186 Page: 2 Date Filed: 01/19/2010N o. 09- 30381

The p ol ic y defines “gainfully employed” a s “the performance of any occupation for 1 wage s, renumerationor profit, for which you are qualified by education , trainin g or experience on a full -time or part-time ba sis, and which provides youw ith sub stanti ally the same e arning capacityas your former earning capacity priorto the start of your disab ility.” Degenerativedisc diseaseis also known as spondylosis or o steoarthritis. Stedman’s 2 M e dic alD ictio n arydef in e ss p o n dylo s i sa s“Ankylo s i sof th evert eb r a ; of

t e nap p lie d non specifically to anyle sio n of the spineof a de ge nerative n ature.” S TED M AN ’ S M ED I CAL D I CT I ON AR Y 181 3 (2 8thed. 200 6). Stedman’s describe soste oarthritis a s: “Arthritis characteriz ed b y erosion of articular cartila ge , either primary or secon daryto trauma or other condition s, whichbecomes soft, fraye d, or thinned with eburnationof subchondral b onean d outgrowths of marginalosteophytes; pain an d loss of functionresult; mainlyaffects weightbearin g joints, is more common in old peopl e and ani mals.” Id
. at 1388
. “Ankylo sis” i s defined as “[s]tiffeningor fixation of aj oint a s theresult of adise ase proc es s , w it h f ib r ous or b ony union acro ss thej oint; fu sion .” Id
. at 9 5
. 3 2) an d n ot[ g] ai n f

u l l y [ e] m pl oyed
. ” Th e pol i cy i s governed by the E m pl oyee 1 R e tir e m e n t In c o m e S e c u r ityA c t o f 1 9 7 4 (E R IS A), 2 9 U .S .C . § 1 0 0 1 , e ts e q. , a nd give s H ar t f

o r d d i s c r e t i o nar y aut ho r i t y o ve r t he i nt e r pr e t at i o n o f t he po l i c y and
e lig ib ilityd e c is io n s . B. McD o nal d’

s I nj ur y andTr e at m e nt I n J ul y 20 03 , M c D o nal d b e g a ne x p e r i e n c i n gh e a da c he s a nd b ac k p ai n. She suff ered a h erni ated d i sc i n a car acci den ti n Ju n e 200 4, w h i ch exa cerbat ed h er pre- exi st i n g sym ptom s. A f t er t h e acci den t , s he b e ga n s e e i ng D r. E vali n a B u rger, a n o r th o p e d ic s u r g e o n . In J u l y 2 0 0 4 , D r . B u r g e rd e te r m in e dth a t M c D o n a ld
s uf fe r e d f r o m de ge ne r at ive di s c di s e as e i n b o t h t he l um ba ra nd c e r vi c alr e gi o ns 2 of her spi n e, bu tshe di d n otthink t h at surgery w ou l d h el p at the t i m e. A f t er a N o v e m b e r 2 0 0 4 a p p o in tm e n t, D r . B u r g e rre c o m m e n d e dth a t M c D o n a lda v o id

“ prol on ged si t t i n g i n f ront of [ a] com pu t er” an d l i m i tan y l i f t i n g. E ven t u al l y, D r. Burg e r r e c o m m e nde d c e r vi c al f us i o n s ur ge r y be t w e e n ve r t e br ae 4– 5, 5– 6, and 6

– 7
. D r . Bur ge r refe r r e d M c D o nal d t o D r . J o hn St e c k, a ne ur o s ur ge o n, w ho
concu rred i n rec om m en din gs u rgery af t er r evi ew i n g M cD on al d’ s M R Is
. D r. St ec k per form ed s urge r y o n M c D onal d’ s l um bars pi ne o n D ec em ber28, 2004; Case: 09-30381 Document: 00511007186 Page: 3 Date Filed: 01/19/2010N o. 09- 30381

I n this letter, Dr. Hubbell se ems to advocate stronglyfor McDonal d to receivecervical 3 facet radiofrequency treatment, and he complains tha t McDon ald’ s he althcare p rovider (Coventry HealthC are) failed toallow a dditionaltestingth at would obj ectivelydemon strate her n e e d f

or thi s typ e of tr e at m e nt
. However , thi s a dvo c acy s e e m s m i s p lace d, as Hartford—the di sabilitybenefits provider—i s unrelated to C oventry—the health insurance provider . 4 M c D o nal d c o nt i nue d wor ki ng f ul l

- t i m e a tB& B unt i l D e c e m be r 27 , 20 04
. Att he t i m e of t h e surgery, i tw as un cl ear how s u cces sf u lt h e procedu re w ou l d be, pa r t i c ul ar l y be c aus e t he de ge ne r at ive di s c di s e as e a f fe c t e d m o r e t han j us tt he l u m bar spi n e. Foll ow i n g t h e surgery, M cD on al d reported i m provem en ti n her p a i n bu t M R Is con ti n u ed to sh o w ev i d en ce of de ge n era tive disc d i sea se. In Februar y 2005, six w ee ks af t ert he s urge r y, D r . St ec k not ed t hatM c D onal d w as d o in gv e r yw e ll a n d g a v e h e rp e r m is s io n t o r e tu r n to w o r k o n a p a r t-t im e b a s is (fo u rh o u r s a d a y , th r e e d a y s a w e e k ). D r . S te c k ’ s fin a l ch a r t n o te fo rM c D o n a ld
w as dat ed Jul y 6, 2005, and s how s t hatherM R I r ef l ec t s “ c ervi ca la n d l um bar
s p o n d y lo s is w ith a r th r itic a n dd e g e n e r a tiv e ch a n g e s in th e ce r v ic o th o r a c ic spi n e. ” M cD on al d at t em pted t o ret u rn t o w ork f or a peri od of t i m e, b u t soon f o und i tt o o pa i nf

ul
. M c D o nal d a ppl i e d f o rl o ng- t e r m di s ab i l i t y be ne f i t s i n J une 2 0 0 5 a n d h e rfin a l d a yo f w o r k a t B & B w a s O c to b e r1 2 , 2 0 0 5
. Beg i nni ng i n Oct o be r200 4, M c D o nal d s t ar t e d t r e at m e ntw i t h Dr. Paul H ubbel l , a pai n m anagem ents pec i al i st , w ho det er m i ned i n a Februar y 13, 2006, l e t t e rt o H ar t f

o r d t hatM c D o nal d “ m aybe abl e t o pe r f o r m pa r t
- t i m e w o r k” b ut
c o ul d no tr e t ur n t o w o r k o n a f ul l

- t i m e b as i s a s a r e s ul to f he r“ s i gnif

i c ant
ar t hr i t i c c o m pl ai nt s i n t he c e r vi calsp i ne w hi c h c aus e r e f l e x [ s i c ] s i gnif

i c ant
m u scl e spasm s, h ead ach es, an d l i m i t ati on of posi t i on . ” D r. H u bbellal so noted i n t h e F ebru ary 200 6 l et t er that M cD on al d’ s su bj ect ive com pl ai n t s of pain w ere sup ported by obj ect ive f i n di n gs of facetp athol ogy an d di sc pa t h ol ogy, b u th e al so recom m en ded t h at s h e rec eive ad di t i on alpain t h erapy , w h i ch h e predi ct ed
m ig h t “ s ig n ific a n tlyim p r o v e h e rp h y s i c a l a c tiv ityca p a b ilitie s .” M c D o n a ld 3 Case: 09-30381 Document: 00511007186 Page: 4 Date Filed: 01/19/2010N o. 09- 30381

5 report ed that her back p ai n i m proved som e af t er her surgery, bu ti tha s s i n ce f l u ct u ated; she st i l lcom pl ai n s of h ead ach es an d m u scl e spasm s. B ecau se of her pa i n , she requ i res h el p w i t h her persona lgroom i n g an d w i t h m ain ta in in g h er h o u s e h o ld
. C
. A d m i n i st rat i ve C laim s Proces s I n J une 200 5, M c D o nal d f i l e d a c l ai m f

o rdi s ab i l i t y be ne f

i t s w i t h H ar t f

o r d. A c cordi ng t o H ar t f

or d, t he 90- day e l i m i nat i on per i od be gan D ec em ber28, 20 04

— t he da y M c D o nal d unde r w e nt s ur ge r y— and e nde d M ar c h 2 8, 2 00 5. The O w n O c c upat i on per i od l as t ed f r om D ece m b er 2 8, 2004, t o M ar c h 28, 2007. Ther e f o r e , t o q ual i f

y f o rdi s ab i l i t y be ne f

i t s , M c D o nal d nee de d t o sho w t hats he
m e tt he de f

i ni t i o n o f

“ di s ab l e d” f

o rt he dur at i o n o f

t he O w n Occ upa t i o n pe r i o d. M cD on al d su bm i t t ed d ocum en t ati on f rom D r. S t eck st ati n g t h at s h e shou l d n ot ben d, st oop, cl i m b, or l i f tm ore t h an t en pou n ds. H art f ord gathered other
m edi c alr ec or ds, i ncl udi ng t he c l ai m not es , D r . St ec k’ s L[ ong] T[ er m ] D [i sa bi l i t y] P h ysi ci an ’ s Stat em en ta n d F u n ct i on alA sses sm en tT ool , cl i n i calnotes f rom D rs. St ec k and H ubbel l , t he di sc harge s um m ar y af t ert he s urge r y, t he o per at ive r epo r t , and f

ourM R I s of

herl um barand c ervi c als pi ne. The Fu nct i onal A ss es sm en t T oo li ndi c at es t hatD r . St ec k di d nott hi nk t hatM c D onal d w as c ap ab l e o f

pe r f o r m i ng f

ul lt i m e w o r k i nvo lvi ng “ s i t t i n g, s t and i ng, a nd wal ki ng f o rv ar yi ng pe r i o ds o f t i m e , t yp i ng o n a c o m put e r , s o m e b e ndi ng, s t o o pi ng, a nd
r e ac hi ng, r e gul ar l y l i f t i ng i t e m s und e r[t e n po unds ] a nd o c c as i o nal l y l i f t i ng ite m s o v e r[te n p o u n d s ]” a s o f J u ly1 4 , 2 0 0 5
. H a r tfo r din te r v ie w e dM c D o n a ld and det er m i ned t hats he w as abl e t o g ethel p atw or k t o a voi d bendi ng, s t oo pi ng, an d l i f t i n g an d that B & B w as coop erat ive, a l l ow i n g h er to get h el p w i t h t asks. A f t er c om pi l i n g M cD on al d’ s m edi calrec ords, H art f ord hir e d D r. B ruce L eF orce, a ph ysi ci an w i t h R eed R evi ew Servi ces, to revi ew M cD on al d’ s f i l e. D r. L eF orce determ i n ed that M cD on al d w as: Case: 09-30381 Document: 00511007186 Page: 5 Date Filed: 01/19/2010N o. 09- 30381

Accordingto Hartford’ s January 25, 200 6, denial letter, McDonal d sub mitted: 4 Letter to Attorneys from D r . E valin a Burger dated July 12, 200 4; A physic al examin at io n form dated 7/12/0 4 whichwas not complete ; A PhysicalTherapy referr al dated 7/12/04; A Spine Assessment Form undated ; MRI of the Cervical S p in e d at e d 9/ 1 0/0 4 ; C linic not e [ s] d at e d 1 0/4/0 4 thro u gh 1 1 / 1 /0 4 f rom Dr. Evalina Burger; Prescrip tionfor medication[inclu ding Vicodin] dates 11/1 /04; LTD Physician’s Statement; MRI of the C ervicalSpine d ated 10/19/0 5; Evalu ation byDr. P aulJ. H ubb elldated 10/26/04; Office notes from Dr. P aulJ. Hubb elldated 1 0/26/04 through 8/16/05; Con sent forms and clinic recor d from [s urgery] date d 1 2/1 3/0 4
. 6 capa bl e of

si t t i n g u p t o eight hou rs per da y gi ven an opp ort u n i t y f or fr e q u e n t b r e a k s a n d ch a n g e s i n p o s i tio n . S h e ca n s ta n da n dw a lk o c c a s io n a lly
. S h e ca n n o t lift o rc a r r ym o r e t h a n t e n p o u n d s a n dth is can b e d on e on l y occasi on al l y. S h e can ex erta neg l i gibl e am ou n tof f orce co n ti n u ou sl y. Sh e cann otcl i m b, ben d, or st oop. Th ese lim ita tio n s s h o u ld b e c o n s id e r e dp e r m a n e n t. . .
. S h e ca n w o r k fu llt i m e given t he o t herr es t r i c t i ons and l i m i t at i ons . . . . [ T] he o bj ec t ive f i ndi ngs i ndi c at e t hatshe i s c apabl e of f ul l

- t i m e w or k pr ovi ded t hat she i s l i m i t ed t o a sed en t ary t yp e j ob w i t h no cl i m bi n g, ben di n g, or s to o p in g . D r . LeForc e c oncl u d ed thatM c D onal d’ s M R I s how ed “ onl y s om e de gener at ive c hang e s w i t ho uts pi nals t en os i s o re vi de nc e o f ne r ve r o o ti m pi nge m e nt
. ” I n a l et t er dated Sep t em ber 30, 200 5, H art f ord determ i n ed that t h e i n f orm ati on c o nt ai ne d i n M c D o nal d’ s f i l e “ fai l [ e d] t o s upp o r ta n i nab i l i t y t o pe r f o r m t he
m at e r i ala nd s ubs t ant i al dut i e s o f [he r ] r e gul aro c c upa t i o n” a nd t he r e f o r e s he
w a s in e lig ib le fo rb e n e fits
. M cD on al d ap pea l ed the den i alan d p resented add iti o n ali n f orm ati on f

or H art f ord’ s r evi ew . H art f ord hir ed D r. B arry T u rner, an orth oped i c s u rgeon 4
e m p lo y e d b yU n iv e r s ityD is a b ilityC o n s o r tiu m (U D C ), to re v ie w th e o r ig in a l file
a n d th e n e w d o c u m e n t s s u b m it t e db yM c D o n a ld . A c c o r d in gto H a r t fo r d ’s Jan u ary 26, 2 0 06, l et t er, D r. T u rner di d n otrevi ew D r. L eF orce’ s c on cl u si on s, bu ti n dep en den t l y revi ew ed the f i l e an d cam e t o h i s ow n con cl u si on s. D r. T u rner at t em pt ed t o c ont ac tM c D onal d’ s t r eat i ng physi c i ans. H e w as unabl e t o s peak di r e c t l y w i t h Dr. St e c k, b uthe s po ke w i t h a p ers o n i n Dr. St e c k’ s o f f i c e w ho Case: 09-30381 Document: 00511007186 Page: 6 Date Filed: 01/19/2010N o. 09- 30381

The recor d doe s not explicitlyshow whether Dr. Pick reviewed Dr. Le Force’s or Dr. 5 Turner’s evalu atio n s . He di d not s p e cif ic ally li s t th e oth er do ctor s ’ r e p ort s in hi s r eview o f McDonal d’s file, and Hartford did not di scuss this i ssue in its finaldeniall et t er . However , Hartford explicitlymentioned in the deni al letter fro m thefir st appe al that Dr. Turner did not review Dr. LeForce’ s conclu sion s; thi s discrepancy raise s thequestion whether Dr. Pick had acc es s to the oth erreviewin gp hy sici an s’c onclu sion s. 7 i n di cat ed that M cD on al d’ s l ast vi si tw as i n O ct ober 2 0 0 5 , at w h i ch ti m e D r. St e c k’ s no t e s r e f

l e c t e d t hat s e de nt ar y- l e ve l w o r k w o ul d b e a c c e pt ab l e , w i t ho ut
a n ylim ita tio n s a s to tim e . D r. T u rne rr e port ed that t h e rec ords he revi ew ed su pp ort ed the concl u si on th a t M cD on a ld s u ff ere d “gen era l i ze dcerv i ca lan dl u m b a r sp on d ylosis w i th art h ri t i c c h an ges consi st en tw i t h her age, ” an d h ad un dergon e a “ sati sfact ory c e r vi c ala nd l u m ba rdi s ke c t o m y [ t he s ur gi c alpr o c e dur e ] w i t h f us i o ns a nd n o com pl i cat i on s orres u lta n t ra d icu lop a th y , m y e lop a th y , o r n e rv e ro o t co m p ress i on no t e d. ” Dr. Tur ne r c o nc l ude d t hatM c D o nal d’ s c o ndi t i o n was “ s e c o nda r y t o t he
n o r m a l a g in gp r o c e s s ” a n d fo u n d “ n o e v id e n c e o f a n ys ig n ific a n t im p a ir m e n t.” H e opi n ed that “ t h ere i s no reason t h at or alan al gesi cs an d an t i

- i n f l am m ator y t her apy w oul d notbe ef fec t ive” and “ pro vi de[ d] no r e s t r i c t i ons orl i m i t at i ons t hat
w oul d pr ec l ude f

ul l

- t i m e w or k ac t ivi t y. ” I n a l et t erdat ed Ja nuary 26 , 2006, H ar t f or d i nf or m ed M c D onal d t hat , f ol l ow i ng t he appea l , i tappear ed t hats he “ at
a m i ni m um r et ai n[ ed] t he f unct i onal c apac i t y f

or se dent ar y- t ype w or k ac t ivi t y”
a n d the refore didn ot m ee t t h e p oli cy ’ s d efi n i ti on of “disab l ed
. ” M c D o nal d a ga i n r e que s t e d t hat H ar t f o r d r e c o ns i de r i t s de c i s i o n, a nd s he
s ubm it t e d a ddit i o naldo c um e nt ati o n, i n cl u di n g l et t ers f rom M cD on al d regar di ng herpai n; a j ob des c r i pt i on f orherposi t i on atB & B ; D r . H ubbel l ’ s Februar y 2006 l et t er r egard i n g h er s u bj ect ive pa i n ; an d a M R I o f her cervi calspi n e f rom Oc t o b e r2 0 0 5 , wh i c h s h e h a d p r e v i o u s lys u b mit t e d
. Ha r t f o r dh i r e da n o t h e rUDC ort h oped i c surgeon , D r. R obert P i ck, t o cond u ct t h e second r evi ew . D r. Pic k
r e vi e w e d a l lo f t he pr e vi o us e vi de nc e s ubm i t t e d by M c D o nal d. D r . Pi c k s po ke 5 Case: 09-30381 Document: 00511007186 Page: 7 Date Filed: 01/19/2010N o. 09- 30381

8 w ith D r . B u r g e r , w h o re p o r te do n lyth a t h e rla s t v i s i t w i t h M c D o n a ldw a s in N ove m ber2004 and she di d n oth ave ac c es s t o M c D onal d’ s r ec or ds, as t hey had be e n a f fe c t e d b y H ur r i c ane K at r i na. Dr. Pi c k a l s o s po ke w i t h D r . H ubb e l l , w ho
s ta te d th a t “ th e o n lyo b je c tiv e f in d in gis t h e M R I,” a n dw h e n a s k e dif M c D o n a ld
c oul d engage i n se dent ar y w or k, repl i ed: “I nst ead of gu es si ng, geta Fun c t i onal C ap aci t y E valuati on . ” D r. P i ck cal l ed D r. S t eck an d s pok e w i t h hi m af t er hou rs w h en he d i d n otha ve access t o M cD on al d’ s r eco rd s; D r. Steck report ed f rom gen eralm em ory t h at M cD on al d could en gag e in seden t ary w ork f or ei gh thou rs a d a y . Fr o m hi s r e vi e w o f

t he do c um e nt s a nd hi s co nve r s at i o ns w i t h t he t r e at i ng ph ysi ci an s, D r. P i ck concl u ded t h at “t h ere i s no docu m en t ati on or sub st an t ati on [ si c] t h at M s. M cD on al d can n oteng age i n at l east th e seden t ary–li gh tw ork
c at ego r y o n f

ul l

- t i m e b as i s. ” H e o bs erved t hatt he f i l e i ndi c at ed M c D onal d had

“ deg en erat ive art h ritic cha n ges of t h e cervi calan d l u m bar spi n e” ; her surgery hadb e e n s uc c e s s f

ul ; a n d s he ha d “ s at i s fac t o r y po s t o pe r at ive pr o gr e s s a nd
r e c o ve r y w i t h i m pr o ve m e nti n [he r ] pr e o pe r at ive s ym pt o m s . ” H e no t e d t hat“ no s pe c i f i c i nt e r ve nt i o n ha s be e n r e c o m m e nde d o t he r t han c o ns e r va t ive c ar e ” a nd

“ t he c as e fi l e do es not doc um ent a n y su b st ant i ve obj ec t i ve ort h oped i c/ m u scul oskel et alf i n di n gs t h at w ou l d p revent M s. M cD on al d f rom en gag i n g i n f

u l l

- t i m e w ork act ivi t i es i n at lea st the seden t ary–li gh tw ork
ca teg ory. . . . ” H e con cl u d ed th a t M cD on a l d ’ s fil e did n ot “estab l i sh a co m p l ete i m pa i r m e ntf

r o m gai n f

u le m pl o ym e nt
. ” Bas e d o n Dr. Pi c k’ s r e vi e w a nd
con cl u sion s, H a rtf

ord sen t M cD on a l d a le tter on A p ri l26 , 20 0 6 , de cl i n i n g to
c hange t he pr i ordec i si on t o de ny benef i t s. The l et t ers t at ed t hati tw as “ f i nal
a n d b in d in g” a n d th a t M c D o n a ld h a d “e x h a u s te da ll [a ]d m in is tr a tiv e re m e d ie s .” D
. Lit iga t i on Case: 09-30381 Document: 00511007186 Page: 8 Date Filed: 01/19/2010N o. 09- 30381

McDo n aldl ater voluntarilydis mi sse d B &B
. 6 9 M cD on al d f

i l ed su i tagainstB & B an d H art f ord on J u n e 12, 200 6, un der 6 ER I SA. M c D o nal d a l l e ge d t hat H ar t f o r d fai l e d t o pa y be ne f i t s und e rt he i n suran ce pol i cy as r equ i red by 29 U
. S
. C
. § 1132 ( a) ( 1) ( B ) an d th at H art f ord breach ed i t s f

i du ci ary du t i es u n der 29 U
. S
. C
. § 110 4( a)
. M cD on al d an d H art f ord bot h f i l ed m ot i ons f

ors um m ar y j udgm ent
. The di st r i c tc our tdet er m i ned t hat t h e adm i n i st rat ive recor d w as i n com pl et e becau se H art f ord ha d rel i ed u pon D r. P i ck ’ s d i scu ssion w i th D r. S teck after h ou rs, w h en D r. S teck w a s at th e h ea l th
c l ub anddi d no tha ve a c c e s s t o M c D o nal d’ s r e c o r ds
. On M ar c h 2 8, 2 00 8, t he d is t r ic t c o u r t r e m a n d e d t o H a r t fo r d fo r fu r t h e r c la r if ic a t io n o f

D r . S t e c k ’s posi t i on , w i t h i n st ructi on s t h at t h e rem an d w as “ f or t h e l i m i t ed p u rp o se of i nt e r vi e w i ng and/o rde po s i ng D r . St e c k t o c l ar i f y hi s po s i t i o n a s r e ga r ds [M cD on a l d ’ s] l i m i tati on s. ” F o llo w in ga n o th e rin te r v ie w w i t h D r . S te c k , H a r tfo r dn o te dth a t h is
o p in io n w a s th a t “ M c D o n a ld ’ s o n g o in gco m p la in t s o f p a in a r e s u b je c tiv e in nat ur e ” a nd h e c o ul d no tde t e r m i ne a tt hi s s t ag e w he t he rs he c o ul d wor k. I n a N o ve m be r2 1, 2 00 8 , l e t t e rt o M c Do n a l d ’ s a t t o r ne y, H ar t f o r d d e t e r m i ne d t hata ny n ew i n f orm ati on f

rom t h e i n t ervi ew of D r. S t eck w as “not com pel l i n g based on t he t o t al i t y o f

t he fac t s pr e s e nt ed” a nd d e c l i ne d t o c hang e i t s pr i o rde c i s i o n. M c D o n a ld re -u r g e d h e rm o tio n fo rs u m m a r yju d g m e n t, a s d idH a r tfo r d
. O n O ct ober 27, 200 7, bef ore t h e d i st ri ctcourti ssued i t s r em an d order, M cD on a l drece ive d a D eclara ti on of D i sa b i l i ty from the S ocial Se cu ri ty Adm i ni s t r at i o n ( SSA a w ar d)
. M c D o nal d d i d no ti nf o r m t he di s t r i c tc o ur to f t he
aw ard at t h e t i m e, bu tsh e di d f orw ard the aw ard, w i t h t h e accom pa n yi n g l et t er of r eas ons , t o H ar t f

or d s hor t l y af

t ert he c as e w as r em anded and r eques t ed t hat H art f ord consi der t h e aw ard. In i t s N ovem ber 21, 200 8, l et t er, H art f ord di d n ot
m en t i on t h e aw ard and t h e recor d does n ot show i f H art f ord i n cl u ded t h e aw ard Case: 09-30381 Document: 00511007186 Page: 9 Date Filed: 01/19/2010N o. 09- 30381

10 i n i t s i n vest i gati on of M cD on al d’ s c l ai m . T h e f i rstt i m e t h at M cD on al d i n f orm ed t h e di st ri ctcourtof

t h e SS Aaw ard w as i n her re- u rged m ot i on f or s u m m ary ju d g m e n t. Th e di st r i c tc our tgr ant ed s um m ar y j udgm entf orH ar t f

or d. In i t s f

i nal ord er on A p ri l29 , 20 0 9 , the distri ct cou rt d ecli n ed to give con troll i n g w eigh t t o t h e opi n i on s of

M cD on al d’ s t reat i n g ph ysi ci an s and f ou n d that “ H art f

ord
c o nduc t e d at ho r o ugh and r e as o nab l e ana l ys i s o f M c D o nal d’ s di s ab i l i t y, b as i ng i t s i n i t i aldeci si on an d tw o app ealdecision s on t h e opi n i on s of t h ree s epa rat e, i n dep en den tph ysi ci an s. ” T h e di st ri ct court n ot ed t h at M cD on al d adm i t s h er j ob i s “ pr i m ar i l y s e de nt ar y” a n d t hats he “ ge t s he l p f i l i ng t o a vo i d b e ndi ng and
s t o o pi ng. ” Fur t he r m o re, the di s t r i c tc o ur tpo i nt e d o utt hat“bo t h he rt r e at i ng ph ysi ci an s an d H art f ord’ s p h ysi ci an s h ave agreed sh e sh ou l d be able t o perf orm [ se dent ar y w or k]
. ” The di st r i c tc our tr ej ec t ed M cD onal d’ s ar gum entt hat H ar t f o r d was b o und t o c o ns i de rher S S A a w ar d— as H ar t f o r d ha d a l r e ad y reached i t s f

i n aldeci si on m ore t h an one yea r pri or t o t h e aw ard, i tcoul d n ot h ave con si dered the ad di t i on ali n f orm ati on , parti cul arl y i n l i gh tof t h e di st ri ct
c o ur t ’ s s pe c i f

i c i ns t r uc t i o ns l i m i t i ng t he s c o pe o f t he in qui r y o n r e m and
. M c D o n a ld tim e lya p p e a le d
. I I . DI S CU S S I ON M cD on al d rai ses t w o m ai n poi n t s on ap pea l
. Sh e argu es t h at t h e di st ri ct court i m properl y ref u sed t o a l l ow h er t o sup pl em en tt h e adm i n i st rat ive recor d
w i t h he rS S A a wa r d , a n d s h e c o n t e n d s t h a tt h e d i s t r i c tc o u r te r r e di n f i n d i ng t h at H art f

ord’ s deci si on t o den y ben ef i t s w as sup ported by sub st an t i alevi den ce. A
. Supp lem entat i on of A d m i n i st rat i ve R ecor d M c D o nal d a r gue s t hatt he di s t r i c tc o ur ta bus e d i t s di s c r e t i o n b y de c l i ni ng t o pe r m i tM c D o nal d t o e nt e r he r SSA a w ar d i nt o t he a dm i ni s t r at ive r e c o r d. The S S Aaw ard w as i ssued O ct ober 23, 200 7, m ore t h an one yea r af t er H art f

ord is s u e d it s fi n a l d e c is io n in A p r il2 0 0 6
. M c D o n a ld a r g u e s t h a tt h e d is t r ic tc o u r t ’s Case: 09-30381 Document: 00511007186 Page: 10 Date Filed: 01/19/2010N o. 09- 30381

Metropolita n Life Insurance C o. v. Glenn , — U. S. —, 1 2 8S .C t. 2 3 4 3 , 2 3 5 0(2 0 0 8), 7 abrogated Vegato the extentth at Vegaadopted a“ s li ding -scale” methodology of wei ghing co nflictsof intere st
. See Holland v. In t’ l Paper C

o. Ret . Plan , 576 F.3 d 240 , 24 7 n .3 (5 th Cir. 200 9). However , we h ave maintaine d th at “much of our ‘slidingscale’ precedent is co mpatib le with the Supre me C ourt’s newlycl arified ‘factor’ methodology, and Glenndoe s not supercede that precedent tothe extenti tr eflects theu se of a conflict as afactor that would alter the relative weight of otherfactors.” Id
. Th eref ore, Vega continu es tobegood law for propositions unrelate d toth e “s li din gsc ale” methodof reviewin gallegedc onflictsof intere st
. 11 r e m andf

o rf ur t he ri nve s t i ga t i o n r e - o pe ne d t he ad m i ni s t r at ive pr o c e s s , m ak i ng i tproper t o sup pl e m e n tt h e adm i n i st rat ive recor d w i t h t h e SS Aaw ard. H art f ord argu es t h at, given t h e l i m i t ed p u rpose of t h e rem an d, t h ere w as no obli gati on f or H ar t f o r d t o co ns i de rne w e vi de nc e o ut s i de o f t he di s t r i c tc o ur t ’ s i ns t r uc t i o ns a nd t he di s t r i c tc o ur ta c t e d wi t hi n i t s di s c r e t i o n in d ecl i ni ng t o c o ns i de rt he SSA
awar d. The de t e r m i nat i o n o f w he t he re vi de nc e s ho ul d b e i nc l ude d i n t he ad m i n i st rat ive recor d i s an evidenti ary deci si on , an d w e r e v iew f or abu se of d is c r e tio n . Corry v. L i berty L if e A ssuran ce Co. of

B ost on , 499 F. 3d 389, 398 n. 12 (5 th C ir . 2 0 0 7 ). W h en condu ct i n g abu se of d i scr et i on revi ew of a den i alof ben ef i t s based
on an adm i n i st rat ive recor d, w e ha ve gen eral l y requ i red t h at t h e sc ope of revi ew b e li m i ted to fa cts kn ow n to t h e p l a n ad m i n i strato r at th e tim e of the be n efi ts d e c is io n . S . F

arm B u reau L if

e I n s. Co. v. Moore , 993 F
. 2d 98, 102 ( 5th C i r. 1 9 9 3 ). H o w e v e r , w e h a v e re c o g n iz e dce r ta in lim ite de x c e p tio n s to th is ru le
. S ee V ega v. Nat’

lL if e I n s. S ervs . , I

n c. , 188 F
. 3d 287 , 299 ( 5th C i r. 199 9) (en b a n c) ( “ To da t e , t h[ e ] e xc e pt i o ns hav e be e n r e l at e d t o e i t he r i nt e r pr e t i ng t he pl an or exp l ai n i n g m edi calt erm s and procedu res rel ati n gto th e cl ai m . ” )
. Th ese 7
ex cep ti on s h a ve be en j u d ge d on a ca se-by -case ba sis, an dw e h a ve de cl i n ed to
a d o p t a n yp e rs e r u le s in th is a r e a . C f
. D u h on v. T

exaco, I n c. , 15 F. 3d 1302, 1309 (5 th C ir . 1 9 9 4 ). W h en com pi l i n g t h e a dm i n i st rat ive recor d, t h e pl an adm i n i st rat or m u st i de nt i f y w hatev i de nc e co ns t i t ut e s t he adm i ni s t r at ive r e c o r d, a nd t he c l ai m ant Case: 09-30381 Document: 00511007186 Page: 11 Date Filed: 01/19/2010N o. 09- 30381

12 m u s t h a v e “a re a s o n a b le o p p o r tu n ityto co n te s t w h eth er th a t r e c o r dis co m p le te .” Es t at eof

B r at t on v. Na t’l Un io n Fi r eI ns. Co. of

Pi t t s burgh , 215 F. 3d 516, 521 ( 5t h Ci r . 2 00 0)
. W hi l e t he a dm i ni s t r at ive r e c o r d i s ge ne r al l y l i m i t e d t o “ r e l e va nt i nf o r m at i o n m ad e a va i l ab l e t o t he a dm i ni s t r at o rp r i o rt o t he c o m pl ai nant ’ s f i l i ng of a l a w su i t a n d i n a m a n n er t h a t give s th e a d m i n i strato r a fair op p ortu n i ty to consi de ri t , ” w e ha ve a t t e m pt e d t o a vo i d a bus e o rm i s t ak e b y al l o w i ng “ t he cl ai m an t ’ s l a w y e r [t o] add add i t i on alevi den ce t o t h e adm i n i st rat ive recor d
s i m pl y bys ubm i t t i ng i tt o t he a dm i ni s t r at o ri n am annertha t g i ve s t he
a d m i n i strato r a fai r op p ortu n i ty to con sideri t. ” I d. a t5 21 & n. 5. W e ha ve been cl ea r, h ow ev er, th a t “ th e d i str ic t cou rt i s p reclu d ed f rom rece ivin g e vid en ce to
r es olve di sput ed m at er i alfac t s— i
. e. , a fac tt he adm i ni st r at or r el i ed o n t o r es olve th e m erits of t h e claim i tself
. ” Vega, 188 F
. 3d at 299
. H ad t h e di st ri ctcourtnot
r e m and e d t o H ar t f

o r d f o rf ur t he ri nve s t i ga t i o n o f D r . St e c k’ s o pi ni o n, t he ques t i on o f

whe t he rt he SS A a war ds ho ul db e i nc l ud e di n t he a d m i ni s t r a t i ve r e c o r d w o u ld b e cle a r : th e a d m in is tr a tive reco rdclo s e dw h e n M c D o n a ldfile d s u it in J u n e 2 0 0 6
. Cf

. Moore , 99 3 F. 2da t1 02
. The SSA awar d d o e s no tfal li nt o t he t w o a c kno w l e dg e d e xc e pt i o ns : e vi de nc e i nt e r pr e t i n g t he pl an o re xp l ai ni ng m e d ic a l te r m s a n d p r o c e d u r e s . T h e t i m i n g of

t h e rem an d order com pl i cat es t h e an al ysis som ew h at, f or Est at eof

Br at t o n sugge st s t hatM c D onal d had t he o p por t uni t y t o o f feraddi t i onal i nf or m at i on t o H ar t fo r d, s o l ong as t he s ubm i ss i on o f new i nf

or m at i on w as con d u cted “i n a m a n n er th a t give s th e a d m i n i strato r a fair op p ortu n ity to
con sideri t. ” Est ateof B rat t on , 21 5 F. 3d at 52 1 n. 5. As s um i ng w i t ho utde c i di ng t h at M cD on al d could ha ve sup pl em en t ed t h e record on rem an d, sh e m i ssed her opp ort u n i t y. Th e SS Aaw ard w as i ssued on O ct ober 23, 200 7, f ive m on t h s bef

ore t h e di st ri ctcourtrem an ded t h e case t o H art f ord on M a rc h 2 8 , 200 8. Y et M c D o n a ld d id n o t b r in gth e S S Aa w a r dto th e d is tr ic t c o u r t ’s a t t e n tio n u n til af t e rt he c o nc l us i o n o f

t he r e m andpe r i o d, de s pi t e at l e as to ne o ppo r t uni t y t o do Case: 09-30381 Document: 00511007186 Page: 12 Date Filed: 01/19/2010N o. 09- 30381

13 so. For exam pl e, H art f ord m oved f

or reconsi derati on of t h e rem an d order, w h i ch M c D o n a ld o p p o s e d in w r itin g— w ith o u t m e n tio n o f th e S S Aa w a r d
. M c D o n a ld
w as aw are of

t h e di st ri ctcourt ’ s s peci f i c i n st ructi on s on rem an d but di d n otask t h e di st ri ctcourtt o expa n d the scope of t h e rem an d t o i n cl u de c on si derati on of t h e aw ard. Th e f

i rst m en t i on of t h e S S A aw ard i n M cD on al d’ s f i l i n gs i s i n her Jan u ary 23, 200 9, reurged m ot i on f or sum m ary j u dg m en t
. In l i gh t of t h e di st ri ct
c ou r t ’ s v e r y s pe c i f

i c i ns t r uc t i o ns l i m i t i ng t he s c o pe o f t he r e m anda nd M cD on al d’ s fai l u re t o subm i tt h e aw ard f o rc o ns i de r at i on at an app ropri ate t i m e, t he di s t r i c tc o ur tdi d no ta buse it s d i sc r e t i o n i n r e f us i ng t o c o ns i de rt he SSA
awar d a nd i n a ppr o vi ng H ar t f o r d’ s de c i s i o n no tt o c o ns i de rt he a w ar d. B
. Su bst an t i al E vi d ence W e t ypi c al l y f

ol l ow a t w o- st ep pro c es s t o det er m i ne i f a n E R IS A pl an a d m in is t r a t o rh a s a b u s e d it s d is c r e t io n , a s k in gf ir s ti f t h e p la n a d m in is t r a t o r ’s determ i n ati on w as l egally corr ect ; if itis n ot , w e proceed t o t h e sec on d qu est i on o f w h e th e r t h e d e c is io n w a s a n a b u s e o f d is c r e tio n . Hol lan dv. I n t ’lPap er Co. R e t . Plan , 576 F
. 3d 240 , 246 n. 2 ( 5th C i r. 20 0 9)
. H ow ever, t h i s proces s i s not
r i gi d; “ w e m ays ki p t h e fi rs ts t e p i f w e c an m o r e r e ad i l y de t e r m i ne t hatt he d ecisi on w a s n ot a n a b u se o f d i scre ti on . ” I d. H ere , w e m a y p roce ed directl y to th e se co n d ste p . M cD o n a ld ra ise s se v e ra l p o in ts th a t sh e co n te n d s e ith e r ju stify
a le s s d e fe r e n tia l s ta n d a r d o f r e v ie w o rs h o w a b u s e o f d is c r e tio n b yH a r tfo r d
. W e revi ew a gran tof sum m ary j u dg m en t in a n E R ISAcase de n ovo, a p p ly in gth e s a m e s ta n d a r d a s th e d is tr ic t c o u r t. W ade v
. He w le t t–Packar d D e v. Co. LP Shor tTe r m D i s ab i l i ty Plan , 4 93 F. 3d 5 33, 5 37 ( 5t h Ci r . 2 00 7)
. The Su pre m e C ou r tr equi r es t hata de ni alof be nef i t s be r evi ew ed undera de novo st an da rd “ u n l ess t h e ben ef i tp la n gives t h e adm i n i st rat or orf i du ci ary d i scre ti on a ryau th o r ity to d eterm i n e eli gibil i ty for be n efi ts. ” Fi res t on e Tir e & R u bber Co. v. B ruch , 489 U
. S
. 1 01, 1 15 (1989). Abu se of di scr et i on i s t h e proper s t and ar d f

o rr e vi e w o f

“ de t e r m i nat i o ns m ad e pur s uantt o a pl an t hatg ive s t he Case: 09-30381 Document: 00511007186 Page: 13 Date Filed: 01/19/2010N o. 09- 30381

14 ad m i n i st rat or d iscr e tion a rya u th o rityto d e te rm in e elig ib il ity ,” a s th is p la n d o es. S w eat m an v . C o m m erc i al Un i on I n s. Co. , 3 9 F .3d 5 9 4 , 5 9 8 (5t h C ir. 1 9 9 4 ). W he r e , as he r e , a c hal l e nge t o a de ni al o f be ne f i t s do e s n ot i n vol ve t he i nt e r pr et at i o n o f

pl an t e r m s b utdi s put e s w he t he ra n i ndivi dua l ’ s c o ndi t i o ns qu al i f y as a di sabi l i t y, t h e i n qu i ry i n vol ves fact u aldeter m i n ati on s; t h eref ore, a b u s e o f d is c r e tio n is th e p r o p e rs ta n d a r d
. Se eW ade , 4 9 3 F .3 da t 5 4 0
. U n der an abu se of

di scr et i on st an da rd, “ [i] f t h e p la n f

i du ci ary’ s deci si on i s s u pp ort ed bysubstanti alevi den ce and i s n ot arbi t rary or capri ci ou s, i tm u st p r e v a i l
. ” E l l i s v. L i berty L if e A ssuran ce Co. of

B ost on , 394 F. 3d 262, 273 ( 5 th Ci r . 200 4)
. “ ‘ Subs t ant i ale vi de nc e i s m o r e t han a s c i nt i l l a, l e s s t han a pr e po nde r anc e , and i s suc h re l e va ntev i de nc e as a re as o nab l e m i nd m i ghta c c e pt
a s ad eq u a te to su p p ort a co n cl u sion
. ’” Corry , 499 F. 3d at398 ( quot i ng E lli s , 394 F. 3da t2 73 )
. I f

a de c i s i o n i s m ad e “ w i t ho uta r at i o nalc o nne c t i o n b e t w e e n t he kno w n fac t s a nd t he de c i s i o n o r be t w e e n t he f o und fac t s and t he de c i s i o n, ” t he d e c is io n is a rb itr a r y . Bel lai r eG e n. Ho s p. v. B l ueC r o s s Bl ueShi e l d of Mi c h. , 97 F
. 3d 8 22, 8 28 ( 5th C i r. 1 996 )
. “A n a dm i n i st rat or’ s d eci si on to den y ben ef i t s m u st b e ‘b a sed on ev i d en ce, ev en if d i sp u tab l e, th a t clear l y su p p orts th e b a sis for i ts d en i a l
. ’” L a i n v . U

N U M L if eI n s . Co . of

A m. , 279 F. 3d 337, 342 ( 5t h C i r . 2002) ( quot i ng V

ega , 1 8 8 F .3 d a t 2 9 9 ). If th e a d m in is tr a to r ’ s d e c is io n to d e n ya cla im is sup ported by “ ‘ som e concret e e vi d ence i n t h e a d m i n i s t r a t iv e r e c o r d , ’” t he
a d m in is tr a to rd id n o t a b u s e d is c r e tio n . I d. ( quot i ng V

ega , 18 8 F. 3da t3 02 )
. The
r evi ew i ng c our tm ay nots ubst i tu te its judgm entf ort hatof

t he pl an a d m in is tr a to r . W

ade , 4 9 3 F .3 da t 5 4 1
. 1. Str u ct u ralC on f

l i ctof I n t erest M c D onal d c om pl ai ns t hatH ar t f or d’ s d u a lrol e a s i nsur erand pl an a d mi n i s t r a t o rg a v e r i s e t o a c o n f l i c to f i n t e r e s tt h a tj u s t i f

i e s d e n o v o r e v i e w, r a t h e rth a n a b u s e o f d is c r e t io n ; a lt e r n a t iv e ly , M c D o n a ld a r g u e s t h a tH a r t fo r d ’s st ructuralconf

l i ctsuf f i ces to s h o w abu se of di scr et i on . Th e Su prem e C ou rt Case: 09-30381 Document: 00511007186 Page: 14 Date Filed: 01/19/2010N o. 09- 30381

15 r e c o gni z e d i n Me t r o po l i t an Lif

e Ins ur anc eCo. v . G le nn t hatw hen “ a pl an a d m in is tr a to rb o th e v a lu a te s cla im s fo r b e n e fits a n dp a y s b e n e fits cla im s ,” it
cr e a te s a str u ctu ra l con fli ct o f i n te re st. — U .S
. a t — , 1 2 8 S
. C t. a t 2 3 4 8
. “If a be ne f i tpl an give s di s c r e t i o n t o a n a dm i ni s t r at o ro rf i duc i ar y w ho i s o pe r at i ng u n d e ra co n flic t o f in te r e s t, t h a t c o n flic t m u s t b e w e ig h e da s a fa c to rin d eterm i n i n g w h eth er th ere i s an ab u se of d i scre ti on . ” Fi r e s t o ne , 489 U
. S. at115 (i nt er nalm odi f

i c at i on and quot at i on m ar ks om i t t ed)
. “ I f t he adm i ni st r at orhas
a c o nf l i c tof i nt e r e s t , w e w e i gh t he co nf l i c tof i nt e r e s ta s a fac t o ri n de t e r m i ni ng w he t he rt he r e i s a n ab us e o f di s c r e t i o n i n t he b e ne f i t s de ni al , m e ani ng w e t ak e a c c o u n t o f s e v e r a l d iffe r e n t c o n s id e r a tio n s o f w h ic h co n flic t o f in te r e s t is o n e .” Ho l land , 576 F
. 3d at 247 (i n t erna l qu ot ati on m arks om i t t ed). I f cl ai m an t s do not pre se nt evi denc e of

t he deg r ee of

t he c onf

l i c t , t he c our tw i l lge ner al l y f i nd t hat
a n y co n fl i ct i s “n ot a sign i fi ca n t fa ctor. ” I d. at249 (f

i ndi ng t hatw he r e c l ai m ant

“ adduce d no evi denc e . . . t hat [ adm i ni st r at or ’ s st r uct ural] c onf l i c t af fected it s benef i t s dec i si on o rt hati thad a hi st or y o f abuse s of di sc r et i on, ” any c onf l i c tw as in s ig n ific a n t in a b u s e o f d is c r e tio n a n a ly s is ). H ere, t h e di st ri ctcourtconsi dered H art f ord’ s “ m ere t echn i cal l y du alrol e”
a n d d e t e r m i n e d t h a t a b u s e o f d i s c r e t i o n wa s t h e p r o p e r s t a n d a r d
. An
e x a m in a tio n o f th e rec ord b e a r s o u t t h e d is tr ic t c o u r t’s d e te r m in a tio n : M c D o n a ld h as not poi n t ed to an y speci f i c evi den ce of

a his t ory of

abu ses of

di scr et i on or of h ow H a rtf

ord ’ s stru ctu ra lcon fl i ct of i n ter e st m a y h a ve affected i ts be n efi ts dec i si on i n t hi s par t i c ul arc as e. I n addi t i on, t he r ec or d doe s nots how t hat M cD on a l dattem p ted to con d u ct discov eryo n a n y p oten ti a lco n fl i cts of i n teres t. Rat he r , t he r e c o r d i ndi c at e s t h a tHa r t f o r d c o nduc t e d no t hi ng l e s s t han a “ c ar e f ul in v e s tig a tio n ” o f M c D o n a ld ’ s cla im
. S ee Corry , 499 F. 3d at 398 n. 11 (f i ndi ng t hat any pot ent i als t r uct u ra lconf l i c tof i nt er es tdi d notadve r se l y af fec tpl an a d m in is tr a to r ’ s h a n d lin go f c la im w h e r e a d m in is tr a to rs p e n t o v e rtw o a n da h a lf ye ar s r e vi e w i ng t he c l ai m a nd h i r e d t hr e e s pe c i al i s t s w ho g ave “ c l e ara nd Case: 09-30381 Document: 00511007186 Page: 15 Date Filed: 01/19/2010N o. 09- 30381

16 u n eq u ivo ca l” op i n i on s). H ere , H a r tfo r d e n ga ge dthre e ou tsi d e sp eciali sts to revi ew M cD on al d’ s f i l e; M cD on al d su bm i t t ed ad di t i on aldocum en t ati on t w i ce; andH ar t f

o r d e nt e r t ai ne d t w o a ppe al s . M c D o nal d ha s fai l e d t o pu t fo r t h a ny evi denc e of t he degr ee of t he al l ege d c onf l i c t , and she has al so fai l ed t o sho w t hat
a n y stru ctu ra lcon flict i m p a cted H a rtf ord ’ s d ecisi on i n h er ca se. T h ere fore, to t he ext ent t hat H ar t f or d’ s dual r ol e as bo t h i nsur erand pl an adm i ni st r at orm ay c r eat e ac onf

l i c t , t hatc onf

l i c ti s nota s i gni f

i c antfact ort hatw oul d j ust i f y a c hange i n t he st andard of rev i ew . Th e di st r i c tcour tdi d noter ri n appl yi ng an ab us e o f

di s c r e t i o n s t andard t o H ar t f o r d’ s de c i s i o n o ri n c o nc l udi ng t hata ny al l eged conf

l i ctdi d n otsup port M cD on al d’ s c l ai m t h at H a rt f ord abu sed di scr et i on i n den yi n g ben ef i t s. 2. Po s s ibl e Bi as b y Rev i e w i ng Phys i c i ans M cD on al d argu es t h at because t h e t h ree r evi ew i n g ph ysi ci a n s are em pl oyed by agen ci es t h at c on t ractw i t h H art f ord, t h e ph ysi ci an s w ere bi ased in fa v o ro f H a r tfo r d ; th e r e fo r e , H a r tfo r d a b u s e dits d is c r e tio n in re ly in go n th e ir opi n i on s. M cD on a ld p o ints t o severalfederaldi st ri ctcourtcases t h at note a pot ent i alc onf

l i c tof i nt er es ton t he par tof U D C , t he o r gani zat i on t hatem pl oys D rs. T u rn er a n d P i ck , be ca u se o f i ts “si gn i fi ca n t a n d on go i n g rel a ti on sh i p ” w i th H a r tfo r d
. See , e . g. , Caplan v . CN A Fi n. Cor

p. , 5 4 4 F
. S u p p . 2 d9 8 4 , 9 9 1

– 9 2 ( N. D. C al
. 200 8) (revi ew i n g H art f ord’ s den i alof

cl a im w ith “ skep t i ci sm ” becau se s t r uc t ur alc o nf

l i ctof i nt e r e s ta c c o m pa ni e d b y “ r e l i anc e o n U D C, a c o m pa ny w h ich H a rtfo rd k n o w s b e n e fits fi n a n cia ll yfro m d o in gre p e a t b u sin e ss w ith it”)
. M cD on a l dn otes th a t D rs. T u rn er a n dP i ck h a ve be en cri ti ci ze dbydistri ct cou rts fo rd e fic ie n t r e v ie w s in s im ila rca s e s . Hi ckl i n v. Hartf ord L if e & A cci d ent Ins. Co. , N o. C V 06- 4543, 2007 W L 4729856, at*7 –8, *1 1 ( C
. D
. C al
. D ec . 12, 2007) (c r i t i c i z i ng H ar t ford f o r“ i gno r [i ng] t he o bv i o us , c o m b[i ng] t he r e c o r d a nd [ t ak i ng] s e l e c t ive e vi de nc e o ut o f c o nt e xt as a pr e t e xt t o de ny” a c l ai m , de t ai l i ng m i ss t at em ent s and om i ss i ons by D r . T urner , an d d es c r ibi ng D r . P i c k’ s r evi ew as Case: 09-30381 Document: 00511007186 Page: 16 Date Filed: 01/19/2010N o. 09- 30381

17 “ def i c i e nt” )
. H ar t f

o r d, i n t ur n, c i t e s s e ve r aldi s t r i c tc o ur tc as e s a f f i r m i ng H a r tfo r d ’ s cla im d e c is io n s th a t r e lie do n o p in io n s o f U D C p h y s ic ia n s . See , e . g. , S i ngl ey v. Hartf

ord L if e & A cci d ent Ins. Co. , 4 9 7 F
. S u p p . 2 d 8 0 7 , 8 1 2 n . 9 ( S
. D. M i ss. 200 7) (u ph ol di n g H art f ord’ s den i alof

cl ai m even t h ou gh H art f ord used
r e v ie w in gp h y s ic ia n s f r o m U D C , in c lu d in gD r . T u r n e r); D o w dy v. Ha rtfo rdL ife & A cci d ent Ins. Co. , 4 5 8 F . S u p p . 2 d2 8 9 , 2 9 6 n .9 (S .D . M is s . 2 0 0 6 ) (s a m e ). W h i l e t h e F i f

t h C i rcui tha s yett o di scuss i n g re a t d et ai lt h e i m pa ctof p o te n tia l p h y s ic ia n b ia s o n th e E R IS As ta n d a r do f r e v ie w , w e h a v e b r ie fly d i s m i s s e d s i m i l a r a r g u m e n t s i n t h e p a s t
. Fo r e x a m p l e , i n S w eat m an v. C o m m erci al Un i on I n suran ce Co. , 3 9 F. 3 d a t 6 0 1 n . 1 4 , we c o n s i d e r e d a nd reje cte d the argu m en tt h at r evi ew i n g ph ysi ci an s w ere bi ased, based sol el y on t he i re m pl o ym e ntw i t h a c o nt r ac t i ng ag e nc y. I n t hatc as e , t he phy s i c i ans r e vi e w e d t w e nt y t o t hi r t y f i l e s pe rm o nt h f

o ra c o nt r ac t i n g ag e nc y, b utt he
c la im a n t p o in te dto n o e v id e n c e to s h o w th a t t h e p h y s ic ia n s w e r e fin a n c ia lly d e p e n d e n t u p o n th e a g e n c yo rth e p la n a d m in is tr a to r . I d. W e no t e d t hat“ t he
on l y w ay f

or [pl an adm i n i st rat ors] t o m eet[t h e cl ai m an t ’ s] st a n da rd f or i m pa rt i al i t y w ou l d be to seek ph ysi ci an s w i l l i n g t o vol u n t eer t h ei r t i m e t o revi ew th e m ed i ca lf

i l es o f d i sa b i l i ty clai m a n ts. ” I d. T h e S e v e n th C ir c u it r e c e n tly
exam i n ed a si m i l ar i ssue w h en a cl ai m an t argu ed t h at de n ovo revi ew — rat h er t h an abu se of di scr et i on — w as w arran t ed because t h e pl an adm i n i st rat or used i n - h o u s e d o c to r s fo rits file re v ie w s . D a v i s v . Un u m L if eI n s . Co . of

A m. , 444 F
. 3d 569 , 575 –76 ( 7th C i r. 200 6)
. Th e S even t h C i rcui t h el d t h at absen tevi den ce of “ any s pec i f

i c i nce nt ive [f

or t he i n- house doc t or s] t o de r ai l[ a] c l ai m , ” s uch as givi ng t he doc t or s “ so m e s pec i f i c s t ake i n t he o ut c om e o f [ a] c as e, ” t he t heor et i c al
a r g u m e n t t h a t “ in -h o u s e d o c to r s h a v e a n in h e r e n t c o n flic t i n e v e r yca s e ” is in s u ffic ie n t t o ch a n g e th e s ta n d a r do f r e v ie w . I d. H ere, M cD on al d d oes n ot ap pea r t o h ave p u rsued d i scovery on t h i s i ssue, n or has she p resented t h e t yp e of speci f i c evi den ce of

bi as tha tw ou l d sh ow abu se Case: 09-30381 Document: 00511007186 Page: 17 Date Filed: 01/19/2010N o. 09- 30381

18 of discreti on or j u sti fy a ch a n ge in th e stan d a rd o f rev i ew . W h i l e sh e p oin ts t o t he c o nc l us i o ns o f

di s t r i c tc o ur t s and c i t e s e vi de nc e pr e s e nt e d i n o t he rc as e s , t he
r e c o r d be f

o r e us c o nt ai ns no do c um e nt ar y o rt e s t i m o ni ale vi de nc e r e ga r di ng t he f i n an cia l r el ati on shi p betw een H art f ord, U D C , an d the i n di vi du alph ysi ci an s. F u rt h erm ore, M cD on al d does n otp resent an y evi den ce sh ow i n g an incentive f or t he do c t o r s t o und e r m i ne he rc as e i n pa r t i c ul ar . M c D o nal d’ s a t t e m pt s t o pr o vi de
s pe c i f i c e vi de nc e o f bi as fai lt o r i s e pa s tt he l e ve lo f c o nc l us o r y al l e ga t i o ns ; t he di st ri ctcourtdi d n oterri n f i n di n g t h at H art f

ord di d not abu se i t s di scr et i on on th is p o in t. 3. La ck of P h ysi calE xam i n ati on M cD on al d argu es t h at H art f ord abu sed i t s di scr et i on by fai l i n g t o order a
n ew ph ysi calexam i n ati on , or F u n ct i on alC ap aci t y E xam i n ati on ( F C E ) , as D rs. H u bbellan d S t eck recom m en d e d d u ri n g t h e adm i n i st rat ive revi ew process . H ow ever, t h e pol i cy pl aces t h e bu rden on the cla i m an tt o provi de p roof of l os s— att he c l ai m ant ’ s ow n expe nse — i ncl u d i n g “ [ o] bj ec t ive m edi c alf i ndi ngs w h i ch sup port [ t h e] di sabi l i t y. O bj ect iv e m e d ic alf i n di n gs i n cl u de bu tare not l i m i t ed to t est s, proce d u re s, or cl i n i calexam i n ati on s s t an da rdl y [ si c] accept ed i n t h e p r a c t i c e o f

me d i c i n e , f

o r[t h e ] d i s a b l i n gc o n d i t i o n ( s )
. ” I n a d d i t i o n , “ t he burde n i s nots ol el y o n t he adm i ni st r at ort o g ener at e e vi denc e r el evantto d ecidin g th e claim
. ” G ood en v. Provi d ent L if e & A cci d ent Ins. Co. , 250 F. 3d 329, 3 3 5 (5t h C ir. 2 0 0 1 ) (m o d ifi ca tion a n din te rn a l qu o ta tion m a rk s o m itted ); Go t h a r d v . Me t r o . L if eI n s . Co , 491 F. 3d2 46 , 2 49 & n. 7 ( 5t h Ci r . 2 00 7) ( de c l i ni ng to re q u ir e a p h y s ic a l e x a m in a tio n p r io rto d e n ia lo f c la im a n dcit in gca s e s in
s u p p o r t ) ; cf

. Ho l land , 57 6 F
. 3 dat 25 0 ( d ecli n i n g to re q u i re a d m i n i strato r to
c ons ul tw i th v oca ti onalex per t , and quot i ng D u h on , 15 F
. 3d at 130 9, f or proposi t i on t h at a “ revi ew in g court [ m ay] deci de, on a case- by-c ase basi s, w h et h er un der t h e pa rt i cul ar fact s t h e pl an adm i n i st rat or abu sed h i s di scr et i on Case: 09-30381 Document: 00511007186 Page: 18 Date Filed: 01/19/2010N o. 09- 30381

McDonald relies ona letter fro m Dr. Hubbell conte nding that it i s “veryunlikelyth at 8 [McDonal d] will be able to return to work in any typeof gainful e mployment” and concluding that sheis “totallyan d per mane ntlydisable d due toh er degenerativecon dition of her c ervical and lumb arspine c ausingh er to h ave persistent pain and muscle spasms.” This letter was written on Au gu st 21, 200 7, and forwarded to Hartford on Septemb er 4 , 20 07. However, a s discussed above , the administrative recor d closed in June 2 006 , whenMcDonald filed suit, and McDonal d did not re qu es t th at the letter b e included in the recor d durin g the reman d. Therefore, this letter fro m Dr. Hubbell i s not part of the a dmini strativerecord and we cannot co n si der itwhenan alyzingwheth erHartfordact edarb itrarilyor capriciou sly . 19 b yn o t o b ta in in gth e o p in io n o f a v o c a tio n a l re h a b ilita tio n e x p e r t” ). M c D o n a ld fa ils to s h o w a b u s e o f d is c r e tio n o n th is p o in t.

4. La c k o f

D e fe r e nc e t o Tr e at i ng Phys i c i ans ’O pi ni o ns M c D o n a ld co n te n d s th a t H a r tfo r da b u s e dits d is c r e tio n b yim p r o p e r ly d i s c o u n t i n gt h e o p i n i o n s o f h e r t r e a t i n gp h y s i c i a n s . H o w e v e r , t h e S u p r e me Cour tha s e xpl i ci t l y di s ap pr o ve d o f a “ t r e at i ng phy s i c i an” r ul e i n t he ER I SA
c ont extand hel d t hat“ pl an adm i ni st r at or s ar e no tob l i ged t o a c c or d s pec i al d eferen ce to th e op i n i on s of t rea ti n g p h ys i ci a n s. ” Bl ac k& D e c ke rD i s ab i l i ty Plan v. Nord , 538 U
. S
. 822 , 825 ( 200 3)
. A dm i n i st rat ors do not bear “a h e igh te n ed b u rd en o f ex p l a n a ti on . . . w h en the y rej ect a trea ti n g p h ys i ci a n ’ s op i n i on . ” I d.
a t 83 0
. “S o l on g as t h e [p ]l a n [a]dm i n i strato r’ s d ecisi on i s ra ti on a l l y re l a ted to t he e vi denc e, w e do not r equi r e t he [ p] l an [ a] dm i ni st r at or t o c r edi ta par t i c ul ar a rea of ex p ertise w h en d ecidin g o n an ap p l i ca n t’ s p rog n osis. ” Ho l land , 576 F. 3d
a t2 4 9 , 2 5 0 ( q u o t i n gl a n g u a g e f r o m B lack & D ecker , 53 8 U
. S
. at 8 3 4 , th a t cou rts
m ay n ot“ i m pose on pl an adm i n i st rat ors a dis cret e bu rden of expl an ati on w h en t h e y c r e d it r e li a b le e v id e n c e t h a t c o n fl ic t s w it h a t r e a t in gp h y s ic ia n ’s
e v a lu a tio n ”). W h ile t h e rec ord do es co n tain som e ev i d en ce ind i ca ti n g th a t M cD on a ld
su ff ers from som e p erm a n en t he a l th i ssu es, H a rtf ord ’ s d ecisi on to d en y b en efi ts 8 al so f i n ds sup port i n t h e rec ord. Th e factt h at H art f ord’ s s u pp ortcom es f rom revi ew i n g ph ysi ci an s does not rend er i t s deci si on arbi t rary or capriciou s; even Case: 09-30381 Document: 00511007186 Page: 19 Date Filed: 01/19/2010N o. 09- 30381

20 M c D o nal d’ s phy s i c i ans ha ve no te xp r e s s e d c o ns i s t e nto pi ni o ns r e ga r di n g t he
e x te n t o f h e rd is a b ilitya n d h e ra b ilityto p e r fo r m s e d e n ta r yw o r k
. F or exam pl e , duri ng t h e rem an d p eri od, w h en H art f ord re- i n t ervi ew ed D r. St ec k— t he neur os urge on w ho per f or m ed M c D onal d’ s sur ger y— he di d notgive a c l e a r“y e s ” o r“n o ” a n s w e rw h e n a s k e da b o u tth e e x t e n to f M c D o n a ld ’s di s ab i l i t y. The i nt e r vi e w e ra s ke d: “ I s t here an ythi ng m e di c al l y r e al l y w hy [M cD on al d] coul d n otha ve don e [ seden t ary w ork] t h ree m on t h s post
- op?” D r. S te c k re p lie d : W e are deal i n g basi cal l y w i t h subj ect ive c om pl ai n t s but t h ey are b a s e d o n o b je c tiv e d a ta in th a t s h e h a s d e g e n e r a tiv e d is c d is e a s e in t he l um barspi ne[ ; ] s he has doc um ent ed l um bardi scher ni at i on t hat w as b ade no ugh t o r e qui r e a lum barde c o m pr e s s i o n f us i o n, a nd I h a ve d ea l t w i th en ou gh of th ese p a ti en ts [t o kn ow ] th a t th er e w ill be a si gn i f

i can tsubset w h o w i l lnot r et u rn to an y t yp e of em pl oym entdue t o c om pl ai nt s of pai n and th ere i s no w ay I c an p r o v e th a ts h e d o e s n ’t h a v e p a in , w e c o u ld a lw a y s s a y w e l lI d o n ’t s e e w h ys h e ca n ’ t w o r k , m o s t p e o p le co u ldb u t n o t e v e r yb o d y. . . . Th e o bj ec t ive dat a i s t hat , yes, she di d h ave s urge r y, t he s ubj ec t ive c o m po ne nti s t hata l t ho ugh s hei s ne ur o logi c all y no r m aland e v e r y t hi ng lo o ks j us tf

i ne , al t h ou gh m an y peop l e i n t h i s s i t u ati on w o u ld b e a b le to w o r k a lth o u g h s h e te lls m e th a t s h e a c t u a llyis bett er f rom t h e surgery, she had i t , bu t doctor I j u sthu rtt oo m u ch t o w ork. B ase d on t h at I j u stcan’ tsi gn a l et t er ordo a dic t ati on s a y in gth a t I th in k s h e ca n w o r k
. ( em phasi s added)
. W hi l e D r . St ec k expr es se d c onc er n f orM c D onal d’ s subj ec t ive com pl ai n t s of p ai n an d n ot ed that t h e subj ect ive com pl ai n t s w ere based obj ec t ivel y on her dege ner at ive di sc di se as e, he al so m ade t he st a tem en t t h at “sh e is n eu rolog i ca l l y n orm a lan dev ery th i n g look s j u st f i n e.” W h en H art f

o rd r e ach ed i t s f

i n aldeci si on , i tha d consi st en treport s f rom t he t hr e e r e vi e w i ng phy s i c i ans i ndi c at i ng t hatM c D o nal d d i d n ot m e e tt he defi ni t i o n o f

“ di s ab l e d” ; i tha d Dr
. St e c k’ s m i xe d s t at e m e nt ; a nd i tha d D r. H u b b e ll’ s le tt e rd a te d F e b r u a r y1 3 , 2 0 0 6 , w h ic h re c o m m e n d e dth a t M c D o n a ld Case: 09-30381 Document: 00511007186 Page: 20 Date Filed: 01/19/2010N o. 09- 30381

21 receive ad di t i on alpain t reat m en ta n d i n di cat ed: “ I kn ow t h at s h e can’ tperf orm f ul l

- t i m e w o r k att hi s t i m e , butI b e l i e ve t hati f he rc e r vi c alpa i n wer e r e s o lve d,
s he w o ul d b e a bl e t o r e t ur n t o a tl e as tt w i c e a s m uc h w ork as she i s a bl e t o do t oday i f notf ul l

- t i m e w or k. ” H ar t f or d’ s dec i si on t o de ny b en efi t s has c l ear s upp o r ti n t he a dm i ni s t r at ive r e c o r d, a nd t he de c i s i o n i s ra t i o nal l y r e l at e d t o t he
e v id e n c e H a r tfo r d h a d b e fo r e it a t t h e t im e o f th e d e c is io n . Se eHo l land , 576 F. 3d at249. “ [ T] he j ob of w ei ghi ng val i d, c onf l i c t i ng p rofessi onalm edi c al opi n i on s i s not t h e j ob of t h e court s . . . [but rather t h e j ob of ] t h e adm i n i st rat ors of E R IS Aplan s, ” Corry , 4 99 F. 3da t4 01 , a nd t he r e f o r e M c D o nal d’ s a r gum e nt t hatH ar t f

o r d fai l e d t o g ive adeq u at e w e i ghtt o t he o pi ni o ns o f he rt r e at i ng p h y s i c i a n s m u s t fa i l
. Ha r t f o r d d i d n o t a b u s e i t s d i s c r e t i o n i n a d o p t i n g t he
o p in io n s o f th e re v ie w in gp h y s ic ia n s o v e rth e tr e a tin gp h y s ic ia n s .

5
. L a c k o f C o n s id e r a tio n o f S u bje c tiv e C o m p la in ts o f P a in M c D onal d ar gues t hat H ar t f or d abuse d i t s di sc r et i on by fai l i ng to gi ve a d eq u a te w eigh t t o h er co n sist en t com p l a i n ts of p a i n . T o su p p ort h er a rg u m en t, M c D o nal d r e l i e s o n Audi no v. R ay t he o n Co mpany S ho r tTe r m D i s ab i l i ty Plan , 129 F
. A pp ’ x 882 ( 5th C i r. 200 5) (per curi am ) , w h ere w e rever se d a sum m ary j udg m e nti n fav o ro f

a pl an ad m i ni s t r at o r t hat had de ni e d be ne f i t s t o a c l ai m ant
w ho c o m pl ai ne d o f

pa i n. I n Audi no , w e f o und an ab us e o f di s c r e t i o n be c aus e t he ad m i n i st rat or i gn ored [ t h e cl ai m an t ’ s] consi st en tcom pl ai n t s of pain as subj ect ive, eit h er m i n i m i ze d or i gn ore dob j ective ev i d en ce of d is a b i l i ty c o r r o b o r a t i n gt h o s e c o m p l a i n t s , a n dc o n c l u d e dt h a tt h e e v i d e n c e d id no ts ho w an i nab i l i t y t o do he rj o b f unc t i o ns w i t ho uta nal yz i ng t he ef fecttha th er c on di t i on s w ou l d h ave on her abil i t y t o perf orm her s p e c ific jo b re q u ir e m e n ts
. 1 2 9 F . A p p ’ xa t 8 8 5
. H o w e v e r , in th a t c a s e t h e c l a im a n t p r e s e n te ds p e c ific
e vi de nc e o f

m i s s t at e m e nt s and o ve r s i ght s b y t he r e vi e w i ng phy s i c i ans t hatt he p la n a d m in is tr a to rr e lie d u p o n in d e n y in gth e cla im
. I d. at 884–85 ( not i ng t hat Case: 09-30381 Document: 00511007186 Page: 21 Date Filed: 01/19/2010N o. 09- 30381

22 one physi c i an m i ss t at ed o bj ec t ive test r es ul t s, w hi l e a not herm ent i oned e xam r e s u lts in a s u m m a r yo f e v id e n c e b u t fa ile dto d is c u s s th o s e r e s u lts in a n a ly s is
o f w h e th e rcla im a n t w a s d is a b le d ). M o r e a ppli c ab l e t han Audi no is th e ca se of Corry v. L i berty L if e A ssuran ce Co. of B ost on , w h ere w e add ress ed i n detai lw h et h er an ad m i n i st rat or’ s r evi ew adequat el y c ons i der ed a c l ai m ant ’ s subj ec t ive c om pl ai nt s of pai n. 499 F. 3d at 3 9 9

– 4 0 1
. T h ere , t h e claim a n t’ s ex p erts op i n ed tha t sh e w a s d i sa b l ed du e to f ibr om yal gi a— a di agnos i s r eac hed by r el i ance on t he c l ai m ant ’ s subj ec t ive r e p o r ts o f p a in
. I

d. a t4 01
. The pl an ad m i ni s t r at o rul t i m at e l y r ej e c t e d t he cl ai m an t ’ s asser t i on t h at s h e w a s d isa bl ed, rel yi n g on t h e opi n i on s of t h ree o u ts id e re v ie w in gp h y s ic ia n s . I d. Al lt hr e e re vi e w i ng phy s i c i ans di s c us s e d t he
c la im a n t’s s u b je c tiv e co m p la in ts a n dh e rp r e v io u s d ia g n o s is o f fib r o m y a lg ia in t h ei r ana l yses; yett h ey each ul t i m atel y concl u ded t h at no m edi calevi den ce e x is te d e s ta b lis h in ga d is a b ility
. I d. I n Corry , w e c o n c lu d e dth a t t h is
con sti tu ted a “ba ttl e of the ex p erts, ” w h ere the ad m i n i strato r w a s “ves ted w i th di s c r e t i o n t o c ho o s e o ne s i de o ve rt he o t he r” ; t he r e f o r e , w e rej e c t e d t he a r gum e nt t hatthe adm i ni s t r at o r“ fai l [ e d] t o c o ns i de ra nd g ive pr o pe rw e i ghtt o r e l e va nt
e v id e n c e ” o f s u b je c tiv e p a in
. I d. H ere, H art f

ord an d it s r e vi e w i ng phy s i c i ans c l e arly “ c o ns i de r e d, e va l uat e d, anda ddr e s s e d” M c D o nal d’ s s ubj e c t ive c o m pl ai n t s of pa i n; ho w e ve r , t he
r e v ie w i n gp h y s ic ia n s s t il l r e a c h e dth e c o n c lu s io n th a tM c D o n a ld ’s adm i ni st r at ive r ec or d di d n ot c on t ai n obj ec t ive m edi c alev i denc e o f di sa bi l i t y. Corry , 499 F
. 3d at 401
. T h e den i all et t ers i n di cat e t h at H art f ord consi dered h er sub j ect ive com pl ai n ts. In t h e f i rstden i all et t er, H art f ord ackn ow l edg ed M cD on al d’ s c on t i n u i n g n eck pa i n an d h er “ di f f i cul t i es w i t h pain” bu tconcl u ded t h at no neu rol ogi calabn orm al i t i es w ere present an d that t h e evi den ce di d n ot

“ s upp o r ta f

unc t i o nali m pa i r m e ntt hatw o ul d pr e c l ude [he r ] f r o m pe r f

o r m i ng t he Case: 09-30381 Document: 00511007186 Page: 22 Date Filed: 01/19/2010N o. 09- 30381

23 m a te r ia l a n d s u b s ta n tia l d u tie s o f [h e r ] r e g u la ro c c u p a tio n o n a fu ll-tim e b a s is .” W h e n d e n y in gh e rfir s t a p p e a l, H a r tfo r din fo r m e dM c D o n a ldth a t:
w e co ns i de r e d yo urse l f

- r e po r t e d s ym pt o m s and t o w hate xt e ntt he f i ndi ngs o n ph ys i c ale xa m i nat i on and t e s t i ng r e s ul t s c o nf i r m t he sy m pt om s. W e al so c ons i der ed t he i m pac t t he f i ndi ngs w oul d have a s fa r a s y o u r a b ility to fu n c ito n o n a d a ilyb a s is a n dh o w it w o u ld con ti n u ou sly affect yo u r ab i l i ty to p erform yo ur r egul aroc c upat i onal w o r k a c tiv ityo n a fu ll-tim e b a s is
. In i t s f i n alden i all et t er, H art f ord m en t i on ed that i tha d consi dered l et t ers f rom M cD on a l dh erse l f a n d f rom D r. H u b b ell d eta i l i n g h er su b j ective com p l a i n ts. In
a d d i ti on , the ad m in is tr a tive reco rd con tain s n otes from an i n terv i ew w i th M c D onal d, det ai l i ng t he i m pac tof herpai n on herdai l y l i fe a t w or k and at h o m e . T h e revi ew i n g ph ysi ci an s al so c l earl y consi dere d a n d ad dressed M c D o nal d’ s s ubj e c t ive c o m pl ai nt s . D r . LeFo r c e , t he i ni t i alr e vi e w i ng phy s i c i an, n o t e d “ c o mp l a i n t s o f n e c k a n d l o w b a c k p a i n , ” a n d“ c o n t i n u e dn e c k p a i n . ” O n t he f i r stadm i ni st ra ti ve appeal , D r . Tu r nerdi sc uss ed M c D onal d’ s r epo r t s t hat she suf fe r s r ad i at i ng l o w b ac k p ai n, a gg r av at e d b y s i t t i ng andw al ki ng and pa rtia ll y r el i eved by rest , as w el las c h roni c neck pa i n . Final l y, D r. P i ck
c ons i der ed e vi denc e t hatM c D on a l d s uf fer ed f r om “ c hro ni c pai n” and c l i ni c al
n ot es f rom her t reat i n g ph ysi ci an s r egard i n g h er s u bj ect ive com pl ai n t s, i nc l udi ng: “ a hi s t o r y o f an i ns ul tw i t h se ve r e l o w bac k p ai n a nd r ad i at i ng r i ght p a in a n d re c e n t o n s e t n u m b n e s s in h e ru p p e re x tr e m itie s ”; “lu m b a rp a in a s w e ll as l eg pa i n ” ; “ [ s] h e st ates t h e pain i s get t i n g w orse” ; “ [ s] h e st i l lha s s om e l ow bac k pai n, s om e b ut t oc k pai n, so m e c hro ni c nec k pai n, butal lt hos e b et t ert han pre op. ” A l lt hre e r evi ew i ng physi c i ans c ons i der ed M c D onal d’ s subj ec t ive com pl ai n t s but ul t i m atel y concl u ded t h at t h ese su b jec t ive com pl ai n t s w ere in s u ffic ie n t t o s u p p o r t a fin d in go f d is a b ility
. Case: 09-30381 Document: 00511007186 Page: 23 Date Filed: 01/19/2010N o. 09- 30381

24 U nl i ke i n Audi no , t h e r e v ie w in gp h y s ic ia n s d id n o tig n o r e M c D o n a ld ’s
c o m pl ai nt s b uti nc l ude d t he m i n t he i ra nal ys e s . M c D o nal d a r gu es t hatt he revi ew i n g ph ysi ci an s “ m i scharacter i zed the resul t s of her M R Is , ” bu teven D r. S te c k , h e rtr e a tin gp h y s ic ia n , st a te dth a t M c D o n a ldw a s “n e u r o l o g ic a lly
n orm al
. ” Any di f

fe r e nc e o f

o pi ni o n b e t w e e n t he r e vi e w i ng andt r e at i ng p h ysi ci an s on t h e i n t erpret ati on of her M R Is fal l s i n t o H art f ord’ s area of di sc re tion; M cD on al d d oes not poi n tt o an y af f i rm ative m i sst atem en t s of
o bj e c t ive t e s tr e s ul t s o f t he ki nd p r e s e nt e d i n Audi no . W h i l e H a rt f

ord’ s c on cl u si on s c on f l i ctw i t h D r. H u bbell ’ s eval u ati on of M c D onal d’ s c o ndi t i o n, D r . St e c k’ s f i nali nt e r vi e w w i t h H ar t f o r d o n r e m and
c o n ta in s la n g u a g e th a t s u p p o r ts th e c o n c lu s io n t h a t th e re c o r dd idn o t c o n ta in obj ect ive m edi calevi den ce of di sabi l i t y. H art f

ord ha s di scr et i on i n t h i s batt l e of exp ert s, an d i n t h e absen ce of evi den ce t h at H art f o rd fail ed to consi der M c D o nal d’ s c o m pl ai nt s o f pa i n, H ar t f

o r d w as w i t hi n i t s di s c r e t i o n t o ac c e ptt he opi n i on s of i t s t h ree qu al i f i ed m edi cal exp ert s. H art f ord’ s deci si on w as neit h er a rb itr a r yn o rca p r ic io u s o n th is p o in t.

6
. In s u ffic ie n t E v id e n c e to S u p p o r t D e n ia l o f C la im Fi nal l y, and m or e gener al l y, M c D onal d c om pl ai ns t hatH ar t f or d “ c her r ypi cked ” qu ot es and fact s ou tof the a dm i n i st rat ive recor d t o su pp ortit s deci si on t o de ny herc l ai m f

orbe nef i t s. H ow eve r , under Fi f t h C i r c ui tl aw , H ar t f or d has d is c r e tio n u n d e rth e p la n to in v e s tig a te th e cla im a n dd r a w th e co n c lu s io n s it dee m s pro per . “ Th e l aw r equi r es onl y t hat subs t ant i al evi denc e s upporta pl an f i duci ar y’ s dec i si ons , i ncl udi ng t hos e t o de ny or t o t er m i nat e b enef i t s, nott hat sub st an t i alevi den ce (or, f or t h at m att e r , e ve n apr e po n deran ce) exi st s t o sup port th e em p l oy ee ’ s cl a i m of d i sa b i l i ty. ” E lli s , 3 9 4 F .3 da t 2 7 3
. H ere, H art f

ord soli ci t ed the m edi calopi n i on s of t h ree s epa rat e ph ysi ci an s. D rs. T u rn er an d P i ck are bo th bo a rd certi fi ed orth op ed i c su rg eo n s, “spe ci a l i sts
an d qu al i f

i ed exp ert s i n [ a] f

i el d[] speci f

i cal l y rel ated” t o M cD on al d’ s s ym ptom s; Case: 09-30381 Document: 00511007186 Page: 24 Date Filed: 01/19/2010N o. 09- 30381

As discu ssed ab ove, the record does not explicitly show wheth er Dr. Pick reviewed Dr. 9 LeForce’sor Dr. Turner’sevalu ation s. 25 a t leas tt w o o f

t he t hre e phys i c i ans r eac hed t hei rc onc l usi ons i ndependent l y. 9 Corry , 4 99 F. 3da t4 02
. I n Corry , w e f ound i t“ i ndi sput a b l e th a tt he m edi c al op i n i on s of [th e p l a n ad m i n i strato r’ s] th ree co n su l ti n g p h ys i ci a n s . . . con sti tu te
su b stan ti a lev i d en ce su p p orting[th e d i sa b i l i ty d ecisi on ]. ” I d. I n ad di t i o n t o t he
o pi ni o ns o f

t he t hr e e r e vi e w i ng phy s i c i ans , t he a dm i ni s t r at ive r e c o r d c o nt ai ns o t h e re v id e n c e i n s u p p o r to f H a r t fo r d ’s d e c is io n : in p a r t ic u la r , D r . S t e c k ’s st atem en tt h at M cD on al d w as “ n eu rol ogi cal l y n orm al an d everythi n g l ooks j u st f i n e. ” Fu rt h erm ore, M cD on al d ad m i t t ed that she gets h el p to f u l f i l lt h e du t i es o f h e rjo b a n d t h a th e re m p lo y e rh a s b e e n c o o p e r a t iv e a n df le x ib le . H a r t fo r d ’s d e c i s i o n d o e s n o t n e e d to b e c o r r e c t; it sim p ly m u s t n o t b e a rb itr a r y . Cf. G ot h ard , 491 F
. 3d at 250 ( “M et L i fe’ s deci si on m ay not be corr ect , bu tw e cann ot say that i tw as arbitra ry . ” )
. O n t h e adm i n i st rat ive recor d, H art f ord’ s deci si on t o den y h er cl ai m w as sup ported by s u bstanti al evi den ce an d t h ere w as no ab u se o f d is c r e tio n . I I I . C ONC L US I ON F o rth e a b o v e re a s o n s , w e A F F IR M
. Case: 09-30381 Document: 00511007186 Page: 25 Date Filed: 01/19/2010