# U n i t e d S t a t e s C o u r t o f A pp e a l s

For the Eig hth Circu it

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No . 1 8 -1 8 48

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Dav i d C. Ni ch o l s o n

ll l l l l l l l l l l l l l l l l l l l Pl a in t i

f f - Ap p el l an t

v

.

St an d ard In s u ran ce Co m

p an y ; St an d ard Ben efi t Ad m i n i s trat i o n ; Lo n g Term

D i s ab i li t y In s u ran ce Po li cy

No 1 4 2 13 4 -B

l l l l l l ll l l l l l l l l l l l l l Def

en d a n t s - Ap p el l ees

Co m p en s at i o n Co m

m i t t ee; Cu d d Pu m

p i ng Serv i ces , In c.; RPC In co rp orat ed

l l ll l l l l l l l l l l l l l l l l l Def

en d an t s

_ __ _ _ __ _ __ _ _

Ap p eal fro m

Un i t ed St at es Di s t ri ct Co u rt
fo r t h e W es t ern Di s t ri ct o f Ark an sas - Ft . Sm i t h

_ __ _ _ __ _ __ _ _

Su b m it t ed : Ap ri l 1 7, 2 0 1 9

Fi l ed : J u l y

3 , 2 01 9 [Un pu b l is h ed ]

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Befo re LOKEN, W OLLM AN, an d STRAS, Ci rcu i t J u d g es

.

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PER CURIAM

.Dav i d C. Ni ch o ls o n b ro u g h t t h i s action u nde r the E m ploy e e R e tir e m e n t In co m e

Secu ri t y Act (ERISA), 2 9 U .S.C. § 1 0 01 et s eq ., cl ai m i n g th at St an d ard In s u ran ce

Co m p an y (St an d ard ) w ro ng fu l ly d en i ed h i s cl ai m fo r d i s ability be ne f it s u nd er a g ro u p

p o l i cy s p o n s o red b y h i s em p l o y er. Th e d i s t ri ct co u rt 1 g ran t ed s u m m ary ju dg m en t fo r

St an d ard . W e affi rm

.

Ni ch o l s o n h as b ack an d n eck pai n fro m a 1 97 8 car acci den t

. H e wo rk ed fo r h i s

em pl o y er fro m 2 0 0 1 u nt i l Sep t em b er 2 0 1 4

, w h en h e s u b m i t t ed a c l a i m fo r b en efi t s

a l l eg i n g t h at h i s pai n had beco m e d i s ab l i n g. At t h e t i m e, Ni ch o l s o n h ad s o u g h t

m ed i cal treat m en t o n l y fro m h i s fam i l y p h y s i ci an , Su h N i b a , M .D., wh o n ot ed t h at

Ni ch o l so n h ad “ b een h av i ng i n creas i n g d i f fi cu l t y at wo rk d ue t o h i s neck p ai n.”

Des pi t e t h i s o bs erv at i o n , Dr. N i b a d i d no t i n creas e Ni ch o l s o n ’ s pai n m ed i ca t i o n,

rep o r t th at Ni ch o ls o n su ffered fro m an y s i d e effect s o n h i s cu rren t d o s ag e o f p ai n

m ed i cat i o n , o rd er an y

i m ag i n g t es t s , o r refer Ni ch o l s on t o a s p eci al i s t

.

Th e p ol icy g ran t s St an d ard d i s c r e t i o n t o res o l v e al l q u es ti o n s ari s i n g i n t h e

p o l i cy ’ s ad m in i s t rat i on , i n t erp ret at i on , an d ap p l i cat i o n, as wel l as t o d et erm i n e wh o

was en t i t l ed t o b en efi ts

. Th e p o l i cy i n s u red Ni ch o l s o n ag ai n st h i s in ab i l i t y t o p erfo rm

h i s “ o wn o ccu p at i o n” as p erfo rm ed i n t h e n at i o n al eco no m y

— n o t s im p l y h i s i n ab i l i t y

t o p erfo rm hi s sp eci fi c jo b

. St an d ard ’ s v o cat io n al ex p ert d et erm i n ed th at Ni ch o l s o n ’ s

o ccu pat io n i n t h e n at i o n al eco n o m y was a l ig h t s tren g t h ran g e o ccu p at i o n

.

Gary Nu d el l

, M.D., rev i ewed Ni ch o l s o n ’ s m ed i cal reco rd s an d d i s cu s s ed

Ni ch o l so n ’ s m ed i cal co n d i t i o n wi t h Dr. N i b a. Dr. Nu d el l fo u n d t h at “ t h ere were n o

n eu ro l o g i c ab n o rm al i t i es d o cu m en t ed

, n o i m ag i n g s tu d i es av ai l ab l e fo r rev i ew, an d

n o o t her cl i n i cal d o cu m en t at io n t o ot h erwi s e s u p p o rt i m p ai rm en t .” He fu r t h e r

co n cl u d ed t h at Ni ch o l s o n “ co u l d p erfo rm l i g h t l ev el act i v i ty on a fu l l t i m e b as i s wi th

1 Th e H o n o rab l e P.K. H o l m es , III, t h en Ch i ef J u d g e, Un it ed St at es Di s t ri ct
Co u rt fo r t he W es t ern Di s t ri ct o f Ark an s as

.

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-reas on ab l e co n t i n u i t y .” St an d ard d en i ed Ni ch o l s o n ’ s cl ai m b as ed u p o n Dr. Nu d el l ’ s

rev i ew an d t h e v o cat i o n al ex pert ’ s o ccu p at io n d et erm i n at i o n

.

Aft er th e den i al

, St an d ard recei v ed fu rt h er co rres p o n d en ce fro m D r. Ni b a an d

Ni ch o l so n ’ s em

p l o y er. Dr. Ni b a ag ai n d i d no t rep o rt an y ch an g e o f p ai n m an ag em en t

t reat m en t

, an y i m ag i ng res u l t s , o r an y referral to a s p eci al is t

. Bas ed o n Ni ch o l s o n ’ s

em pl o y er’ s co rres p o n d en ce, h o wev er, St an d ard d et erm i n ed t h at Ni ch o l s o n ’ s

o ccu pat io n was b et t er des cri b ed as a m ed i u m s t ren g t h ran g e o ccu p at i o n. D r. Nu d el l

rev i ewed Ni ch o l s o n ’s m ed i cal reco rd i n l i gh t o f Dr. Ni b a’ s fu rt h er co rres p o n d en ce

b u t s t i l l d et erm i n ed t h a t N i ch o l s on w as n o t di s ab led

. St an d ard al s o s o u g h t t h e

o p i n i o n o f ort h o p ed ic s urg eo n Ken n et h J

. Ko p a c z , M .D., wh o co n cl ud ed t h at

Ni ch o l so n co u l d p erfo rm m ed i um l ev el d u ti es

. St an d ard i nfo rm ed Ni ch o l s on t h at i t

h ad co n si d ered h i s s u p p lem en t al m at eri al s b u t d et erm i n ed t h at h e h ad n o t p res en t ed

ev i d en ce s h o wi n g t hat h e was d i s ab led

.

Ni ch o l s o n fo rm al l y ap p eal ed St an dard ’ s d eci s i o n, wh ereu p o n St an d ard s o u g ht

t h e o p i n i on of M ark Sh i h

, M .D., wh o is s p eci al t y cert i fi ed i n ph y s ical m ed i ci n e an d

reh ab i l i t at i o n

. Dr. Sh i h rev i ewed Ni ch o l s o n’ s m ed ical r e c o r d a n d n o t ed th at t h ere

were n o ch an g es ap p eari n g o n an y i m ag i n g t es t s , an d al th o u g h Ni c h o l s o n rep o rt ed

m o re pai n, “ t y

p i cal l y t h ere wo u l d b e a ch an g e i n h i s p ai n m ed i cat i o n reg i m en , referral

t o a s p eci al t y p ro v i d e r , a n d fu rt h er ev al u at io n of h i s co n d i ti o n

. ” Dr. Sh i h al s o

co n cl u d ed t h at th e m ed i cal reco rd d i d n o t rev eal t h at N i ch o l s o n s u ffered fro m an y

co g ni t i v e im

p ai rm en t o r d efi ci t fro m h i s p ai n m ed icat i o n

. Dr. Sh i h u l t i m at el y

co n cl u d ed t h at Ni c holson c o uld pe r f orm a m ed i um l ev el o ccu p at io n

. St an dard u p h el d

t h e d en i al o f Ni ch o l s o n ’ s c l a i m , ex p l ai n in g t h at wi th o u t an y ob ject iv e ev i d en ce to

s u p p ort hi s as s ert i o n o f i n creas ed p ai n , t here was n o s at i s fact o ry p ro o f t h at Ni ch o l so n

s at i s fi ed t h e p o l i cy ’ s d efi n i t i o n o f “ d i s ab i l it y .” Ni ch o l so n s ub s eq u en t ly fi led s u i t in

fed eral d i s t ri ct co u rt

. Th e co u rt co n cl ud ed t hat St an d ard d i d n o t ab u s e i t s d i s cret i o n

i n d en y i n g Ni ch o l s on ’ s cl ai m an d g ran t ed St an d ard s u m m ary ju dg m en t

.

-3

-W e rev i ew d e n o vo a d i s t ri ct co u rt ’ s g ran t o f s u m m ary ju d g m en t

. Han k i n s v.

St an d ard In s

. Co

., 6 7 7 F.3 d 8 3 0, 83 4 (8 t h Ci r. 2 0 1 2 ). “ W h ere an ERISA p lan g i v es

t h e ad m i n i s t rat o r d i scret i o n ary p o wer to c onstr ue a m biguous t erm s o r m ak e el i g i b i l i t y

d et erm i n at i o n s, th e ad m i n is t rat o r’ s d eci s i o n i s rev iewed fo r an ab u s e of d i s cret i o n.”

Id

. Un d er an ab us e o f d i scret i o n s t an d ard

, we wi l l u p h o ld St an d ard ’ s d en i al i f i t was

“ reas o nab l e; i.e.

, s u p p ort ed b y s u b s t an t i al ev i d en ce.” M cGee v

. Rel i an ce St an d ard

Li fe In s. Co

. , 3 6 0 F.3 d 9 2 1

, 9 2 4 (8 t h Ci r. 2 0 0 4 ) (q u ot i n g Do nah o v

. FM C Co rp ., 7 4

F.3 d 89 4

, 89 9 (8 t h Ci r.1 9 9 6 )). Su b s t a n t i a l e v i den ce i s d efi n ed as “ s u ch rel ev an t

ev i d en ce as a reas o n ab l e m i nd m i g h t accep t as ad eq u at e t o s u p p o rt a co n cl u si o n .” Id

. (q u o ti n g Co n s o l

. Ed i so n Co

. v

. N.L.R.B., 3 0 5 U.S. 1 97

, 2 2 9 (1 9 38 )). “ If s u b s t an t i al

ev i d en ce s u pp o rt s t he d e c i s i o n , it s h o u l d n o t b e d i s tu rb ed ev en i f a di fferen t

,

reas on ab l e i nt erp ret at i o n co u l d h av e b een m ad e.” Id

.

Ni ch o l s o n fi r s t c h a l l en ges t h e d i s t ri ct co u rt ’ s ap p l i cat i on o f th e ab u s e o f

d i s cret i o n s t an dard

. Ni ch o l s o n arg ues t h at t h e co u rt s h o u l d h a v e a p p l i ed d e n o vo

rev i ew b e c a u s e t h e p o l i cy i s s u b ject t o Ark an s as In s u ran ce Dep art m en t Ru l e 1 0 1,

wh i ch p ro h i b i t s d i s cret i o n ary cl au s es i n “ al l di s ab il i ty i n co m e p o l i ci es is s u ed i n t h i s

St at e wh i c h are i s s u ed o r ren ewed o n an d aft er M arch 1

, 2 01 3

. ” See Ark

. Ad m i n.

Co d e 0 5 4 .0 0 .1 01

. Th e po l i cy was i s s u ed o n J an u a r y 1

, 2 0 0 7

, an d l as t am en d ed o n

J a n u ary 1

, 2 0 1 3

. T h e po l i cy i t s el f st at es t hat i t “ m ay b e ren ewed fo r s u cces s i v e

r e n e w a l p eri o ds b y t h e p ay m en t o f t h e p rem i u m s et b y [St an d ard ] o n each ren ew a l

d at e. Th e l en g th of each ren ewal p eri o d w i ll be s et by [St an d ard ]

, bu t wi ll n o t b e l es s

t h an 12 m o n t h s .” Nei t h er t he po l i cy , n o r an y t h i ng el s e i n th e ad m i n i s t rat i v e reco rd

,

s i gn i fi es t h at St an d ard ex p l i ci t ly s et a ren ewal d at e aft er M arch 1

, 2 01 3

. Th e d i s t ri ct

co u rt t hu s co rrect l y

rev i ewed St an d ard ’ s d eci s i o n fo r an ab u s e o f d i s cret i o n

.

Ni ch o l s o n co n t en d s , al t ern at iv el y , t h at t h e d i s t ri ct co u rt erred i n g r an t i n g

s u m m ary ju d g m e n t u n d er th e ab u s e o f d i s cret i o n s t an dard

. St an d ard s o u g h t t h e

o p i n i o n o f t h ree do ct o rs , wh o , aft e r r e v i ewi n g Ni ch o l s o n’ s m ed ical reco rd s , fo u n d

t h at t h ere was n o o b

ject i v e ev i den ce o f a d i s ab i li t y

. See M cGee, 3 6 0 F.3 d at 9 2 5 (“ It

-4

-i s n o t u n r e as o n ab l e fo r a p l an ad m i n i s trat o r t o d en y ben efi t s b as ed u p o n a l ack o f

o b ject i ve ev i d en ce.”); s ee al s o Prezi os o v. Pru den ti al In s

. Co

. o f Am

., 7 48 F.3 d 7 9 7,

8 0 6 (8 th Ci r. 2 01 4 ) (co n cl u d i n g t h at an i n s uran ce c o m p a n y “ d i d n o t ab u s e i t s

d i s cret i o n b y acco rd i n g m o re wei g h t t o t h e op i n i o n s o f i t s own ex p ert s ”). Fi n al l y , al t h o u g h Ni ch o l s on cl ai m s t h at h i s n arco t i c p a i n m e d i cat i on p rev en t ed h i m fro m

p erfo r m i n g h i s own o ccu p at i o n , n o t h i n g i n t h e ad m i n i s t rat i v e reco rd rev eal s t h at

Ni ch o l so n ex p eri en ced ad vers e s i d e effect s fro m h is m ed i cat i o n o r t h at h e was b arred

fro m p erfo rm i n g h i s o wn o ccu p at i o n in t h e n at i o n al eco n o m y b ecau s e o f h i s n arco t i c

m ed i cat i o n . It was t h u s reas o n ab l e fo r St an d ard t o d en y t h e cl ai m

.

Ni ch o l s o n al so fa i l s t o s h o w t h at St an d ard act ed u n d er a co nfl i ct o f i n t eres t

wh en i t as k ed Dr. Nu d el l t o ag ai n rev i ew Ni ch o l s o n ’ s m ed i cal reco rd aft er i t recei v ed

fu rt h e r co rres p o nd en ce fro m Ni ch o ls o n ’ s em pl oy er an d Dr. N i ba. Ni ch o l so n

s eem i n g l y cl ai m s th at s u ch co rres p o n d en ce co n s ti tu t ed a fo rm al ap peal

, t h ereb y

req u i ri n g St an d ard t o s eek o u t th e op i n i o n o f a d i fferen t m ed i cal co n s u l tan t

. See 2 9

C.F.R. § 2 5 6 0 .5 0 3-1 (h )(3 )(v ). Yet Ni ch o l so n d i d n ot fi l e a fo rm al ap p eal u n t i l aft er

St an d ard h ad rev i ewed t he s up p l em en t al m at eri al s, at wh i ch t i m e St an d ard s o u g h t Dr.

Sh i h ’ s o p i n i o n

. St an d ard t hu s was i n co m p li an ce wi t h fed eral reg u l at i o ns

.

Th e ju d g m en t i s affi rm ed

.

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