The Honor able L ouis F. Obe rdorf er, United States District Court for the District of * Columbi a, sitting by

desig nation. -1- NO T REC OM M EN DE D F OR F UL L- TEX T P UB LIC AT ION F ile Nam e: 07a0533n.06 F iled: July 27, 2007 No. 06-3644 UN ITED STA TES C OU RT OF AP P EA LS F OR THE SI XT H C IR CU IT
Pauletta HOUSTON , Pla int if f- Ap pe lla nt,
v. UNUM L I FE I

NSURANCE CO. OF AMERI CA, Def endant- Appellee
. ) ) ) ) ) ) ) ) ) ) ) ON APPEALFROM THE U NI TED STATES DI STRI CT COURT FOR THE N O R T H E R

N D IS T R IC T O F O H IO

Be fore : DAUGHT REY and ROGERS, Circuit J udg es; OB ERDORFER, District Judge. *
OB ERDORFER, District Judge : In this ERI SA action, Plaintiff-Appe llant appea ls a district court orde r upholding Def endant- Appellee ’s termination of he r long -term disability benef its. For the r easons he re stated, we REVERSE the district court judgme nt and orde r, and REMAND for f urther proce eding s consistent with this opi nion. I. BACK GR OUND A. The Di ag nos is a nd Ini ti al D isa bili ty De te r m ina ti ons-2-

T h e a dmi n is tr ati v e r e c o r d r e v e a ls th e f

o ll o w in g f

a c ts . Pa u le tt a H o u s to nw o r

k e d f o r Ri tz Carlton Hotels for a

pproxi mately

22 y ear s. She was last employ ed ther e on Apr il 18, 2002, when she wa s 57 y ear s old. Her most rec ent title was “house keepingoffice coordinator.” In that position, she coordinated the schedule s and assig nments of the houseke epingstaff, ma intained and set-up house keepingsupplies, and assisted with housekee ping duties a s neede d, including filling in for

absent staf

f. [J A 753-55]. As Houston later e x plained, these duties require d pushing house keepingcar ts and lifting he avy

laundry bag s. [J A 277]. Ritz Carlton provided Houston with a g roup long -term disability insurance plan (the

“ Plan” ) a dmi nis te re d b y

Un um L if e Ins ur anc e Com

pa ny of Am e ri c a (“ Un um” ). Th e Pla

n w a s, and is, g overne d by

ERI SA. I t vests Unum with “discretionar y authority to determine . . . elig ibilit y for be nefits and to interpr et the ter ms and provisions” of the Plan. [J A 817]. An employ ee is e ligible f

or long -term disability

benef its under the Plan when Unum determines that sh e is “ lim ited from per formingthe m at e r ialand s ubst ant ial d u ti e s o f [h e r ] regular
oc c upat ion d

u e to [h e r ] sickness or injury .” [J A 813, bolding in or igina l] . The Plan def ines “re g ular oc cupation” a s the occ upation the employ ee is routinely perf orming at the onset of disability . [J A 794]. I n deter mining an e mploy ee’ s regular oc cupation, “Unum will look at [ the] occupation as it is normally perf ormed in the national economy , instead of how the work tasks
are perf ormed for a spec ific employ er or

at a spe cific loc ation.” [J A 794]. A claimant who has
re c e ive d d isa

bil ity pa y me nts fo r 2 4 mo nth s ma

y c on tin ue re c e ivi ngpa

y me nts on ly

if sh e is
un a ble to w or

k in any “ g a inf ul o c c up atio n” , i. e . “ an o c c up a tio n th a t is or c an b e e xpe c te d to provide . . . a

n income at lea st equal to [her] gross disability pay ment within 12 months of [her] return to wor

k.” [J A 796]. I f a c laimant is less than 60 y ear s old at the time of the disability , he-3-

or sh e is o nly

e lig ibl e fo r b e ne fi ts unti l a g e 65 . [JA 8 07 ]. T he Pla n a lso of fe rs a ssi sta

nc e to employ ers with wor

kplace modification and voluntary vocational r ehabilitation service s (the “re turn-to-wor

k” program). [J A 802]. InAp r i l 2 0 0 2 , D r s . N i c h o l s o nan d P r i c e d i a g n o s e d

H o u s t o na s h av i n g b r e a s tc an c e r . [J A 444-45]. On May

11, 2002, Dr. Nic holson perfor med a lumpec tomy , including a n axil lary ly mph
no de dis se c tio n. [JA 44 1- 42 ]. F or se ve ra l mo nth s, Dr . Pr ic e a dmi nis te re d c he mot he ra py to Houston. [J A 526]. Once the c hemothera py was c omplete, Dr. B lair administere d radiation. [ J A 4 4 6 -4 7 ]
. M ean wh i l e, Dr
. P ri ce re s tri ct edh er fr o m“h ea v y

l i ft i n g, cl i mb i n g, s t o o p i n g, pushing, pulling .” [J A 873]. In J uly 2002, afte r her

lumpectomy

with axi llary

ly mph node dissection was c omplete, Ho us ton a pp lie d to Un

um f or be ne fi ts und e r t

he Pla n. Un um a pp ro ve d s ho rt -t e rm

dis a bil ity pay ments. At the same time, Unum initiated a r eview of Houston’s elig ibilit y

for long -term disability benef its. I n a discussion with a cla ims repre sentative on Septembe r 11, 2002, Houston explained that her c hemothera py treatments would not end until som etime in November 2002, and she w as unce rtain if ra diation would be re quired ther eaf ter. She infor

med them that she wa s experiencingsome allerg ies in response to the c hemothera py , and that she ha d joint pain. She could shower

by herse lf, but neede d help from he r family for ba sic household tasks. [J A 946]. Noting the se side ef

fec ts of her br east c ance r treatments, Dr. Price’ s restrictions, and H ouston’s repor ted phy sical limitations, Unum approved her claim for long -term disability benef its on September 27, 2002, r etroa ctive to J uly 18, 2002. [J A 941-43]. The appr oval letter r equeste d that Houston “provide pe riodic medica l evidence and vocational information to support [ her] claim for c ontinued disability benef its.” [J A 942]. Unum paid Houston $1,002.56 per month.The ty pe of e dema a ssociated with bre ast ca ncer is ly mphedema, a

“chr onic, 1 de bil itatin g ” sw e lli ngin t he arm that c an o c c ur

“ a ft e r l y mph ve sse ls o r l y

mph no de s in the a xilla (ar mpit) . . . are r emoved by surg ery or dama g ed by

radiation.” W EB S TER ’ S N EW W O RLD M ED I CA L D I C TI ONAR Y (ele ctronic e dition), MedicineN et.com (e ds.), available at htt p ://www.medterms.com/scr ipt/main/art.asp? article key = 4219. -4- [JA9 4 3 ]. In May 2003, Unum conducte d its first complete post-treatment reviewof Houston’s status . H ou sto n h a d c omp le te d c he mot he ra py and ra diatio n tr e a tme nt i n Jan ua ry 20 03 . In Apr il, Ho us ton e xpla ine d to Un

um t hat sh e wa s una

ble to u se he r r ig ht a

rm fu lly . [JA 9 09 ]. Sh e a lso submitt ed her

then cur rent medic al re cords, includingDr. Nic holson’s notes of a F ebrua ry 26, 2003 visit [ J A 502]; Dr. Blair’ s notes of a Ma rch 13, 2003 of

fice visit [ J A 521]; and notes from Dr. Ha rris, her g ener al pra ctitioner, of F ebrua ry 10, 2003 and May

5, 2003 office visits. [ J A 769, 422]. Dr. Nicholson and Dr. H arr is noted pain and some swe lling, while Dr . Bla ir noted no signific ant side ef

fec ts. On or about May

14, 2003, Kar en Mills, a nurse on Unum’ s staff, revie wed these rec ords. Awa re that Houston had underg one an ax illary ly mph node dissection
and ra diatio n tr e atme nt f

or he r b re a st c anc e r, Mil ls c on sid e re d e a c h d oc tor ’s ob se rv a tio ns ;
c on c lud e d th at in toto , the re cord e stablished that Houston was suff eringfrom ede ma; and 1
rec ommended extending H ouston’s benef its unti l at least Oc tober 2003. [J A 908]. An Unum “roundta ble” r eviewe d the same r ecor ds and appr oved Mills’ conclusion and r ecommendation. [J A 840]. B. The Term ination of B enefits - January 29, 2004 On Octobe r 17, 2003, Unum initiated a fur ther re view of H ouston’s claim to “monitor for improvement with rig ht arm swelling .” [J A 841]. During this time, Houston rema ined under the regular c are of Drs. H arr is and Nicholson. Duringvisits t o them, she complaine d of var ying-5-

deg ree s of pain, swe lling, and numbne ss in her rig ht arm and shoulder . As the district court noted, Dr. H arr is observed some sw elling on e ach of her visits, and Dr. N icholson presc ribed
me d ic a ti o nf

o r h e r p a in , w h ic hs h e to o k

e v e r y f o ur h o ur s . [JA4 2 4
- 2 5 , 5 7 0
- 7 1 , 4 3 1 , 5 9 5 ]. A nxray repor t of Octobe r 20, 2003 noted ax illary clips from her

lumpectomy , but found no signs of fra cture , joint space na

rrowing , or ca lcifications that could be ca using he r pain, numbness, a nd
sw e lli ng . [JA 4 18 ]. B e tw e e n O c tob e r 2 7, 20 03 and De c e mbe r 3 0, 20 03 , H ou sto n s po ke wi th Un um r e pr e se ntativ e s o n at le a st thr e e oc c a sio ns . Sh e e xpla ine d to the m th a t sh e ha d tr ou ble lifting. F or example, she told them that she re lied on her f amily to take her

shopping, c ould not lift soap powder

to do laundry , and explained that a g allon of milk would be too heavy for he r. [JA5 8 5 , 5 9 5 , 6 9 3 ]. Duringthis review pe riod, Unum classified H ouston’s occupation as administrative and thus “sedenta

ry .” [J A 912]. I n Dec ember 2003, Unum staff nur se Elaine F erma nis reviewe d the up date d f ile . Witho ut e xplanatio n, and c on tr ary to Unum’ s in iti a l de te rm inatio n b a se d o n M ill s’
rec ommendation, Fe rmanis conc luded that the re cord showe d that Houston’s doctors ha d not observe d edema

in her e x tremities. [J A 561]. S he dete rmined that the medic al evidenc e did not
s h o wa c o n d i t i o nth atw o u l d

p r e v e n th e r

f r o m“ r e s u m [i n g ] h e r

f o r m e r f un c t i o n a l c a

p a c i ty . ” [J A 560]. Fermanis pre pare d a summary of the re cords r efle cting her own conclusion. The summar y
c on sp ic uo us ly

omi tte d a

ny re fe re nc e to Unum’ s p re vio us fa vo ra ble c on c lus ion

ba se d o n M ill s’ revie w. [J A 560-61]. Fer manis forwa

rded he r summary

to Dr. L awr ence Br oda, a doc tor employ ed by

Unum, for r eview. H e agree d with her c onclusion. [J A 559]. An Unum letter of

J anuar y 29, 2004 terminated H ouston’s benef its for the re asons stated by Fe rmanis and B roda. [J A 550]. The letter stated that Unum had classifie d her r egularWe a g re e wi th t he dis tr ic t c ourt ’s c omm e nt t hat D r. Ha

rr is’ no te s a

re e xtre me ly 2 difficult to rea d. We do not purport to make a f actua l finding a s to their conclusive me dical import; our holding is based on the other re strictions and observations in t he re cord. -6- oc c up a tio n a s se de nta

ry . T he le tte r a lso no tif

ie d h e r o f h e r r ig ht t o a

pp e a l and to s ub mit
a dd iti on a l me dic a l and

vo c atio na l in fo rm a tio n, inc lud ing , s pe c if ic a lly , u pd a te d a c tiv ity
re str ic tio ns pr e sc ri be d b y he r d oc tor s. C. Houston’s App eal Houston appea led this determination, re sponding dire ctly to the rea sons Unum ga

ve her
. She su bmi tte d a fo rm c omp le te d b y

Dr . N ic ho lso n a

bo ut h e r p hy sic a l c a

pa c ity , w hic h g e ne ra lly restric ted her

to lifting no more tha

n 5 pounds at a time. He attributed the re strictions to the conseque nces of

the “ax illy

dissection with brea st biopsy .” [J A 433-34]. A simil ar r estriction fo rm , ap p ar en t l y

co mp l et edb y

Dr
. P ri ce i nl at e 2 0 0 3 o r e ar l y 2 0 0 4 , l i m i t edHo u s t o nt o l i ft i n g 2 pounds with her rig ht arm and 10 pounds with her left. [J A 524]. S he submitted additional handwr itten notes by

Dr. Ha rris fr om appointments with Houston in J anuar y and Apr il 2004; th e y a p p e ar t o s t at e th ath e c o n t i nu e d t o o b s e r v e s o m e e d e m a

an d t e n d e r n e s s i nh e r

ar m . [J A 426, 428]. She also provided doc umentary verific ation of her

treatment with a presc ription 2 p a ink il le r . [JA4 3 1 ]. On J une 26, 2004, Houston visited Mark Ande rson, not an M.D., but a L icense d Professional Counselor (L .P.D.) and Cer tified Disability

Manag ement Specia list (C.D.M.S ). He conducte d a deta iled vocational a ssessment that included seve ral tests and a phy sical examination. Anderson observe d that Houston was unable to complete a pe gboard te st for
manu a l de xter ity

du e to p a in a

nd ina bil ity to r e a c h w ithhe r r ig ht a

rm . [JA 1 54 ]. In h is r e po rt , An d er s o nn o t eda n u mb er o f l i m i t at i o n s , i n cl u d i n g:-7-

“consta nt pain in the rig ht arm alongwith swelling a nd numbness. She is right ha nded and is only

able to wr ite for a

pproxi mately

2-3 minutes at a time. She is limit ed to lifting less than 5 lbs., is unable to rea ch for war d or pull with her rig ht ext remity and has difficulty sitti ng , standing or wa lking f or prolong ed per iods of time.” [JA 15 3]. A ft e r h e re vie we d th e lim itatio ns pr e sc ri be d b y Ho us ton ’s do c tor s, and

makin g his
ow n o bs e rv atio ns , A nd e rs on c on c lud e d th a t “ Ho us ton is p hy sic a lly

c a pa ble of le ss t ha n th e fu ll rang e of se dentar

y work.” [J A 152]. Of particula r import, Ander son also conclude d that she require d “assistanc e with ac tiviti es of da ily living includinglaundry , clea ning a nd shopping.” [JA1 5 2 ]. In addition, Anderson f

ormally revie wed Houston’s r egular oc cupation of H ousekee ping Offic e Coordinator a

nd classified it as “ clea

ner/houseke eping ” and “ laundry worke r I I .” The D e p art m e n to f

L a b o r d e f i n e s th i s p o s i t i o na s un s k i l l e d , r e qu i r i n g l i g h tt o m e d i u ms tr e n g th
. [J A 1 5 4 ]
. F i n a l l y, H o u s t o ns u b m i t t e d h e r o w na f f i d av i tth a th e r

o c c u p a t i o nw a s n o ti nf

a c ts e d e n t ar

y, and that she c ould not meet its more demandingphy sical re quirements, which inc luded “a g ood de a l of wa lki ng , p us hin g c art s, be nd ingand lif tin g la un dr y ba g s th a t c ou ld w e ig h u

p to tw e nty ( 2 0 ) p o un d s e a c h
. ” [JA2 7 7 ]. In August 2004, Unum occupational review ers “ clar if[ied] ” [J A 179] Houston’s
o cc u p at i o n : n o tas s ed en t ary , b u t , as p er fo rm edi nth e n at i o n al ec o n o m y , as re qu i ri n g “[ l ] i ft i n g, [c]a rr ying , [p]u sh ing , a

nd [p]ul lin g 20 [l]bs. oc c a sio na lly , f re qu e ntl y up to 1 0 [l]b s. or

ne g lig ibl e amount constantly .” [J A 178]. Unum then submit ted to Fe rmanis and Dr . Br oda the r estrictions presc ribed by

Houston’s phy sicians and updated medica l rec ords. On August 16, 2004, despite the fore g oing inf ormation, Fe rmanis er

roneously rec orded “Restrictions/L imitations : none cur rently provided.” [J A 184]. Ferma nis opined that HoustonI t is unclear if Fe rmanis consider ed the c hang e in job classification during he r re view. 3 -8- manifested no e dema a

nd conclude d that “[t] here is no evidence in the new medic al information of a sig nificant c ondition that chang es the prior medical opinion.” [J A 184]. On August 17, 3 2 0 0 4 , D r . B r o d a

r e v ie w e d an d a g r e e d w it hF e r ma n is ’ c o n c lu s io n s . [JA1 8 2 ]. On September

10, 2004, Unum wrote H ouston that it would not rec onsider its J anuar y 29, 2004 decision to terminate he r bene fits. The September letter did not addre ss Dr. Ande rson’s conclusions; rathe r, Unum only noted that the vocational analy sis “ref lected a first g rade rea ding level and a

third g rade or less math leve l” and that the de x terity test was “inc omplete.” [J A 168]. Un um f ur the r j us tif ie d th e te rm inatio n b e c a

us e : ( 1) “ on ly

y our p ri mary

c are phy sic ian r e po rt s shoulder pain a

nd . . . exams are limited without appare nt edema of the ar m . . .” and ( 2) the vocational a ssessment, “conside red a lone” wa s “inconc lusive beca use there is no globa l assessment of c og nitive, psy cholog ical/psy chiatric and phy sical func tion that would provide context for these low scor es.” Id. F ina lly , U num e xpla ine d th a t it wo uld fo rw ard Ho us ton ’s fi le to its Quality

Perfor mance Support Unit for a fina l, “impartial” r eview on a ppeal. Id
. D. The Final Denial - October15, 2004 In September 2004, Unum’s Quality Perfor mance Support Unit forwar ded a summar y of Houston’s claim file a

nd the medica l rec ords to Dr. Allan L ipton, an oncolog y surg eon at Pe nn sylva

nia State Un ive rs ity . H e no te d th e re str ic tio ns in t he re c or d, but c on c lud e d, in pertinent pa

rt, that: (1) the r estrictions and limitations provided by Houston’s phy sicians “we re not supported by

appropr iate medica l workup”; (2) “the patient should have bee n ref err ed to an
or tho pe dic surg e on

wh o s pe c ia lize s in

sh ou lde r p ro ble ms a s w e ll a s a ne ur olo g ist

to p e rf or m a workup of he r sy

mptoms. I n the abse nce of a more extensive workup it is not poss ible to say that-9-

the patient wa s indeed disabled a nd not able to per form her usual work duties” ; and (3) “ the patient’s complaints of r ight a rm and shoulder

pain and disability

are not consistent with her d o c u me n te d

me d ic a l f

in d in g s . ” [JA1 4 0 ]. On Oc tob e r 1 5, 20 04 , U num is su e d a fi na l de nia l le tte r. Th is l e tte r t old he r f or the fi rs t time that she nee ded to see an orthope dic surg eon or ne urolog ist in order to eva luate prope rly and to d ia g no se the sy

mpt oms sh e re po rt e d. [JA 13 1]. T hat le tte r o ff e re d H ou sto n n o o pp or

tun ity to
re a c t or re sp on d to thi s n e w r e qu ir e me nt. II
. P ROCEDURAL BACK GR OUND On Janu ary 11 , 2 00 5, Ho us ton

fi le d a c omp la int

in t he No rt he rn Di str ic t of

Oh io challeng ing Unum’s deter mination, alleg ing violations of ERI SA and bre ach of fiduciar y duty
. She soug ht reinstatement of benef its and attorney s’ fe es. On Septembe r 15, 2005, the pa rties filed cr oss-motions for judgme nt on the administrative re cord. Unum contended, a s summarized in a proposed f

indings of f

act a nd conclusions of lawfiled on Oc tober 14, 2005, that its actions
we re no t arb itr ary

and c a pr ic iou s, but ba se d o n s ub sta nti a l e vid e nc e of

Ho us ton ’s fa ilure to
s u p p o rt h e r c la im b y a p p r o p r iate me d ic a l e v id e n c e . [JA7 2
- 7 3 ]. In a brie f filed Oc tober 18, 2005, Houston counte red that there w as “undisputed medic al
e vid e nc e . . . th at Mr s. Ho us ton c ann ot p e rf

or m a fu ll r ang e of

se de nta ry po sit ion s” and

that “ no evidenc e in the re cord de monstrates that Mrs. Houston is capa ble of pe rfor

ming he r old position, or any other oc cupation.” [J A 80, emphasis in orig inal]. I n addition, she contende d that Unum “foc used on information that Mrs. Houston was not g iven an oppor tunity to rebut.” [J A 81]. S he also emphasized what she claimed wa s Unum’s arbitra ry and ca pricious shift of its rationale f or the te rm inatio n o f h e r b e ne fi ts: “ [w]he n th e y we re no lon g e r a

ble to s ub sta

nti a te the ir

fi rs tHouston’s filings be fore the district court did not specif ically invoke 29 U.S.C. § 1133, 4 but plainly

raised the substance of

such a violation.

-10- re a so n f or de nia l,” sh e a lle g e s th at U num “ sim ply c ha ng e d it s r a tio na le
. . ., le avin g Mr s. Houston with no opportunity to respond to their ne w re port of a non- treating, non- examining p h y s ic ia n[D r . L ip to n ]. ” [JA7 6 ]. On Marc h 9 , 2 00 6, the dis tr ic t c ourt g ra nte d ju dg me nt o n th e a dmi nis tr a tiv e re c or d to Unum. The district cour

t acc epted Unum’ s argument that its termination was based on suf ficient
su bs tanti a l e vid e nc e . T he dis tr ic t c ourt re a so ne d th a t, whil e Ho us ton ’s “ do c tor s o bs e rv e d s ome swelling . . . by

J anuar y 2004, Unum saw insuffic ient fac ts demonstrating that the plaintiff suffe red f rom debilitating phy sical sy mptoms bey ond the self- repor ted ones” and that the

“ s i tu a t i o nh a d

n o ts u b s t an t i a l l y

c h an g e d ” b y

O c t o b e r 2 0 0 4 w h e nU nu md e n i e d h e r a p p e a l
. [J A 115]. I t held that Unum’s re asoningwas c onsistent and that its determination had a r ational ba sis . H ow e ve r, the dis tr ic t c ourt c on sp ic uo us ly

fa ile d to a dd

re ss H ou sto n’ s c ha lle ng e to Unum’s fa ilure to aff

ord her an opportunity

to respond to Unum’s late- blooming rationale for termination of her

benef its: failure to consult a neur ologist or or thopedist. On Ap ri l 7, 20 06 , H ou sto n ti me ly fi le d th is a

pp e a l. She argues that Unum’s shifting rationale for ter

minating he r bene fits failed to comply with 29 U.S.C. § 1133 and that its decision
was a rbitrar y and ca pricious. We find that Unum’s shifting r ationale violated 29 U .S.C. § 1133,

4 and conc lude, for a dditional reasons, that Unum’s ultimate ter mination of Houston’s benef its was
arb itr ary and c a pr ic iou s. III . STA ND AR

D O F RE VI EW Se c tio n 1 13 3 o f E RI SA p ro vid e s:-11- In acc ordanc e with re g ulations of the Secr etar y , ever y employ ee be ne fi ts p lan s ha ll– (1) provide a dequate notice in writingto any participa nt or benef iciary whose c laim for bene fits under the pla n has been de nied, setting forth t he spec ific reasons for such denial , written in a manne r ca lculated to be unde rstood by the par ticipant, and (2 ) a ff

or d a re a so na ble op po rt

un ity to a ny pa rt ic ipa nt who se claim for be nefits has be en denie d for a full and fair review b y th e a p p r o p r i a t e n am e d

f i d u c i ar y of the decision deny ing thec lai m . 29 U.S.C. § 1133 (2007) (empha sis added) ( “§ 1133”) . The implementingregulations require that an E RI SA a dmi nis tr ator pr ov ide a c la ima nt w ithwr itt e n n oti c e of

any a dv e rs e be ne fi t deter mination, including “[t]he specific r eason or rea sons for the a dverse deter mination” and “[a] descr iption of any

additional materia l or information nec essar y for the c laimant to perfe ct the claim and a

n explanation of why

such mater ial or information is necessar y .” 29 C.F.R. § 2560.503-1(g ) (2007) . We review de novo the leg al question of whe ther the pr ocedur e employ ed by a plan a dminist rator in ter minating be nefits meets the r equire ments of § 1133. McCartha v. National City Corp. , 4 1 9 F. 3 d

4 3 7 , 4 4 4 (6 thC i r. 2 0 0 5 ) ( ci t i n g Ke nt v . U nite d O ma ha LifeIn s. Co. , 96 F.3d 803, 806 ( 6th Cir. 1996)). We also review de novo the district court’s de cision g rantingjudgme nt on the administrative re cord in a n ERI SA disabilit y

action. Gle nn v . M

e tLif e , 4 61 F .3 d 6 60 , 6 65 (6 th C i r. 2 0 0 6 ) ( ci t i n g W

hitaker v. H

artford L ife &Acc ident Ins. Co. , 404 F.3d 947, 949 ( 6th Cir. 2005)). Where , as her e, an insura nce pla n administrator is vested with discre tion to int erpr et the plan, we r eview the decision to terminate be nefits under the ar bitrary and ca pricious standar d. See Ev an s v . U

nu mPro v ide nt C

or p ., 434 F.3d 866, 875 ( 6th Cir. 2006) (citations omitted). I f the-12-

administrative re cord e vidence s a “r easone d explanation” for a n administrator’s de cision, the decision is not arbitrar

y or ca pricious. W

illiams v. Int’l Paper Co. , 227 F.3d 706, 712 ( 6th Cir. 2000). Howe ver, “ mere ly beca use our r eview must be de fer ential does not mea n our re view must also be inconseque ntial. . . . [ F]eder al cour ts do not sit in reviewof the a dminist rator’ s decisions only

for the pur

pose of r ubber stampingthose dec isions.” Moon v. U num Provident Cor p ., 405 F.3d 373, 379 ( 6th Cir. 2005). ERI SA r e qu ir e s in sura

nc e c omp anie s to a c t a s f idu c iari e s: p lan a dmi nis tr a tor s “ sh a ll discharg e [their] dut ies with respe ct to a plan solely in the interest of the participa nts and be ne fi c iari e s and

[] fo r t he e xclu siv e purp os e of

[] pr ov idi ngbe ne fi ts t o p art ic ipa nts and the ir benef iciarie s . . . in acc ordanc e with the docume nts and instruments gove rningthe plan insofar as such docume nts and instruments are consistent with the provisions of this subchapter . . .” 29 U. S.C. § 1 10 4( a )( 1) (2 00 7) . T he pr oc e ss i s n ot i nte nd e d to be a dv e rs ari a l. I n a dd iti on , “ [c]o ur

ts should be particula

rly vigilant in situations where , as her e, the plan sponsor bear s all or most of the risk of pa

ying c laims.” University Hosps. of Cleve land v. Eme rson Elec. Co. , 202 F.3d 839, 846 n.4 (6th Cir. 2000). IV . AN AL YSI S A. Did Unum “Substan tially Com ply” With § 1133? Th e “ e sse nti a l pu

rp os e ” of § 1 13 3 is tw of

old : ( 1) to n oti fy

the c la ima

nt o f t he sp e c if ic
rea sons for a c laim denial, and ( 2) to provide the c laimant an opportunity to have that de cision f u l l y an d f a i r l y r e v i e w e d

b y th e f i d u c i ar y. See M oore v. Lafaye tte Life Ins. Co. , 458 F.3d 416, 4 3 6 (6 thC i r. 2 0 0 6 ) ( ci t i n g Kent , 96 F.3d at 807). This court has a dopted a “ substantial compliance ” test in dec iding whe ther de nial or termination notices me et the re quirements of §-13-

1133. McCartha, 4 1 9 F. 3 d at4 4 4 (c i t i n g Marks v . Newcourt Credit Group, Inc. , 342 F.3d 444, 460 (6th Cir. 2003) and Kent , 96 F.3d at 807-08). Her e, Unum ar g ues that its rea son for the te rmination of bene fits was consistently “lac k of me dic a l e vid e nc e .” Ho we ve r, the re c or d s ho ws that U num w a s a pp lyingthat g e ne ri c la

be l to its de te rm inatio n f

or tw o v e ry dif fe re nt r e a so ns . U num in iti a lly te rm inate d H ou sto n’ s b e ne fi ts beca use it err oneously

conclude d that her oc cupation wa s sedentar y , and that the medic al evidenc e wa s insufficient to show that she c ould not perfor m a sede ntary

job. I n response , Houston provided the a dditional evidence reque sted and a sked Unum to corr ect the job classification. Unum failed to ac knowledg e its initi al er ror in the job cla ssification, and arbitra rily reiter ated that the me dical evide nce did not show that she w as disabled f rom her
re g ula r o c c up atio n. Mo st i mpo rt ant, Un um’ s f ina l le tte r d e nyinghe r a

pp e a l to ld h e r, fo r t

he fi rs t tim e , th a t he r m e dic a l e vid e nc e wa s in su ff ic ie nt becauseshe did had not seen the prope r sp e c ial ist ( i.e . a n o rth op e dis t or

ne ur ologis t) to o bta in t

hec orre c t di ag

no sis
. This proce ss did not properly “notify [] [Houston] of [Unum’s] rea sons for deny ing [her] claims and a ffor d[] [Houston] a fa ir opportunity for r eview.” Marks , 3 42 F .3 d at 46 0 ( e mph a sis added, c itations omi tted). F ull and fair r eview doe s not mean that an insura nce c ompany

can sim ply mouth t he same re a so n: “ the pe rs ist e nt c or e re qu ir e me nts of re vie w i nte nd e d to be fu ll and fa ir include knowingwhat evide nce the decision-make r re lied upon, ha v ing an op po rtu nit y to address the acc uracy and re liabili ty of that evidenc e , and havingthe dec ision-maker c onsider the evidenc e pre sented by both parties prior to r eac hing a nd rende ringhis decision.” Halpin v. W .W . Grainger, Inc ., 9 6 2 F
. 2 d 6 8 5 , 6 8 9 ( 7 thC i r . 1 9 9 2 ) ( e mp h a s i s a d d e d , qu o t a t i o no m i t t e d )
. In vio latio n o f § 11 33 , U num f a ile d to pr ov ide an o pp or tun ity fo r H ou sto n to re sp on d, wi thWe note that the district court ba sed its holding in par t on a findingthat Houston’s 5 disability claim was pr imarily

based on se lf-re ported sy mptoms. For disabilities based on “ se lf -r e po rt e d s y

mpt oms ,” Un

um w ill g e ne ra lly

ma ke no mor e tha

n 1 2 mo nth ly

dis a bil ity -14- argument or ac tion, to Unum’s revised rationale for te rminating her be nefits, including Dr. L ipton’s opinion that she be seen by “prope r” spe cialists, and, if indicate d, to obtain the ty pe of
car e Unum re commended in its final ter mination letter. See, e .g., McCartha , 419 F. 3d at 445- 47. B. Was Unu m ’s Dec ision “Arbitrar y and Cap ricious”? The for eg oing violation of § 1133 is not the only problem with the dete rmination proce ss. In o rd e r t o d e te rm ine wh e the r Unum’ s u lti mate de c isi on wa s a rb itr ary and c a pr ic iou s, we a lso consider whether

Unum’s dec ision “is the result of a de liberate , principled re asoningproce ss and [whether] it i s supported by substantial evidence .” Glenn , 4 6 1 F. 3 d at6 6 6 (qu o t i n g Bake r v. United Mine W

orkers of Am. He alth & Ret. Funds , 9 29 F .2 d 1 14 0, 11 44 (6 th C ir .1 99 1) ); se e als o Kill ian v . H

e alt hs ou rc e Pr ov ide nt A dm ’r s , 152 F.3d 514, 520 ( 6th Cir. 1998). “Ac cording ly , we revie w not only

the insurer ’s conc lusion, but also it s rea soning.” Metropolitan Lif e Ins. Co. v. Conger , 474 F.3d 258, 265 ( 6th Cir. 2007). Here , Unum’s re asoningsuffe red f rom sever al critica l flaws. First, Unum’s a

brupt, inexpl icable r ever sal of its own conc lusion that Houston was
su ff e ri ngfr om p os t- br e a st c anc e r e de ma in h e r a rm is per se unrea soned and unpr incipled. See Part I .B., su

pra . T he re c or d s ho ws that he r t re a tin g phy sic ians , a s w e ll a s a vo c a tio na l sp e c ia lis t, observe d and docume nted var ying de g ree s of pain, tende rness, a nd related phy sical limitations. Whil e Dr . Har

ris’s handwr itten notes are difficult to rea d, we a g ree with the district court that they at least indicate observation of some swelling
. Whil e an obse rvation of e dema in and of 5pay

ments. [J A 807]. The Plan defines “ self-r eporte d sy mptoms” as sy

mptoms “that are not verifia ble using tests, proce dures, or clinical examinations,” including “hea dache s, pain, fatigue, stiffness, sore ness, ring ing in e ars, dizzi ness, numbness, and loss of e nergy .” [J A 793]. Ho we ve r, Un

um n e ve r i nv ok e d th e po lic y ' s li mit a tio n o n p ay me nts fo r s e lf

-r e po rt e d s y

mpt oms in the te rm inatio n le tte rs . T hat pr ov isi on , e ve n if it w e re a pp lic a ble , c an n ot b e us e d r e tr os pe c tiv e ly to justi fy a ter mination decision that was the r esult of a f lawed r easoningproce ss. -15- itself might not be suff

icient to demonstrate disa bility , it evidence s a potentially disabling condition. Second, Unum’s r easoningalso suffe rs independe nt flaws. The administrative re cord
reve als that Unum did not give full consideration to Houston’s objective voca tional evidence of disability , particula

rly the Ander son repor

t. Under the terms of the policy , Houston must prove that she is limit ed fr om perfor ming the material duties of he r re g ular oc cupation “due to injury or sickness.” [J A 813]. Vocational evide nce ma y and should be c onsidered in de termining her occupational abilities. Cf. Rochow v. Life Ins. Co. of N . Am. , 482 F.3d 860, 865- 66 (6th Cir. 2007). Wit hout expl anation, Unum cha rac terized the peg

board te st results as “incomplete ” and dis c ounte d th e ana ly st’ s o bs e rv atio ns of Ho us ton ’s phy sic a l li mit a tio ns . Ins te a d, it i ne xplic a bly fo cu s edo nth e c o gn i t i v e f un ct i o nfi n d i n gs , claiming that there was no medic al support for Ho us ton ’s low

lit e ra c y and math t e st s kil ls. These te sts, while perha ps important in a later deter mination of the rea lm of g ainful occ upations available to Houston, are not releva nt to the
curr ent inquiry

on appea l: whether or

not she was phy sically

limit ed fr om the full use of he r ar m d u e t o s ymp t o m s r e l at e d

t o an y s i c kn e s s o r

i n j ur y. Given that ther e wa s no conflictingvocational evidenc e in the re cord, Unum failed to g ive Ander son’s vocational conclusions and obser vations proper considera

tion. See, e .g., Evans , 434 F.3d at 879-80; Rochow , 482 F.3d at 866. F ina lly , th e re are many

re a so ns to v ie w w ithsk e pti c ism Un um’ s me dic a l r e vie we rs ’The Plan g ives Unum the rig ht to require a claimant to be “ examined by a phy sician, 6 o th e r me d ic a l p r a c ti ti o n e r

o r v o c ati o n a l e xp e rt o f

[i ts ] c h o ic e . ” [JA8 1 3 ]. -16- conclusions. When assessinga non-tre ating phy sician’s opinion, the cour t may consider se vera l fac tors, including: ( 1) whe ther the r eviewingphy sician has a conflict of inter est, Moon , 405 F.3d at 381-82; (2) whether

the administrator de cided that the phy sician should conduct a file re view rathe r than a

phy sical exam, particular ly when it has the r ight to re quire a phy sical exam , Cal

v e rt 6 v. Firstar Fin. Inc., 409 F.3d 286, 295 ( 6th Cir. 2005); and (3) whether the non-tre ating phy sician’s c onclusion makes a “ critica l cre dibilit y deter mination[ ] reg ardinga cla imants’s medical history

and sy mptomology” without observingthe claimant, id. a t 29 7. I t is we llestablished that Unum is not require d to defe r to the opinions of treating phy sicians, Black & Dec ker D isabili ty Plan v. Nord, 538 U.S. 822, 834 (2003); it is equally clea r that a pla

n administrator may

not disreg ard those opinions. See E vans, 434 F.3d at 877. Her e, two of H ouston’s treatingphy sicians imposed restric tions on li fting duringthe rele vant time period, a

nd Dr. Nic holson’s form spec ifically stated that the re ason for the ong oing restric tion was the axill ary node dissection assoc iated with her lumpectomy . Nurse F erma nis and Dr. B roda did not consider these re strictions. [ J A 182, 184]. Further more, in lig ht of Unum’s
o w ni n i t i a l c o n c l u s i o nth atH o u s t o na p p e ar e d t o b e s u f f e r i n g f r o mp o s t - b r e a s tc an c e r

e d e m a [J A 908, 840], i t is not reasonable that Dr. L ipton gave no cr edenc e to the ca use stated by

Dr. Nicholson (the ax illy

node dissection), or

that he fa iled consider whether the re strictions provided mig ht be prophylactic in natur e due to he r risk of e dema, a s noted by Mills. [ J A 908]. See, e .g., Evans , 434 F.3d at 879 (noting that restrictions and limitations can be pr eventive, notCourt s h ave ob se rv e d th at ly mph e de ma

is a c hr on ic c on dit ion

that ma y e bb and fl ow ; it 7 can ta ke months or eve n y ear s after brea st canc er tre atment to develop a nd be diagnosed. See generally Slay ton v. Apfel, 175 F.3d 1016 ( table), 1999 WL152614 at * 1-*2 (4th Cir. Mar . 22, 19 99 ) ( de sc ri bin g ly

mph e de ma

and its e ff e c ts) . L if tin g re str ic tio ns may

be imp os e d a ft e r b re a st canc er sur g ery

or ra diation to prevent ly mphedema. Se e, e .g., J

an e zic h v . B ar

nh ar t , 453 F. Supp. 2d 10 19 , 1 02 3 (N. D. I ll. , 2 00 6) (d e sc ri bin g lif tin g re str ic tio ns imp os e d to avo id l y mph e de ma ); see also WebMD Medical Ref ere nce & The Clevela

nd Clini c, Breast Cancer: SideEffects of Tre atm e nt: Ly mp he de ma , a v ail ab leat http:// www.medic inenet.com/bre ast_ca ncer _and_ ly mphedema/a

rticle.htm (women at risk for ly mphedema should “ avoid re petitive movements of the af fec ted ar m (such as sc rubbing , pushing, or pulling)” and should “not ca rry a purse or bagon y our shoulder ( the side whe re you had surg ery )”)
. -17- mere ly prohibitive, in order to support a claim of disability). 7 We a lso take int o c on sid e ratio n th e fa c t th a t U num’ s inte rn a l r e vie we rs , w ho se persua siveness is diminis hed by a conf lict of interest, dre w their c onclusions about Houston’s sy mptoms sol ely

on a file r eview. We a lso view Unum’s ultimate relianc e on Dr . L ipton’s opinion with som e skepticism bec ause it wa s essentially “a c ritical cr edibility

deter mination” about Houston’s complaints made w ithout the benefit of a phy sical exam. See Calve rt, 409 F.3d at 297. The issue be fore us is not whether discr ete a cts wer e ar bitrary and ca pricious, but whether the ultimate decision, and the making of it, were arbitra ry and ca pricious. Spangler v. Lock heed Martin Energy Sy

s., Inc., 313 F.3d 356, 362 ( 6th Cir. 2002). Here , the re cord r evea ls internal inc on sis te nc e s. Ob

je c tiv e vo c atio na l e vid e nc e (i .e . th e An de rs on re po rt ) w a s n ot f

ull y considere d. I t is not clear that the doc umented re strictions were revie wed f rom the per spective of the cor rec t job classification. The r eviewe rs neve r consulted with Houston’s doc tors. The revie wingphy sicians made c redibility deter minations about her re ports of pain without bene fit of independe nt exam. Viewing the se flaw s in the context of the entire re cord, w e conc lude that-18-

Unum’s final de cision to terminate Houston’s be nefits was a rbitrar y and ca pricious: neither “ the result of a deliberate principled r easoningproce ss”, nor “ supported by substantial evidence .” Kill ian, 15 2 F .3 d at 52 0; see also Smith v. Continental Cas. Co., 450 F.3d 253, 264 ( 6th Cir. 20 06 ); Elliott

v. Me tropolit an Life Ins. Co., 473 F.3d 613, 619- 20 (6th Cir. 2006)

. C. Re m e dy For violations of § 1133, reve rsal and r emand to the district cour t or to the plan administrator for

full and fa ir revie w is ordinarily appropr iate. Marks , 342 F.3d at 461 (citing VanderKlok v. Prov ident Life & Acc ident Ins. Co. , 956 F.2d 610, 619 ( 6th Cir.1992)). Where, a s he re , a n in sure r’ s f

ina l de te rm inatio n is a lso arb itr ary and c a pr ic iou s, the c ourt

ha s d isc re tio n to fashion an a

ppropriate reme dy . Whil e this circuit has not a dopted a c ateg orica l rule, it has noted that, g e ne ra lly

a “ re tr oa c tiv e awa

rd is u su a lly

pr op e r whe n [th e ] cl a ima nt h a d b e ne fi ts a

nd los t them,” while “ rema

nd is appropriate when a

decision-make r fa ils to m ake a dequate finding s or fails to provide [] adequa te re asoning .” El lio tt , 4 7 3 F. 3 d at6 2 2 (qu o t i n g Buffonge v. Prude ntial Ins. Co. of America , 426 F.3d 20, 31 ( 1st Cir.2005) (internal c itation omit ted)). Her e, bec ause ( 1) Unum pre viously deter mined that Houston was entitled to continued long- term bene fits due to brea st canc er- related ede ma in her r ight a rm, and (2) Houston prese nted objective e vidence of ong oing disa bility in the form of r estrictions presc ribed by her doc tors and
a vocational analy sis perfor med by a license d counselor, w e conc lude that Houston rema ins presumptively

entitled to continuation of her pr eviously awa rded long -term disability

benef its. Thus, reinstateme nt of Houston’s long -term disability pay ments ($1002.56 per

month) is the appropr iate re medy

in this case. See, e .g., Evans , 434 F.3d at 880. Th is d e c isi on

is w ith out pr e

jud ic e to Unum’ s r e ini tiatin g fu rt he r r e vie w t o d e te rm ine if-19-

Ho us ton re ma ins un a

ble to w or

k und e r t he “ g a inf ul o c c up a tio n” sta

nd ard . I f Unum e le c ts t o
un de rt ake su c h a

re vie w, it s ho uld

g ive a de qu a te c on sid e ratio n to An de rs on ’s vo c a tio na l ana ly sis , including H ouston’s limi ted literac y and mathematical skills that he identified. CO NC LU SION Acc ording ly , the district court’s or der is REVERSED and REMANDE D for f urther proce eding s consistent with this opi nion.