F ILED U.S. COURT O F APP EALS EL EV EN TH C IRC UIT Ja nua ry 1 6, 2007 T HOMA S K. KA HN CLERK [DO N OT PUBLISH] IN THE UN ITED STATES COURT OF APPEALS FO R T HE EL EV EN TH CIRC UI T

____ ____ ____ ____ ____ ____ N o. 05- 1667 1

____ ____ ____ ____ ____ ____ D. C. Docket N o. 04-00480 -CV -3-CSC GEORGE HEL MS, Pl ai nt iff -Ap pe ll an t, ve rs us G EN E RA L D YN A MI CS CO RP . , ac or por at ion , THE GENERAL DYNA MIC S SHORT TERM DISABI LITY PLAN, a wel fare di sabi li ty pla n, et al., Defen da nt s- App el le es .

____ ____ ____ ____ ____ ____ Appe al f ro m the U nit ed

S ta te s D istri ct

Co urt f o r th e M i d d l e D i s t r i c to f

A l ab a ma

____ ____ ____ ____ ____ ____ _ (J an ua ry16, 200 7) Be fo re BI RC H , P RY O R and F A Y , Ci rc uit Jud ge s. BIRC H, Circuit Judge: G eo rg e H el m s a

ppe al s th e m ag istrate j udge ’ s e ntr y of j udgm en t i n f

av or of2

Ge neral D ynam ics Corporation (“ Ge neral D ynam ics”) and A etna L ife Insurance Co m pany ( “ A etna ”) in his a ct ionf or aw ro ngf ul d en ia l of

be ne fi ts unde r the Em pl oyee Ret ire m en t In co m e Sec ur it y Act (“ ERISA”) , 29 U.S.C. § 1 00 1 e t s eq . W e hold that Aetna acte d arbitrarily and capriciously

in deny ing Helm s short-term dis ab ili ty ( “ ST D ”) be ne fi ts, that H el m s f ai le d to e xhaust

his a dm ini str at ive r e me d i e s w i t h r e s p e c tt o h i s l o n g - t e rm d i s ab i l i t y ( “L T D ” ) c l a i m, an dth a tH e l ms ha s an a ppr opr ia te r em edy

und er § 50 2( a) (1 )( B) . A s ar es ult , w e RE V E RS E in pa rt, AFF IRM in pa rt, a ndREMAND fo r pr oc eed in gs co ns is te nt wit h t hi s o pi ni on . I. BACKG ROUND He lm s worked for Ge neral D ynam ics as a f unction al analy st, a j ob that required him

to work at a

desk with a com

puter. H elm s was c overed under Ge neral D ynam ics’ ER ISA -m aintained STD and LT D benef it plans, which w ere adm inistered by

Ae tna. T he ST D plan defines disability as a hea lth cond ition that re sul ts i n on e’ s be ing “ co nti nuou sly una ble to pe rf

orm the e sse nti al dut ie s of [o ne ’ s] r eg ular oc cu

pa tio n insub stanti al ly

the sam e m anne r as [ one ] did j ust before incurr ing a m edically determ ined phy sical or m ental im pairm ent.” R1, 29-5 a t2 0 . T h e me d i c a l p r o o f o f d i s ab i l i t y r e qu i r e dth a tH e l ms “[ p ]r o v i d e th e C l a i ms A dm ini str at or

w ithinf orm at ionf

ro m [ his ] phy sic ian th at : - V er if ie s [ his ] D isa

bil ity and - E xplains the nature and extent of [his] Disability .” Id. at 22. H elm s was3

advised that Aetna could require H elm s to sub m it to an exam by a phy sician selected by

Ae tna, otherw ise known as an independ ent m edical exam (“ IME ”). T he S T D plan pr ovi de d f or tw o le ve ls o f ap pe al , both w ithA etnaD isa bil ity Service s. I f A etna denied a ST D c laim it would provid e a written explanation that detailed “ [t] he specific r easons for the denial, [ t] he specific r efer ences in the plan doc um en t t o su

ppor t those r ea sons , [ a] de sc ri pti on o f ad dit ion al m at er ia l or inf orm at ion[ the c la im an t] c oul d pr ovi de to supp ort the c la im - - an d th e re as ons why that inform ation is necessary , and [t] he procedures available for a further reviewof [the] claim .” Id. at 28 (em phasis in original). O n 2 7 J u n e 2 0 0 3 , H e l ms ap p l i e df o r an dw a s g r a n t e dS T D b e n e f i t s f r o m 8 July 2003 through 18 August 20 03 in con nection with a m edical leave f or surgery to repair a torn rotator cuff. H elm s’ s application li sted his o ther health issues as hig h bl ood pr es sur e, an e nlarg ed pr ost at e, and thy

ro id p ro ble m s, but

it did not m en t i o n h ea d ac h es . On 2 0 Au g u s t2 0 0 3 , Dr . La rry W. Ep p er s o n , He l m s ’s neurolog ist, subm itted an Attending Phy sician Statem ent (“ AP S”) stating th at H el m s su ff

er ed f ro m c hr oni c he ad ac he s. D r. E ppe rs on f ir st h ad tr eate d H el m s on 27 February

2003 for com

plaints o f nausea and daily headaches H elm s had experienced for the several m onth s. D r. Epperson found the headaches “ very w or ri som e. ” R1 , 29- 6, a t 32 .4

In a follow- up vis it on 11 Marc h 200 3, H elm s described his headaches as constant. Dr . E pperson no ted Helm s’ s seizure in 1996 andthat He lm s’ s headaches we re at the base of his skul l and back. Am agnetic resonance im aging (“ MRI”) scan of H elm s’ s brain was norm al and an MRI of He lm s’ s cervical spine re vealed a “ sm al l f oc al dis c bul ge on the r igh t and r igh t of the m idl ine a t C 6- C7 w ith chronic appearing com

pression of the superior endplate at T 2.” Id. at 27. D r. E ppe rs on a lso c hange d H el m s’ s m ed ic at ion s be ca use L or ce t P lus w as too str ong an d M id rin was i ne ffec ti ve . Helm s’s n eu ro lo gi stals o p la nn eda fo ll ow- up in two m onths, sug ge sti ng H el m s c al l f or an up da te in thr ee w ee ks i f his c ondi tio n di d no t im prove. Helm s re tu rn edto Dr. Epp ers on wit h c hr on ic he ad ach es on 31 Marc h 2 00 3. D r. E ppe rs on’ s im

pr es sio n w as “ [c ] hr oni c he ad ac he s, c er vic al spi ne , ba ck

of the base of his skul l and top o f his head with no m eningeal sign s.” Id. at 29. D r. Epperson noted Helm s’ s histo ry of lym phom a, disconti nued Neurontin, and tried ne wm ed ic at ion s, a s w el l a s L or ce t P lus a ga in. D r. E ppe rs on a lso planne d a fo llo w -u p f or f ive to six w ee ks l at er

and r ec or de d th at

he w as c onsi de ri ng a lum bar puncture. H el m s r et ur ne d ali ttl e ove r tw o w ee ks l at er , on 1 5 Apr il 2003 , c om pla ini ng of c hr oni c he ad ac he s. D r. E ppe rs on n ote d th at he w as “ re al ly

c onc er ne d a bout5

[H el m s] in that he ha s hi sto ry of ly m phom a an d ha s c hr oni c he ad ac he s si nc e m idFe br uary . ” I d. a t 27 . Whil e H el m s di d no t a ppe ar il l at the appoi ntm en t, he de sc ri be d th e he ad ac he s a s oc curr ing da ily , start ing a t the ba ck and t op o f his head. D r. Epperson m ade additional chang es in m edications and o bserved that Me dr ol D ose pak gave H el m s si gni fi cant r el ie f w he n he w as on i t f or asho rt pe ri od of ti m e an d r ec om

m en de d af

oll ow -u p inthr ee to fo ur

w ee ks. Dr . E pperson also scheduled a lum bar puncture to rule out lym phom a, carc inom atous m eningit is, or any fungal infection. Approxim ately one wee k after the lum bar punc tur e, H el m s c om pla ine d of

se ve re spi na l he ad ac he s. H el m s w en t to the em ergency

room and the hosp ital adm itted him for observation and an epidural spin al bloodpatch. Dr . E pperson recorded that the bloo d patch resolved the spinal headaches but left H elm s with a chronic headac he in the occipital head region. D r. Epperson w rote that He lm s m ight require an occipital nerve block at his ne xt a ppoi ntm en t. On 8 May

2003 , H elm s returned to Dr . E pperson for a follow-up. D r. E ppe rs on n ote d th at

H el m s’ s he ad ac he s w er e “ som ewha t i m pr ove d onT opom ax ; but [ that] he f

e[ lt] hor ri ble . ” I d. a t 24 . H el m s to ld D r. E ppe rs on tha t he f el t wa s h ed -o u tan dfa t i g u edan dh add i ff i cu l t y d o i n g h i s jo b atwo rk . Dr . Ep p er s o n ’s im pr es sio n w as that H el m s’ s f at igu e an d di ff

ic ulty c onc en tr at ing w er e sid e ef fe ct s6

of the T opom ax he wa s taking. As a result, D r. Epperson tapere d Helm s off T opom ax “ fa ir ly

r ap idl y , ” be gan H el m s onN euro nti n, and p lanne d af oll ow -u p in four to five w eeks. Id. At the e nd of his n otes Dr. Epperson w rote: “ Consid er sh or t-t erm

di sabi li ty andhe m ay

ne edlo ng -te rm

di sabi li ty.” Id. O n 2 June 200 3, H el m s r et ur ne d to his ne ur olo gis t and D r. E ppe rs on n ote d: H el m s th ink s he m igh t be ali ttl e be tte r. H e is n owof f Pa xil and T opam ax and h e fe el s be tte r j ust be ing of f tho se dr ugs. . . . H e is ve ry c onc er ne d a bout his w ork and h e state s he ha s di ff ic ulty w orkin g be ca use of he ad ac he s and a lso his m ed ic at ion s c au se him to be se da te d a nddro wsy at ti m es . Id. at 21. D r. Epperson’ s im pression was that He lm s’ s chronic headaches w ere

“ m uc h im pr ove d. ” I d. H e re co m

m en de d af

oll ow -u p inthr ee to fo ur

m onths and co nsi de re d othe r m ed ic at ion s inthe f uture f or he ad ac he c ontro l. On 20 August 200 3, D r. Epperson faxed to A etna an A PS that detailed H el m s’ s c hr oni c he ad ac he s and i ndi cate d hi s op ini on tha t H el m s w as una ble to re tur n to w ork, but

c ap ab le of

“ [s ] ed en tary

w ork a ct ivi ty

[ as ] m ode rate li m itatio n of fun ct io na l capa ci ty.” R1, 29 -7 at 9 -1 0. On 26 Augus t 2003 , r egistered nurse L orna Blackm er c ondu cted a r eview o f t h e f o rms s ub m i t t edfo r H el m s . Nu rs e B l ac km erd ec i d edth at He l m s ’s re str ic tio ns o n li ft ing w ithhis r igh t arm w er e onl y

appr opr ia te thr ough21 Sep te m be r 20 03 .7

O n 3 S ep te m

be r 2003 H el m s r et

ur ne d to D r. E ppe rs on f

or af oll ow -u p re gard ing his c hr oni c he ad ac he s and h is h ist or y of ly m phom a. D r. E ppe rs on wro te t h a tH e l ms is d oin g r em ar

kably w el l w ithno f

urthe r he ad ac he s. H e is a lso on N euro nti n 30 0 m g on e q. i. d. , T ra zo done qhs , Co ve ra 180 qhs , and Sy nth ro id. H e is r et ir ed

and i s tr y ing to ge t D isa

bil ity and I tot al ly supp ort hi m . I have tr ie d hi m on num er ous m ed ic at ion s w ith num er ous tr ia ls i n th e pa st, a s w el l. R1 , 29- 6 a t 19 . U nde r the “ Im pr es sio ns” se ct ionD r. E ppe rs on wro te : “ Ch ro nic he ad ac he s, m

uc h im pr ove d onpr es en t r eg im en t. A dve rs e sid e ef fe ct s to P ax il an d T opam ax . ” I d. U nde r the “ Pl an ” se ct ion , he a dvi se d: “ 1. C ont inu e the above m ed ic at ion s. 2. H e m ay

de cr ea se his N euro nti n e ve ntu al ly by one e ve ry

m onth unt il he ge ts o ff

N euro nti n. F urthe rm or e, he c ande cr ea se his Me tha done . . . if he would like . . . 3. I suppo rt him in his endeavo r to retire . 4. F ollow-up in 3-4 m onths. ” I d. On 11 Septem

ber 2003, Dr . E pperson com pleted and faxed to Aetna an APS ad dr es sin g H el m s c hr oni c he ad ac he s th at not ed that H el m s’ s pr im ar

y dia gnos is w as c hr oni c he ad ac he s w ithase co ndary dia gnos is o f ly

m phom a. D r. E ppe rs on de sc ri be d H el m s’ s a

bil iti es /li m itatio ns a s, “ [n ] o a bil ity to w ork. S ev er e lim itatio n of f unc tio na l c ap ac ity ; i nc ap ab le of m ini m al a ct ivi ty . ” I d. a t 10 . U nde r the questio n “ What m edical re strictions/ lim itations are y ou placing on patient,” D r.8

E ppe rs on c onc lud ed

“ una ble to w ork. ” I d. N ur se Bl ac km er

c ondu ct ed

anothe r re vie won 2 5 S ep te m be r 2003 . S he re co rd ed r es tr ic tio ns and l im itatio ns ( R& L s) of “ no R [e tur

n] T [o ] W [o rk ] . ” R1 , 29- 12 at 5. T he next day , a ccording to Aetna’ s notes, Nurse Blackm er’ s review co nc lu de d t ha t “ [b ]asedon lac k o f cl ari ty of R&Ls an d c au sa ti on of i m pa irment,” A etnasho uld

r eque st the of

fi ce vis it not es f

ro m both D r. D . D . T hor

nbur y , the ph y si ci an Helm s s aw fo r hi s ro ta to r cu ff i nju ry , andDr. Epp ers on . R1, 2 9- 13 at 1 . O n 30 S ep te m

be r 2003 , H el m s c al le d to inquir e ab out the status of

his c la im and Aetn a to ldhi m

th atth e m ed ic al reco rd s i t h adrece iv ed“ [were ] no t en ou gh .” Id . O n 3 O ct obe r 2003 , D r. E ppe rs on r ef ax ed his 11 S ep te m

be r 2003 A PS , thi s tim e w ith addit ional comm ents. U nder the heading “ Obj ective findings th at subs tanti at e im

pa irm en t, ” D r. E ppe rs on r ec or de d th at “ [p ] at ie nt h as [ he ad ac he s] ev er y day ” an d w as “ una

ble to func tio n. ” R1 , 29- 6 a t 12 . H el m s’ s ne ur olo gis t al so i ndi cate d th at

he ha d tr ie d se ve ra l m ed ic at ion s onH el m s. O n 6 O ct obe r 2003 A etna ’ s no te s r ef

le ct that H el m s c al le d to c he ck on the status of

his c la im and t old A etnathat hi s m ed ic at ion s le ft him in a se da te d st at e, that he c oul d no t dr ive , and th athe ha d t ro ub le foc us in g a ndco nc en tra ti ng . Nur se Hol ly M. Jo hn so n t he n re vi ewedHelm s’s cl ai m on 8 Oct ob er 2 00 3. A etna ’ s no te s in dic at ed

that “ R& L s M D a dvi se s no w ork du e to c hr oni c9

headaches” and concluded “ [t] here [ wa s] not enou gh ob j ective m edical inf orm at ionto supp ort c ont inu ed dis ab ili ty . ” R1 , 29- 13 at 3. In a 13 Oc tober 2003 letter, Ae tna advised Helm s that his b enefits had been te rm inate d be ca

use “ A etnac [o uld

] not c er tif y [ his ] dis ab ili ty

be ca use [ it did ] not re ce ive [] m ed ic al inf

orm at ionto showthat [ he ] r em ai n di sa ble d. ” R1 , 29- 4 a t 7. The le tter directe d Helm s to provi de addition al inform ation if he had m edical in fo rm at io n h e wan te d Aet na to co ns id er. In a letter dated 14 October 2003, D r. Epperson w rote to Ae tna: Fortunately , w e have found a com binatio n that has worked, but it can ca use m ild se da tio n. H e is a

ppl y ing f or D isa bil ity and I tot al ly supp ort hi m

in that e nde av or . I do n ot b el ie ve he c anf unc tio n onthe pr es en t m ed ic at io ns co up le d wi th hi s ch ro ni c d ai ly head ach es . . . . H e cannot

c ont inu e to w ork onm ed ic at ionand w ithc hr oni c da ily he ad ac he s. R1 , 29- 6 a t 15 . On 27 Oc tober 2003 , Nurse Blackm er c onclud ed that Helm s’ s headaches we re im proved, that he w as cutting do wn his m edication, and that since he had worked w ith headaches while on m edications before, she w as “ unclear as to w hat changed” bey ond Helm s’ s rotator cuff repair. R1, 29-13 at 5. She c onclud ed “ that m ed ic al doe s no t su

ppor t on goi ng R &L s . . . [ H el m s’ s] c ondi tio n is im pr ove d so that hi s m ed ic at ionis be ing de cr ea se d and e lim inate d, so i f [H el m s] w orke d w ith10

m or e m ed ic at ion , [ it is] r ea sona ble [ that H el m s] c oul d w ork no wthat [ his sym pto m s] are so m

uc h be tte r an d m ed ic at ionis inc re as ed . ” I d. O n 30 O ct obe r 2003 , A etnac al le d H el m s to e xpl ai n th e cl ai m de ci sio n. T he notes stated: “ Advised that based on th e m edical, AP is indicating that [H elm s] has l o w e r e dh i s me d s . [ H e l ms ] s t a t e dth a tth i s i s u n t r u e , a s h e i s s t i l l t ak i n g th e s a me d o s a g e s ” o f

med i c a t i o n s f

o r h i s h e a d a c h e s . R 1 , 2 9 - 1 4 a t1 . On th a ts a me d a y, A etnase nt H el m s ale tte r an d D r. E ppe rs on a f ax r eg ar din g A etna ’ s de nia l of H el m s’ s S T D c la im . T he le tte r to H el m s st at ed , f or ase co nd t im e, that A etna

“ c[ould ] not certify

y our disabil ity

because w e [did] not receive[] m edical inf orm at ionto showthat y ou r em ai n di sa ble d. ” R1 , 29- 4 a t 10 . A etna ’ s 30 Oc tober 2003 fax to D r. Epperson stated that the m edical inform ation it had re ce ive d di d no t su

ppor t H el m s’ s im

pa irm en t pa st 2 2 S ep te m

be r 2003 . A etna re que ste d th e of

fi ce vis it not es f

ro m Apr il 2003 to pr es en t, de ta ile d R &L s, and the res ul ts of a ny MRIs , X-ray s, o r an y ot he r te st s re su lt s. On 13 Novem

ber 2003 Dr. Epperson provided Aetna w ith his office notes d o cu m en t i n g h i s tre at m en to f H el m s . Nu rs e B l ac kn erth en re v i ew edHe l m s ’s cl ai m , not ing that “ D r. state d [ H el m s] is una ble to w ork du e to s om e sli ght se da tio n. H ow ev er , no n ewm ed ic al giv en , no R &L s gi ve n. ” R1 , 29- 14 at 2. S he obse rv ed that H el m s ha d ahis tor

y of usi ng “ dif

fe re nt m ed ic at ion s, inc lud ing11

H y dr oc odon e pr ior

to L D W . ” I d. T he r ev ie wc ont inu ed , c onc lud ing , “ [b ] as ed on no R&Ls, given the fact that [H elm s] is able to drive, do m achinery , e tc. m edical co nti nue s to not

sup port i m

pa irm en t. ” I d. O n 19 N ove m

be r 2003 , A etnauph el d it s te rm inatio n of be ne fi ts i n ale tte r to H el m s, c la im ing , f

or the thi rd ti m e, that i t “ c[ oul d ] not

c er tif y y our dis ab ili ty be ca use w e [d id] not

r ec ei ve [] m ed ic al inf

orm at ionthat y ou r em ai n di sa ble d. ” R1 , 29- 4 a t 15 . A etna ’ s 19 N ove m be r 2003 not es ind ic at ed

that the “ im

pa irm en t i s no t supp orte d pa st 9 /22 /03 , a s m ed ic al inf orm at iondoe s no t have any R+ L ’ s. ” R1 , 29- 14 at 2. H el m s th ensub m itt ed

aw ri tte n a

ppe al . H e ar gue d th at

he ha d se ve re da ily headaches that required strong m edication to cont rol and that he felt that m ethadone and Neurontin had an adverse effe ct on his abili ty to work and perf

orm activities com

m ensurate w ith his duties as a com puter sy stem s analy st. I ncluded w ithH el m s’ s a

ppe al w as ale tte r fr om

D r. E ppe rs on tha t st at ed : Mr . H el m s su ff

er s f ro m da ily c hr oni c he ad ac he s of

ade bil itatin g na tur e. H e is p re se ntl y

takin g m ed ic at ionto co ntr ol the se ve ri ty of the headache episodes. T hese m edications, neurontin andm ethadone, ca use se da tio n in te rf

er ing w ithhis abil ity

to w ork or

dr ive ave hic le and num erous other daily activities. Mr . H elm s is unabl e to work w hil e takin g th e m ed ic at ion s r equir ed f or his c ondi tio n. H e m

ust h a v e th e me d i c a t i o n t o c o n t r o l th e p a i n . M r . H e l ms w a s s e e n b y me in m y of fi ce thi s date , his c ondi tio n r em ai ns the sam e an d he m ust co nt in ue hi s m ed ic at io n re gi m e in ord er t o c on tro l t he pa in .12

R1, 29-7 at 19. He lm s also provid ed a Social S ecurity Adm inistration (“ SSA ”) que sti onna ir e w ithhis appe al w he re in H el m s de sc ri be d so m e of the da ily dif fi cu lti es he e nc ount er ed . H e state d th at he ha d tr ie d to r ef

ra in f ro m takin g som e m edication so h e could function at w ork but th e intense pain would return when he om itted m edications. A etna acknowledged rec eipt of He lm s’ s appeal an d e xpl ai ne d th at

H el m s w oul d r ec ei ve aw ri tte n r es pons e w ith in 4 5 day s or be not if ie d if an e xte nsi on w as ne ce ssary , and w oul d be tol d w hy a ddi tio na l t im e is needed. A etna notified Helm s within 45 day s that it was extending the appeal de ad li ne by 45 d ay s. A etnade nie d H el m s’ s a

ppe al and c onc lud ed

that i t w as c or

re ct in its original decisio n to term inate benefits. A etna ref erence d Helm s’ s SSA que sti onna ir e w he re in H el m s w ro te that he w as not able to dr ive of

te n and tha t he ha d to li e down se ve ra l t im es aday . A etnac onc lud ed : [ t ]h i s qu e s t i o n n a i r e p r o v i d e s i n s i g h ti n t o th e a c t i v i t i e s M r . H e l ms m ay be able to do o r not

do w ith in the c our se of

the day . I t do es not ad dr es s any

ty pe of j ob r el at ed

f unc tio ns. I t do es not

inquir e ab out re str ic tio ns and o r lim itatio ns, w hic h w oul d pr ev en t M r. H el m s f ro m re tur nin g to his pos iti on a s asy ste m s ana ly st. R1 , 29- 7 a t 12 . A etna ’ s le tte r sum m ar iz ed D r. E ppe rs on’ s 14 O ct obe r 2003 narr at ive not e an d c onc lud ed that i t di d no t pr ovi de “ m ed ic al inf orm at ionto13

subs tanti at e a tot al dis ab ili ty f ro m w ork a s asy ste m s ana ly st. ” I d. A etnaa lso decided that Dr. Epperson’ s 25 Novem ber 2003 narrative note provid ed “ no new inform ation to su pport restrictions andlim itations from work. ” Id. T he letter co nti nue d by

statin g th at

a t the ti m e H el m s su

bm itt ed his ini tia l c la im

( re la tin g to his rotator cuff), he did not m ention recurrent headac hes. A lthou gh Helm s was out of work from

20 April 2003 th rough 2 May 2003 for r ecovery

from a lum bar punc tur e co m

pli catio n, A etnar ea sone d th at H el m s di d no t sp ec if

ic al ly m en tio n s ev er e h ea d ac h es as a r ea s o n fo r t h e p ro ce du re , r at h ero n l y “p ai n .” Ae t n a’s analy sis conclud ed that Mr. He lm s began com

plainin g of severe hea daches in February 2003 . H e w orke d, f

ull ti m e w hil e takin g m

ult ipl e m ed ic at ion s, i n c l u d i n g an a r c o t i c . . . D r . E p p e r s o n h a s s t a t e dth a tM r . H e l ms expe ri en ce s se da tio n f

ro m his m ed ic at ion , w hic h is w hy he c annot w ork. T he m ed ic at ionMr . H el m s w as takin g a t the ons et of di sabi li ty w as rep orte d . . . to be Synt hr oi d, Fl om ax an d C ov era. T he re is no m en tio n of

ase da tin g, narc oti c m ed ic at ion . Me dic at ion he ha s b een tak in g wh il e o ut of wo rkis Met ha do ne an d Neu ro nt in . If Mr . H el m s w as not

on this m ed ic at ionr eg im e at the ons et of disabili ty in July2003 , and has no t worked since this m edication was pr es cr ibe d he c annot

a de quate ly

be e va luate d w ithr es pe ct to restrictions and lim itations in the workplace. T he re fo re , ba se d onour

r ev ie w. . . the m ed ic al inf orm at iondoe s no t co nta in any

obj ec tiv e co ndi tio ns, w hic h w oul d su ppor t a dis ab ili ty

of suc h ase ve re na tur e as to pr ec lud e him f ro m r et ur nin g to w ork. Id . a t 13 .14

On 1 8 M ay

20 04 Helm s fi le d aco m

pl ai nt un de r 29 U.S.C. § 1 13 2. He soug ht S T D be ne fi ts, L T D be ne fi ts, and a lso e qui ta ble r el ie f. T he part ie s f

ile d a consent to jurisdiction by m agistrate j udge and filed cross-m otion s for sum m ary j udgm ent. A fter br iefing and oral argum ents, the m agistrate j udge granted D ef en dants ’ m oti on f

or sum m ar y j udgm en t and d en ie d H el m s’ s m oti on f or su m m ary jud gm en t. Hel m s t im el y ap pe al edth e m ag is tra te jud ge ’s dec is io n. II. ST AN DA RD OF RE VIEW W e re vie wadis tr ic t c ourt’ s gr an t of sum m ar y j udgm en t i n an E RI SAc as e de novo , ap p l yin g th e s ame l eg al s t an d ar d s th at co n t ro l l edth e d i s t ri ct co u rt ’s de te rm inatio n. W ill iam s v. Be llS outh T el ec om m s. , I nc . , 373 F . 3d 1 132, 113 4 (1 1t h C ir. 2 00 4) . W e apply the following procedure in review ing deni als of benefits under E RI SAplans: (1) Applythe de novo standard to de te rm ine w he the r the c la im adm inistrator’ s benefits-denial decision is “ wr ong” (i.e. , the c ourt dis ag re es w iththe a dm ini str at or ’ s de ci sio n) ; i f it is n ot, the n e nd the inquir y and a ff irm the de ci sio n. (2 ) If the a dm ini str at or ’ s de ci sio n inf ac t i s “ de novo wr ong,” then de te rm ine w he the r he w as ve ste d w ithdis cr et ionin re vie w ing c la im s; if not , e nd j udi ci al inquir

y and r ev er se the de ci sio n. (3 ) If the a dm ini str at or ’ s de ci sio n is “ de novo wr ong” and he was vested with discretion in reviewing claim s, then determ ine whether15

“ reasonable” grounds su pported it (hence, r eview his decision und er the m ore defe rential arbitrary and capricious standard). (4 ) If no r ea sona

ble gr ound s e xis t, the n e nd the inquir y and r ev er se the adm inistrator’ s decision; if re asonable groun ds exist, then de te rm ine if

he ope rate d un de r a co nf lic t of int er es t. (5 ) If the re is no c onf

lic t, the n e nd the inquir

y and a ff irm the de ci sio n. (6) If there is a c onflict of interest, then apply heightened arbitrary an d c ap ri ci ous re vie wto the de ci sio n to a ff irm or de ny it . Id. at 1137 -38 (footnotes om itted). W e fo llo wthi s a

ppr oa chin re vie w ing both an a dm ini str at or ’ s in te rp re ta tio n of a plan and its factual deter m ination s. S ee id. at 1134 n.3. H ere, the parties ag re e that A etnaw as ve ste d w ithdis cr et ionand tha t, the re fo re , the arb itr ar y and ca pr ic iou s st an dard

appl ie s he re in som e fo rm . T he y dis ag re e, how ev er , a s to whe th er t he he ig ht en edst an da rdap pl ie s. He lm s argues that Ae tna is operating un der a c onflict of interest betwee n its fiduciary

role and its profit-m aking role because, a lthou gh Aetna does not pay be ne fi ts t o S T D plan part ic ipants out of it s own a sse ts, H el m s a sse rt s th at A etna pay s L T D plan part ic ipants out of it s own a sse ts. T he re fo re , H el m s c la im s, A etna ha s af inanc ia l i nc en tiv e to d eny S T D c la im s, the re by

r ed uc ing the a m ount

of ST D c la im s th at

e ve ntu al ly

be co m e L T D c la im s. W e ne ed not de ci de that i ssu e to da y be cau se , as we d is cu ss be lo w, we ho ldth atAetn a’s de ci si on to de ny STD16

be ne fi ts d oe s no t surv ive e ve n th e m or e de fe re nti al arb itr ar y and c ap ri ci ous standard (as oppos ed to a heightened arbitrary and capricious standard of review w he n ac onf

lic t of int er es t i s pr es en t) . S ee id. a t 11 38 ( statin g th at “ [i ] f no re as o n ab l e g ro u n d s ex i s t , t h en en dth e i n qu i ry an dre v er s e t h e a d m i n i s t ra t o r’s decision; if reasonable ground s do exist , then deter m ine if he operated under a conflict of interest . . . . ”). III. D ISCU SSION A . S T D Be ne fi ts C la im Inde te rm ini ng whe the r A etnaw as de novo w ro ng and unr ea sona ble in term inating He lm s’ s ST D benef its, w e begin with the plan itself, since an ERI SA plan a dm ini str at or

m ust “ dis ch ar ge his dut ie s w ithr es pe ct to a plan . . . in accordance with the docum ents and ins trum ents gov erning the plan in sofar as such docu m ents and ins trum ents are c onsis tent with the provisio ns of [E RISA ] .” 29 U . S. C. § 11 04( a) (1 )( D ). U nde r A etna ’ s pl anse ct ionla be le d “ Me dic al P ro of

of Disability ,” He lm s was r equired to provid e inform ation from his phy sician that verified and explained the nature and extent of his dis ability . He lm s argues that he has m et A etna’ s ST D r equirem ents and that no t onlywa s Aetna’ s procedural handl ing of

his S T D c la im

f law ed , but

that A etna ’ s su

bst an tiv e re as oni ng f

or the denial of his STD claim

wa s faulty . For the following rea sons , w e agre e.17

1. A etna ’ s P ro ce dur al H an dli ng o f H el m s’ s S T D Cl ai m A etnane ve r subj ec te d th e m ed ic al e vid en ce pr ovi de d by D r. E ppe rs on t o peer r eview, nor did Aetna ever subject H elm s to an indepen dent m edical exam (“ IME ”). W e have been cr itical of a nurse’ s reviewwhen a m eaningful review dic ta te d a sse ssm en t of

spe ci al iz ed

te sts be y ond a nur se ’ s tr ai nin g. S ee L ev ins on v. Re li an ce St an da rdLife I ns . Co., 2 45 F.3d13 21 , 13 26 -2 7 (1 1t h C ir. 2 00 1) . Here, wh il e n o re vi ews of s pe ci al iz edtes ts were n eces sa ril y req ui red , th e STD be ne fit s h in ge d o n adi ag no si s t ha t ev en Nurs e Bl ack m er ad m it te d was su bjec ti ve . A etnaw as pr es en te d w ithno e vid en ce that su gge ste d th at H el m s w as a m alingerer; conversely , the r ecord w as replete w ith nu m erous office visit notes an d narr at ive s f

ro m D r. E ppe rs on e xpr es sin g w or ry ove r H el m s’ s c ondi tio n and cred it in g h is co m

pl ai nt s o f de bi li ta ti ng ch ro ni c h ead ach es . In Godfr ey

v. Be llsou th Telec omm

unication s, I nc., a nurse prac tition er ne ve r bothe re d to ga the r the tr eatin g do ct or ’ s no te s and t es t r es ult s. 89 F. 3d 7 55, 758- 59 ( 11th C ir . 199 6) . H er e, A etna ’ s no te s c onc lud ed that A etnasho uld re que st the of

fi ce vis it not es f

ro m both D rs . T hor

nbur y and E ppe rs on. S im ilar to the facts in G odfrey , A etna’ s records do not reflect that A etna ever followed thr oughon i ts n o t a t i o n th a ti t“ [ w a s ] n e c e s s a ry” t o g at h eral l o f D r. Th o rn b u ry’sAdmittedly , Dr. Thor nbury treated Helms’s for

his rotator cuf

f injury , not his headac hes. 1 Neve rtheless, the r ecor d fails to indicate that Ae tna followed through on its own sugg ested c ours e of a c tio n la id o ut i n it s inte rn a l no te s. Al tho ugh n ot d ir e c tly re late d to He lms ’s he a da c he s, the complete or

thopedic re cords c ould have indicated whethe r Dr. T hornbury noted any

signs of m al i n ger i n g. We a re no t e sp ou sin ga

ru le that qu a lif

ie d nur se s c an n e ve r r e vie w c la ims , b ut i n 2 circ umstances suc h as these, w ith highly subjective de terminations, a pee r re view or a n I ME was war rante d. 18 of fi ce not es and t es t r es ult s. S ee id. 1 G ive n th e ci rc um stanc es , A etna ’ s r el ianc e on a r eg ist er ed

nur se ’ s r ev ie wof an adm ittedly

subjective diagnosis withou t so m uch as a peer

reviewor an IME w as w ro ng and unr ea sona ble . S ee G odf

re y , 89 F . 3d at 75 8- 759 (h old ing that the re co rd sup porte d th e dis tr ic t c ourt’ s f ind ing that de fe ndant’ s ph y sic ians arb itr ar ily re j ec te d c le ar

m ed ic al e vid en ce that pl ai nti ff sub m itt ed

and i gnor ed

the m edication that claim ant had to take on a daily basis without exam ining her the m se lve s or

se ek ing the tr eatm en t no te s of he r doc tor s) ; se e al so K

uni n v. Benefit T rust Life Ins. C o., 910 F.2d 534, 538 (9th Cir. 1990 ) (holding th at an E RI SAa dm ini str at or ’ s in ad equa te inv es tig at ionand r el ianc e on n on- expe rt s in t h e f i el dfa i l edt o p ro v i d e are as o n ab l e b as i s fo r t h e a d m i n i s t ra t o r’s d e t e rmi n a t i o n ) . L i k e o u r s i s t e r c i r c u i t , w e b e l i e v e th a t“[ a ]l t h o u g h i n s o me 2 co nte xts it

m ay not be arb itr ar

y and c ap ri ci ous to r eq

uir e cl ini ca l e vid en ce of

the et iol ogy of the a lle ge dly

dis ab lin g sy

m pto m s inor de r to v er if

y that the re is no19

m alingering, we conclude that it was ar bitrary and capricious to require such evidence in the context of this [p] lan” and He lm s’ s case. See Mitchell v. E astm an Kod akCo ., 11 3 F .3d43 3, 4 42 -4 3 (3 d C ir. 1 99 7) . A etna ’ s own pr oc ed

ur es se t f orth tw o a

ppe al s le ve ls H el m s ne ed ed to ex ha us t b efo re b rin gi ng su itin eit he r st at e o r fed eral co ur t. At app eal “ Lev el 1,” A etna ’ s “ de ci sio n w [o uld ] be f or w ar de d to [ the c la im an t] in w ri tin g and w [o uld ] include the sp ecific reasons and plan refer ences on which the decision is based.” R1, 29-5 at 29. At a

ppeal “ Le vel 2,” A etna’ s procedures state that it would notify a cl ai m an t of

A etna ’ s de ci sio n w ith in 4 5 day s of A etna ’ s r ec ei pt o f the r eque st f or a L ev el 2 r ev ie w . I f A etnane ed ed a ddi tio na l t im e, it

w oul d no tif

y the c la im an t

“ du rin g t ha t 4 5- da y

pe rio d o f why add it io na l t im e is ne ed ed .” Id . A etnaw as w ro ng i n f

ai lin g to c om

m uni cate suf

fi ci en tly it s j ust if ic at ion s fo r both th e vari ous ini tia l de nia ls H el m s r ec ei ve d and the e xte nsi on A etna gr an te d it se lf

in ult im at el y

de ny ing H el m s’ s L ev el 2 Appe al . T he thr ee ide nti ca l, ini tia l de nia l l ette rs la ck

the r equir ed

spe ci fi ci ty . A etna ’ s le tte rs f ro m 13 and 3 0 Oc tober 2003 and 19 Novem ber 2003 all stated that Aetna “ c[ould ] not certify [H el m s’ s] dis ab ili ty

be ca use [ the y ] ha [d ] not

r ec ei ve d m ed ic al inf

orm at ionto s h o wth a t[ H e l ms ] r e mai n [ e d ] d i s ab l e d . ” R 1 , 2 9 - 4 a t7 , 1 0 , 1 5 . I n t e rn a l l y, however, even before the 13 October 2003 denial, Ae tna’ s review er c onclud edAetna’ s internal notes va cillated betwe en the c onclusion that the restric tions and 3 limit ations prese nted wer e insuffic ient and the c onclusion that Helms failed to pre sent any re str ic tio ns and

lim itatio ns . Co mpa

re R1, 29 -1 3 at 3 ( no tin g“ R& L s MD a dv ise s n o w or k d ue to chronic heada ches” ) with R1, 29-14 at 2 (c oncluding“[b] ased on no R& L s, g iven the fa ct that [Helms] is able to drive, do mac hinery , etc. medic al continues to not support impairment”) . Given that Ae tna has discr etion in terms of what it considers ade quate “ proof” of 4 disability , we c annot say

that it is alway s unrea sonable for Aetna to de mand objective e vidence . Acc ord Wang enstein v. Equifax , Inc., 191 F ed. Appx. 905, 913-14 (11th Cir. 2006) (unpublished) (“ [G] iven that KNS has discr etion in terms of what it considers ade quate ‘ proof’ of continuing disa

bility , we c annot say

that it is unreasonable for KN S to demand objective evidenc e.”) . We note, howeve r, that this case is disti nguishable fr om Wange nstein on its facts. As an initial matter, the plan a dminist rator in Wang enstein had f our doctors c onduct five independe nt paper

peer revie w consultations and a ne urolog ist conduct an I ME, neither of which was pe rfor

med her e. I d. at *2-4. The re, the neurolog ists recommende d specific additional documentation and pr ocedur es that would be he lpful. I d. at *8. Her e, in contra st, Aetna re pe ate dly

g ave no ind ic atio n to He lms a s to wh at it ne e de d, e ve n a s it

int e rn a lly

no te d th at it la c ke d o bje c tiv e e vid e nc e and su ff ic ie nt r e str ic tio ns and

lim itatio ns . 20 that H el m s la ck ed

“ en oughobj ec tiv e m ed ic al inf orm at ion ” to s uppo rt

c ont inu ing his S T D be ne fi ts, R1 , 29- 13 at 3, an d th at H el m s f ai le d to pr es en t su ff

ic ie nt ( or any ) re str ic tio ns and l im itatio ns. N ow he re in A etna ’ s f ir st thr ee de nia l l ette rs did 3 A etnae xpl ai n it s c onc lus ionr eg ar din g ob j ec tiv e ev ide nc e. F urthe rm or e, A etna fa ile d to ide nti fy

any spe ci fi c ex am

ple s of obj ec tiv e ev ide nc e that H el m s c oul d have subm itted in support of his STD claim , despite A etna’ s own policy that stated that denied claim ants would receive “ [a] description of addit ional m aterial or inf orm at ion[ the y ] c oul d pr ovi de to supp ort the c la im - - an d th e re as ons w hy that i nf orm at ion[ w a] s ne ce ssary . ” R1 , 29- 5 a t 28 . In fac t, on A etna’ s own AP S 4 fo rm und er the que sti on tha t a sks f

or “ O bj ec tiv e fi ndi ngs that su bst an tiate21

im pairm ent,” Ae tna gives exam ples that includ e “ current laboratory , phy sical an d/o r m en ta l st at

us e xam inatio n, and o the r te sti ng. ” S ee , e . g. , R1 , 29- 6 a t 12 (e m pha sis a dde d) . N ot o nly

did A etnar ep eate dly

ne gle ct to inf orm H el m s th at

it re qu i re d“ o b

je ct i v e” ev i d en ce , b u t , b as edo n i t s o wn fo rms, Dr . Ep p er s o n ’s ex am inatio ns o f H el m s sh oul d have qua lif ie d a s “ obj ec tiv e fi ndi ngs. ” N or do the three initial denial letters specifically ref erence a need to provide or clarif y H el m s’ s r es tr ic tio ns and l im itatio ns. U nde r the pla in l an gua ge of it s pl an , A etna w as w ro ng t o se nd H el m s th es e te rs e le tte rs . S ee Mi tc he ll, 113 F . 3d at 44 2 ( “ T he A dm ini str at or ’ s de nia l l ette rs are te rs e, and w e ar e not a lto ge the r ce rt ai n of

the ir m eaning.”). N o reasonable interpretation of Ae tna’ s plan docu m ents perm itted A etnato se nd b oil er

plate le tte rs that di d no t su ff ic ie ntl y dis cl ose A etna ’ s r ea sons f o r th e d e n i a l o f

H e l ms ’s S T D c l a i m. At a ppeal “ Le vel 2,” A etna’ s procedures stated that it would not ify cl ai m an ts o f A etna ’ s de ci sio n w ith in 4 5 day s of A etna ’ s r ec ei pt o f the r eque st f or a L ev el 2 r ev ie w . A etnapr om ise d th at a ll ex te nsi on n oti ce s f

or r ev ie w ing disabili ty claim s would explain: “ - T he standards used in determ ining whether a part ic ipant i s e nti tle d to abe ne fi t, - T he unr es olv ed iss ue s th at

pr ev en t a de ci sio n on the claim , and - The a dditi onal inform ation needed to resolve th ose issues.” R1 , 29- 5 a t 28 . W ithr eg ar d to L ev el 2 a ppe al s sp ec if

ic al ly , A etnac la im ed

that i f22

it ne ed ed a ddi tio na l t im e, it

w oul d no tif

y the c la im an t “ dur ing that 45 -d ay pe ri od of why addition al tim e is needed.” Id. at 29. A etna’ s letter notify ing Helm s that A etnaw as e xte ndi ng the appe al de ad lin e fa ile d to giv e any r ea son as to w hy

the ad dit ion al ti m e w as ne ed ed to re ac h ac onc lus ion . N o r ea sona ble int er pr et at ionof the plan a llo w s A etnasim ply to ign or e the sub stanc e of it s own no tif

ic at ion re qui re m en t. 2. A etna ’ s A na ly sis of

H el m s’ s S T D Cl ai m In addition to asserting that Aetna’ s claim s procedures we re inadequate, Helm s al so arg ue s t ha t Aet na ’s subs ta nt iv e an al y si s o f hi s STD cl ai m was fl awed . W e ag re e. I n r ev ie w ing the r ec or d a s aw hol e an d takin g th e ev ide nc e in the li ght m ost favorable to Aetna, we find no su fficiently contradictory

evidence fr om

Dr . Epperson regar ding He lm s’ s im pairm ent. A etna and the dissent try to paint Dr. Epperson’ s opin ions as in consist ent, but we find that the portio ns of the m edical evidence that cast H elm s as im proving are qualified by

the undis puted fact that his im pr ove m en t w as de pe nde nt o n m ed ic at ionthat l ef t hi m se da te d and interfer ed with his daily

functions. It is true that D r. Epperson rec orded an im pr ove m en t i n H el m s’ s he ad ac he s inhis of fi ce vis it not es of

3 S ep te m

be r 2003 , but D r. E ppe rs on’ s no te s f

ro m that day a lso r ec om

m en de d th at

H el m s c ont inu e his m ed ic at ion s and s ugge ste d th at he c oul d de cr ea se his m ed ic at iondos ag e at hisAe tna ’s re c or ds re fl e c t th at H e lms no tif ie d A e tna that he ha d n ot, in f

a c t, r e du c e d h is 5 medication af

ter the 3 Septe mber 2003 visit with Dr. Epper son. 23 ow n di sc re tio n. D r. E ppe rs on’ s late r A PS , and h is l ette rs of 14 O ct obe r 2003 5 an d 25 N ove m

be r 2003 , f

urthe r cl ar if

ie d and c ont ex tua liz ed

his of fi ce vis it not e fr om 3 S ep te m

be r 2003 . S ta te d si m

ply , H el m s’ s c ondi tio n “ im pr ove d” onl y t h r o u g h me d i c a t i o n th a tc o n t r o l l e dth e s e v e r i t y o f th e h e a d a c h e s b u tl e f

tH e l ms se da te d and i nte rf

er ed w ithhis abil ity

to w ork and dri ve . R 1, 29- 7 a t 19 . A t no p o i n td i dD r . E p p e r s o n v a c i l l a t e r e g a r d i n g h i s u l t i ma t e c o n c l u s i o n th a tH e l ms qualified for disabilitybenefits. Ae tna essentially pulled two posi tive sentences out of D r. E ppe rs on’ s 3 S ep te m be r 2003 not es and d isc re dit ed or ign or ed the undi sput ed

e vid en ce c onsi sti ng o f the ne ur olo gis ts’ num er ous of fi ce vis it not es , A PS s, and n ar

rativ es that st at ed

that H el m s’ s c ondi tio n di d no t c ont inu e to im pr ove unl es s onse da tin g m ed ic at ionand tha t H el m s w as una ble to w ork inhis co ndi tio n. Adoc tor ’ s tr eatm en t r ec or ds w ill of te n no te im

pr ovi ng and de te ri or at ing c ondi tio ns, e spe ci al ly in sit ua tio ns s uc h a s th es e, w he re in a doc tor ha s tr ie d di ff

er en t c om bin at ion s of

m ed ic ine s w ithvari ous re sul ts. U nde r the dis se nt’ s lo gic , any

not ed im pr ove m en t, how ev er

e xc ise d f ro m the c ont ex t of

the unr ef ute d m ed ic al c onc lus ionthat H el m s w ar rante d di sa

bil ity , m ust r es ult in a tr ia ble que sti on o f fa ct . V ie w ing the e vid en ce in the li ght m ost f av or ab le toFur thermore , Aetna’ s argument on appea l that Dr. Epper son merely stated that He lms’s 6 medication could “ cause mild sedation” but did not claim that the medication ac tually cause d H e l m s s e d at i o ni s n o to n l y post hoc rea soning, but a lso wrong . See R1, 29-7 at 26. Dr . Epperson note d in a 25 Novembe r 2003 letter submitted with Helms’s appe al that the medications “c ause[d] sedation interfer ing w ith his abili ty to work or dr ive a ve hicle and numerous other

daily activities.” R1, 29-7 at 19. Even Ae tna’s own notes a cknowledg e that “[m] eds leave him in a sedated state, c an’t drive , and has trouble focusing/conce ntrating .” R1, 29-13 at 2. 24 Ae tna still leaves Aetna unable to ref ute the fact that H elm s’ s im proved status at the ti m e w as ar es ult

of ar eg im en t of

dr ugs that l ef

t hi m se da te d and, in the opi nio n of

the onl y doc tor inv olv ed in H el m s’ s r ev ie w , una

ble to w ork. I f A etna be lie ve d th at

the re w as ac ontra dic tio n inthe D r. E ppe rs on’ s no te s, it c oul d have ha d c ondu ct ed

ape er r ev ie wof

H el m s’ s f

ile and i t c oul d have or de re d an I ME to gain additi onal perspective, especia lly since Nurse Blackm er her self adm itted that

“ [m ] igr ai ne is a subj ec tiv e dia gnos is. ” R2 , 44- 2 a t 85 . 6 T o c onc lud e, a s A etnadid , that H el m s pr ovi de d in suf fi ci en t r es tr ic tio ns o r lim itatio ns, or

e ve n no r es tr ic tio ns and l im itatio ns at a ll, is w ro ng b ec au se it is co ntr ar y to the und isp ute d e vid en ce . I n li ght of it s own f orm s, A etna unr ea sona

bly c onstru ed

w ha t qu al if

ie d a s “ re str ic tio ns and l im itatio ns. ” Whil e Ae t n a w as n o ts at i s fi edwi t h Dr . Ep p er s o n ’s re s t ri ct i o n s an dl i m i t at i o n s , Ae t n a’s A PS f orm onl y giv es pithy

e xam ple s of r es tr ic tio ns and l im itatio ns, sug ge sti ng:

“ A ct ivi tie s of

D ai ly L ivi ng, D ri vin g, L if

tin g, P ull ing , P ushi ng, and A m ount s, et c. ” R1 , 29- 6 a t 12 . D r. E ppe rs on s ta te d th at H el m s ha d di ff

ic ulty dr ivi ng andThe dissent asse rts that the fa ct that Helms per formed his wor k throug hout the period of 7 treatment is evidence that allows a re asonable infere nce that Helms’s hea dache s did not render him disabled. We have c onsidered similar a rguments in prior ca ses and noted doubt that a n applicant’ s status as a full-time employee c onstitut es evide nce that he was a ble to perf

orm the materia l duties of his occupation on a full-time basis. L evinson, 245 F.3d at 1327 n.6 (“[Applicant] ‘g ave it a g o’ and he r attempt to work doe s not foreve r bar her c ollection of sickness disability

benef its.’” (c iting Mar ece k v. Be llSout h Telec omms., I nc., 49 F .3d 702, 706 (11th Cir. 1995)). 25 w orkin g. A etna ’ s 18 Augus t 20 03 n ote s c onf irm ed that H el m s ha d r es tr ic tio ns re gard ing dr ivi ng and w orkin g w ithm ac hin er y . R 1, 29- 12 at 2; 29- 13 at 2. A lso , He lm s presented evidence, such as his question naire, wher ein Helm s indicated that he had troubl e driving, am ong o ther things , and frequently needed to lay down and rest through out th e day . A etna’ s appeal denial letter adm itted that 7 He lm s’ s questio nnaire “provide[d] insig ht [into] the a ctivities of Mr. He lm s m ay be able to do or not d o within the course of the day .” R1, 29-7 at 12. In the very next line, however , A etna then concluded th at the question naire “ d[id] not inq uire ab ou t re st ric ti on s an d l im it at io ns ” th atpre ve nt edHelm s fr om returni ng to work . Id . I t i s ba ff

lin g ho wA etnac oul d c onc ed e that H el m s ha d di ff ic ulty dr ivi ng and ne ed ed to lay down oc ca sio na lly

and the n go on t o c onc lud e in the ve ry ne xt l ine that H el m s f

ai le d to sub m it any

r es tr ic tio ns and l im itatio ns. A etna ’ s r el ianc e on B la ck & D ec ke r D isa

bil ity P lan v. N or d, 538 U . S. 822 , 123 S. Ct . 196 5 ( 2003 ), is unc onvi nc ing . N or d in str uc ts u s th at

w e m ay not im pose on p lan a dm ini str at or s “ a dis cr et e bur de n of e xpl an at ionw he n th ey

c re dit26

reliable evidence that conflicts w ith a treating phy sician’ s evaluation,” 538 U. S. at 834 , 123 S . Ct . a t 19 72, but he re the re w as no e vid en ce oth er than th at of He lm s’ s treating phy sician Dr. Epperson and He lm s him self. P u tan o t h e r wa y, thi s is not ac as e w he re in the plan a dm ini str at or r ef use d to c re dit

the opi nio ns o f doc tor s th at

sup porte d di sa

bil ity but ins te ad a cc or de d gr eate r w ei ght

to co nf li ct in g o pi ni on s o f do ct or s t ha t d idno t s up po rt d is ab il it y . See, e.g ., Wan g en s t ei n , 1 9 1 Fe d . Ap p x . a t9 1 2 -1 3 (up h o l d i n g a p l an ad m i n i s t ra t o r’s w ei ghi ng o f m

ult ipl e ne ur olo gis ts’ e xam inatio ns and r ev ie w s bu t ul tim at el y crediting neurolog ists that d id not suppo rt a f indin g of disabili ty ). W ith on ly Dr . E ppe rs on’ s m ed ic al e va luatio n inthe f orm of his of fi ce not es , te st r es ult s, A PS s, an d narr at ive s, A etnae xc ise d narr owsni ppe ts o f D r. E ppe rs on’ s no te s, w hil e it discredited or igno red w hole tracts of his m edical evaluation that sup ported H el m s’ s S T D c la im , a ll w ith out ape er r ev ie wor

an I ME . A etna ’ s r ev ie win thi s ca se w as m al ign an t at w or st, and arb itr ar y a t be st. S ee N or d, 538 U . S. a t 83 4, 123 S. Ct . a t 19 72 ( “plan a dm ini str at or s . . . m ay not arb itr ar ily

r ef use to cr ed it a claim ant’ s reliable evidence, includin g the opin ions o f a tr eating phy sician.”) . H er e, A etnapos se sse d on ly asc int ill a of

e vid en ce pul le d ou t of

c ont ex t ag ai nst the e xte nsi ve doc um en ta tio n of H el m s’ s c hr oni c he ad ac he s and p ow er fu l m ed ic at ion . Whil e A etnase iz ed ali ne in D r. E ppe rs on’ s S ep te m be r 2003 r ec or dsTh e dis se nt’ s su g g e sti on that “ [t]hin g s c ha

ng e d o nly a ft e r H e lms un de rw e nt s ur g e ry to 8 repa ir a torn r otator cuf

f on Jul y 8” is simply

a mischar acte rization of the rec ord. He lms had so ught t re atme nt f

or he a da c he s si nc e F e br

ua ry 20 03 and in M ay 20 03 Dr . E pp e rs on

wr ote , w ith reg ard to He lms’s heada ches: “ Consider short-ter m disabilit y

and he ma

y need long -term disability .” R1, 29-6 at 24. Fur thermore , any

intimation by

Aetna or the dissent that Dr. Eppe rson somehow 9 imp ro pe rl y

“ pr omi se [d]” that he wo uld su pp or t H e lms in v iol atio n o f h is e thi c a l dutie s a s a phy sician is completely

unsupported in the re cord. See Scotto v. Almenas, 143 F .3d 105, 114 (2d Cir. 1998) (holdingthat the par ty opposing summar

y judgme nt “may

not rely on conclusory alleg ations or unsubstantiated spec ulation”). 27 that no te d H el m s’ s c ondi tio n gr eatly im pr ove d, that e vid en ce a lon e doe s no t cr eate atr ia

ble iss ue of

f ac t whe n it

is undi sput ed

that the r em ar

k w as w ri tte n in the c ont ex t of

the dr ugs H el m s c ont inu ed

to take -- dr

ugs that l ef

t hi m m ild ly sedated and interfere d with num erous daily activities. In a le tter dated O ctober

8 2003 , D r. Epperson clar ified that while H elm s’ s conditi on had im proved, it wa s sti ll his opi nio n th at

H el m s w ar

rante d di sa

bil ity be ne fi ts a s ar es ult

of his decrea sed functionalit y

due to present m edications and li ngering headaches. If 9 A etnaw as dis sa tis fi ed

w iththe e vid en ce of

dis ab ili ty

and r es tr ic tio ns and l i mi t a t i o n s s ub mi t t e db y H e l ms an dD r . E p p e r s o n , i tw a s e n t i t l e dt o r e qu i r e H e l ms unde rg o an I ME or

to subm it H el m s’ s f

ile to a pe er

r ev ie w . H ad

A etnadon e so, Ae tna would have been entitled to d iscount Dr . E pperson’s opinion in favor of a co ntr ar y opi nio n pr oduc ed

by an I ME or

ape er r ev ie w . S ee H ouse v. P au l Revere Lif

e Ins. Co., 241 F.3d 1045 , 1048 (8th Cir. 2001) (“ If P aul Revere wa s28

dis sa tis fi ed

w iththe m ed ic al e vid en ce sub m itt ed by N ole w aj ka , it

w as e nti tle d to re qui re H ouse to subm it to an [ IM E ] . H ad it don e so, P au l R ev er e w oul d have been entitled to di scount Nolewaj ka’ s opin ion entirely in favor of a contrary op in io n p ro du cedby the in de pe nd en t ex am in er.”) . W e fi nd i t i s un re as ona

ble , and the re fo re arb itr ar y and c ap ri ci ous, f

or A etna to h av e re pe at ed ly

she athe d it s tr

ue j ust if ic at ion s inboi le rp la te langua ge in its first three denial letter s to Helm s. A etna wa s also unreasonable to h ave ignored s ub m i t t edre s t ri ct i o n s an dl i m i t at i o n s an dex ci s edo n l y s n i p p et s o f D r. Ep p er s o n ’s ev al ua tio ns w ith out

the c ont ex t of

the se da tin g m ed ic at ion s indis cr ed iti ng o r igno ring overwhelm ing po rtions of Dr. Epperson’ s m edical evidence that supp orte d H el m s’ s S T D c la im . F ina lly , A etnaw as unr ea sona ble w he n it

f ai le d to ini tiate ape er

r ev ie wor

an I ME that c oul d have pr ovi de d a ddi tio na l pe rs pe ct ive on thi s adm ittedly

subjective diagnosis. T o be clear , w e ar e not hold ing th at A etnam ust a lw ay s have adoc tor

pe rf orm a c la im s r ev ie wor

e ve n th at af ai lur e to pe rf orm an I ME is ne ce ssari ly

arb itr ar y and c ap ri ci ous. R athe r, w e fi nd tha t, in thi s c as e, A etna ’ s m

y opi c an d f

law ed r ea soni ng and i ts p ro ce dur al f ai lur es to pr ope rl y inf orm H el m s of the spe ci fi c re as ons fo r his de nia l i n ati m el y f as hio n, co upl ed w iththe la ck

of an I ME of

an a dm itt ed ly

sub j ec tiv e co ndi tio n, is ar bitrary and c ap ri ci ous. S im ilar to the c onc lus ionr ea ch ed by the dis tr ic t c ourt i nThe dissent cites non- binding c asela w that sug g ests a re mand to the plan administrator 10 may be the a ppropriate course of ac tion. W e disagree . As the majority in L evinson held, we too find that “[Aetna] had more tha n adequate opportunities to establish an administrative re cord containingevidenc e contr adicting[Helms’s] evidenc e pointing to disability . . . . [Aetna] did not do this.” See 245 F .3d at 1328. 29 L ev ins on, “ the re w as absol ute ly no j ust if ic at ionf or [ A etna ’ s] de nia l of

[ H el m s’ s] be ne fi ts c la im . [ A etna ] did not have adoc tor

r ev ie w[ H el m s’ s] c ondi tio n and pr es en te d no e vid en ce to [s uppo rt ] it s f ind ing s th at

[ H el m s] w as not

e nti tle d to be ne fi ts. I n e sse nc e, the re w as no d isp ute d m at er ia l i ssu e of f ac t i n [ A etna ’ s] determ ination , which is why summ ary j udgm ent [for H elm s is] appropriate.” See Le vinso n v. Reliance Standard L ife Ins. Co., 2000 W L 193623, at *5 (S. D. Fla. Jan. 5, 200 0) ( unpu

bli she d) , a ff

irm ed , 245 F . 3d at 13 31. 10 B. L ong T er

m D isa bil ity Be ne fi ts C la im W e ag ree wi th th e m ag is tra te jud ge th atno th in g i n e it he r th e STD orLTD pl an s re qu ire d Hel m s t o e xh au sthi s STD b en efi ts be fo re b ei ng eli gi bl e fo r LTD be ne fi ts. S inc e H el m s ne ve r ap pli ed f or L T D be ne fi ts, he ha s f

ai le d to e xhaust his a dm ini str at ive r em ed ie s r eg ar din g hi s c la im f or L T D . S ee P er

ri no v . S . Be ll Te l. & Te l. C o., 209 F.3d 1309 , 1315 (11th Cir. 2000). C. E qui ta

ble Re lie f Cl ai m He lm s has stated a cause of a ction and has an approp riate r em edy under § 5 0 2 (a )( 1 )( B) . As a r es u l t , we af fi rm th e mag i s t ra t e ju d g e’s d i s m i s s al o f H el m s ’s30

claim for E RISA§ 502(a)(3) equitable relief . See Jones v. Am . G en. L ife & Ac cident Ins. Co. , 370 F. 3d 10 65, 1072-73 (11th Cir. 2004) (“ [A ] n ERI SA pla int if f w ithan ‘ ad equa te r em edy ’ und er S ec tio n 50 2( a) (1 )( B) c oul d no t alternatively

plead and proceed under Sec tion 5 02(a)(3). ”).

III. C ONC LUS ION A etna ’ s pr oc ed

ur al handl ing of

H el m s’ s S T D c la im

w as f au lty and i ts subs tanti ve r ea soni ng b othw ro ng and unr ea sona ble . A cc or din gly , w e co nc lud e that Aetna w as arbitrar

y and capricious in term inating He lm s’ s short-term disabili ty benefits. W e REV ERS E the de ci sio n of the dis tr ic t c ourt m ag istrate j udge w ithr es pe ct

to H el m s’ s sh ort- te rm

dis ab ili ty

be ne fi ts d et er

m inatio n, AFFIRM the district court m agistrate j udge with respect to He lm ’ s long -term dis ab ili ty be ne fi ts c la im

and H el m s’ s c la im

f or e qui ta ble r el ie f, and h er eb y REMAND to the district court m agistrate j udge with instructio ns to enter a final j udgm en t c onsi ste nt w iththi s op ini on and d et er m ine the a m ount

of dam ag es .31

PR Y O R, Ci rc uit

Jud ge , c onc ur

ri ng i n part

and d iss en tin g inpart : I agre e w ith the m aj ority

that the m agistrate j udge prop erly granted sum m ar y j udgm en t f

or A etnaon H el m s’ s c la im

f or lon g- te rm

dis ab ili ty

be ne fi ts an d onH el m s’ s c la im

f or br ea chof

f idu ci ar y duty , but I r es pe ct fu lly

dis se nt f ro m t h e majo ri t y’ s d ec i s i o n t o re v er s e t h e g ra n to f s u m m ary ju d g m en to n He l m s ’s cl ai m forsh or t-t erm

di sabi li ty ben efi ts . For H elm s to be entitled to summ ary j udgm ent on his claim

for short-term dis ab ili ty be ne fi ts, w e m

ust c onc lud e that H el m s’ s e vid en ce pr ove s, w itha ll re as ona ble inf er en ce s dr awn inf

av or of A etna , that H el m s is “ co nti nuou sly una ble to pe rf

orm the e sse nti al dut ie s of

[ his ] r eg ular oc cu

patio n insub stanti al ly the sam e m anner as [ he] did just before incurr ing a m edically determ ined phy sical or m en ta l i m

pa irm en t . . . w ithany

a dj ustm en ts tha t the Co m pany m ak es to tho se re spon sib ili tie s. ” D ef

ini tio n of D isa bil ity , 200 3 S T D P lan a t 2. “ If the m ovant be ar s th e bur de n of pr oof , ” as H el m s do es he re , he “ m ust e sta bli sh tha t the re is no ge nui ne iss ue of

m at er ia l f

ac t a s to any

e le m en t [ of

his c la im ] . ” I n’ l S tam

p A rt , In c. v. U . S. P ost al S er

v. , 456 F . 3d 1 270, 127 4 ( 11th C ir . 200 6) . T his bur de n is co m poun de d w he n w e ap ply

ade fe re nti al arb itr ar

y and c ap ri ci ous standard

of re vie wto the de te rm inatio n of the plan a dm ini str at or . H el m s ha s no t satis fi ed thi s bur de n.32

Consid er the f

ollowing tim e line. On F ebruary 27, 2003, He lm s saw D r. Epperson and com

plained of daily

headaches “ for the past several m onth s.” Dr . E ppe rs on o rd er ed

se ve ra l t es ts, pr es cr ibe d N euro nti n, H y dr oc odon e, and Topom ax, and tol d Helm s to return in a fewwe eks. D r. Epperson noted that He lm s was “ alert and oriented” with a “ norm al attention span and concentration.” I n Apr il, D r. E ppe rs on e xpr es se d hi s c onc er n f or H el m s bu t no te d th at

“ [H el m s] does not appear ill presently .” D r. Epperson did not s uggest th at H elm s was dis ab le d, and H el m s di d no t su gge st tha t he c oul d no t w ork be ca use of his headaches. On May

8, 2003, D r. Epperson noted that Helm s’ s headaches w ere

“ som ewha t i m

pr ove d” but

that he “ ha s di ff

ic ulty doi ng h is j ob at w ork” be ca use T opom ax m ad e him

dr ow sy . A ga in, no o ne sa id H el m s w as dis ab le d. O n June 2, D r. E ppe rs on n ote d th at

H el m s’ s he ad ac he s w er e “ m uc h im pr ove d” and tha t he fe lt be tte r af

te r sto ppi ng T opom ax . D r. E ppe rs on s ch ed ule d th e ne xt a

ppoi ntm en t fo r thr ee or

f our m onths i nst ea d of

thr ee or f our w ee ks. T hr ough out

thi s pe ri od o f tr eatm en t, H el m s pe rf

orm ed his w ork and d id n ot a lle ge that he w as dis ab le d by h i s h ea d ac h es . Al l o f t h i s ev i d en ce al l o ws a r ea s o n ab l e i n fe re n ce th at He l m s ’s he ad ach es di d n ot ren de r hi m di sabl ed . T hin gs c hange d on ly

a ft er H el m s un de rw en t surg er y to re pa ir ator n r otator cu ff on July 8. A lth oughthe m aj or ity sug ge sts that this state m en t i s a33

“m i s c h a r a c t e r i z a t i o n o f

th e r e c o r d , ” I d i s a g r e e . F o l l o w i n g th a ts h o u l d e r s u r g e ry, He lm s soug ht and ob tained disabil ity benefits, but those benefits wer e unrelated to h is m igr ai ne he ad ac he s. O nly a ft er H el m s le ft

w ork and r ec ei ve d th es e shortte rm be ne fi ts d id h e sugg es t t o D r. E ppe rs on tha t hi s he ad ac he s m ad e w orkin g i mp o s s i b l e an do n l y t h e n d i dD r . E p p e r s o n b e g i n t o a s s e rtc o n f i d e n t l y t h a tH e l ms w as “ co m ple te ly una ble to w ork. ” N ot o nly

did thi ngs ch an ge , but

the c hange w as larg el y

une xpl ai ne d. While Helm s was on disabilityleave f or the repair

of his torn rotator cuff, Dr . E pperson filed a phy sician statem ent, based on an otherwise unre corded August 15 o ffice visit, that noted Helm s could perform sedentary

work but left blank th e space to describe a patient’ s restrictions and lim itations . On Se ptem ber 3, H el m s r et

ur ne d to D r. E ppe rs on. D r. E ppe rs on n ote d th at H el m s w as “ doi ng re m ar kably w el l w ithno f

urthe r he ad ac he s” and c oul d de cr ea se his m ed ic at ion unt il he w as c om

ple te ly of f N euro nti n. D r. E ppe rs on a lso not ed that H el m s “ is re tir ed and try ing to ge t D isa

bil ity ” an d “ I tot al ly

sup port hi m

in his e nde av or

to re tir e. ” T o m ak e good

on h is p ro m ise of

“ tot al [] sup port, ” D r. E ppe rs on s en t several letter s to Aetna. First, on Septem ber 11, he subm itted a new phy sician state m en t tha t i ne xpl ic ab ly c ontra dic te d hi s e ar lie r state m en t tha t H el m s c oul d perform sedentary

work and stated ins tead, without explanatio n, that H elm s was34

com pletely “ unable to work.” This statem ent was a lso incon sistent with Dr. Epperson’ s notes abou t the visit o n Septem ber 3, which described H elm s as

“ doi ng r em ar

kably w el l w ithno f

urthe r he ad ac he s” and “ m uc h im pr ove d on pr es en t r eg im en . ” S ec ond, a ft er H el m s’ s c la im

w as de nie d, D r. E ppe rs on s en t an oth er state m en t and a

le tte r that r ea sse rt ed

that H el m s w as “ una

ble to w ork” be ca use of his he ad ac he s. D r. E ppe rs on s en t this state m en t w ith out any int er ve nin g of fi ce vis it. O n N ove m

be r 25, D r. E ppe rs on f

ina lly sawH el m s a ga in an d, that sam e day , se nt anothe r le tte r to A etnaa sse rt ing , in co nc lus or y te rm s, that H el m s w as tot al ly

una ble to w ork be ca

use his he ad ac he m ed ic at ionle ft him se da te d. N otw ith standi ng the sug ge sti on o f the m aj or ity , I c annot say that this ev ide nc e supp orts a

r ea sona ble inf er en ce that D r. E ppe rs on “ vio la t[ ed ] . . . his ethic al dut ie s a s aphy sic ian. ” I c ansay that this r ec or d a llo w s ar ea sona ble inf er en ce that D r. E ppe rs on r ea ch ed his opi nio n th at

H el m s w as c om

ple te ly

“ una ble to w ork” be ca

use he ha d pr om ise d to sup port H el m s’ s de sir e to r et ir e, not be cau se Helm s’s co nd it io n h adwors en ed . H el m s of fe rs nothin g m or e to s uppo rt his appl ic at ion . H el m s w ro te on a fo rm that, w hil e he c oul d pe rf orm hou se hol d c hor es , he ha d di ff ic ulty dr ivi ng and co nc en tr at ing . H el m s ne ve r expla ine d w hy he c oul d no t pe rf

orm his w ork if giv enr ea sona

ble a cc om

m odatio ns. H el m s a lso ne ve r of fe re d e vid en ce of

any35

change in his m edical condition following the Septem ber 3 visit when Dr . Epperson described him

as “ doin g rem arkably

we ll with no further headaches. ” A lth oughthe m aj or ity

not es that H el m s a sse rt ed that hi s m ed ic at ion“ m ild ly sedated” him , D r. Epperson only asserted “ sedation” as a basis for disabilityafter fi rs t a sse rt ing no b as is f

or dis ab ili ty

and the n a sse rt ing pa in f ro m he ad ac he s a s a ba sis f or dis ab ili ty . A t no ti m e did H el m s pr ovi de e noug h e vid en ce to supp ort a co nc lus ionthat he w as dis ab le d un de r the te rm s of the plan. A lth oughD r. E ppe rs on’ s di ag nosi s of c hr oni c he ad ac he s is unr eb utt ed , his as se rt ionthat H el m s is “ dis ab le d” is a le ga l op ini on, not am ed ic al one . S hawv. Co nn. G en . L if

e In s. Co . , 353 F . 3d 1 276, 128 5 ( 11th C ir . 200 3) ( “ [T ] he que sti on of w he the r [a

c la im an t] is ‘ tot al ly

dis ab le d’ is a m ixe d on e, inv olv ing iss ue s of both plan interpretation and fact.” ). Bec ause Dr . E pperson never identified what He lm s could andcould no t do, the rec ord does no t contain the evidence necessary to c onc lud e that H el m s c oul d no t do his j ob. I n f ac t, the r ec or d c ont ai ns am ple ev ide nc e, suc h a s D r. E ppe rs on’ s no te s, his f ir st p hy sic ian’ s st at em en t, and H el m s’ s a

bil ity to w ork th ro ugh his he ad ac he s and T opom ax , that c om pe ls the oppo sit e co nc lus ion . This appeal is absolutely

not lik e L evinson . In that case, a doctor gave a dia gnos is o f a de bil itatin g he ar t i lln es s, sup porte d hi s di ag nosi s w ith36

echocardiogram s and other evidence, and explain ed how the diagnosi s rendered Le v i n s o n u n ab l e t o fu n ct i o n atwo rk . A n u rs e d i s ag re edwi t h th e d o ct o r’s dia gnos is o f a he ar

t c ondi tio n and d et er

m ine d th at

the c la im an t w as a sym

pto m at ic based on hi s own rea ding of the echocar diog ram s. W e held that the insu rance com pany could no t credit the nurse, who had no expertise in this field and lacked t h e t ra i n i n g t o ev al u at e t h e med i ca l ev i d en ce , a g ai n s tth e d o ct o r’s d i ag n o s i s . We expla ine d th at

the ins ur an ce c om

pany sho uld have ha d anothe r doc tor

e xam ine the c la im an t i f the c om

pany w an te d to dis put e the m ed ic al dia gnos is. A ft er the nur se ’ s di ag nosi s w as dis re gard ed , onl y the doc tor ’ s di ag nosi s r em ai ne d and sum m ar y j udgm en t w as appr opr ia te f or the c la im an t. I n c ontra st w ithL ev ins on, H el m s of fe re d adoc tor ’ s op ini ons an d no te s th at are int er na lly inc onsi ste nt, co nc lus or y , and d o no t r equir e the le ga l c onc lus ionthat H el m s is dis ab le d. A ny lay person (a nurse, a claim s adm inistrator, a f ederal j udge, or re asonable juror) co uld f ind the m ins uf fi ci en t t o pr ove that H el m s m ee ts the plan’ s de fi nit ionof di sabi li ty. In short, this appeal is not a case of A etna “ rebutting” Helm s’ s expert evidence with a nurse’ s opin ion, but of Aetna c onclud ing th at H elm s’ s evidence did not pr ove his c la im

of dis ab ili ty . A ll w e ne ed

to do i s r ea d th e fi le . A ft er a ll, He lm s actually

perform ed the duties of his j ob du ring the period that he su ffer ed37

fr om the w or st h ea da ch es and whil e he w as dr ow sy f ro m T opom ax . Be ca use I c anarr ive a t this c onc lus ionw ith out any m ed ic al e xpe rt ise , it

is di ffi cu ltform e to un de rs ta ndho w th e m ajor it y ’s cri ti ci sm of “ a n ur se ’s rev ie w” is d if fe re nt f ro m “ a ru le that qu al if

ie d nurs es c anne ve r re vie wc la im s” or ar ule that an IME is alway s required. Per haps, the m aj ority ’ s rule is that a qualified nurse m ay

reviewa claim

but can never deny

it? T he problem

for H elm s, as I see it, is not that he f ai le d to pr ovi de obj ec tiv e ev ide nc e of his m ed ic al c ondi tio n bu t that the obj ec tiv e ev ide nc e he pr ovi de d—d oc tor ’ s no te s, doc tor ’ s op ini ons, med i c a t i o n d o s a g e s , wo rkh i s t o ry, e t c . —w a s i n t e rn a l l y i n c o n s i s t e n t , c o n c l u s o ry, an d t en de d t o u nd erm in e h is cla im . If A etna“ she athe d it s tr

ue j ust if ic at ion[ fo r the de nia l] in boi le rp la te langua ge ” as the m aj or ity sug ge sts , the n th e m aj or ity is ri ght ly c onc er ne d a bout its handl ing of

H el m s’ s c as e. S til l, “ [a ] de ci sio n to de ny be ne fi ts i s arb itr ar

y and capricious [only ] if no reasonable basis exists for the decision.” Shannon v. Jack E ck er d C or

p. , 113 F . 3d 2 08, 210 ( 11th C ir . 199 7) . O nc e sue d, an a dm ini str at or is not li m ite d to the r ea son fo r de nia l tha t i t gave the appl ic an t bu t m ay arg ue any reasonable basis for its decision based o n the record befor e it. “ W e cannot over em pha siz e the im

portanc e of

the dis cr et iona ff

or de d ac la im s a dm ini str at or ; the underly ing prem ise of arbitrar y and capricious, r ather than de novo, reviewis that38

ac o u rtd e f

e r s t o th e d i s c r e t i o n a f

f o r d e dth e c l a i ms a d mi n i s t r a t o r u n d e r th e t e rms of the plan. ” H CAH ea lthS er vs. of G a. , I nc . v. E m

plo y er s H ea lthI ns. Co . , 240 F. 3d 98 2, 994 (11th Cir. 2001). If a ll H el m s w an te d f

ro m A etnaw as ar ea sone d e xpl an at ionf or it s de nia l of be ne fi ts o r fo r A etnato or de r anI ME , the n H el m s c oul d a sk u s to or de r the district court to rem and this claim to Aetna. See , e .g, Miller v. United W elfar e Fund, 72 F . 3d 1 066, 107 4 ( 2d C ir . 199 5) ( or de ri ng the dis tr ic t c ourt t o r em an d to the adm inistrator because the “present recor d is incom plete and we therefore cannot c onc lud e that the re is no p oss ibl e ev ide nc e that c oul d su ppor t a de nia l of be ne fi ts” ); Rakoc zy

v. T rave le rs I ns. Co . , 914 F . S upp. 166 ( E . D . Mi ch . 199 6) (r em an din g to a dm ini str at or “be ca use it f ai le d to a de quate ly

state the r ea sons f

or denial or describe additional m aterials that plaintiff could adduce to perfect her cl ai m ”) . E RI SAc harg es the a dm ini str at ive f idu ci ar y and n ot the f

ed er al c ourts with providin g an initial “ full and fair r eview” of benefit claim s, 29 U. S. C § 1133 ; “ [t ] he r em edy

w he n [ anE RI SAa dm ini str at or ] f ai ls t o m ak e ad equa te fi ndi ngs or

to expla in i ts g ro unds a de quate ly is to s en d th e ca se ba ck

[ to the adm ini str at or ] f

or f urthe r fi ndi ngs or

e xpl an at ion . ” G al lo v . A m oc o C or p. , 102 F. 3d 9 18 ( 7thCi r. 199 6) . T he r em edy is not to ch an ge the sum

m ar y j udgm en t s t an d ar di n He l m s ’s fa v o r a n dp l ac e t h e b u rd en o n Ae t n a t o d i s p ro v e H el m s ’s39

cl ai m to be ne fi ts. “ [T ] ha t the plan a dm ini str at or f ai le d to pr ovi de the a de quate pr oc ed ur es doe s no t m ean th at

the c la im an t i s auto m at ic al ly e nti tle d to be ne fi ts [b ec au se ] suc h ahol din g m igh t pr ovi de the c la im an t ‘ w ithan e co nom ic w ind fa ll shou ld s he be de te rm ine d no t di sa ble d up on a

pr ope r re co nsi de ratio n. ’ ” H ac ke tt v. X erox Corp. Long-T erm Disability

Incom e Plan, 315 F.3d 771, 776 (7th Cir. 20 03 ). I fi nd n oth ing in ei the r E RI SAor thi s pl anthat w oul d r equir e A etnato order another doctor to exam ine Helm s before deny ing benefits. T he plan affir m atively places the burden on Helm s to provi de Ae tna inform ation that

“ ve ri fi es . . . and e xpl ai ns the na tur e an d e xte nt o f [h is] dis ab ili ty . ” A lth ough A etnac oul d have giv enH el m s abe tte r explana tio n f or the de nia l of

his application for benefits, A etna should not be criticized for having a m edical p r o f e s s i o n a l

— anu r s e —r e v i e wH e l ms ’s me d i c a l r e c o r d s . I n d e e d , ac l a i ms ad m i n i s t ra t o r w i t h n o m ed i ca l tra i n i n g co u l dh av e d et er m i n edth at He l m s ’s m ed ic al r ec or ds d id n ot “ ve ri fy ” or “ expla in” his dis ab ili ty , but a ct ua lly c as t doub t onit . L ike the m ag istrate j udge , I thi nk e ve n af ed er al j udge sho uld

be able to see th at .