2009 D e c i sion s O p inion s of the U nit e d S t at e s C our t of Appe al s for the Thir d C ir c uit 1-5-2009 

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w . vi ll anova . e du/thir dc ir c uit_2009/2077NOT P RE CE DE NT I AL UN I TED STATES CO UR T OF A PP EALS F O R T H E T H IR D C IR C U IT N o. 07- 4256 LA W RE N CE M I CH A ELS, A ppel l ant v. THE EQ UI TAB LE LI FE ASS UR AN CE SOCI ETY O F TH E U N I TED STA TES E M PLO Y EES, M A N A G ER S, AN D A GEN TS LONG - TERM DI SABI LI TY PLAN , ET AL.

O n A p p ea l from the U n it ed S tat es D istri ct C o u rt forthe E as t ern D i s tr i ctof Penns y l vani a ( C i vi l N o. 04- cv- 3250 ) D i s tr i ctJ udge: H onor abl e J . C ur t i s J oyner A r gued on D ece m ber1, 2008 B e f o re : A M B R O , W E IS , a n d V A N A N T W E R P E N , C i r cui tJudges .

( Fi l ed: J anuary5, 2009) R onal d H . Sur ki n, E s q. ( A r gued) G a l l a gh e r , Sc ho e nf

e l d, Surki n, Chupe i n & D e mi s , PC 2 5 W . S e c o n d S tre e t P. O . B ox 900 M edi a, PA 19063 C ouns el f orAppel lant D ani el J . Z ucker , E s q. ( A r gued) D ebor ah Z. W i nfi el d, E s q.1

L aw O ffi ces of D ani el J . Z ucker 260 Sout h B r oad Str eet , St e. 1200 Phi l adel phi a, PA 19102 C ouns el f orAppel l ee s

OPI NI ON O F THE COURT VAN AN TWERP EN, Circuit Judge . A ppel l ant - Pl ai nt i ff Law r ence M i chae l s appea l s fr om the D i s tr i ctC our t ’ s deci s i on aff i r m i ng the deni al of l ong- t erm di s abi l i tybenef i t s bythe Equi t abl e Li fe A s s ur ance S o c ietyo f

th e U n ited S tate s E m p lo y e e s, M a n a g e rs, a n d A g e n ts L o n g -T e rm D isa b ili ty P lan a n d A X A F in a n c ial, In c ., th e A p p e llee s-D e f e n d a n ts. F o r th e f

o llo w in g re a so n s, th is C o u rt w ill v a c a te th e D istric t C o u rt’s d e c isio n a n d re m a n d f o r f u rth e r p ro c e e d in g s in acc or dance w i th t hi s opi ni on. I. F ac ts an d P roc ed u ral H ist o ry A ppel l antL aw r ence M i chae l s s us t ai ned a mi ds haftfr actur e of hi s l eftfemur dur i ng a hor s ebac k r i di ng acc i denton J ul y12, 1997. A s a r es ul tof thi s i nj ury , a r od w as im p la n te d in to h is f

e m u r. App. at669, 943. Fol l ow i ng thi s s ur gery , M i chae l s began tr eatm entw i th D r . E r i c K at z, an orthopedi c s ur geon, and he ha s cont i nued thi s tr eatm ent thr oughoutal l per i ods r el evantt o thi s l i t i gat i on. A tth e t i m e o f

h i s i n j u r y, M i c h a e l s w a s e m p l o ye d a ta l a w f i r m a s a t a x a t t o rn e y, butthe l aw fi r m t erm i nat ed hi s empl oym enteff ect i ve D ece m ber31, 1998 beca us e he w asT he Equi t abl e Li fe A s s ur ance Soci etyi s now A X A E qui t abl e Li fe I ns ur ance 1 C o m p a n y . T h e s e o rg a n iz a tio n s a re c o lle c tiv e ly re f e rr e d to a s “ E q u ita b le .” T he Pl an i s an empl oy ee w el far e bene fi tpl an w i thi n the meani ng of s ect i ons 3( 1) 2 and 4 of the Em pl oy ee Ret i r ementI ncome Secur i tyA ctof 1974 ( “ER I SA ”) , 29 U . S. C . §§ 1 0 0 2 (1 ), 1 0 0 3 . T h e P la n is n o w k n o w n a s th e L o n g T e rm D is a b ility P la n . A notherpl an w as adopt ed af t erthe SPD ; s peci fi cal l y , E qui t abl e and A etna 3 a d o p ted a M a n a g e d D isa b ili tyC o v e ra g e p lan (“ M D C ” ) th a t d if f e re d f ro m th e S P D in so m e re sp e c ts. In p a rticu lar , the M D C p ro v id e d th a t “a c e rtifie d p e rio d o f d isa b ili tyw ill end af t er24 m onths i f A etna det erm i nes thatthe di s abi l i tyi s , atanyt i m e[, ] caus ed t o any ext entbya ment al condi t i on. ” App. at210. A l though the M anage d D i s abi l i tyPl an w as s chedul ed t o be ef

fec t i ve on J anuary1, 1995, M i chae l s cl ai m ed thathe neve rr ece i ved the M D C pl an document , and Equi t abl e di d notcont es tthatcl ai m . A ccor di ngl y , the D i s tr i ct C o u rt f o u n d th a t “to th e e x ten t th a t [ th e S P D ] d if f e rs f ro m th e [ M a n a g e d D isa b ili ty C over age doc um ent ] , w e fi nd thatthe l anguage des cr i bi ng the 24- m onth pr ovi s i on i n the SD P [si c] s houl d govern. ” Mi chael s v. E qui tabl e Li

f e Ass ur ance Soc i et

y of the U ni t ed S ta tes E m

p lo y e e s, Ma n a g e rs , a n d

A g e n ts L o n g -T

e rm D isa b ili ty P la n e t a l. , No . 0 4 - CV 3 2 5 0 , 2 0 0 7 W L 3 0 2 4 5 7 1 , at * 8 (E .D . P a . O c t. 15 , 2 0 0 7 ). E q u itab le d o e s n o t co n tes t th is f in d in g o f th e D istric t C o u rt. 2 unabl e t o per form the dut i es r equi r ed of hi m due t o hi s “phy s i cal [] i m pai r [m ent ] and s ever e[] r es tr i ct [i on] w i th r es pectt o tr avel forthe purpos e of bus i nes s devel opm entand s ervi ci ng of cl i ent s . ” App. at677, 679. I n J anuary1999, fol l ow i ng thi s t erm i nat i on, M i chae l s acc ept ed a pos i t i on w i th the Equi t abl e Li fe A s s ur ance Soci etyof the U ni t ed S tate s (“ E q u itab le” ), a n o rg a n iza tio n th a t p ro v id e d sh o rt- a n d lo n g -te rm d isa b ili ty 1 i ns ur ance t o i t s empl oy ees vi a the Equi t abl e Li fe A s s ur ance Soci etyof the U ni t ed St at es E m p lo y e e s, M a n a g e rs, a n d A g e n ts L o n g -T e rm D isa b ili tyP lan (“ P lan ” ); M ich a e ls 2
en roll ed in the P lan a n d rec eive d a c o p yo f th e S u m m aryP lan D esc ri p ti o n (“S P D ”). 3 A etna U S H eal thcar e ( “A etna”) admi ni s t er ed Equi t abl e’ s Pl an unt i l D ece m ber31,T h e S P D g ra n ted th e a d m in istra to r d isc re tio n a rya u th o rityto d e ter m in e e lig ib ili ty 4 f o r b e n e f its a n d to in terp re t th e P lan ’s te rm s. S p e c if ica lly , itp ro v id e d th a t: [t ] he Pl ans w i l l be admi ni s t er ed— and al l benef i t s author i zed— bythe Pl an A dm i ni s tr at orori t s agent . T he Pl an A dm i ni s tr at or , ora des i gnat ed p a rty , h a s th e d isc re tio n a rya u th o rityto d e ter m in e e lig ib ili tyf o r b e n e f its u n d e r th e se P lan s. T h is d isc re tio n a rya u th o rityin c lu d e s th e rig h t to m a k e a ll det erm i nat i ons aboutthe r i ghtof anyper s on t o r ece i ve bene fi t s underthe P la n a n d to in te rp re t th e te rm s o f th e P la n . App. at147. 3 2003, and M et L i fe be came the Pl an admi ni s tr at oron J anuary1, 2004. T he SPD pr ovi des 4 th a t “[ a ] p e rio d o f

to tal d isa b ili tyw ill e n d a f ter 2 4 m o n th s o f

re c e iv in g d isa b ili tyb e n e f its i f i ti s det erm i ned thatthe di s abi l i tyar i s es fr om oron acc ountof . . . a ment al condi t i on des cr i bed i n the mostcurr entedi t i on of the D i agnos t i c and St at i s t i cal M anual of M ent al D i s or der s . ” App. at152. Fur ther , the Pl an s etfor th tw o di ffe r entdefi ni t i ons for“t ot al d isa b ili ty ” b a se d o n th e d u ra tio n o f th e c laim a n t’s d isa b ili typ e rio d :

• d u rin g th e f

irst tw o y e a rs o f

y o u r p e rio d o f

d isa b ili ty , y o u ’re u n a b le to reportt o w ork and perform al l of the m at eri al or ess enti al du t i es of your ow n occupat i on due t o i l l nes s ori nj ury ; and
• aft erthe fi r s ttw o y ear s of y ourper i od of di s abi l i ty , y ou’ r e unabl e t o engage i n any gai nf

uloccupat i on forw hi ch y ou ar e, orm ayr eas onabl ybecome, qual i fi ed byeduca t i on, tr ai ni ng, orexper i ence , otherthan w or k underan a p p r o v e d r e h a b i l i t a t i o n p r o g r a m. I d. (e m p h a s is a d d e d ). O n M a y2 5 , 1 9 9 9 , M ich a e ls s to p p e d w o rk in g a n d f iled a c laim f

o r to tal d isa b ili ty benef i t s ; he has notengage d i n anygai nful empl oym ents i nce thatdat e. A etna ce r t i fi ed M i chae l s fora per i od of s hor t - t erm di s abi l i tybegi nni ng i n M ay1999. W hi l e thi s i ni t i al cert i fi cat i on di d nots t at e the bas i s forthe gr antof bene fi t s , an entryi n A etna’ s i nt ernal4

cl ai m s s y s t em from M ay26, 1999 m akes r efe r ence t o M i chae l s ’ s i m pl ant ed fe m or al r od as w el l as hi s m aj ordepr es s i on. T o fac i l i t at e i t s di s abi l i tyas s es s m ent s , A etna r eques t ed M i chaels ’s exis t i ng m edical recor ds as w el l as ong oing “M anag ed D i sabi l i tyS t at em ents ” fr om D r . K at z and D r . A ar on T es s l er , M i chae l s ’ s ps y chi atr i s t . Fol l ow i ng the r ece i ptof a M anage d D i s abi l i tySt at ementfr om D r . K at z on J une 2, 1999, i n w hi ch he c har act er i zed M icha els’s return to w o rk a s “u n k n o w n , ”A etna ex tend ed h is certi fica ti o n fo r sho rt -t erm b e n e f its th ro u g h J u ly 6 , 1 9 9 9 . I d. at247- 48, 697. K at z des cr i bed M i chae l s ’ s “per s i s t ent and i ncr eas i ng” pai n i n hi s l efthi p r es ul t i ng fr om the i m pl ant ed fe m or al r od and r ecomm ended thathe l i m i thi s “ambul at oryand s i t t i ng act i vi t i es . ” I d. at248, 702. A etna r ece r t i fi ed M i chae l s ’ s cl ai m forbenef i t s foranotherthi r ty - one day s begi nni ng on J ul y22, 1999 bas ed on the cl i ni cal i nform at i on s ubm i tt ed byD r . K at z. A n e n tryin A e tn a ’s c laim s p ro c e ss in g sy ste m d e tails a Ju ly2 3 , 1 9 9 9 v o ice m a il f ro m D r. T e ss ler , w h ich sta ted th a t M ich a e ls s u f f e re d f ro m d e p re ss io n , h a d d if f icu lty c o n c e n tra tin g , an d e x h ib ited d im in ish e d o rg a n iza tio n a l sk ill s. In a M a n a g e d D isa b ili ty S tate m e n t re c e iv e d o n Ju ly2 8 , 1 9 9 9 , D r. T e ss ler a d d e d th a t M ich a e ls’s a b ili tyto re tu rn to w or k w as “uncl ear . ” I

d. a t 2 6 5 , 7 1 7 . A e tn a p e rio d ica llyre c e rtifie d M ich a e ls a n d , in N ovember1999, appr oved M i chae l s forl ong- t erm di s abi l i tybenef i t s . T her eaf

t er , A etna per i odi cal l yr ece r t i fi ed hi m forcont i nued l ong- t erm benef i t s underthe Pl an. T he l ett er n o tify in g M ich a e ls o f

h is a p p ro v a l f

o r lo n g -te rm b e n e f

its d id n o t sp e c if

yth e b a sis f

o r h is b e n e f its, b u t itd id p ro v id e th a t h e w o u ld b e in e lig ib le f o r lo n g -te rm d isa b ili typ a ym e n ts5

aft ertw enty - fourm onths i f hi s di s abi l i tyw as “the r es ul tof a ment al condi t i on. ” I d. at 5 7 7 -7 9 . F u rth e r, itp ro v id e d th a t if M ich a e ls w a s s til l elig ib le f o r lo n g -te rm d isa b ili ty benef i t s aft erM ay25, 2001, he w oul d be r equi r ed t o m eetthe “mor e s tr i ngent‘ any occupa t i on’ defi ni t i on of di s abi l i ty . ” App. at579. T hi s pr ovi s i on of the SPD , quot ed supra , p ro v id e s th a t th e c laim a n t’s in a b ili tyto p e rf o rm th e d u ties o f

h is o w n o c c u p a tio n is su f f icie n t to q u a lifya s “ to tallyd isa b led ” in th e f irst tw e n ty -f

o u r m o n th s o f

d isa b ili ty , b u t, aft ertw enty - fourm onths of di s abi l i ty , the cl ai m antm us tbe unabl e “t o engage i n any g a in f u l o c c u p a tio n .” F o llo w in g A e tn a ’s a p p ro v a l o f lo n g -te rm d isa b ili tyb e n e f its f o r M ich a e ls, D r. K a tz and D r . T es s l ercont i nued t o t r eathi m . D r . K at z r eport ed M i chae l s ’ s ongoi ng “pai n and s t i ffne s s i n t he l efthi p r egi on” thatw as “aggr avat ed byeven s hor tper i ods of s i t t i ng and stan d ing ” a s w ell as M icha els’s “d ifficu ltyin am b u lat ion . ” In the c o u rse o f treatm en t, D r. K a tz a n d M ich a e ls re p e a ted lyd isc u ss e d th e p o ss ib le r e m o v a l o f th e f e m o ra l ro d ; th is p roc ed u re w as n ev er c o m p let ed , ap p are n tl yb ec au se th e d o ctors c o u ld n o t assu re M i chae l s thatthe s ur geryw oul d r el i eve hi s s ym pt om s . D r . T es s l err eport ed cont i nued m ood i ns t abi l i tyforM i chae l s and di agnos ed hi m w i th B i pol arD i s or deri n M ar ch 2000. I n J une 2000, A etna arr anged appoi nt m ent s forM i chae l s t o under go a p sy c h o lo g ica l ex a m in a tio n a n d a n In d e p e n d e n t M e d ica l E x a m in a tio n (“ IM E ” ) w ith p sy ch o log istD r. D o n ald H iebe l and p sy ch iatri st D r. Jero m e S ch n itt, resp ec ti v ely . D r. H ei bel r eport ed thatM i chae l s w as “expe r i enci ng a s ever e B i pol arI D i s or derm ani fes t ed6

c u rr e n t l y b y a n i n c a p a c i t a t i n g d e p r e s s i o n ” a n d s t a t e d th a tM i c h a e l s w a s “ p r o b a b l y” c a p a b le o f

so m e w o rk a lth o u g h h e w a s “ n o t ab le c u rre n tlyto d o th e k in d o f jo b h e d id b e f o re ” a n d w a s “ c e rt a in ly n o t a b le to c o m m a n d a n yw h e re n e a r h is p re v io u s in c o m e .” App. at593- 95. D r . Schni t t ’ s I M E di agnos ed M i chae l s as bi pol ar , char act er i zed hi m as “s ever el ydebi l i t at ed byhi s i l l nes s , ” and c oncl uded that“[a ] tthi s t i m e he c annotw or k at anyl evel , i n anycapa ci ty . ” I d. at45456, 596- 97. B a se d o n th e re p o rts o f D rs. K a tz, T e ss ler , H ieb e l, an d S c h n itt , A e tn a c o n tin u e d to r ece r t i fyM i chae l s unt i l M ay2001. A etna t erm i nat ed M i chae l s ’ s benef i t s on M ay26, 2001, tw enty - fourm onths aft erhe bega n r ece i vi ng benef i t s , and i nform ed hi m vi a l ett er s hor t l yther eaf

t er . A s perm i t t ed bythe Pl an, on J ul y16, 2001, M i chae l s t i m el yappea l ed A et na’s deci si on t o term i nate hi s benef i t s, con t end i ng that hi s di sabi l i tydid not “ar i se f ro m o r o n a c c o u n t o f

” a m e n ta l c o n d itio n . App. at 61 2 -16 . F o ll o w ing this ap p ea l, D r. O y ebode Tai w o, A etna’ s m edi cal cons ul t ant , r evi ew ed M i chae l s ’ s fi l e, w hi ch i ncl uded the re p o rt s o f D rs. K atz, T essler, H eibe l, an d S ch n itt, an d co n clud ed that “the p ri m ary h e a lth p ro b lem p re v e n tin g [ M ich a e ls] f ro m g a in f

u l em p lo ym e n t is h is p sy c h iatric condi t i on. ” W i th r es pectt o M i chae l s ’ s abi l i tyt o w or k, D r . T ai w o found that , i n l i ghtof h is p h y s ic a l lim ita tio n s , “ h e s h o u ld b e p h y s ic a lly c a p a b le o f p e rf o rm in g s e d e n ta ry w o rk .” I d. at424- 26, 548- 51. A ccor di ngl y , A etna deni ed M i chae l s ’ s fi r s tappea l i n N ovember 2001. M ich a e ls re q u e ste d a se c o n d re v iew o f A e tn a ’s te rm in a tio n o f h is d isa b ili ty7

benef i t s on M ay23, 2003; hi s appea l , w hi ch i ncl uded updat ed r ecor ds , w as r efe rr ed t o t he E qui t abl e B enef

i t s A ppeal s C om m i t t ee f ora fi nal deci s i on. T hi s C om m i t t ee s ought addi t i onal i nform at i on r el at i ng t o M i chae l s ’ s or thopedi c pr obl em and r eques t ed, i nt eral i a, th a t M ic h a e ls s u b m it to a n o rt h o p e d ic IM E . App. a t 7 5 7 -5 8 . I n a l ett erdat ed N ovember10, 2003, D r . R obertG ei s tr eport ed thathe conduc t ed a n o rt h o p e d ic IM E o f

M ic h a e ls a n d f

o u n d th a t M ic h a e ls ’s m e d ic a l p ro g n o s is w a s “ p o o r.” D r. G eistind icated that M icha els w as “ u n li k elyto b e a b le t o resu m e h is prev iou s w o rk st atus” and that he “w ou l d b e el i gibl e, atm ost , for part -t i m e seden t aryw ork. ” D r. G ei st al s o not ed that , i f M i chae l s r eturned t o w or k, he “w oul d r equi r e a j ob thatcoul d al l ow a l t e rn a t e s i t t i n g a n d s t a n d i n g e v e r yh a l f h o u r ” a n d a n “ e n v i r o n me n t a l l yc o n tr o l l e d ” r o o m. App. at87 8-81. I n A et na’s Em ploy abil i tyand Im pairm ent Sum m aryF orm , D r. G ei st re sp o n d e d “ N /A ” to th e f o rm ’s in q u irya b o u t th e e m p lo y e e ’s a b ili tyto re tu rn to w o rk w ith o r w ith o u t m o d if

ica tio n . In re sp o n se to th e p o rtio n o f th e f o rm th a t sta ted “ [ n ]o t ab le to r eturn t o anygai nful w or k atthi s t i m e, [m ] ypr ognos i s forhi s /herr eturn t o s om e type of empl oym enti s , ” D r . G ei s tw r ot e “pe ndi ng r emoval of fe m or al r od. ” I d. at876- 77. I n a supp l em ental l et t er dat ed F ebruary11 , 20 04 , D r. G ei streport ed that“the longe st [M i chae l s ] can s i tr eas onabl yatone t i m e i s 30- 60 m i n[ut es ] , and then the pai n fr om t he r od t i p becomes s ever e. ” I d. at888- 89. I n a meet i ng i n A pr i l 2004, the C om m i t t ee c oncl uded thatM i chae l s w as di s abl ed due t o hi s “maj ordepr es s i on” and, acc or di ngl y , thathe w as no l ongerel i gi bl e for8

b e n e f its . App. at621. T he C om m i t t ee a l s o det erm i ned thatM i chae l s ’ s phy s i cal i m pai rm ent s di d notr enderhi m t ot al l ydi s abl ed and thathe w as capa bl e of pe r form i ng s edent aryw or k. I n doi ng s o, the C om m i t t ee c har act er i zed D r . G ei s t ’ s I M E as i ndi cat i ng that“M i chae l s i s capa bl e of pe r form i ng a s hor t - t erm s edent aryoccupa t i on and . . . s uch a job w o u ld n ee d to p rov ide [ h im ] th e o p p o rtu n ityto alterna te si tt ing an d stan d ing ev ery hal f- hourand t o be s i tuat ed i n an envi r onm ent al l ycontr ol l ed r oom . ” I d. at62 2. A s a re su lt, th e C o m m itt e e u p h e ld A e tn a ’s d e n ial o f b e n e f its b a se d o n its f

in d in g th a t M ich a e ls
w as notphy s i cal l ydi s abl ed underthe t erm s of the Pl an. M icha els fil ed su itin the D istri ct C o u rto n Ju ly9 , 2 0 0 4 , all eg ing that E q u it ab le’s d en ial o f b en ef

it s v iolated th e term s o f th e P lan a n d co n sti tuted a b rea ch o f a fid u ciary d u ty . B o th p arti es a g ree d that the D istri ct C o u rtsh o u ld d ec ided this m att er w ith o u t a j u ry o n th e b a s is o f

th e a d m in is tr a tiv e re c o rd . App. at945. O n O ct ober15, 2007, the D i s tr i ct C o u rtaf firm ed E q u it ab le’s de n ial o f lo n g -t erm d isab il ityb en ef it s an d d en ied M icha els’s c la im f o r r e lie f. Mi chael

s v. E qui tabl e Li

f e Ass ur ance Soc i et

y of the U ni t ed Stat es E m p lo y e e s, Ma n a g e rs , a n d

A g e n ts L o n g -T

e rm D isa b ili ty P la n e t a l. , N o. 04- C V - 3250, 2007 W L 3024571 ( E . D . Pa. O ct . 15, 2007) . M i chae l s fi l ed a not i ce of appea l of the D i s tr i ctC our tdeci s i on on N ovember5, 2007. I I . J ur i s di ct i on T he D i s tr i ctC our texer ci s ed s ubj ectm att erj ur i s di ct i on overM i chae l s ’ s cl ai m for r e c o v e ryo f

p l a n b e n e f

i t s p r o v i d e d b yERI S A p u r s u a n tt o 2 8 U. S . C. § 1 3 3 1 a n d 2 9 U. S . C.9

§ 1132( e) - ( f) . T hi s C our thas appel l at e j ur i s di ct i on pur s uantt o 28 U . S. C . § 1291. III. A n a ly sis A
. Standar d of

R evi ew T h is C o u rtex erc ises p lena ryrev iew o f th e D istri ct C o u rt ’s de cisi o n to af firm E qui t abl e’ s deni al of l ong- t erm di s abi l i tybenef i t s and appl i es the s ame st andar d as the D i s tr i ctC our tappl i ed. Sm athers v. Mul t i - Tool , I nc. , 2 9 8 F . 3 d 1 9 1 , 1 9 4 (3d C ir . 2 0 0 2 ). In F i r es t one Ti r e & R ubberC o. v. B r uch , 489 U . S. 101 ( 1989) , the Supr eme C our tpr ovi ded th a t, ba se d o n p rin c ip les o f tru st la w , the d e n ial o f

b e n e f its u n d e r 2 9 U .S .C . § 1 1 3 2 (a ) is s u b je c t to d e n o v o re v ie w u n le s s th e p la n a t is s u e “ g iv e s th e a d m in is tr a to r . . . di s cr et i onaryauthor i tyt o det erm i ne el i gi bi l i tyforbenef i t s ort o cons true the t erm s of the pl an. ” F i r es t one Ti r e & R ubberC o. v. B r uch , 489 U . S. 101, 115 ( 1989) . W her e, as her e, the pl an gr ant s i t s admi ni s tr at ordi s cr et i onaryauthor i tyt o det erm i ne el i gi bi l i tyfor b e n e f its o r to c o n stru e th e p lan ’s te rm s, th is C o u rt re v iew s th e d e n ial o f E R IS A b e n e f

its
u n d e r a n a rb itr a ry a n d c a p ri c io u s s ta n d a rd . P os tv. H ar t f or d I ns . C o. , 501 F. 3d 154, 161 (3 d C ir. 2 0 0 7 ); Sm athers , 2 9 8 F .3 d a t 1 9 4 -9 5 ; P i nt o v. R el i ance Standar d Li f e I ns . C o. , 2 1 4 F .3 d 3 7 7 , 3 7 8 (3 d C ir. 2 0 0 0 ); see al so F i reston e T

i re , 4 8 9 U .S . at 1 1 5 (n o tin g in d ictu m th a t w h e re p lan v e sts a d m in istra to r w ith d isc re tio n , the d e n ial o f b e n e f its sh o u ld be r evi ew ed foran abus e of di s cr et i on) . A ccor di ngl y , the arbi tr aryand capr i ci ous stan d ard o f re v iew ap p li es to this ap p ea l. U n d er this st an d ard , the p lan a d m inistrator’s deci s i on w i l l s t and unl es s “‘ i ti s cl ear l ynots uppor t ed bythe evi dence i n the r ecor d ort heA etna admi ni s t er s the Pl an and makes i ni t i al det erm i nat i ons of el i gi bi l i tyfor 5 b en ef it s. B en ef

it s p ay m en ts are tak en fro m an ind ep en d en t trust fu n d ed b ythe e m p loy er, E q u ita b le , a n d b e n e f

its p a ym e n ts a re n o t f

u n d e d o n a c a s e -b y -c a s e b a s is . Mich a e ls , 2007 W L 3 0 2 4 5 7 1 , at * 6 ; App. atA 187- 88. I n A bnathya , thi s C ourtexami ned a pl an i n w hi ch the empl oy eract ed as the admi ni s tr at orof an e m pl oy ee be nefi t s pl an. U nderthatpl an, t he empl oy err egul ar l ypai d i nt o a fund thatw as hel d bya trus t ee, and the fund’ s pr ocee ds coul d onl ybe us ed forthe bene fi tof pl an mem ber s ; thi s C our tconcl uded thatanyconfl i ct thatexi s t ed w as “nots i gni fi cantenough t o r equi r e s peci al att ent i on ora more s tr i ngent s t andar d of r evi ew . ” A bnathya , 2 F. 3d at45 n. 5. 10 admi ni s tr at orhas fai l ed t o compl yw i th the pr ocedur es r equi r ed bythe pl an. ’ ” Sm athers , 298 F. 3d at199- 200 ( quot i ng O r vos h v. P r ogr am of G r oup I ns . f orSalar i ed Em

pl oyee s of V olks w agen of

A m . , I nc. , 2 2 2 F .3 d 1 2 3 , 1 2 9 (3 d C ir. 2 0 0 0 )). T o d e ter m in e if a d e c isio n is arbi tr aryand capr i ci ous , thi s C our tm us tcons i derw hetherthe admi ni s tr at orhad a re a s o n a b le b a s is f

o r i ts d e c is io n . I

d. B efor e the D i s tr i ctC our t , M i chae l s uns ucce s s ful l yar gued forappl i cat i on of a h e ig h ten e d v e rsio n o f

th e a rb itrar ya n d c a p ric io u s s tan d a rd b a se d o n c a se law f ro m th is C our tendor s i ng a hei ght ened ve r s i on of the s t andar d w her e a pl an admi ni s tr at orw ho exer ci s es di s cr et i onaryauthor i tyhas a conf l i ctof i nt er es t . I n part i cul ar , thi s pr ece dent p rov ided that w h ere the a d m inistrator w as o p era ti n g u n d er a co n fli ct of interest, the c o u rt w oul d appl ya “s l i di ng s cal e” t o gi ve the admi ni s tr at or ’ s deci s i on l es s defe r ence as the s e v e ri ty o f

th e c o n f lic t o f in te re s t r is e s . P in to , 2 1 4 F . 3 d at 39 3 . T h e D istri ct C o u rt co n clud ed that “the stru ctura l and p roc ed u ral cir cu m stan ce s p rese n t [d id] n o t call fo r a hei ght ened f

or m of arbi tr aryand capr i ci ous r evi ew ” and c i t ed A bnathya v. H of f m anLaR oche, I

nc. , 2 F. 3d 40, 45 n. 5 ( 3d C i r . 1993) , as fi ndi ng thata s i m i l ar l ys tructur ed pl an 511

d id n o t p re s e n t a c o n f

lic t. App. atA 18. Si nce the D i s tr i ctC our tdeci s i on, how ever , the Supr eme C our thas pr ovi ded gui dance as t o how court s s houl d appr oach pot ent i al confl i ct s of i nt er es t . A ddr es s i ng a pl an thatves t ed di s cr et i on i n an i ns ur ance companyw i th a dual s t atus as admi ni s tr at or and pay erof bene fi t s , the Supr eme C our tconcl uded thats uch a pl an cr eat ed the type of confl i ctof i nt er es tthati nform ed the abus e of di s cr et i on i nqui ry , even though thatconfl i ct w a s “ le s s c le a r” th a n if

th e e m p lo y e r f

u n d e d th e p la n a n d e v a lu a te d c la im s . Metr opol i tan Li f e I ns . C o. v. G l enn , --- U .S . ---, 1 2 8 S . C t. 23 4 3 , 2 3 4 6 , 2 3 4 8 -4 9 (2 0 0 8 ); buts ee Sm athers , 2 9 8 F .3 d a t 1 9 7 (“ [ W ]e h a v e e x p lain e d th a t th e risk o f a c o n f lict o f in ter e st is decr eas ed w her e the admi ni s tr at orand funde rof the pl an i s the empl oy er , r atherthan an i ns ur ance company , beca us e the empl oy erhas ‘ i ncent i ves t o avoi d the l os s of m or al e and hi gherw age de m ands thatcoul d r es ul tfr om deni al s of bene fi t s ’ s ugges t i ng thatther e i s at l eas ts om e count ert o the i ncent i ve nott o paycl ai m s . ” ( quot i ng N az ay v. Mi l l er , 949 F. 2d 1 3 2 3 , 1 3 3 5 (3d C ir . 1 9 9 1 ))) . F u rth er, th e C o u rto b serv ed that a p lan a d m inistrator’s p o tential co n fli ct of

interest sho u ld co n sti tute just on e f ac tor i n ev alua ti n g w h ethe r th ere w as an abus e of di s cr et i on i n t he dec i s i on- m aki ng pr oces s — i ts houl d nottr i ggera cha nge in th e s ta n d a rd o f

re v ie w . G l enn , 1 2 8 S . C t. at 2 3 5 0 (“ W e d o n o t b e liev e th a t F i r es t one ’s s t at ementi m pl i es a cha nge i n t he stan da rd of r evi ew , s ay , fr om defe r ent i al t o de novo re v iew .”); see al

so F i r es t one , 489 U . S. at115 ( concl udi ng thatw hen an a dm i ni s tr at or e n tru ste d w ith d isc re tio n a rya u th o rityis o p e ra tin g u n d e r a c o n f lict o f in ter e st, th a t co n f

lict12

m u st be “w eigh ed as a ‘fa ctor in d eterm ining w h ethe r th ere is an ab u se o f d iscreti o n ’” (qu o ti n g R estatem en t ( S ec o n d ) of T rusts § 1 8 7 , cm t. d (19 5 9 ))) . T h u s, u n d er G l enn , a pl an admi ni s tr at or ’ s confl i ctof i nt er es tw oul d notgi ve r i s e t o a hei ght ened ve r s i on of the arbi tr aryand capr i ci ous s t andar d of r evi ew ; i ns t ead, thatconfl i ctw oul d r epr es entone of se v e ra l f a c to rs th a t in f

o rm e d th e in q u irya s to w h e th e r th e a d m in istra to r a b u se d its d is c re tio n . G l enn , 1 2 8 S . C t. at 2 3 5 1 (“ W e b e liev e th a t F i r es t one m ea n s w h at th e w o rd

‘ fac t or ’ i m pl i es , namel y , thatw hen j udges r evi ew the l aw ful nes s of bene fi tdeni al s , they
w ill o f ten tak e a c c o u n t o f

se v e ra l d if

f e re n t co n sid e ra tio n s o f

w h ich a c o n f

lict o f in ter e st is one. ”) . A s a r es ul t , M i chae l s abandone d hi s ar gum entforappl i cat i on of a he i ght ened
v e rsio n o f

th e a rb itrar ya n d c a p ric io u s s tan d a rd o f re v iew o n a p p e a l. B . Ter m i nat i on of

B enef i t s A f t erTw ent y- FourMonths U n d e r t h e P la n , a f

te r t h e f ir s t tw e n ty-f

o u r- m o n th p e ri o d o f

to ta l d is a b ility, a cl ai m anti s el i gi bl e forbenef i t s i f he i s “unabl e t o engage i n anygai nful occupa t i on for
w h ic h [ h e is ], o r m a yre a s o n a b ly b e c o m e , q u a lif ie d b ye d u c a tio n , tr a in in g o r e x p e ri e n c e .” App. atA 152. Fur ther , E qui t abl e’ s SPD pr ovi ded that“a pe r i od of t ot al di s abi l i tyw i l l end aft er24 m onths of r ece i vi ng di s abi l i tybenef i t s i f i ti s det erm i ned thatthe di s abi l i tyar i s es fr om oron acc ountof . . . a ment al condi t i on des cr i bed i n the mostcurr entedi t i on of the D i agnos t i c and St at i s t i cal M anual of M ent al D i s or der s . ” Id
. M i chaels assert s that these pr ovi s i ons m ean thati f hi s phy s i cal di s abi l i typr ecl udes hi m fr om engagi ng i n anygai nful occupa t i on, he s houl d cont i nue t o r ece i ve di s abi l i tybenef i t s underthe Pl an. Ap

p ella n t’s13

B r. at14. T h e D istric t C o u rt o b se rv e d th a t M ich a e ls “ w o u ld h a v e o n lyb e e n e n tit led to r ece r t i fi cat i on of the per i od of di s abi l i tyi f he s at i s fi ed the ‘ anyoccupa t i on’ defi ni t i on based so l el yon his phys i cal condi t i on. ” Mich a e ls , 2007 W L 3024571, at*11. T he D i s tr i ct C o u rt’s s tate m e n t co u ld b e in terp re ted se v e ra l d if f e re n t w a y s. If

it m e a n s th a t a to tally di s abl i ng phy s i cal di s abi l i tyw oul d al l ow r ecove ryof bene fi t s r egar dl es s of a ment al di s abi l i ty , then the D i s tr i ctC our tw as corr ect . I f i tm eans thatanym ent al condi t i on r ender s M i chae l s i nel i gi bl e forbenef i t s , r egar dl es s of the exi s t ence of a t ot al l ydi s abl i ng p h y s ic a l d is a b ility, w e b e lie v e th e D is tr ic t C o u rt u s e d th e w ro n g s ta n d a rd . E q u itab le in terp re ts th e D istric t C o u rt’s s tate m e n t to m e a n th a t “M ich a e ls w o u ld be ent i t l ed t o benef

i t s i f hi s di s abi l i tyw er e due o n ly t o hi s phy s i cal condi t i on. ” App el l ees’ B r. at9. W e bel i eve thatthe s t andar d advoca t ed byE qui t abl e mi s cons trues the Pl an. U nderE qui t abl e’ s i nt erpr et at i on, i f M i chae l s w er e phy s i cal l yand ment al l ydi s abl ed, and hi s phy s i cal di s abi l i tyal one w er e s uffi ci entt o r enderhi m unabl e t o engage i n anygai nful occupa t i on, he w oul d be barr ed fr om r ece i vi ng benef i t s beca us e hi s di s abi l i tyw oul d not be due o n ly t o h i s p h y s i c a l c o n d i t i o n . Byl i mi t i n g b e n e f i t s f o rd i s a b i l i tya r i s i n g f

r o m a m ent al condi t i on, how ever , the Pl an i m pl i ci t l yperm i t s benef i t s t o cont i nue bey ond tw enty - fourm onths w her e el i gi bi l i tyar i s es fr om s om ethi ng otherthan a ment al condi t i on. T he v i ew that this P l an’s l i m i t at i on on ben efi t s appli es i f a m ental con dit i on exis t s, n o tw ith sta n d in g th e p re se n c e o f a to tallyd isa b lin g p h y sic a l co n d iti o n , is p lain lyA s M ich a e ls’s b rie f p o in ts o u t, fo llo w in g M ich a e ls’s se c o n d a p p e a l o f h is 6 benef i t s deni al , the Pl an r eques t ed an orthopedi c i ndepende ntm edi cal exami nat i on ( “I M E ”) . I f Equi t abl e bel i eved, as i tnow ar gues , thati t s Pl an l i m i t ed bene fi t s aft er tw e n ty -f o u r m o n th s w h e re a c laim a n t h a s a n ym e n tal c o n d iti o n , the re w o u ld b e n o n e e d to or deran orthopedi c exa m i nat i on. I n r eques t i ng thi s exami nat i on, the C om m i t t ee c har ged w i th eval uat i ng the appe al s oughtthe exa m i nat i on t o “det erm i ne i f hi s phy s i cal condi t i on i s s uch thathe i s el i gi bl e t o r ece i ve bene fi t s . ” App. at778. 14 u n re a so n a b le a n d u n d e rm in e d b yE q u itab le’ s c o n d u c t. E q u itab le’ s in terp re tatio n w o u ld 6 lea d to th e a b su rd re su lt o f re n d e rin g M ich a e ls’s p h y sic a l co n d iti o n c o m p lete lyirre lev a n t, as the pr es ence of anym ent al condi t i on w oul d negat e the ef fec tof t ot al phy s i cal d isa b ili ty . In d e e d , at o ra l ar g u m e n t co u n se l f o r E q u itab le a c k n o w led g e d th a t, un d e r its i nt erpr et at i on of the Pl an’ s tw enty - four - m onth l i m i t at i on, i f an a cci dentcaus ed an in d iv id u a l to b e c o m e a to tallyd isa b led q u a d rip leg ic, a n d th a t in d iv id u a l su b se q u e n tly devel oped depr es s i on, thati ndi vi dual w oul d be barr ed fr om r ece i vi ng benef i t s aft er tw e n ty-f o u r m o n th s n o tw ith s ta n d in g h is to ta l p h y s ic a l d is a b ility. U n d e r t h is v ie w , a ph y si cal l ydis abled cl ai m ant’ s subsequ ent developm ent of a m ental con dit i on act s as a penal ty ; s uch a r es ul ti s unr eas onabl e and undul yhar s h w i thouta cl ears t at ementi n the Pl an thatthe pr es ence of anym ent al condi t i on r ender s voi d a cl ai m ant ’ s el i gi bi l i tyfor benef i t s . H er e, the Pl an mer el ypr ovi ded that“a pe r i od of t ot al di s abi l i tyw i l l end af t er24 m onths of r ece i vi ng di s abi l i tybenef i t s i f i ti s det erm i ned thatthe di s abi l i tyar i s es fr om or on acc ountof . . . a ment al condi t i on des cr i bed i n the mostcurr entedi t i on of the D i agnos t i c and St at i s t i cal M anual of M ent al D i s or der s . ” Thi s l anguage fai l s t o put p arti cipa n ts on n o ti ce that an ym en tal co n d it ion , n o m att er h o w sli g h t, b ars the rec o v ery15

of b enef i t s aft er tw enty -four m on ths. T h e d if f e re n c e in th e lan g u a g e o f E q u itab le’ s S P D a n d M D P is in stru c tiv e . W h ile the SPD l i m i t s el i gi bi l i tyforbenef i t s t o tw enty - fourm onths i f di s abi l i ty“ar i s es fr om or on acc ountof” a m ent al condi t i on, the M D P pr ovi des thata per i od of di s abi l i ty“w i l l end a f te r 2 4 m o n th s if

A e tn a d e te rm in e s th a t th e d is a b ility is , atany t i m e caus ed to any ex t ent bya ment al condi t i on. ” App. at749- 50 ( emphasi s added) . T he M D P i l l us tr at es the p o sitio n th a t E q u itab le n o w a d v o c a tes

— a f ter tw e n ty -f

o u r m o n th s, u n les s a d isa b ili tyis e x c l u s i v e l yp h y s i c a l i n n a tu r e , th e c l a i ma n ti s b a rr e d f r o m r e c e i v i n g b e n e f

i t s . T h e S P D, w hi ch appl i es t o M i chae l s ’ s cl ai m , s t ops s hor tof r equi r i ng s uch a s how i ng. W e h o ld th a t, un d e r th e ter m s o f E q u itab le’ s P lan , if a c laim a n t w e re to tally d isa b led , an d h is p h y sic a l d isa b ili tyw e re in d e p e n d e n tlysu f f icie n t to re n d e r h im to tally dis abled, his el i gibi l i tyfor ben efi t s w ou l d n ot t erm i nate aft er tw enty -four m on ths beca use the cl ai m antal s o s uffe r ed fr om a ment al condi t i on. I f a di s abl ed cl ai m ants uffe r ed fr om both m ent al and phy s i cal condi t i ons , nei therof w hi ch w er e i ndepende nt l ydebi l i t at i ng u n d e r th e P lan , an d th e c o m b in e d e f f e c t o f th o se c o n d iti o n s re n d e re d th e c laim a n t to tally d isa b led , the a d m in istra to r w o u ld h a v e d isc re tio n to d e ter m in e th e c laim a n t’s e lig ib ili ty forbenef i t s bey ond tw enty - fourm onths . T hus , forM i chae l s t o r ece i ve bene fi t s bey ond tw e n ty -f o u r m o n th s u n d e r E q u itab le’ s P lan , h e w o u ld h a v e to sh o w th a t, by i tse lf , h is phy s i cal di s abi l i typr ecl uded hi m fr om engagi ng i n anygai nful occupa t i on, r egar dl es s of anyconcurr entm ent al condi t i on. T he r ecor d cont ai ns fac t s w hi ch coul d s uppor ts uch aA l though t he D i s tr i ctC our tpoi nt ed outthatD r . G ei s t ’ s r eport s di d nots t at e that 7 M i chae l s w as “unabl e t o w or k atal l , ” D r . G ei s t ’ s r es pons es t o the Em pl oy abi l i tyand I m pai r m entSum m aryFor m di d r eportan i nabi l i tyt o r eturn t o w or k w i thoutthe r emoval o f th e f e m o ra l r o d . 16 fi ndi ng, as det ai l ed i nfr a .

C
. A bi l i t y t o E ngage i n “A ny G ai nf ulO ccupat i on” M i chae l s al l eges thatthe admi ni s tr at or ’ s fi ndi ng thathe w as abl e t o engage i n “any gai nful occupa t i on” cons t i tut ed an a bus e of di s cr et i on. A s the D i s tr i ctC our tnot ed, A etna’ s gr antof l ong- t erm di s abi l i tybenef i t s i n N ovember1999 “di d noti ndi cat e the m edi cal bas i s foraw ar di ng benef i t s . ” Mich a e ls , 2 0 0 7 W L 3 0 2 4 5 7 1 , at * 2 . T h e f a ilu re to i dent i fythe bas i s forM i chae l s ’ s el i gi bi l i tyfordi s abi l i tys ugges t s thatM i chae l s m ayhave been a bl e t o es t abl i s h t ot al di s abi l i tybas ed on ei therhi s m ent al condi t i on orhi s phy s i cal condi t i on. A s t o M i chae l s ’ s phy s i cal condi t i on, the D i s tr i ctC our tfound that“the det erm i nat i on thatPl ai nt i ff c oul d engage i n ‘ anyr eas onabl e occ upat i on’ . . . i s not ‘clearlyu n su p p o rt ed ’ i n the re co rd,” n o ti n g that “[ b ]oth D r. G eist ’s an d D r. T aiw o ’s re p o rt s c o n c lu d e th a t P la in tif f w o u ld b e a b le to e n g a g e in a t le a s t s o m e s e d e n ta ry w o rk .” I d. at*11. I n m aki ng thi s fi ndi ng, the D i s tr i ctC our tm i s s t at ed D r . G ei s t ’ s concl us i on, 7
w h ic h in d ic a te d th a t M ic h a e ls w a s “ c a p a b le o f p e rf o rm in g , at m ost , sh o rt -t erm sed en tary w or k. ” I d. ( emphasi s added) . Fur ther , the D i s tr i ctC our tm ayhave i gnor ed otherevi dence i n the r ecor d t hats uppor t s a fi ndi ng of M i chae l s ’ s i nabi l i tyt o engage i n anygai nful occupa t i on bas ed on hi s phy s i cal di s abi l i ty . Forexampl e, an entryi n A etna’ s fi l e on17

M i chae l s dat ed Sept ember25, 2000 s t at es that“[b] as ed on updat ed cl i ni cal i nform at i on i nvol vi ng [hi s ] per s i s t entpai n i n t he l efthi p r egi on and pos s i bi l i tyof s ur gi cal r emoval of [ th e ] t ita n iu m ro d , . . . [ M ic h a e ls ] i s u n a b le to p e rf o rm th e e s s e n tia l f

u n c tio n s o f

a n yjo b .” App. at915. T w o o rth o p e d ic s p e c ialists , D r. K a tz a n d D r. G e ist, m e t w ith M ich a e ls a b o u t h is phy s i cal condi t i on. T hr oughouttr eatm ent , D r . K at z obs erved thatM i chae l s exper i ence d “per s i s t ent ” and “ s ever e” pa i n r es ul t i ng fr om the “pr om i nence of the i nt ernal fi xat i on r od. ” App. at702- 03. D r . K at z r ecor ded “e s s ent i al l yno i m pr ovement ” overthe cour s e of tr eatm entand r egul ar l yi ndi cat ed thatM i chae l s exper i ence d “di ffi cul tyw i th ambul at i on and s t ai r - cl i m bi ng as w el l as a s ens at i on of ‘ bei ng off ba l ance . ’ ” I d. D r . K at z further d o c u m e n ted M ich a e ls’s “ d if f icu ltyw ith sittin g f

o r lo n g p e rio d s o f

tim e ” a n d “ d if

f icu lty
w ith sta n d in g f

o r lo n g p e rio d s o f

tim e .” D r. K a tz a n d M ich a e ls d isc u ss e d th e p o ss ib le su rg ica l re m o v a l o f

th e ro d , b u t D r. K a tz e x p lain e d th a t “th e re a re n o g u a ra n tee s w ith r emoval of the r od and . . . the s ym pt om s m ayper s i s teven though the r od i s r emoved. ” I d. A s t o M i chae l s ’ s abi l i tyt o w or k, D r . K at z poi nt ed t o hi s di m i ni s hed capaci tyt o funct i on in h is o w n jo b b u t d e c lin e d to e x p re ss a d e f in iti v e o p in io n a s to w h e th e r M ich a e ls c o u ld engage i n anyoccupa t i on, opt i ng i ns t ead t o des cr i be M i chae l s ’ s r eturn t o w or k as “t o be det erm i ned” or“unknow n. ” I d. a t 6 9 7 . D r. G e ist d e sc rib e d M ich a e ls’s m e d ica l d iag n o sis as “poo r” and st at ed that“[h]e i s unli kelyt o b e able t o resum e his previ ou s w ork st atus” and that“[h] e w oul d be el i gi bl e, atm os t , forpart - t i m e s edent aryw or k. ” I d. at880.18

F u rth e r, D r. G e ist w ro te “ N /A ” in re sp o n se to a f o rm in q u irya s to M ich a e ls’s a b ili tyto re tu rn to w o rk w ith o r w ith o u t m o d if ica tio n a n d re sp o n d e d to th e p ro m p t “[ n ]o t ab le to r eturn t o anygai nful w or k atthi s t i m e, [m ] ypr ognos i s forhi s /herr eturn t o s om e t i m e of empl oym enti s ” byw r i t i ng “pendi ng r emoval of fe m or al r od. ” I d. at876- 77. T hus , of the tw o doct or s w ho phy s i cal l yexami ned M i chae l s , one conc l uded that h is a b ili tyto re tu rn to w o rk w a s “ u n k n o w n .” T h e o th e r c h a ra c ter ize d M ich a e ls’s a b ili tyto r eturn t o w or k w i th orw i thoutacc om m odat i on as “N / A ” and r es ponded t o the s t at ement “notabl e t o r eturn t o anygai nful w or k atthi s t i m e” byw r i t i ng “pendi ng r emoval of f e m o ra l ro d .” F in a lly , the se c o n d e x a m in in g d o c to r sta ted th a t “a t m o st” M ich a e ls c o u ld
w o rk tw o h o u rs p e r d a yin a s e d e n ta ry p o s itio n . W hen M i chae l s appea l ed the deni al of hi s benef i t s , A etna and M et L i fe s ol i ci t ed fur theri nform at i on fr om tw o m edi cal pr ofes s i onal s , D r . T ai w o and an uni dent i fi ed Indepe nd ent Phy si ci an C on sul t ant. A l tho ug h n ei ther of these doctor s exam i ned M i chaels , the admi ni s tr at orgave de t erm i ni ng w ei ghtt o thei rconcl us i ons M i chae l s w as not p h y s ic a lly d is a b le d . Forexampl e, i n m aki ng i t s fi nal el i gi bi l i tydet erm i nat i on, the C om m i t t ee s ol i ci t ed in p u t f ro m M e tL if

e . M e tL if

e re sp o n d e d th a t it s In d e p e n d e n t P h y sic ian C o n su ltan t “f e lt thatD r . G ei s t ’ s r es tr i ct i ons / l i m i t at i ons and opi ni on thatM r . M i chae l ’ s [s i c] w oul d be el i gi bl e, atm os t , forpart - t i m e s edent aryw or k w as notcons i s t entw i th the I M E phy s i cal exami nat i on fi ndi ngs . ” App. at895- 96. M et L i fe s t at ed thati t s I ndepende ntPhy s i ci anT he Supr eme C our t ’ s deci s i on i n B lack & D ecker D isabil i t y P lan v. N

ord , 538 8 U . S. 822, 831 ( 2003) , m akes cl earthatno s peci al defe r ence i s ow ed t o the opi ni ons of tr eat i ng phy s i ci ans w hen cons i der i ng the deni al of bene fi t s underE R I SA . 538 U . S. at 834. A few y ear s befor e N ord , this C o u rt c o n c lu d e d th a t an a d m in istra to r’s d e c isio n to t erm i nat e bene fi t s w as notarbi tr aryand capr i ci ous w her e i tw as bas ed on the 19 C ons ul t ant , w hos e i dent i tyand qual i fi cat i ons ar e neve rdi s cl os ed bey ond an as s ert ed s peci al tyi n Phy s i cal M edi ci ne and Rehabi l i t at i on, as ked D r . G ei s ts ever al fol l ow - up q u e stio n s. In re sp o n se to its q u e stio n o f w h yh is f

in d in g s w o u ld lim it M ich a e ls to p a rtt i m e w or k, the I ndepende ntPhy s i ci an C ons ul t antchar act er i zed D r . G ei s t ’ s r es pons e as foll ow s: D r . G ei s ti ndi cat ed thatthe l onges tM r . M i chae l s coul d s i ti s 30- 60 m in u tes . T h is is b a se d o n th e p a tien t’s p a in o v e r th e p o ste ria l lef t h ip d u e to th e p ro m in e n c e o f

th e in ter m e d u llary ro d . D r. G e ist g o e s o n to sa yth is is unl i kel yt o change unl es s the r od i s r emoved. H e then s t at es ther e w as no assur ance thatthe rem ov al of the rod w ou l d rel i eve the sym ptom s. O ur[I ndepende ntPhy s i ci an C ons ul t ant ] fel tthatthi s w as contr adi ct oryand the pai n i s s ubj ect i ve. App. at896. M et L i fe’ s I ndepende ntPhy s i ci an C ons ul t ants t at ed that“M r . M i chae l s [s i c] s ubj ect i ve compl ai nt s of pai n and the i nact i vi tyof hi s upperextr emi t i es s eem t o be the m aj orfac t or s i n pr event i ng hi m fr om w or k” and that“ther e i s a l ack of obj ect i ve cl i ni cal evi dence t o s uppor ta t ot al di s abl i ng condi t i on. ” I d. at896. A ccor di ngl y , the I ndepende nt P h y s ic ia n C o n s u lta n t o p in e d th a t M ic h a e ls d id n o t q u a lif yf o r l o n g -t e rm b e n e f

its . I d. at 896- 97. A d m inistrators o f E R IS A p lans n ee d n o t aff o rd sp ec ial d ef

ere n ce to the claim an t’ s tr eat i ng phy s i ci an, and, i n B lack & D ecker D isabil i t y P lan v. N

ord , the S u p rem e C o u rt 8r ecomm endat i ons of i t s phy s i ci ans and hea l th car e w or ker s des pi t e the vi ew of the

c la im a n t’ s tr e a tin g p h y s ic ia n th a t th e c la im a n t w a s to ta lly d is a b le d . O r vos h v. P r ogr am of G r oup I ns . f orSalar i ed Em

pl oyee s of

V olks w agen of

A m . , I nc. , 222 F. 3d 123, 127- 31 ( 3d C ir. 2 0 0 0 ); see al

so S e mi e n v . L i

f e I n s . Co
. o f N. A m. , 436 F. 3d 805, 812 ( 7th C i r . 2006) (n o tin g d e f

e re n tial n a tu re o f

a rb itrar ya n d c a p ric io u s s tan d a rd ); Sl om cens kiv. C i t i bank, N. A. , 432 F. 3d 1271, 1279- 80 ( 11th C i r . 2005) ( “G i vi ng m or e w ei ghtt o the opi ni ons of s om e expe r t s than t o t he opi ni ons of otherexpert s i s an notarbi tr aryorcapr i ci ous pr act i ce. ”) . B eca us e the l anguage i n the Supr eme C our t ’ s s ubs equentdeci s i on i n N ordis contr ol l i ng, w e foc us on thatdeci s i on. 20 sta ted th a t “c o u rts h a v e n o w a rra n t to re q u ire a d m in istra to rs to a c c o rd sp e c ial w e ig h t to the o pini on s of a clai m ant’ s phy si ci an” an d m ayno t“i m po se on p l an ad m i nis trat ors a di s cr et e bur den of e xpl anat i on w hen theycr edi tr el i abl e evi dence thatconfl i ct s w i th a tr ea ti n g p h y sici an ’s ev alua ti o n . ” 5 3 8 U . S . 8 2 2 , 8 3 4 (20 0 3 ). T h e S u p rem e C o u rt co n ti n u ed , h o w ev er, th at ad m inistrators “ m ayn o t arbitraril yref u se to cre d ita c lai m an t’ s r el i abl e evi dence , i ncl udi ng the opi ni ons of a tr eat i ng phy s i ci an. ” I d. ; see al so E vans v. U num P r ovi dent

C or p. , 4 3 4 F . 3 d 8 6 6 , 8 7 7 (6th C ir . 2 0 0 6 ) (“T h e S u p rem e C o u rt n o n e th e les s a d m o n ish e d th a t ‘[ p ]la n a d m in istra to rs . . . m a yn o t ar b itrar ilyre f u se to c re d it a cl ai m ant ’ s r el i abl e evi dence , i ncl udi ng the opi ni ons of a tr eat i ng phy s i ci an. ’ ” ( quot i ng N ord , 5 3 8 U .S . at 8 3 4 )). T h u s, th e C o m m itt e e w a s n o t o b lig a ted to g iv e “ sp e c ial w e ig h t” t o th e a s s e s s me n t s o f

Dr . Ka t z o rDr . Ge i s t , th e P l a n ’ s a p p o i n t e d o r th o p e d i s t ; a tth e s a me t i m e, i tcoul d not“arbi tr ar i l yr efus e t o cr edi t[M i chae l s ’ s ] r el i abl e evi dence , i ncl udi ng t he opi ni ons of . . . tr eat i ng phy s i ci an[s ] . ” I d. W e musts etas i de the D i s tr i ctC our t ’ s deci s i on t o aff i r m E qui t abl e’ s deni al of b e n e f its. T h e D istric t C o u rt m a yh a v e a p p lied th e w ro n g sta n d a rd , an d , in a d d iti o n , it21

appea r s t o have di s cr edi t ed s ubs t ant i al evi dence thatM i chae l s ’ s phy s i cal condi t i on r ender ed hi m unabl e t o engage i n anygai nful occupa t i on w hen the C our tconcl uded that E q u ita b le ’s d e n ia l o f

b e n e f its w a s n o t c le a rl yu n s u p p o rt e d b yth e f a c ts . D . Appl i cat i on of

Tw ent y- FourMonth Li m i tat i on W her e MentalC ondi t i on H as P hys i cal C au se M i chae l s fur therar gues thathi s m ent al condi t i ons , bi pol ardi s or derand depr es s i on, s t em sol el yfr om hi s phy s i cal condi t i on and that , as a r es ul t , the tw enty - four m onth l i m i t at i on on benef i t s s houl d notappl ybeca us e hi s phy s i cal condi t i on s erved as t he p re c ip itatin g c a u se o f

h is d isa b ili ty . T h is C o u rt h a s n e v e r a d d re ss e d th e sig n if ica n c e , if a n y , o f th e e tio lo g yo f

a m e n tal d iso rd e r in d e ter m in in g b e n e f its. T h e c o u rts o f

a p p e a ls ar e di vi ded as t o w hethera di s abi l i typl an’ s m ent al di s or derl i m i t at i on appl i es w her e a m ent al condi t i on has a phy s i cal caus e. T he D i s tr i ctC our tcons i der ed thi s i s s ue and a gr eed
w i th thos e court s thathave appl i ed the l i m i t at i on on benef i t s w hen the cl ai m ant ’ s phy s i cal in ju ry o r c o n d itio n c a u s e d h is m e n ta l c o n d itio n . Mich a e ls , 2 0 0 7 W L 3 0 2 4 5 7 1 , at * 1 0 ; s ee als o Ful l erv. J. P . Mor

gan & Co. , 423 F. 3d 104, 107 ( 2d C i r . 2005) ( cons i der i ng c l a i m a n t ’ s a r g u m e n tth a th e rb i p o l a rd i s o r d e ra r i s e s f r o m a p h ys i c a l c o n d i t i o n , n a m e l y a chemi cal i m bal ance , and fi ndi ng thatthe ques t i on of “w hetherFul l er ’ s ‘ di s abi l i ty ’ ‘ ar i s es fr om ’ a ment al di s or der ” t o be “qui t e di s t i nctfr om w hetherthe di s or deri t s el f ar i s es fr om a p h y sical ca u se” ); Tol

s on v. A vondal e I

ndus
. , I nc. , 141 F. 3d 604, 610 ( 5th C i r . 1998) (re itera tin g e a rlier h o ld in g th a t “d e p re ss io n is a ‘m e n tal d iso rd e r,’ irre sp e c tiv e o f its p h y sic a l ca u se s o r sym p to m s” ); buts ee Lang v. Long- t er m D is abi l i t y Pl an of Spons orA tor al ar gum ent , couns el forM i chae l s as s ert ed thatM i chae l s ’ s di d nothave a ny 9 m ent al condi t i on befor e hi s i nj ury - caus i ng acc i dent . T hi s as s ert i on i s underm i ned byt he r ecor d, w hi ch i ncl udes r efe r ence s m ade byD r . H i ebel t o M i chae l s ’ s pr eexi s t i ng m ent al p ro b le m s . App. at427 ( “Though bri ght , cr eat i ve, and s ucce s s ful fory ear s , i tappea r s t hat M r . M i chae l s m ani fes t ed s i gns of emot i onal pr obl ems dat i ng back s ever al y ear s , none of w hi ch w er e i ncapa ci t at i ng . . . . H i s pas tbehavi or al patt erns i ndi cat e thathe had c y c lo th ym ic te n d e n c ies , b u t h e n e v e r e x p e rie n c e d a f u ll em o tio n a l b re a k d o w n .”); i d. at 4 5 4 (“H e d esc ri b es m o o d sw ing s thro u g h m u ch o f h is l ife.”). In d e e d , the in c lu sio n o f b ip o lar d iso rd e r a n d d e p re ss io n a s m e n tal c o n d iti o n s in 10 the D i agnos t i c and St at i s t i cal M anual of M ent al D i s or der s l ends fur thers uppor t . T he Pl an expr es s l yi ncorpor at ed “the curr entedi t i on of the D i agnos t i c and St at i s t i cal M anual of M ent al D i s or der s publ i s hed bythe A m er i can Ps y chi atr i c A s s oci at i on” i nt o the det erm i nat i on of w hethera di s abi l i tyar i s es fr om a “ment al condi t i on. ” App. at152. 22 Appl i ed Rem ot e Tech. , I nc. , 125 F. 3d 794, 799 ( 9th C i r . 1997) ( i nt erpr et i ng pl an l i m i t at i on fordi s abi l i ty“ca us ed orcontr i but ed t o” by“ment al di s or der ” and f i ndi ng t hat d ep ression resu lt ing fro m p h y sical diso rde r did n o t con sti tute a m en tal d isord er). W e agr ee w i th the D i s tr i ctC our tthatE qui t abl e di d notactarbi tr ar i l yand capr i ci ous l yi n t aki ng the pos i t i on thatthe tw enty - fourm onth l i m i t at i on coul d appl yeven i f the di s abl i ng m ent al condi t i ons w er e pr eci pi t at ed bya phy s i cal i nj ury . A s the Second C i r cui tobs erved i n Fuller, th e P l a n ’ s f o c u s o n wh e th e rth e “ d i s a b i l i ty ” a r i s e s f r o m a m ent al di s or derpr es ent s a di ffe r entques t i on than w hetherthe cl ai m ant ’ s “di s or der ” w as c a u s e d b ya p h y s ic a l a ilm e n t. See Ful l er , 423 F. 3d at107. T hatM i chae l s ’ s depr es s i on and bi pol ardi s or derappea rt o have be en ca us ed, oratl eas texac erbat ed, byhi s phy s i cal 9 i njurydo es not chang e t he ch aract eri zat i on of these di sorder s as m ental con dit i on s. 10 A ccor di ngl y , i f a c l ai m anti s m ent al l ydi s abl ed, the s our ce of thatm ent al condi t i on does notaff ectthe appl i cabi l i tyof a pl an’ s l i m i t at i on on benef i t s . N everthel es s , t o the ext ent23

th a t th e c laim a n t ca n d e m o n stra te th a t h is p h y sic a l d isa b ili tyin d e p e n d e n tlyp re c lu d e s h im fr om engagi ng i n anygai nful occupa t i on, he mays t i l l be el i gi bl e forbenef i t s underthe Pl an. I V . C oncl us i on W e have cons i der ed al l ot herar gum ent s m ade bythe part i es on appea l and c o n c lu d e th a t n o f

u rth e r d isc u ss io n is n e c e ss a ry . F o r th e a b o v e re a so n s, w e w ill v a c a te th e d e c isio n o f

th e D istric t C o u rt a n d re m a n d f o r f u rth e r c o n sid e ra tio n c o n sis ten t w ith th is O pi ni on.