Source: https://www.debofsky.com/Past-Case-Notes-Of-The-Month/Semien-v-Life-Insurance-Co-of-North-America.shtml
Timestamp: 2019-04-23 04:00:07+00:00

Document:
Semien v. Life Insurance Co. of North America, 2006 U.S.App.LEXIS 2823 (7th Cir. 2/6/2006)( Issues: Standard of Review, Discovery, Scope of Review) . It is very difficult for us to write about this case because it is one of our cases and we feel that the ruling was fundamentally wrong. This case involved a 54 year old chemical engineer who had worked for BP Amoco until May 2000 when she began receiving disability benefits. After two years, her benefits were cut off when LINA determined she could return to work, even though plaintiff had submitted substantial evidence pertaining to a host of medical and psychiatric conditions which showed that she remained disabled.
After submitting a substantial package of additional evidence following the benefit termination, the insurer had the file reviewed by a psychiatrist, Dr. Jack Greener, who initially found Semien incapable of performing her regular job, but who then wrote a report finding the plaintiff could perform another job with less stress. The file was also reviewed by Dr. Eddie Sassoon, although the court acknowledged it was "unclear exactly what information he reviewed" in preparing a two page report. Dr Sassoon found Semien capable of working at a sedentary job; and LINA also had a vocational counselor list several jobs the plaintiff was capable of performing which could earn her more than 80% of predisability earnings. Hence, the benefit denial was affirmed.
The first issue considered by the court was the appropriate standard of review. The court affirmed the lower court's determination that the summary plan description was sufficient to confer discretionary authority, even though the plan document itself named a different insurer as the party possessing discretion. The court also cited to the administrative services agreement, but completely disregarded the fact that the ASA explicitly divested the insurer of fiduciary responsibility. The ASA's description of administrative services reserved to the plan administrator; i.e., BP Amoco (the entity specifically named as plan administrator) sole fiduciary responsibility: "[T]he plan Administrator shall be the fiduciary designated under ERISA regulations for the determination of appealed claims and that in this process LINA shall serve solely as Plan Administrator's agent to coordinate and facilitate the appeal process." (R. 20 Part IV Tab C, Schedule A at 3).
Nelson v. EG & G Energy Measurements Group, Inc., 37 F.3d 1384, 1388-89 (9th Cir. 1994) (benefit decision by an employee not explicitly given discretion is reviewed de novo); Sanford v. Harvard Indus., Inc., 262 F.3d 590, 597 (6th Cir. 2001) (when a "decision is made by a body other than the one authorized by the procedures set forth in a benefits plan," the standard of review is de novo); see also McKeehan v. CIGNA Life Ins. Co., 344 F.3d 789, 793 (8th Cir. 2003) ("Insurers are accustomed to de novo judicial review of their decisions, and therefore we do not infer discretionary authority when an employer or plan sponsor has funded its obligations under an ERISA plan by purchasing a standard-form group insurance policy. Rather, we require 'explicit discretion-granting language' in the policy or in other plan documents to trigger the ERISA deferential standard of review." (citations omitted)). Because we find that BP provided LINA with an express delegation of discretionary authority to act as plan administrator, we need not reach the question of whether an implied delegation of authority would be sufficient to shift discretionary authority from the original plan administrator to an insurer. *12-*13.
Nonetheless, the court found that discretion could be "inferred from a series of documents," citing Ruiz v. Continental Casualty Co., 400 F.3d 986 (7th Cir. 2005)( March 2005 ), but disregarding the fact that Continental was explicitly named in the plan at issue in that case as a party with discretionary authority. The court also cited Ruiz for the proposition that LINA was a "functional" fiduciary and therefore entitled to discretion.
The reports by the physicians LINA hired to review Semien's claim demonstrate a thorough consideration of the available information. These physicians found Semien capable of activities that would disqualify her from long-term disability coverage. Although Semien's treating physicians reached different conclusions as to her abilities, under an arbitrary and capricious review, neither this Court, nor the district court, will attempt to make a determination between competing expert opinions. Instead, an "insurer's decision prevails if it has rational support in the record." Leipzig v. AIG Ins. Co., 362 F.3d 406, 409 (7th Cir. 2004).
The two physician reports prepared for LINA, coupled with the Transferable Skills Analysis prepared based upon those reports, provide a sufficient basis and rational support for the conclusion that Semien was ineligible for long-term disability benefits. While the conclusions in the medical reports submitted by Semien are also rational, "raising debatable points does not entitle [the claimant] to a reversal under the arbitrary-and-capricious standard." Sisto v. Ameritech Sickness and Accident Disability Benefit Plan, 429 F.3d 698, 701 (7th Cir. 2005). *17-*18.
The confines of the ERISA statute and the constraints of judicial resources do not permit this Court, nor the district courts, to engage in the complex weighing of expert testimony when a plan administrator has been granted discretionary authority. Where an insurance plan gives discretionary authority to a plan administrator, ERISA provides a limited Article III review. Engaging in the type of in-depth review Semien advocates not only runs contrary to statutory intent, but would tax the judicial resources of the district courts and magistrate judges beyond the breaking point. *18.
In the instant case, a substantial amount of medical evidence was analyzed by physicians compensated by LINA. These physicians were not employees of the company, they did not fail to analyze relevant medical evidence, and the claimant has not presented any evidence to demonstrate a prima facie case of misconduct or conflict of interest. The fact that a plan administrator has compensated physicians for their consulting services is not, in and of itself, sufficient to establish a conflict of interest worthy of further discovery. Although a plan administrator's self interest may be a "factor" to "weigh" in evaluating plan determinations, there is no reason to assume independent consultants are not impartial when evaluating medical records. See Perlman, 195 F.3d at 981. Thus, we have no basis to believe that the physicians in this case did not conduct a full and fair evaluation of Semien's condition. *22 - *23.
Congress has not provided Article III courts with the statutory authority, nor the judicial resources, to engage in a full review of the motivations behind every plan administrator's discretionary decisions. To engage in such a review would usurp plan administrators' discretionary authority and move toward a costly system in which Article III courts conduct wholesale reevaluations of ERISA claims. Imposing onerous discovery before an ERISA claim can be resolved would undermine one of the primary goals of the ERISA program: providing "a method for workers and beneficiaries to resolve disputes over benefits inexpensively and expeditiously." Perry v. Simplicity Eng'g, 900 F.2d 963, 967 (6th Cir. 1990) (internal citation omitted). While claimants who believe they are the victims of arbitrary and capricious benefits decisions should feel free to seek relief in federal court, trial judges must exercise their discretion and limit discovery to those cases in which it appears likely that the plan administrator committed misconduct or acted with bias.
*27. Hence, the judgment was affirmed.
It is hereby declared to be the policy of this chapter to protect interstate commerce and the interests of participants in employee benefit plans and their beneficiaries, by requiring the disclosure and reporting to participants and beneficiaries of financial and other information with respect thereto, by establishing standards of conduct, responsibility, and obligation for fiduciaries of employee benefit plans, and by providing for appropriate remedies, sanctions, and ready access to the Federal courts. 29 U.S.C. §1001(b).
The Seventh Circuit's ruling is fundamentally at odds with the purpose of the ERISA statute. Nowhere in the statute or legislative history is there support for the conclusion that a goal of the ERISA statute is to provide "a method for workers and beneficiaries to resolve disputes over benefits inexpensively and expeditiously." The citation for that comment can be traced to Senate Report 93-383 accompanying S.1179, a predecessor to the bill that eventually became the ERISA law. In that bill, a provision that was never enacted provided for a grievance or arbitration proceeding before the Secretary of Labor; and the report refers to such a proceeding as providing "the opportunity to resolve any controversy over [ ] retirement benefits under qualified plans in an inexpensive and expeditious manner...Accordingly, the committee has decided to provide that controversies as to retirement benefits are to be heard by the Department of Labor." S.Rep. 93-383, reprinted in 1974 U.S. Code Cong. & Admin. News 5000. The addition of welfare benefits to the ERISA law did not even come about until the bill was before the conference committee, and nothing contained in House Conf. Rep. 93-1280 reiterates a provision for an administrative mechanism to resolve pension or even welfare disputes. The only discussion in that report is a recitation of what is now contained in §502 of the ERISA law providing for a "civil action" to be brought by a participant or beneficiary to recover benefits due under the plan. See, 1974 U.S. Code Cong. & Admin. News at 5107. This is further confirmed by remarks made by Senator Jacob Javits, one of ERISA's main sponsors, who explained that House conferees were opposed to an administrative dispute mechanism "on grounds it might be too costly to plans and a stimulant to frivolous benefit disputes, and at their insistence it was dropped in conference." 3 Legislative History of ERISA, n. 4 at 4769.
Since all of the legislative history relating to the ERISA law describes a participant or beneficiary's cause of action as a "civil action" without any specific restriction or limitation, there is no basis whatsoever for restricting ERISA claimants' ability to utilize the adjudicative rights they possess under the Federal Rules of Civil Procedure. Rule 1 of the Federal Rules of Civil Procedure states that the Rules apply to "all suits of a civil nature" with the exception of certain actions enumerated in Rule 81, none of which encompass ERISA claims. Nor is there any other legislative limitation on ERISA claims.
Yet even if there were some basis for believing hat the treatment of a benefit suit as an evidentiary proceeding would interfere with "prompt resolution of claims by the fiduciary," the rationale would still fail. For it to be plausible, one would have to add two premises: that "prompt resolution of claims" is something Congress intended for the protection of sponsors and fiduciaries; and that such protection of sponsors and fiduciaries is more important than protection of the participants' right to receive benefits due. Merely to state thee premises is to reveal their untenability.
Plan administrators are not governmental agencies who are frequently granted deferential review because of their acknowledged expertise. Administrators may be laypersons appointed under the plan, sometimes without any legal, accounting or other training preparing them for their responsible position, often without any experience in or understanding of the complex problems arising under ERISA, and, as this case demonstrates, little knowledge of the rules of evidence or legal procedures to assist them in fact finding.
Also see, DeBofsky, "The Paradox of the Misuse of Administrative Law in ERISA Benefit Claims," 37 John Marshall L.Rev. 727 (2004)(pointing out that the fundamental due process protections preserved in administrative law are absent in ERISA cases).
Nor is there even support for the economic efficiency argument in the Firestone opinion, which explicitly rejected the possibility that the increased cost of additional litigation constitutes grounds for limiting court review; the ruling further provides ammunition for an argument that claimants should not fare worse under ERISA as they did before its enactment. 489 U.S. at 114. Certainly, had Semien's claim been litigated in state court under the law of the State of Illinois, both discovery and an evidentiary hearing would have been available to her. Taking away those rights could not possibly have been what Congress intended.
The Seventh Circuit also diminishes the societal importance of employee benefits - surely the protection of employee benefits deserves the full attention of Article III courts. Insurance company statistics show that "one out of five 35-year-olds will experience a disability that lasts three months or more before age 65." Working women are even more adversely affected and are deemed "three times more likely than men to miss work due to a disability related illness." www.efmoody.com/insurance/disabilitystatistics.html. According to the Social Security Administration, more than 2.1 million individuals applied for Social Security disability insurance in 2005, a 4.39% increase over the prior year. www.ssa.gov/OACT/STATS/dibStat.html.
There are also obvious drawbacks to relying on private insurers, however. Although the profit motive drives companies toward efficiency, it creates a substantial risk that they will cut costs by denying valid claims. The market is somewhat inapt to punish insurers for engaging in such practices, particularly if the denials are not too flagrant, because the complexity of the insurance market and the imperfect information available to consumers make it difficult to determine whether an insurer is keeping its costs down through legitimate or illegitimate means. An individual claimant who encounters an insurance company that is disposed to deny valid claims must struggle to vindicate his rights at a time when he is at his most vulnerable. Often a newly disabled person will simultaneously confront increased medical bills and either termination of employment or diminished pay.
The judiciary provides a check on these potential abuses; under ERISA, aggrieved claimants can seek redress in the courts of justice. Congress and the courts have made two decisions, however, that limit this checking effect. The first is to place limitations on judicial review of plan administrators' and fiduciaries' decisions similar to the ones placed on judicial review of governmental agency action, even though, unlike officials in governmental agencies, administrators and fiduciaries are not answerable to the public or to elected officials. Second, and perhaps more troubling, the courts have interpreted ERISA to restrict or eliminate the role of juries in deciding disputes between claimants and insurers. See Liston, 330 F.3d at 24 & n.4; Andrews-Clarke v. Travelers Ins. Co., 984 F. Supp. 49, 63 & n.74 (D. Mass. 1997). In the process, they have removed one of the most important guarantees of fairness in the judicial process. Id. at 240-41.
Caveat Emptor! This case attests to a promise bought and a promise broken. The vendor of disability insurance now tells us, with some legal support furnished by the United States Supreme Court, that a woman determined disabled by the Social Security Administration because of multiple disabilities which prevent any kind of work cannot be paid on the disability insurance she purchased through her employment. The plan and insurance language did not say, but the world should take notice, that when you buy insurance like this you are purchasing an invitation to a legal ritual in which you will be perfunctorily examined by expert physicians whose objective it is to find you not disabled, you will be determined not disabled by the insurance company principally because of the opinions of the unfriendly experts, and you will be denied benefits. Loucks v. Liberty Life Assur.Co. of Boston, 337 F.Supp.2d 990 (W.D.Mich. 2004)(vacated following settlement).
The media has also begun focusing on ERISA and the need for more penetrating judicial review. The story of how a law intended to protect employee benefits has been used to shield insurers was told in the Los Angeles Times by Peter G. Gosselin in his article, "The Safety Net She Believed in Was Pulled Away When She Fell." (August 21, 2005). Another reporter observed, "All this makes ERISA cases much harder to litigate than regular civil cases." Karin Rives, "Premiums paid, claims denied," Raleigh News-Observer December 11, 2005. Even the authoritative medical journals have concluded that "ERISA plans have a financial incentive to deny care...without liability, there is nothing in the law to counterbalance the financial incentive to deny care." Mariner, "What Recourse? - Liability for Managed-Care Decisions and the Employee Retirement Income Security Act," New England Journal of Medicine 343: 592, 595 (August 24, 2000).
Consequently, contrary to both the language of the statute and Congressional intent, the courts have created a situation aptly characterized by University of Chicago economist Steven D. Levitt as "freakonomics." Levitt and his co-author Stephen J. Dubner, in their book Freakonomics, focus on how economic incentives often lead to perverse unintended results, some beneficial, but many of which are harmful. Clearly, when insurers are motivated by profits and have no worry about paying damages or even having the reasons given for their determinations given close scrutiny, there is an opportunity for mischief. The parent of LINA, CIGNA, Inc., reported an overall loss in 2002 that was turned into a significant profit according to the corporation's 2004 annual report. Page 29 of that report attributes "improved expense management" as one of the keys to profitability. Although one of CIGNA's competitors, the Unum Provident Corporation, has received a significant amount of adverse publicity for its claims tactics, why should there be any reason to believe that Unum Provident is a rogue and that other insurers are not behaving in the same manner under the identical system of incentives? Could that perhaps be what is meant by "improved expense management?"
The problem, therefore, with the Seventh Circuit's treatment of Kathleen Semien's disability claim, is not that courts lack the resources to deal with such claims; it is that they need to find the resources to do so. The solution is at hand. Unlike other court systems that place the burden of investigation on the court system itself, which would understandably concern a judiciary worried about having to readjudicate complex disability claims, the Federal Rules of Civil Procedure place the tools of discovery in the hands of private litigants to prove their claims and/or disprove their opponent's defenses. Discovery should be allowed in all cases where it is sought.
The Seventh Circuit's approach of allowing discovery in ERISA cases only if the insured can come forth with credible evidence justifying discovery applies circular reasoning. How is an insured to prove bias without the means of investigating the witness? The Supreme Court pointed out that "physicians repeatedly retained by benefits plans may have an incentive to make a finding of 'not disabled' in order to save their employers money and preserve their own consulting arrangements." Black & Decker Disability Plan v. Nord, 538 U.S. 822, 832, 155 L. Ed. 2d 1034 (2003). Without discovery, though, that proposition can never been proven. The case cited in Semien, Bennett v. Unum Life Ins. Co. of Am., 321 F. Supp. 2d 925, 932-33 (E.D. Tenn. 2004), allowed a claimant to pursue discovery because the fruits of discovery taken in prior actions suggested bias. Likewise, Gunn v. Reliance Standard Life Insur.Co., 399 F. Supp. 2d 1095 (C.D.Cal. 2005) relied on a deposition which showed that the consultant retained by the insurer derived a substantial portion of his overall earnings from the defendant. In most cases, though, litigants are not fortunate enough to have such forthright evidence of bias; and without discovery, there is no way to determine whether the plan administrator overlooked key evidence. As set forth by the United States Supreme Court in Motor Vehicle Manufacturers Association v. State Farm Mutual Automobile Insurance Co., 463 U.S. 29, 43 (1983), a decision is arbitrary and capricious if the decision-maker 'entirely failed to consider an important aspect of the problem [or] offered an explanation for its decision that runs counter to the evidence.' '' Discovery is essential in order for a party to meet that burden.
However, ERISA litigation generally arises only in close cases, and there would seem to be insufficient incentive for the carrier to treat borderline cases (unlikely to become cause celebres) with the level of attentiveness and solicitude that Congress imagined when it created ERISA "fiduciaries." Rather, insurance carriers have an active incentive to deny close claims in order to keep costs down and keep themselves competitive so hat companies will choose to use them as their insurers, an economic consideration overlooked by the Seventh Circuit.
Likewise, the Third Circuit observed that while pension plans are set up in the nature of trusts, where "money paid into the fund may be used only for maintaining the fund and paying out pensions," the typical insurance company is structured such that its profits are directly affected by the claims it pays out and those it denies." Id.
Perhaps all of this is the reason why there is substantial disagreement among the Circuits about how to go about deciding ERISA claims. Raising significant doubts about the validity of opinions obtained from consultants retained by plans to review claim files rather than examine claimants, the Sixth Circuit recently issued a trio of opinions which explicitly direct parties to seek discovery on potential bias: Calvert v. Firstar Finance, Inc., 409 F.3d 286 (6th Cir. 2005); Kalish v. Liberty Mutual/Liberty Life Assur.Co. of Boston, 419 F.3d 501 (6th Cir. 2005); Evans v. Unum Provident Corp., 2006 U.S.App.LEXIS 1359 (6th Cir. 1/20/2006). In particular, Footnote 2 to the Calvertopinion suggested that discovery would provide the court with "a better feel for the weight to accord this conflict of interest." Therefore, in order to protect employee benefits, ERISA's paramount purpose, courts must allow the claimants to take necessary discovery, especially if they face the daunting arbitrary and capricious standard of review. It is well-nigh impossible to demonstrate the arbitrariness of a claim decision without the tools of discovery, especially here, where the court even acknowledges that it has no idea what evidence was reviewed by LINA's reviewing doctor. The same could be said for the vocational consultant, since the only evidence that individual identified having reviewed was the amended report prepared by the consulting psychiatrist.
Finally, there is a disturbing element to the manner in which the court applied a deferential standard of review. The Seventh Circuit has been strongly moving in the direction of requiring explicit discretionary authority, as evidenced both by Herzberger, supra. and Diaz v. Prudential Insur.Co. of America, 422 F.3d 635 (7th Cir. 2005). After acknowledging substantial contrary authority from other circuits requiring that discretion be delegated to the appropriate named fiduciary, the Seventh Circuit split from the Sixth, Eighth and Ninth Circuits, as well as the explicit requirements of 29 U.S.C. §1105 in allowing discretion to be "implied" from a series of documents. Particularly since the explicit plan document delegated discretion to an entity other than the one that made the claim determination, and because the administrative services agreement expressly disclaimed fiduciary responsibility by anyone other than the employer, who was named as plan administrator, the application of an arbitrary and capricious standard of review was contrary to the authority of Firestone v. Bruch.
This regime must be changed. The American worker will not be protected until this new Carthage is destroyed ( Carthago delenda est!) and ERISA claimants are given the same rights in court as any other civil litigant is afforded.

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