Opinion ID: 794560
Heading Depth: 4
Heading Rank: 3

Heading: CCC's Failure to Conduct an Independent Evaluation of Smith

Text: 62 Smith argues that CCC's failure to conduct an independent evaluation is additional evidence that the denial of her disability claim was arbitrary and capricious. Smith relies on this circuit's holding in Calvert to advance the theory that a disability determination based on a file review alone may, in some instances, be an indication that the administrator's decision was arbitrary and capricious. 63 In Calvert, the plaintiff suffered a back injury and did not return to work. 409 F.3d at 289. The disability plan administrator denied her request for long term disability benefits based on a review of the plaintiff's medical record alone, even though the plan afforded the administrator the right to have the patient examined. 409 F.3d at 295. When the plaintiff objected to the pure paper review, this court found that although the plan provision allowed the administrator to conduct an independent examination, the plan was not required to do so. Id. However, we stated: 64 while we find that Liberty's reliance on a file review does not, standing alone, require the conclusion that Liberty acted improperly, we find the failure to conduct a physical examination — especially where the right to do so is specifically reserved in the plan — may, in some cases, raise questions about the thoroughness and accuracy of the benefits determination. 65 Id. This court ruled that although there is nothing inherently objectionable about a file review by a qualified physician in the context of a benefits determination, the file review performed in Calvert was inadequate because the physician did not describe the data that he reviewed in reaching his decision, and he made credibility determinations concerning the patient's subjective complaints without the benefit of a physical examination. Id. at 296. 5 66 The facts here are similar to those in Calvert. Like the reviewer in Calvert, Kaplan made a credibility determination concerning Smith's complaints of pain. In his letter, Kaplan states: Ms. Smith has ongoing pain complaints. Pain is a subjective complaint and often times is out of proportion to physical findings. JA 179 (emphasis added). This conclusory statement about Smith's pain suggests that Kaplan does not believe Smith's pain is a credible complaint. 67 CCC distinguishes Calvert by stating that the court found that the paper review conducted in Calvert was inadequate because the physician did not identify the objective medical evidence he reviewed in order to reach his determination. Further, CCC argues that the evidence in Calvert's record was in conflict with the reviewing physician's determination, while here, the evidence in the record is in keeping with Kaplan's decision. We agree that Kaplan does discuss objective medical findings in his peer review report, however, Kaplan also makes credibility findings concerning Smith's pain without the benefit of a physical exam. 68 Here, as in Calvert, CCC has reserved the right to obtain an independent medical examination of a claimant. Following the ruling in Calvert, we consider CCC's decision to not require an examination as part of the arbitrary and capricious review, especially because Kaplan made credibility determinations concerning Smith's subjective complaints. CCC could have obtained an independent medical examination to evaluate Smith's pain. Their decision to not perform this examination supports the finding that their determination was arbitrary. 69