Opinion ID: 1373111
Heading Depth: 2
Heading Rank: 1

Heading: Summary Judgment on Midgett's Short-Term Disability Claim

Text: We review the district court's grant of summary judgment de novo, applying the same standards as the district court. Craig v. Pillsbury Non-Qualified Pension Plan, 458 F.3d 748, 752 (8th Cir.2006). But [w]hen an ERISA plan grants the administrator discretion to construe the plan and to determine benefits eligibility, as in this case, both courts must apply a deferential abuse-of-discretion standard in reviewing the plan administrator's decision. Jessup v. Alcoa, Inc., 481 F.3d 1004, 1006 (8th Cir.2007).
Midgett first argues that the district court erred in granting the defendants' motion for summary judgment as to her short-term disability claim because she did not receive the full and fair review of that claim required by 29 U.S.C. § 1133(2). Under ERISA, employee benefit plans must afford a reasonable opportunity to any participant whose claim for benefits has been denied for a full and fair review by the appropriate named fiduciary of the decision denying the claim. 29 U.S.C. § 1133(2). In accordance with the authority of ... 29 U.S.C. [§ ] 1133, 29 C.F.R. § 2560.503-1 sets forth minimum requirements for employee benefit plan procedures pertaining to claims for benefits. 29 C.F.R. § 2560.503-1(a). Following Broadspire's denial of Midgett's first-level appeal, Dr. Blumberg, Dr. Mendelssohn, and Dr. Ulfarrson completed peer reviews in which they concluded that the medical evidence did not support the conclusion that Midgett was suffering from a condition that would prevent her from performing her job duties. Aetna relied on these peer reviews in denying Midgett's second-level appeal. Midgett alleges that Aetna failed to provide her with access to the peer reviews of Dr. Blumberg, Dr. Mendelssohn, and Dr. Ulfarrson until after Aetna rendered its decision. According to Midgett, she was entitled to review and rebut these peer reviews before Aetna denied her second-level appeal. In support of her argument, Midgett relies principally on our decision in Abram v. Cargill, Inc., 395 F.3d 882 (8th Cir.2005). In Abram, the plan administrator denied the claimant's long-term disability claim. Id. at 885. On administrative appeal, the claimant submitted a functional capacity evaluation (FCE) supporting her disability claim. Id. The plan administrator sent the FCE to an independent medical examiner, who concluded that the FCE did not establish that the claimant was disabled. Id. On the basis of the independent medical examiner's report, the plan administrator denied the claimant's appeal almost a month after its decision was due. Id. The claimant appealed the decision to the district court, which granted summary judgment to the plan administrator. Id. We explained in Abram that [f]ull and fair review includes the right to review all documents, records, and other information relevant to the claimant's claim for benefits, and the right to an appeal that takes into account all comments, documents, records, and other information submitted by the claimant relating to the claim. Id. at 886. The plan administrator solicited the independent medical examiner's report after the deadline for an appeals decision had passed and sent the report to the claimant only after the Plan issued its final denial decision. Id. We stated that [t]his type of `gamesmanship' is inconsistent with full and fair review. Id. (quoting Wilczynski v. Lumbermens Mut. Cas. Co., 93 F.3d 397, 403 (7th Cir.1996)). We concluded that [t]he process used by the Plan was not consistent with a full and fair review because the claimant was not provided access to the ... report ... that served as the basis for the Plan's denial of benefits until after the Plan's decision. Id. Noting that [a] claimant is caught off guard when new information used by the appeals committee emerges only with the final denial, we held that the claimant should have been permitted to review and respond to the report. Id. Midgett contends that just as the claimant in Abram was denied the opportunity to review and dispute the independent medical examiner's report, she was denied the opportunity to review and rebut the peer reviews of Dr. Blumberg, Dr. Mendelssohn, and Dr. Ulfarrson. But this case presents one of those exceptional circumstances where a change in the law renders a prior decision non-binding. Buchholz v. Aldaya, 210 F.3d 862, 866 (8th Cir.2000). In 2000, the Department of Labor amended the minimum procedural requirements for benefit claims under employee benefit plans. 65 Fed.Reg. 70,246, 70,246 (Nov. 21, 2000). The amended requirements apply to claims filed under a group health plan on or after the first day of the first plan year beginning on or after July 1, 2002, but in no event later than January 1, 2003, and to claims filed under [other] plan[s] on or after January 1, 2002. 66 Fed.Reg. 35,886, 35,888 (July 9, 2001) (codified at 29 C.F.R. § 2560.503-1( o )). Because the claimant in Abram filed for benefits in 2000, 395 F.3d at 884, the amended Department of Labor requirements were inapplicable to her claim. The regulatory scheme applicable to the claim in Abram required employee benefit plans to establish and maintain an appeal procedure under which a claimant was entitled to [r]eview pertinent documents, 29 C.F.R. § 2560.503-1(g)(1)(ii) (2000), but it did not specify what constituted a pertinent document. In light of the substantial public confusion concerning the meaning of the term `pertinent,' the Department of Labor substituted relevant for pertinent and provide[d] a specific definition of that term in its 2000 amendments. 65 Fed.Reg. 70,246, 70,252. The regulatory scheme governing the claim in Abram also failed to specify when a claimant was entitled to review pertinent documents. 29 C.F.R. § 2560.503-1(g)(1)(ii) (2000). But the amended regulations set forth specific stages in the claims process at which a claimant is entitled to review the materials relevant to his or her claim. Section 2560.503-1(h) of the amended regulations is entitled Appeal of adverse benefit determinations. 29 C.F.R. § 2560.503-1(h). Section 2560.503-1(h)(1) requires employee benefit plans to establish and maintain a procedure by which a claimant shall have a reasonable opportunity to appeal an adverse benefit determination. Under § 2560.503-1(h)(2)(iii), a plan only provides a claimant with a full and fair review of a claim and adverse benefit determination if the claims procedures ... [p]rovide that [the] claimant shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits. The adverse benefit determination referred to throughout § 2560.503-1(h) is the plan administrator's initial denial of a claim for benefits. See Price v. Xerox Corp., 445 F.3d 1054, 1056 (8th Cir.2006) (stating that the regulation's language indicates that only the initial denial of benefits is an `adverse benefit determination'). Accordingly, following an initial denial of a claim for benefits, § 2560.503-1(h)(2)(iii) entitles a claimant to review the materials relevant to his or her claim. Midgett concedes that she received copies of her administrative record following Broadspire's initial denial of her short-term disability claim. Section 2560.503-1(I) of the amended regulations sets forth the time limits within which a claimant must be notified of a benefit determination on review.  29 C.F.R. § 2560.503-1(i)(1)-(4) (emphasis added). Section 2560.503-1(i)(5) provides as follows: In the case of an adverse benefit determination on review, the plan administrator shall provide such access to, and copies of, documents, records, and other information described in paragraphs (j)(3), (j)(4), and (j)(5) of this section as is appropriate. (Emphasis added.) Section 2560.503-1(j)(3), in turn, refers to all documents, records, and other information relevant to the claimant's claim for benefits. The inclusion of the language `on review' [in § 2560.503-1(i)(5)] differentiates the initial `adverse benefit determination' from later internal appeals of it. Price, 445 F.3d at 1057. Accordingly, following a denial of a first-level or second-level appeal, § 2560.503-1(i)(5) entitles a claimant to review the materials relevant to his or her claim on appeal. Midgett does not contend that she was denied the opportunity to review materials in connection with Broadspire's denial of her first-level appeal; indeed, because the peer reviews of Dr. Blumberg, Dr. Mendelssohn, and Dr. Ulfarrson were completed subsequent to the denial of her first-level appeal, they were only relevant to Aetna's determination of her second-level appeal. See 29 C.F.R. § 2560.503-1(m)(8) (defining material as relevant if, inter alia, it [w]as relied upon in making the benefit determination or [w]as submitted, considered, or generated in the course of making the benefit determination). Nor does Midgett contend that she was denied access to the peer reviews following Aetna's denial of her second-level appeal. Instead, she argues that she was entitled to review and rebut the peer reviews before Aetna denied her second-level appeal. But the amended regulations state that Midgett was entitled to access those peer reviews only after Aetna made its adverse benefit determination on review. 29 C.F.R. § 2560.503-1(i)(5). Section 2560.503-1(h)(3)(iii), another amendment to the Department of Labor regulations that was inapplicable to the claim in Abram, also runs counter to Midgett's argument that she was entitled to review and rebut the peer reviews of Dr. Blumberg, Dr. Mendelssohn, and Dr. Ulfarrson prior to Aetna's determination of her second-level appeal. Section 2560.503-1(h)(3)(iii) clarifies the nature of review to which a claimant is entitled. This section states that the claims procedures of a group health plan only provide a claimant with a full and fair review of a claim and adverse benefit determination if the procedures [p]rovide that, in deciding an appeal of any adverse benefit determination that is based in whole or in part on a medical judgment, ... the appropriate named fiduciary shall consult with a health care professional. Conspicuously absent from § 2560.503-1(h)(3)(iii) is any requirement that the claimant be given the opportunity to review and rebut the health care professional's conclusion. Furthermore, we agree with the observation of the Tenth Circuit that requiring a plan administrator to grant a claimant the opportunity to review and rebut medical opinions generated on administrative appeal would set up an unnecessary cycle of submission, review, re-submission, and re-review. Metzger v. UNUM Life Ins. Co. of Am., 476 F.3d 1161, 1166 (10th Cir. 2007). Such a cycle would undoubtedly prolong the appeal process, which, under the regulations, should normally be completed within 45 days. Id. (citing 29 C.F.R. § 2560.503-1(i)(3)(i)). As noted by the Tenth Circuit, because the amendments to § 2560.503-1 did not apply to the claim in Abram, we did not consider the potential for circularity of review in that case. Id. at 1167 n. 3. Finally, our interpretation of the full and fair review to which a claimant is entitled under 29 U.S.C. § 1133(2), as clarified in 29 C.F.R. § 2560.503-1, is supported by the Department of Labor's rationale for adopting the definition of relevant in 29 C.F.R. § 2560.503-1(m)(8). The Department of Labor explained that it believes that this specification of the scope of the required disclosure of `relevant' documents will serve the interests of both claimants and plans by providing clarity as to plans' disclosure obligations, while providing claimants with adequate access to the information necessary to determine whether to pursue further appeal.  65 Fed.Reg. 70,246, 70,252 (emphasis added). According to the Department of Labor, the purpose of the production of these documents is to enable a claimant to evaluate whether to appeal an adverse determination. Glazer v. Reliance Standard Life Ins. Co., 524 F.3d 1241, 1246 (11th Cir.2008). And the determination that claimants are entitled to pre-decision access to relevant documents generated during the administrative appealwould nullify the Department's explanation. Access to documents during the course of an administrative decision would not aid claimants in determining `whether to pursue further appeal,' because claimants would not yet know if they faced an adverse decision. Metzger, 476 F.3d at 1167. The amendments to § 2560.503-1 enacted in 2000, which were inapplicable to the claim in Abram, indicate that the full and fair review to which a claimant is entitled under 29 U.S.C. § 1133(2) does not include reviewing and rebutting, prior to a determination on appeal, the opinions of peer reviewers solicited on that same level of appeal. Therefore, we conclude that Midgett was not denied a full and fair review of her claim by Aetna's failure to provide her the opportunity to review and rebut the peer reviews of Dr. Blumberg, Dr. Mendelssohn, and Dr. Ulfarrson prior to denying her second-level appeal. Midgett's remaining contentions in support of her argument that she was denied a full and fair review of her claim are without merit. Midgett emphasizes that (1) the peer reviews were performed by physicians who had never examined her; (2) the peer reviewers were unidentified other than by name, title, and academic degree; (3) the peer reviews appear on a form bearing Broadspire's corporate logo; and (4) the notice she received of Aetna's denial of her second-level appeal did not specifically address certain evidence supporting her claim. But Midgett cites no authorityand we are aware of nonerequiring peer reviews to be performed by examining physicians, requiring a plan administrator to provide detailed credentials of peer reviewers, or prohibiting peer reviews from appearing on a plan administrator's form. Additionally, 29 C.F.R. § 2560.503-1(j) sets forth the requisite content of a notification of a benefit determination on review, and it does not require the plan administrator to discuss specific evidence submitted by the claimant. Accordingly, we hold that Midgett was not denied a full and fair review of her claim.
Midgett next argues that the district court erred in concluding that the plan administrator's denial of her short-term disability claim was not arbitrary and capricious. Under the abuse of discretion standard applicable in this case, we will reverse the plan administrator's decision `only if it is arbitrary and capricious.' Groves v. Metro. Life Ins. Co., 438 F.3d 872, 874 (8th Cir.2006) (quoting Hebert v. SBC Pension Benefit Plan, 354 F.3d 796, 799 (8th Cir.2004)). To determine whether a plan administrator's decision was arbitrary and capricious, we ask whether the decision to deny ... benefits was supported by substantial evidence, meaning more than a scintilla but less than a preponderance. Schatz v. Mut. of Omaha Ins. Co., 220 F.3d 944, 949 (8th Cir.2000). Provided the decision `is supported by a reasonable explanation, it should not be disturbed, even though a different reasonable interpretation could have been made.' Id. (quoting Cash v. Wal-Mart Group Health Plan, 107 F.3d 637, 641 (8th Cir.1997)). The requirement that the [plan administrator's] decision be reasonable should be read to mean that a decision is reasonable if a reasonable person could have reached a similar decision, given the evidence before him, not that a reasonable person would have reached that decision. Jackson v. Metro. Life Ins. Co., 303 F.3d 884, 887 (8th Cir.2002) (internal quotation marks omitted). The crux of Midgett's argument is that Broadspire and Aetna improperly disregarded the conclusions of Dr. Chakales and Dr. McDonald, who had examined her, and relied instead on the conclusions of the peer reviewers, who had not examined her. The Supreme Court has recognized that treating physicians are not automatically entitled to special weight in disability determinations under ERISA: Plan administrators, of course, may not arbitrarily refuse to credit a claimant's reliable evidence, including the opinions of a treating physician. But, we hold, courts have no warrant to require administrators automatically to accord special weight to the opinions of a claimant's physician; nor may courts impose on plan administrators a discrete burden of explanation when they credit reliable evidence that conflicts with a treating physician's evaluation. Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834, 123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003). In Weidner v. Fed. Express Corp., we applied Nord to hold that a plan administrator did not abuse its discretion in denying a claimant total disability benefits despite a treating physician's opinion that the claimant was fully disabled. 492 F.3d 925, 930 (8th Cir.2007). We emphasized that consultative specialists had concluded that the medical evidence did not reflect total disability and that the claimant's annual MRI scans indicated that her condition had progressed very little during the relevant period. Id. Likewise, in Dillard's Inc. v. Liberty Life Assurance Co. of Boston, we rejected the contention that the plan administrator abused its discretion when it credited [a peer reviewer's] analysis over [a primary care physician's] conclusions because [the peer reviewer] did not physically examine [the claimant]. 456 F.3d 894, 899 (8th Cir.2006). We noted that [w]e have held ... that a plan administrator has discretion to deny benefits based upon its acceptance of the opinions of reviewing physicians over the conflicting opinions of the claimant's treating physicians unless the record does not support the denial. Id. at 899-900 (citing Johnson v. Metro. Life Ins. Co., 437 F.3d 809, 814 (8th Cir.2006); Coker v. Metro. Life Ins. Co., 281 F.3d 793, 799 (8th Cir. 2002)). The decision to deny Midgett's short-term disability claim was supported by substantial evidence. Schatz, 220 F.3d at 949. First, the eight peer reviewers unanimously concluded that the evidence did not support Midgett's short-term disability claim. Midgett attempts to discount the peer reviews, characterizing them as conclusory. She relies on Kalish v. Liberty Mutual/Liberty Life Assurance Co. of Boston, in which the Sixth Circuit held that the plan administrator acted arbitrarily and capriciously in denying [the claimant] disability benefits on the basis of his cardiac condition. 419 F.3d 501, 511 (6th Cir. 2005). The court specifically noted that the plan administrator relied exclusively on the conclusion of a peer reviewer who had not physically examined the claimant and rejected the conclusion of a physician who had examined the claimant on numerous occasions. Id. at 509. The court emphasized that the peer reviewer's report was inadequate because, inter alia, it failed to mention certain contrary findings and failed to rebut the contrary conclusions reached by the examining physician. Id. at 510. In contrast, the peer reviews in this case, viewed together, accurately represent Midgett's medical record and adequately address the evidence supporting her claim for disability. In particular, Dr. Blumberg and Dr. Cohan acknowledged the findings of Dr. Chakales, and Dr. Mendelssohn acknowledged the findings of Dr. McDonald, but they all explained that these findings did not demonstrate that Midgett was unable to perform her job duties. In addition to the peer reviews, the results of Dr. Rutherford's nerve conduction studies and needle examination were normal, and Dr. Safman noted that Midgett's examination did not reveal a significant pathology in her trunk or extremities and that Midgett's pain was under control. Where the record reflects conflicting medical opinions, the plan administrator does not abuse its discretion in finding the employee not to be disabled. Delta Family-Care Disability & Survivorship Plan v. Marshall, 258 F.3d 834, 843 (8th Cir. 2001). In light of the conflicting medical opinions in this case, the denial of Midgett's short-term disability claim was not arbitrary and capricious. Because Midgett was not denied a full and fair review of her claim and the denial of her claim was not arbitrary and capricious, we affirm the district court's grant of summary judgment to the defendants.