Opinion ID: 787313
Heading Depth: 2
Heading Rank: 1

Heading: The Legally Correct Interpretation

Text: 22 In order to ascertain the legally correct interpretation of the plan, we must consider (1) whether a uniform construction of the [plan] has been given by the administrator, (2) whether the interpretation is fair and reasonable, and (3) whether unanticipated costs will result from a different interpretation of the policy. Lain v. UNUM Life Ins. Co. of America, 279 F.3d 337, 344 (5th Cir.2002). Applying these factors, the district court correctly determined that the essential inquiry here is whether MetLife's interpretation of the plan was fair and reasonable, as Vercher did not allege that the construction of the plan was not uniform or that there were unanticipated costs. 7 23 Under Alexander's long-term disability plan, a person becomes  disabled if, because of injury or sickness: You are completely unable to perform any and every duty of your regular occupation; and After benefits have been paid for 60 months, you are completely unable to perform the material duties of any gainful occupation for which you are reasonably suited by training, education, or experience. The district court correctly determined that Vercher's claim falls under the first part of this definition, requiring her to be completely unable to perform any and every duty of her regular occupation. 24 Vercher appeals the district court's holding as to the legally correct interpretation of any and every. In its memorandum ruling of September 23, 2002, the district court stated that in order to be considered disabled under the plan's definition, an employee must be unable to perform all of the duties the employee's occupation demands. It is insufficient, under the Plan's definition, to be unable to perform some of the duties of one's regular occupation. To be eligible for long term disability benefits, an employee must be completely unable to work.... As long as Vercher has some ability to work at her position as administrative services manager, she does not meet the required eligibility standard. 25 We believe that the district court's definition of any and every goes too far. In Saffle v. Sierra Pacific Power Co. Bargaining Unit Long Term Disability Income Plan, 85 F.3d 455 (9th Cir.1996), the Ninth Circuit examined a similar provision in a long term disability plan containing the phrase each and every. That court determined that the phrase was ambiguous 8 because there were two extreme constructions possible: Reading `each and every' literally could mean either that a claimant is not totally disabled if she can perform any single duty of her job, no matter how trivial — or that a claimant is totally disabled if she cannot perform any single duty, no matter how trivial. 85 F.3d at 458. The court then notes that were the phrase to be given the former construction, total disability would only exist if the person were essentially non-conscious, while the latter effectively convert [s] benefits for total disability into benefits for partial disability. Id. at 458-59. 26 The Saffle court held that the Benefit Committee could reasonably interpret the Plan as providing for payment of total occupational disability benefits when the participant is unable to perform all of the substantial and material duties of her regular occupation, i.e., each and every duty that mattered. Id. at 460. However, the court found that the Committee arbitrarily construed the plan by defining total disability, which for purposes of occupational benefits depends on whether the participant can perform the duties of her regular occupation, to include modifications or accommodations to work available for which she is qualified. Id. at 459. In effect, even though the committee had discretion, the court held that their construction of total disability was not reasonable because premising occupational disability (unable to perform each and every duty of her regular occupation) on the existence of other work available for which she is qualified that would have accommodated her limitations was inconsistent with the plan. Id. 27 Vercher also cites the Ninth Circuit opinion in McClure v. Life Ins. Co. of North America, 84 F.3d 1129 (9th Cir.1996), where discretion to interpret the plan was not present. In that case, where the ERISA policy at issue defined disability in terms of the claimant's inability to perform every duty of his occupation, the court determined that every was ambiguous, and that the language should be construed against the insurer. 84 F.3d at 1133-34. The court stated that the provision should be construed in a practical sense to refer to essential duties .... total disability exists if an employee is unable to perform one of the essential duties of his or her position. Id. at 1134. Cf. Provident Life and Acc. Ins. Co. v. Knott, 128 S.W.3d 211, 216-17 (Tex., 2003) (When total disability is defined as unable to perform the duties of your occupation, a permissible reading is that a person is totally disabled when he is unable to perform all of the important duties of his occupation, and therefore, the plaintiff was not totally disabled because he was able to perform some of his duties.). 9 28 From our review of the record, it does not appear that the district court's definition of any and every was the one that Alexander and MetLife actually applied when considering Vercher's disability claim. Rather, Alexander and MetLife seem to have believed that Vercher was able to do her job, not just that she could do certain minor or nonessential parts of it. 10 29 Specifically, in its letter of November 27, 1995 initially denying her claim, MetLife wrote to Vercher that based on the information provided, you have the ability to perform your regular occupation  (emphasis added). Then, in the November 5, 1996 letter denying her appeal, MetLife stated, 30 It was the opinion of the independent physician reviewer that the documentation we have does not demonstrate the presence of a significant neuromuscular impairment that would prevent you from performing the job activities of an Administrative Services Manager. This occupation is considered sedentary in nature and not physically demanding. Depression is a treatable condition and the evidence does not support any ongoing impairment that would prevent work .... the documentation in your particular case does not support an inability to perform sedentary types of activities  (emphasis added). 31 We must also note that Vercher in fact stipulated for purposes of this case that the physical demands of plaintiff's job were sedentary in nature. 32 MetLife's key inquiry was what had changed since 1991, when the accident and injuries occurred, to preclude Vercher, in 1995, from working. In a faxed letter to one of Vercher's doctors, Dr. Fresh, MetLife nurse Ferrante wrote Information is needed to indicate what precluded her [Vercher] from doing her occupation.... Please provide copies of test results and physical exams done that would support a Total Disability to her occupation. Please indicate what happened to preclude her continuing to work since this condition has been in existence since 1991. 33 After reviewing her records, MetLife's Dr. Petrie's assessment was that [a] review of the medical records provided does not demonstrate the presence of a neuromuscular impairment which would prevent this claimant from performing her previous job activities as an Administrative Services Manager.... This claimant does not have objective evidence of a neuromuscular or psychiatric impairment which prevents her from working. 34 We are unable to conclude that MetLife applied or utilized other than a legally correct interpretation or definition of plan terms. In deciding that she could perform her regular occupation, it appears that MetLife essentially determined that, if there were something she was unable (despite reasonable accommodation) to do that was indispensable or essential to the proper performance of her regular occupation, she would have received benefits. However, so long as she was able to perform all the substantial and important aspects of her job, with reasonable accommodation, and any aspects of the job that she could not perform with reasonable accommodation were, singularly or together, not indispensable or essential to the job, then she was not disabled. 35 Therefore, under either a de novo or an abuse of discretion standard, we hold that MetLife and Alexander applied a legally correct, fair, and reasonable construction of the plan terms. Because theirs was a legally correct interpretation, we need not determine whether the interpretation itself was an abuse of discretion. See Lain, 279 F.3d at 344. 4. Facts and evidence 36 Though we have determined that a legally correct standard was applied, we still must consider whether the facts before MetLife and underlying its decision to deny benefits support that decision or whether its factual determinations were an abuse of discretion. Again, in this Circuit, factual determinations under ERISA plans are examined using the abuse of discretion standard of review; federal courts owe due deference to the administrator's factual conclusions that reflect a reasonable and impartial judgment. Pierre, 932 F.2d at 1562. 37 The district court correctly noted that the administrative record contains evidence that Vercher did suffer from some degree of disability. 11 For example, Dr. Fresh, one of Vercher's doctors, concluded that she suffered from cervical disc herniation, depression, hyperthyroidism, persistent neck and arm pain, and was severely limited in functional capacity and incapable of minimal sedentary activity. Additionally, doctors Fresh and Tumbaco recommended medical retirement for Vercher. 38 However, the district court was also correct in noting that the administrative record also contains evidence that Vercher's disability did not render her completely unable to perform any and every duty of her regular occupation. MetLife had Vercher submit to a Functional Capacity Assessment (FCA) in 1996 which presented her physical capabilities based upon consistencies and inconsistencies in her performance. The FCA concluded that Vercher had a workday tolerance of seven to eight hours and was able to work at a sedentary level. 39 Additionally, the district court addressed Dr. Petrie's review of Vercher's records. 12 Upon reviewing the FCA and the findings of those physicians who had treated Vercher, Dr. Petrie stated in an October 24, 1996 letter that there was no objective evidence of a neuromuscular or psychiatric impairment which prevents employment, and that the less than maximal effort demonstrated on testing of neuromuscular structures [during the FCA] ... indicate[s] attempts on the part of an individual to exaggerate impairment. Intolerance for prolonged sitting, inability to balance or walk on the heels and toes, and difficulty climbing stairs cannot be attributed to previous cervical disk surgery. 40 There is also other factual evidence in the record supporting the administrator's determination that Vercher should not receive long-term disability benefits. Vercher worked for more than four years after she was initially injured in the accident. She accepted a promotion on May 1, 1993, from Manager of Accounting to Manager of Administrative Services, and performed under her new position for nearly two years. Notably, between March of 1994 and March of 1995, Vercher had only taken seven days off work due to her injury-related illness. Though she had depression, which her doctor's believed was a result of her 1991 injury and related pain, she was not undergoing special psychiatric treatment. 13 41 After she left work, Vercher listed her daily activities to include light cooking, cleaning, make bed daily — Have to have weekly help for changing beds ... walk in my yard or sit outside. Elsewhere in the record, it is stated that since leaving work, Vercher occasionally works around the yard, which, unlike her job, does not appear to be a sedentary activity. 14 42 We agree with the district court that, though medical retirement was recommended by her treating physicians, there was enough evidence in the record to show that Alexander and MetLife did not abuse their discretion by relying on the FCA and Dr. Petrie's conclusions in making their decision to deny Vercher's claim. See Sweatman v. Commercial Union Ins. Co., 39 F.3d 594, 602 (5th Cir.1994) ([W]e agree with the district court that MetLife's disability determination was not an abuse of discretion. See Donato v. Metropolitan Life Ins. Co., 19 F.3d 375, 380 (7th Cir.1994) (MetLife's denial of benefits was not arbitrary and capricious when its `decision simply came down to a permissible choice between the position of UMAC, MetLife's independent medical consultant, and the position of [the claimant's physicians].')). 5. Treating Physician Argument 43 Finally, Vercher contends that the district court erred in determining that it could give no greater weight to the opinions of her treating physicians than to those of the doctors hired by MetLife. Under Salley v. E.I. DuPont de Nemours & Co., 966 F.2d 1011, 1016 (5th Cir.1992) and the treating physicians rule, this Court held that, under appropriate circumstances, a court is required to defer to a patient's treating physician's testimony unless there is substantial evidence which contradicts it. 44 Vercher's argument that special, determinative deference had to have been given to the opinions of her treating doctors by both MetLife and the district court, must fail in light of recent Supreme Court precedent. In Black & Decker Disability Plan v. Nord, 538 U.S. 822, 123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003), the Supreme Court held that ERISA does not require plan administrators to accord special deference to opinions of treating physicians. The Court stated, 45 [p]lan administrators may not arbitrarily refuse to credit a claimant's reliable evidence, including the opinions of a treating physician. But 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 administrators a discrete burden of explanation when they credit reliable evidence that conflicts with a treating physician's evaluation. Id. at 1966-67. 46 Therefore, MetLife appropriately considered Vercher's treating physicians' diagnoses, however, it was not required to give those opinions determinative weight.