Opinion ID: 4673684
Heading Depth: 3
Heading Rank: 1

Heading: Medical Professional Review

Text: Roebuck argues USAble Life improperly relied on the opinion of an in-house nurse in denying her claim, and USAble Life’s failure to seek the opinion of an independent medical professional violated ERISA regulation 29 C.F.R. § 2560.503- 1(h)(3)(iii). 4 We disagree. Because this issue challenges both USAble Life’s interpretation and application of the Policy, we review under both the Finley factors and the substantial evidence standard.
Roebuck argues USAble Life’s interpretation of the Policy was flawed because its use of an in-house nurse failed to provide the appropriate medical review required under ERISA. When reviewing whether an administrator’s plan interpretation constitutes an abuse of discretion, we consider whether: (1) “the administrator’s interpretation is consistent” with the Policy’s goals; (2) the administrator’s interpretation renders any of the Policy’s language “meaningless or internally inconsistent”; (3) the “administrator’s interpretation conflicts with the substantive or procedural requirements of the ERISA statute”; (4) “the administrator has interpreted the relevant terms consistently”; and (5) the interpretation contradicts 4 The Policy incorporates this regulation by reference. -9- the Policy’s clear language. Shelton v. ContiGroup Cos., Inc., 285 F.3d 640, 643 (8th Cir. 2002) (summarizing the five-factor test set forth in Finley). Analyzing the first factor, we conclude USAble Life’s use of an in-house nurse was consistent with the Policy’s goals. The ERISA regulation at issue requires USAble Life to “consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment.” 29 C.F.R. § 2560.503-1(h)(3)(iii). The regulation also requires that the chosen medical professional provide independent evaluations of claims. Id. at (h)(3)(v). A nurse is a health care professional, and whether a nurse or any other professional has appropriate training and experience depends on the facts of the case. There is no evidence in the record demonstrating that Nurse Benwell did not possess the proper training and experience to review Roebuck’s claim. Additionally, despite the inherent conflict of interest, there is no evidence in the record demonstrating that USAble Life’s interpretation of the Policy was intended to or resulted in preventing its in-house nurse from providing her independent, professional opinion on claims for benefits. Therefore, we conclude USAble Life’s use of an in-house nurse was consistent with the goals of the Policy. Second, USAble Life’s use of an in-house nurse did not render any of the Policy’s language meaningless or inconsistent. The ERISA regulation does not explicitly discuss whether nurses qualify as medical professionals. We have held that 29 C.F.R. § 2560.503-1(h)(3)(iii) only requires “a full and fair review of [the] claim,” which can be achieved with a nurse’s review and medical opinion. Cooper, 862 F.3d at 662–63 (quoting Grasso Enters., LLC v. Express Scripts, Inc., 809 F.3d 1033, 1038 (8th Cir. 2016)). The regulation does not exclude nurses from the category of medical professionals “in the field of medicine involved in the medical judgment” qualified to review a claim for disability benefits. 29 C.F.R. § 2560.503- 1(h)(3)(iii). Therefore, USAble Life’s interpretation of the Policy allowing an inhouse nurse to review Roebuck’s claim did not render the language of the Policy meaningless or inconsistent. -10- Third, we conclude USAble Life did not breach ERISA’s substantive or procedural requirements by interpreting the Policy to allow a nurse to review Roebuck’s medical records or make recommendations denying Roebuck’s claim. While ERISA requires insurers to consult with medical professionals who have “appropriate training and experience in the field of medicine involved in the medical judgment,” the regulation is flexible on the level of education or professional training necessary to qualify as a medical professional. 29 C.F.R. § 2560.503- 1(h)(3)(iii). We agree with the Sixth Circuit that there is no per se rule that precludes an administrator from consulting a nurse rather than a physician in deciding an administrative appeal. See Boone v. Liberty Life Assurance Co. of Bos., 161 F. App’x 469, 474 (6th Cir. 2005). Therefore, USAble Life’s interpretation of the Policy did not breach ERISA’s substantive or procedural requirements. Because of the lack of evidence in the record regarding USAble Life’s past interpretations of the provision, we consider the fourth Finley factor a neutral factor. Finally, USAble Life’s interpretation of the Policy does not contradict the Policy’s clear language. As discussed, there is no basis to conclude the in-house nurse assigned to review Roebuck’s claim did not qualify as a medical professional. And, USAble Life’s interpretation of the regulation allowing nurse review of Roebuck’s claim does not contradict the plain terms of the ERISA regulation. The terms of the Policy do not require USAble Life to employ an independent medical professional to refute the opinions of Roebuck’s treating physicians. The ERISA regulation only requires a full and fair review of Roebuck’s claim by an unbiased medical professional. That standard was met by Nurse Benwell’s review of Roebuck’s claim. Therefore, we hold USAble Life did not abuse its discretion in its interpretation of the Policy or use of an in-house nurse to review Roebuck’s claim.
Under the abuse of discretion standard, we will uphold USAble Life’s “decision so long as it is reasonable and supported by substantial evidence.” Cooper, -11- 862 F.3d at 660. “Substantial evidence is more than a scintilla, but less than a preponderance, of evidence.” Sepulveda-Rodriguez v. MetLife Grp., Inc., 936 F.3d 723, 729 (8th Cir. 2019). “If substantial evidence supports the decision, it should not be disturbed even if a different, reasonable interpretation could have been made.” Id. (quoting Johnson v. United of Omaha Life Ins. Co., 775 F.3d 983, 989 (8th Cir. 2014)). An insurer’s “decision is reasonable if a reasonable person could have reached a similar decision, given the evidence before him.” Boyd, 879 F.3d at 319 (quoting Green v. Union Sec. Ins., 646 F.3d 1042, 1050 (8th Cir. 2011)). To determine this, we look to the record that was before the administrator of the plan at the time the claim was denied. Farfalla v. Mut. of Omaha Ins. Co., 324 F.3d 971, 974–75 (8th Cir. 2003). As discussed, nurses can provide a full and fair review and medical opinion to satisfy the requirements of 29 C.F.R. § 2560.503-1(h)(3)(iii). Cooper, 862 F.3d at 662–63. Both parties agree an independent physical therapist performed the FCE, and the results of the independent FCE found Roebuck could perform work with a sedentary physical demand level for eight hours a day for forty hours a week. This is especially significant since Roebuck’s occupation was performed at a sedentary level of physical demand according to the vocational review. The independent FCE serves as the most important piece of evidence to support USAble Life’s denial of Roebuck’s claim. Jackson v. Metro. Life Ins. Co., 303 F.3d 884, 888 (8th Cir. 2002) (stating an FCE “alone constitutes more than a scintilla of evidence” in finding the results of an FCE support an administrator’s denial of benefits even where there is competing evidence from claimant’s treating physician). Absent a finding that disrupted the FCE results, USAble Life was well within its discretion to deny Roebuck’s claim, and USAble Life’s reliance on Nurse Benwell’s opinion does not conflict with the substantive or procedural requirements of the Policy or ERISA. Even accounting for USAble Life’s inherent conflict of interest, we hold USAble Life did not abuse its discretion in denying Roebuck’s claim. While there is evidence in the record of Roebuck’s various medical diagnoses, Nurse Smith noted the opinions of Roebuck’s treating physicians were inconsistent. And, even -12- after Roebuck’s submission of additional evidence of her medical issues, Nurse Benwell concluded there was not persuasive evidence in the record showing Roebuck was disabled or that the results of the FCE should be disturbed. Accordingly, we conclude substantial evidence supports USAble Life’s denial of Roebuck’s claim.