Opinion ID: 1359557
Heading Depth: 2
Heading Rank: 2

Heading: Sufficiency of Explanation

Text: ERISA requires employee benefit plans that deny disability benefits to set[] forth the specific reasons for such denial, written in a manner calculated to be understood by the participant. 29 U.S.C. § 1133. The accompanying regulations further require the plan to describe any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary. 29 C.F.R. § 2560.503-1(g)(iii). These requirements are designed both to allow the claimant to address the determinative issues on appeal and to ensure meaningful review of the denial. Halpin v. W.W. Grainger, Inc., 962 F.2d 685, 689 (7th Cir.1992). We will reverse any denial of benefits that does not substantially comply with these regulations. Id. at 693-94. In this case neither the initial termination letter nor the subsequent letter denying Love's appeal sufficiently explained the denial. Both letters asserted that all relevant medical evidence had been considered, but neither letter explained why the reviewer chose to discredit the evaluations and conclusions of Love's treating physicians. See id. at 694. Liberty Mutual conducted the initial review, retaining Dr. Sands as an independent medical consultant. After reviewing Love's medical file, Dr. Sands concluded that Love was not totally disabled because there was no objective evidence that Love suffered any functional limitations. However, Love's file contained numerous test reports indicating a reduced functional capacity, such as an MRI of her spine, evoked-response tests, several physical-capacity reports, and various lab reports. The file also contained several evaluations by Dr. Bielkus, Love's primary physician, opining that Love's functional limitations stemming from her multiple sclerosis made her unable to work. She concluded that Love was medically disabled on a permanent basis from any form of gainful occupation. In fact, every doctor that personally examined Love concluded that she was unable to work more than a few hours a day and that she could not stand, sit, or walk for more than an hour at a time. Dr. Sands did not address any of these reports in his cursory report, which dedicated less than half a page to its analysis and recommendation. Liberty Mutual's termination letter merely recited the various items in Love's medical file in a bulleted list, stated that Dr. Sands had found no objective limitations in Love's functional ability, and terminated her benefits without any further discussion or explanation. We are troubled by the fact that neither Dr. Sands's report nor Liberty Mutual's letter addressed the contrary findings of Love's treating physicians or explained why Liberty Mutual chose to discredit them. On appeal, Love submitted additional reports demonstrating her functional incapacity to the Plan's internal appeals committee. These reports showed that Love had significant impairments: She could not walk, sit, or stand for more than an hour at a time; she could only lift light items occasionally; she had limited flexibility, serious vision impairments, and diminished muscular strength; and she experienced frequent spells of dizziness, vertigo, and fatigue. Dr. Winkler, who was retained by the Plan to review Love's file on appeal, noted these problems but concluded that Love could perform a job either seated or standing, that entails the use of a telephone, that entails the intermittent reference to a computer display or printed material without requirements of speed, and that requires conversation with members of the general public. While acknowledging that Love could not perform her current job, Dr. Winkler concluded that Love was not totally disabled but did not adequately explain his conclusion. For example, Dr. Winkler noted Love's chronic fatigue but dismissed it by asserting that there are medications that are used to treat fatigue. Additionally, Dr. Winkler noted that Love was limited to a six-hour workday. In fact, however, only one physical therapist had concluded that Love would be able to work for up to six hours; the rest of Love's treating physicians had concluded that she was limited to, at most, two or three hours of work each day. Dr. Winkler did not address the opinions of these other physicians. These explanations are insufficient to meet ERISA's requirement that specific and understandable reasons for a denial be communicated to the claimant. Halpin, 962 F.2d at 688-89. As we have noted, [b]are conclusions are not a rationale. Id. at 693. The Plan must provide a reasonable explanation for its determination and must address any reliable, contrary evidence presented by the claimant. Nord, 538 U.S. at 834, 123 S.Ct. 1965 (Plan administrators, of course, may not arbitrarily refuse to credit a claimant's reliable evidence, including the opinions of a treating physician.); see also Kalish v. Liberty Mut./Liberty Life Assurance Co., 419 F.3d 501, 510 (6th Cir.2005) (holding that a plan acted arbitrarily in denying disability benefits when its medical consultant failed to rebut the contrary medical conclusions of the claimant's primary physician). The Plan did not explain why it chose to discount the near-unanimous opinions of Love's treating physicians. While plan administrators do not owe any special deference to the opinions of treating physicians, see Nord, 538 U.S. at 834, 123 S.Ct. 1965, they may not simply ignore their medical conclusions or dismiss those conclusions without explanation. We do not hold that the evidence here requires a finding that Love is totally disabled, only that ERISA requires the Plan to provide a more thorough explanation for its determination than it has here. The Plan acted arbitrarily by terminating Love's benefits without sufficiently explaining its basis for doing so. One final point bears a brief word. Love complains that the Plan's determination is suspect given the Social Security Administration's (SSA) determination that she qualified for disability benefits. In 2002 the SSA determined that Love met its definition of disabled because of her multiple sclerosis and awarded her retroactive disability benefits from August 2001the date she stopped working at National City. We note, however, that the Plan's definition of disabled is different from-and arguably more stringent than the SSA's definition. See 42 U.S.C. § 423(d)(1)(A) (defining disability as the inability to engage in any substantial gainful activity by reason of any ... physical or mental impairment which ... has lasted or can be expected to last for a continuous period of not less than 12 months). But see Diaz v. Prudential Ins. Co. of Am., 499 F.3d 640, 644 (7th Cir. 2007) (suggesting that the differences between the Plan's definition and the SSA definition are minor). In addition, we have repeatedly emphasized that the SSA's determination of disability is not binding on employers under ERISA. See Mote v. Aetna Life Ins. Co., 502 F.3d 601, 610 (7th Cir.2007). SSA determinations are often instructive, but they are not determinative. Id. Because we are remanding, the Plan will have an opportunity to consider the SSA's determination when it reevaluates Love's eligibility.