Opinion ID: 2972151
Heading Depth: 3
Heading Rank: 2

Heading: Severe Labile Hypertension

Text: Regarding Moon’s hypertension, the medical evidence and opinions available to Unum were as follows. First, Unum had before it various records relating to Moon’s admission to Borgess in June 2000 for hypertension. Records compiled at that time by Dr. Reagan show that doctors at Borgess, including Reagan and Lapenna, had diagnosed Moon with atypical chest pain, chronic stage III hypertension, hypertensive emergency and a history of serious hypertension. The terms of Moon’s discharge, Reagan’s records show, were that she receive home care and prompt followups from Dr. Watson. In addition, the discharge records from Borgess include a June 17, 2000 memo from cardiologist Dr. Janos Gellert who found that Moon did not have a heart problem at that time but noted that her uncontrollable hypertension was a risk factor. Second, the administrative record included Dr. Watson’s September 2000 physician’s statement, filed as part of Moon’s original claim for LTD benefits, in which Watson explained that Moon could not engage in activities for more than one or two hours without frequent resting and could not lift more than 10 pounds or engage in any strenuous activity. Third, the record contained Moon’s October 2001 appeal submissions, which included a letter from Watson to the effect that Moon was “absolutely not able to return to work,” and, indeed, could not perform daily activities due to her uncontrollable hypertension. Further records from 1 Unum’s decision with regard to the thumb pain was not arbitrary and capricious merely because it was at odds with the findings of a Michigan Worker’s Compensation officer who, in September 2001, granted Moon’s claim for worker’s compensation benefits. The hearing officer expressly noted that two doctors who had examined Moon, Drs. Smith and Wessinger, arrived at different conclusions regarding her ability to work in Borgess’s admissions department in a light sedentary capacity. The hearing officer elected to credit Dr. Smith to the extent he disagreed with Dr. Wessinger, who would have permitted Moon to work. J.A. 141. As we have previously held, where there are two reasoned medical opinions on an issue, it is not arbitrary and capricious to select one over the other. See Mcdonald, 347 F.3d at 169. In addition, the hearing officer credited Dr. Smith even in light of his admissions on cross examination that he had not examined Moon since May 25, 2000. Unum observed when it terminated Moon’s benefits, and again when it upheld the termination, that the only medical opinions offered by Moon with regard to her thumb pain were based on examinations performed at a time when she was still working and by doctors who did not recommend that Moon stop working. No. 03-1626 Moon v. Unum Provident Corp. Page 8 Watson and records from Lapenna accompanied Watson’s letter, with Watson’s records showing that Moon’s hypertension continued to endure despite attempts at treatment, and Lapenna’s records showing that despite the absence of coronary problems, Moon retained “typical exertional angina.” Significantly, Lapenna was not asked, nor spoke to, whether Moon was able to work. Fourth, the administrative record included the report of Dr. O’Brien, who examined Moon in May 2001 on behalf of Borgess in relation to Moon’s worker’s compensation claim. O’Brien’s single blood pressure measurement reflects that Moon’s blood pressure was higher in the supine position than in the sitting position. Yet O’Brien did not comment on this; instead, he noted that Moon has “chronic severe hypertension, which has been refractory to multiple medications.” J.A. 114. Notable is the fact that O’Brien did not speak to whether Moon was able to work. Finally, Unum had Watson’s April 2002 Social Security testimony to consult. As recounted in detail above, Watson carefully explained in that testimony how Moon’s uncontrollable labile hypertension rendered her unable to work. As discussed above, Unum committed the analysis of this record to Dr. Feagin each time it was further developed with new submissions. Each time, Dr. Feagin rejected Watson’s medical opinion. Feagin’s own report indicates that the primary basis for rejecting Watson’s view was the blood pressure measurement performed on Moon by Dr. O’Brien in May 2001. Indeed, it is on the strength of this one measurement that Feagin described Watson’s view that Moon was unable to work as “unsupported.” This does not constitute a reasoned explanation for the termination of benefits in light of the administrative record available to Feagin. As we have discussed, O’Brien himself declined to make a prediction regarding Moon’s ability to work and did not even refer to the blood pressure measurement in his discussion of Moon’s condition. Instead, O’Brien’s analysis indicates the severity of Moon’s hypertension and its apparent immunity to various medicines. In addition to the fact that O’Brien’s overall analysis is consistent with Watson’s analysis, we note that he examined Moon only once. By contrast, Watson is Moon’s primary treating physician. And as we have recounted, Watson has consistently offered detailed explanations for her conclusion that Moon is unable to work.2 According to Unum’s own documents, the only medical opinion contrary to Watson’s was Dr. Feagin’s. He arrived at his opinion not upon examination of Moon, but rather upon what our discussion here shows was a selective review of the administrative record. See Spangler, 356 F.3d at 359-62 (observing that a selective review of the administrative record is inappropriate). Furthermore, Dr. Feagin’s role was not as a neutral independent reviewer, but as an employee of Unum. It is not enough for Unum to offer an explanation for the termination of benefits; the explanation must be consistent with the “quantity and quality of the medical evidence” that is available on the record. McDonald, 347 F.3d at 172. It must be a “reasoned explanation” that supports the outcome reached by the administrator. See id.; see also Williams, 227 F.3d at 706. We determine whether an explanation is reasoned solely by reference to the administrative record; we ask whether, in light of the administrative record as a whole, the explanation for the decision to deny or terminate benefits is rational. Furthermore, when a plan administrator’s explanation is based on the work of a doctor in its employ, we must view the explanation with some skepticism. See Univ. Hosp. of Cleveland v. Emerson Elec. Co., 202 F.3d 839, 846 (6th Cir. 2000) (holding that a plan administrator’s conflict of interest is a factor to consider when reviewing for whether the administrator’s decision was arbitrary or capricious). With these principles in mind, we cannot 2 We do not hold that Unum was required to defer to Watson’s judgment. The Supreme Court has made clear that mandatory deference to treating physicians, while appropriate in the Social Security context, is not appropriate in the context of ERISA benefits determinations. Black & Decker Disability Plan v. Nord, 538 U.S. 822, 829-833 (2003). However, Black & Decker does not alter the typical arbitrary-and-capricious standard of review. We still must ask whether, viewing the administrative record as a whole, Unum has offered a reasoned explanation for its final decision. Dr. Watson’s letters and notes as well as her testimony, presented in the context of a Social Security hearing, are all part of the administrative record in this case. No. 03-1626 Moon v. Unum Provident Corp. Page 9 conclude that Feagin’s explanation for rejecting Watson’s recommendation for her own patient was “reasoned.” As we have discussed, there was a wealth of medical evidence available to Feagin. Rather than contend with the reality that all of the doctors who examined Moon agreed she had chronic and severe hypertension which was not susceptible to successful treatment, Feagin seized upon a single blood pressure measurement performed by a doctor who himself cautioned that Moon’s hypertension appeared to be intractable. Unum does not present us with the opinion of any doctor, except Feagin’s, to the effect that Moon’s hypertension was not a barrier to returning to work. Cf. McDonald, 347 F.3d at 169 (observing that a plan administrator’s decision to rely on the medical opinion of one examining doctor over another is ordinarily not arbitrary and capricious). Indeed, the only independent medical opinion in the administrative record regarding Moon’s ability to work was that of Dr. Watson. Viewing the administrative record in its entirety, Unum has not offered a reasoned explanation to support its conclusion that Watson’s analysis is flawed and that Moon is able to work.