Opinion ID: 2981317
Heading Depth: 3
Heading Rank: 1

Heading: The Independent Reviewers

Text: Cook challenges the validity of Prudential’s independent reviewers on numerous grounds. Initially, Cook attempts to discredit Dr. Topper’s opinion, maintaining that Dr. Topper is both biased due to his frequent consulting work for disability plan administrators and unqualified to render an opinion about Cook’s post-polio syndrome. We have clearly recognized that an independent reviewing physician’s potential bias can be a factor in determining whether the plan administrator’s decision was arbitrary or capricious. Moon, 405 F.3d at 381–82. This is due to the possibility that “a consultant engaged by a plan may have an incentive to make a finding of not disabled.” Kalish v. Liberty Mut./Liberty Life Assurance Co., 419 F.3d 501, 508 (6th Cir. 2005) (internal quotation marks omitted) (indicating that potential for biased evaluation factors into our analysis of “whether the plan administrator acted arbitrarily and capriciously in deciding to credit the opinion of its paid, consulting physician.”). To support his allegations of bias, however, Cook offers no more than cursory statements that lead only to the innocuous conclusion that Dr. Topper has been involved in other independent 10 No. 11-3364, Cook v. Prudential Ins. Co. of Am. medical reviews; they do not suggest that Dr. Topper had any tendency to decide cases against the claimants. Under our precedents, such allegations are insufficient to render Prudential’s reliance on Dr. Topper arbitrary or capricious. See id. (requiring statistical or other specific evidence to conclude that a physician consistently gave opinions in favor of plan administrators); see also Elliott v. Metro. Life Ins. Co., 473 F.3d 613, 620 (6th Cir. 2006) (remanding for further review in part because the district court failed to consider bias arguments against a physician whose opinions had been questioned in three prior federal cases). We therefore do not afford this argument any weight here. The same is true regarding Cook’s claim that Dr. Topper is unqualified. Although Cook does not contest Dr. Topper’s board certification in neurology, he faults Dr. Topper for having a pediatric specialization. Cook, however, cites no authority in support of his proposition that this additional specialization somehow renders Dr. Topper unqualified to review his case. Cf. Kansky v. Coca-Cola Bottling Co., 492 F.3d 54, 60 (1st Cir. 2007) (concluding that a physician was not unqualified to review a disability file purely on the basis that the physician had not specifically researched the claimant’s particular condition). Furthermore, Cook’s assertion that Dr. Topper “misdiagnosed” his condition as polio rather than post-polio syndrome is betrayed by a complete review of Dr. Topper’s evaluation, which clearly has not confused the two. Cook next challenges the reliability of Prudential’s reviewers based on their failure to conduct independent examinations. As with the issues above, failure to conduct such an examination may contribute to a finding that the plan administrator’s decision was arbitrary or capricious. Calvert v. Firstar Finance, Inc., 409 F.3d 286, 295 (6th Cir. 2005) (noting that the absence of a 11 No. 11-3364, Cook v. Prudential Ins. Co. of Am. physical examination “may, in some cases, raise questions about the thoroughness and accuracy of the benefits determination”). Although reliance on a file review does not alone evidence arbitrary or capricious decision making, id., if the physician fails “to describe the data he reviewed in reaching his decision” or makes “credibility determinations concerning the patient’s subjective complaints without the benefit of physical examination,” reliance on such opinions may tip the scale toward unreliability. Smith v. Cont’l Cas. Co., 450 F.3d 253, 263 (6th Cir. 2006); see also Helfman v. GE Group Life Assurance Co., 573 F.3d 383, 395–96 (6th Cir. 2009) (“[C]redibility determinations made without the benefit of a physical examination support a conclusion that the decision was arbitrary.”). Here, a few conclusions in the reviewers’ reports tend to support Cook’s argument that a separate examination would have been the most appropriate course. For instance, at one point in his report, Dr. Topper concluded that Cook’s subjective claims of chronic pain were “not supported.” A.R. at 145 (Page ID #194). This is, in effect, a subjective credibility determination best made with the assistance of an actual medical examination. Nevertheless, Dr. Topper’s remaining conclusions were amply supported by the record. The only physician to have even suggested that Cook’s subjective pain would prohibit any employment was Dr. Bains. The remaining evidence generally supports the conclusion that Cook was both believable in his presentation of symptoms and that he was objectively capable of performing sedentary work. The same is true with respect to Dr. Gitlow’s conclusion that Cook’s depression did not support his disability claim. The record supports Cook’s long-time depression, as well as other mild to moderate mental impairments. But, as the district 12 No. 11-3364, Cook v. Prudential Ins. Co. of Am. court correctly observed, nothing in the record suggests that Cook was disabled or otherwise limited as a result of these findings. The existence of considerable objective evidence in support of Cook’s ability to perform sedentary work distinguishes his case from others in which the absence of a medical exam carried additional weight—for example, where consulting physicians concluded both without examination and in the face of substantial contrary evidence that the claimant’s subjective symptoms were unreliable. Cf. Morris v. Am. Elec. Power Long-Term Disability Plan, 399 F. App’x 978, 990 (6th Cir. 2010) (unpublished opinion) (rejecting a similar argument after noting that the case did not involve “a situation in which the reviewing psychiatrists and psychologists are flatly contradicting the conclusions of those who examined the patient”). Given the record before us, we thus cannot conclude that Prudential’s reliance on these file reviewers—even absent independent medical exams—merits much weight in determining whether the final decision was arbitrary or capricious. Finally, Cook challenges Prudential’s determination on the basis that it provided Drs. Topper and Gitlow with a “cherry-picked” record. Appellant Br. at 31. Under this circuit’s case law, when a physician reviewer conducts a file review, “the plan administrator must provide [a reviewing physician] with all letters from a claimant’s physician, which the file reviewer must consider.” Helfman, 573 F.3d at 393; see also Glenn, 461 F.3d at 671 (indicating that the plan administrator’s failure to provide two letters from the claimant’s treating physician was a consideration in the overall evaluation of the plan administrator’s decision). In Spangler v. Lockheed Martin Energy Systems, Inc., 313 F.3d 356, 362 (6th Cir. 2002), for example, we determined that the plan administrator’s attempt to “cherry-pick[]” a file in which all but one of the physician reports supported a disability 13 No. 11-3364, Cook v. Prudential Ins. Co. of Am. finding “in the hopes of obtaining a favorable report from the vocational consultant” rendered the denial of benefits arbitrary or capricious. Here, a few materials likewise appear to have been omitted, including the letter in which Dr. Bains discussed his belief that Cook was completely disabled from full-time employment. Prudential does not seem to challenge this point, and instead notes that the letters did not contain significant objective evidence necessary for an accurate file review and that Prudential itself considered the omitted evidence even if the file reviewers did not. Under our precedents, these arguments are beside the point. Nevertheless, although Prudential’s omissions do weigh in Cook’s favor, they are not alone enough to render Prudential’s decision arbitrary or capricious. “[T]he ultimate issue in an ERISA denial of benefits case is not whether discrete acts by the plan administrator are arbitrary and capricious but whether its ultimate decision denying benefits was arbitrary and capricious. For this, we must examine [the plan administrator’s] decision in light of the administrative record.” Id. Furthermore, “[t]his is not a situation, as in Spangler, where the plan administrator picked one aberrant medical evaluation from the administrative record and provided it to a ‘neutral’ reviewer for evaluation.” Schwalm v. Guardian Life Ins. Co. of Am., 626 F.3d 299, 311 (6th Cir. 2010) (rejecting a similar claim of “cherry-picking”). Instead, the record as a whole supports the reviewers’ opinions, and, although we do not condone Prudential’s failure to provide its reviewers with Cook’s complete file, we cannot conclude that this shortcoming is sufficient to overcome the substantial evidence supporting Prudential’s decision. 14 No. 11-3364, Cook v. Prudential Ins. Co. of Am. 2. Prudential’s Analysis of Cook’s Occupational Requirements Cook next argues that Prudential failed to consider his medical limitations in relation to his ability to perform his specific job duties. Prudential’s letter, however, explicitly noted its consideration of this issue and concluded that “[b]ased on the medical records in [the] file, Mr. Cook retained the capacity to perform his own sedentary level occupation as a Telephone Collector from October 28, 2004 forward.” A.R. at 1030 (Page ID #1079) (emphasis added). Furthermore, Prudential reached its conclusion after considering both Cook’s specific description of his job requirements and the more generic “Collection Clerk” description. Although additional analysis would have been desirable, Prudential’s analysis of this issue does not render its decision arbitrary or capricious. 3. Prudential’s Alleged Failure to Consider Other Evidence in the Record Cook’s final arguments relate to Prudential’s allegedly insufficient consideration of other record evidence supporting Cook’s claim. First, Cook faults Prudential’s denial letter for doing little more than citing the Social Security determination without evaluating the reasoning behind it. A plan administrator’s failure to consider an award of benefits by the Social Security Administration (“SSA”) is not per se arbitrary, but it is nonetheless a consideration in the court’s review. Glenn, 461 F.3d at 669. Cook’s case, however, is distinguishable from those in which failure to consider the SSA’s determination played a role in undermining the plan administrator’s decision-making process. Unlike this case, those prior cases mainly involve instances in which the disability determinations of the SSA and the plan administrator were in conflict. See, e.g., Bennett, 514 F.3d at 553 (faulting the plan administrator for failing “to explain why it reached a conclusion 15 No. 11-3364, Cook v. Prudential Ins. Co. of Am. contrary to that of the SSA” (emphasis added)); Glenn, 461 F.3d at 669 (finding administrator’s failure to consider the SSA’s total-disability determination a “significant factor”). Here, however, Prudential and the SSA essentially reached the same conclusions concerning Cook’s capacity to engage in sedentary work. The only discernable difference between the decisions was that the ALJ, for unexplained reasons, found that Cook’s position at BankOne involved “light” level work, despite Cook’s own characterization of the work as sedentary. The ALJ did not make a finding of total disability, and instead determined only that there were no comparable sedentary-level jobs for Cook to perform. Because the ALJ’s decision ultimately supports Cook’s ability to perform sedentary work, Prudential’s failure to address it substantively is entitled to very little weight. Cook’s second argument, which maintains that Prudential failed to consider the opinions of his treating physicians, suffers from similar deficiencies. A plan administrator’s unexplained dismissal of the opinions of treating physicians clearly can lead to a finding that the plan administrator’s decision was arbitrary or capricious. Glenn, 461 F.3d at 671. Although such opinions are not entitled to special deference, a plan administrator “may not arbitrarily repudiate or refuse to consider” them. Id. (citing Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003)). Admittedly, Prudential’s decision never addressed Dr. Bains’s letter, which opined that Cook was completely disabled from any full-time work. Instead, Prudential relied almost entirely on the opinions of its independent reviewers. Given that a plan administrator’s decision to give “greater weight to a non-treating physician’s opinion for no apparent reason lends force to the conclusion that [it] acted arbitrarily and capriciously,” Elliott, 473 F.3d at 620 (internal quotation marks omitted), 16 No. 11-3364, Cook v. Prudential Ins. Co. of Am. this omission weighs in Cook’s favor. Nevertheless, much of the administrative record consists of objective medical evidence that supports Prudential’s conclusion that Cook was capable of performing sedentary work. As discussed above, Prudential’s decision is also consistent with the ALJ’s determination that Cook’s “residual functional capacity is diminished to sedentary work.” A.R. at 161 (Page ID #210). Two pieces of evidence—Dr. Bains’s letter stating skepticism that Cook could be employed at all and the most recent FCE, which suggests substantial physical limitations—constitute the majority of the evidence in favor of Cook’s assertion of complete disability, and the FCE is only partially supportive because of the confusion regarding the exertion level required for Cook’s occupation. Although Cook places substantial significance on Dr. Kellum’s opinion, Dr. Kellum’s stated restrictions relate only to the “use of [Cook’s] lower extremities.” Id. at 474 (Page ID #523). The other two physician reviewers, Drs. Derrow and Hinzman, though recognizing certain limitations on Cook’s ability to work, also support Prudential’s decision finding Cook capable of sedentary work. Although we view Prudential’s cursory analysis as somewhat troubling, we cannot conclude on these facts that the omission renders Prudential’s decision arbitrary or capricious. “[C]omplete consensus is not required to establish a reasoned basis for an administrative decision.” Univ. Hosps. of Cleveland v. Emerson Elec. Co., 202 F.3d 839, 847 (6th Cir. 2000). Instead, the plan administrator’s decision need only be “sufficiently grounded in reason and evidence to satisfy the least demanding form of judicial review.” Id. (internal quotation marks omitted). To be sure, Prudential’s decision letter is hardly a model of clarity, and at many points, its stated reasons for denying Cook’s claims are unduly perfunctory. Even so, we simply cannot conclude from the 17 No. 11-3364, Cook v. Prudential Ins. Co. of Am. evidence before us that the record compels—or even strongly supports—a different result. Because Cook’s claim fails on the merits, we decline to address the timeliness issues raised in his brief.