Opinion ID: 4673684
Heading Depth: 2
Heading Rank: 3

Heading: Adjudication of Roebuck’s Disability Claim

Text: Roebuck appeals USAble Life’s failure to (1) use an independent medical professional in reviewing her claim and (2) award disability benefits based on her radiculopathy diagnosis. We review Roebuck’s challenges for abuse of discretion. Abuse of discretion, however, is evaluated differently depending on whether the challenge is based on plan application or plan interpretation. We address challenges to USAble Life’s application of the Policy under the substantial evidence standard and challenges to its interpretation of the Policy under the five-factor Finley test. Mitchell v. Blue Cross Blue Shield of N.D., 953 F.3d 529, 537 (8th Cir. 2020) (stating where “an administrator evaluates facts to determine the plan’s application in a particular case . . . the substantial evidence test governs our review” (ellipses in original) (quoting Donaho v. FMC Corp., 74 F.3d 894, 899 n.9 (8th Cir. 1996))); Finley v. Special Agents Mut. Ben. Ass’n, Inc., 957 F.2d 617, 620–22 (8th Cir. 1992). As an examination of Roebuck’s argument demonstrates, the distinction between a challenge based on plan application and plan interpretation is not always clear cut. Roebuck initially characterizes her claim as a challenge to USAble Life’s “application” of the occupation test in the Policy. Roebuck then outlines two arguments in support of this challenge: (1) USAble Life’s application of the -8- occupation test disregarded ERISA’s requirements (incorporated in the Policy) regarding evaluation of her claim by an appropriate medical professional; and (2) USAble Life ignored Policy language that implicitly accepts radiculopathy as a disabling condition. The first of the two arguments was presented largely as one of Policy application. Yet, it encompasses an underlying argument that Policy language (as incorporated from ERISA) was interpreted too broadly. The second argument is clearly one of Policy interpretation. Thus, our analysis will necessarily reflect consideration of both of these components of Roebuck’s challenge.
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.
Lastly, Roebuck argues that USAble Life ignored her radiculopathy diagnosis in denying her claim, and that an award of benefits is required because radiculopathies are excepted from the definition of “Special Conditions” under the Policy. We disagree, concluding Roebuck’s radiculopathy diagnosis did not automatically entitle her to benefits under the Policy. Analyzing the first Finley factor, we conclude USAble Life’s interpretation of the “Special Conditions” provision of the Policy is consistent with the Policy’s goals. The discretionary clause gives USAble Life authority to determine which claims qualify for benefits. In this case, the Policy allows for benefits to be paid only if Roebuck is disabled, and the “Special Conditions” provision of the Policy does not materially alter this requirement. Roebuck’s medical records and the FCE demonstrate Roebuck’s ailments do not prevent her from performing sedentary work. Nurse Benwell considered Roebuck’s radiculopathy diagnosis prior to recommending denial of Roebuck’s claim. And, Nurse Benwell found Roebuck’s radiculopathy diagnosis was insufficient to disturb the FCE findings because Roebuck’s diagnoses were “inconsistent among providers.” Accordingly, we conclude USAble Life’s interpretation was consistent with the Policy’s goals. Second, we evaluate whether USAble Life’s interpretation of the Policy renders any of the Policy’s language meaningless or internally inconsistent. Roebuck argues the denial of her claim violated those terms because the Policy expressly excepted radiculopathies from the definition of “Special Conditions,” and USAble Life failed to consider Roebuck’s radiculopathy diagnosis in denying her -13- claim. The record does not demonstrate USAble Life completely ignored Roebuck’s radiculopathy diagnosis. Instead, the record reflects Nurse Benwell considered Roebuck’s post-FCE medical records, noted Roebuck’s physical fitness level had changed, and found there was insufficient evidence to upset an earlier finding that Roebuck was not disabled within the Policy’s terms. Accordingly, we conclude USAble Life’s denial of Roebuck’s claim did not render the Policy’s terms meaningless or internally inconsistent, even in light of Roebuck’s radiculopathy diagnosis. Next, we must consider whether USAble Life’s interpretation conflicted with ERISA’s substantive or procedural requirements and whether USAble Life has interpreted relevant Policy terms consistently. Based on an absence of relevant argument and evidence in the record, we view these as neutral factors. Regarding the fifth Finley factor, USAble Life’s interpretation does not contradict the Policy’s clear language. Not only did the Policy give USAble Life the ability to determine a claimant’s eligibility for benefits, but the plain terms of the Policy require a finding of disability prior to payment of a claim. The plain terms of the Policy except radiculopathies from the definition of “Special Conditions,” but the terms of the Policy do not state that any radiculopathy diagnosis entitles a claimant to benefits. In this case, Dr. Putty diagnosed Roebuck with radiculopathy, but Dr. Putty did not state Roebuck was disabled or unable to perform sedentary work. There is no support in the record for Roebuck’s position that a radiculopathy diagnosis, absent a finding of disability, entitles her to benefits under the Policy. Therefore, USAble Life’s interpretation does not contradict the Policy’s clear language. The judgment of the district court is affirmed. _____________________________ -14-