Opinion ID: 2976248
Heading Depth: 2
Heading Rank: 4

Heading: File Review

Text: Bennett also takes issue with the defendants’ decision to conduct only a file review. Although “we find nothing inherently objectionable about a file review by a qualified physician in the context of a benefits determination,” Calvert, 409 F.3d at 296, “a plan’s decision to conduct a file-only review—‘especially where the right to [conduct a physical examination] is specifically reserved in the plan—may, in some cases, raise questions about the thoroughness and accuracy of the benefits determination.’” Elliott v. Metro. Life Ins. Co., 473 F.3d 613, 621 (6th Cir. 2006) (alteration in original) (quoting Calvert, 409 F.3d at 295). In Calvert, we were unable to credit the conclusions reached in the file review when the reviewer based his conclusion that the plaintiff was not disabled on adverse credibility determinations and when the reviewer’s conclusion stood in direct conflict with objective medical data in the record. Calvert, 409 F.3d at 296-97. 2 We note that Broadspire’s final determination letter does mention the SSA’s decision. However, mere mention of the decision is not the same as a discussion about why the administrator reached a different conclusion from the SSA. In Glenn we concluded that the administrator failed to “discuss” a letter from the plaintiff’s treating physician. Although the administrator argued that the denial letter did discuss the letter, we “f[ou]nd the word ‘discussed’ is somewhat misleading; ‘mentioned’ would be a more accurate choice.” Glenn, 461 F.3d at 671 n.3. Here the final determination letter simply lists the SSA decision as one item in a list of approximately ninety items “[i]ncluded in th[e] review.” J.A. at 311-12 (Final Decision at 1-2). 3 At the root of all of the defendants’ SSA arguments is that Glenn was wrongly decided. See Defs.’ Br. at 3438. As Glenn is a published decision in our court, and therefore, binding precedent, we decline to entertain the defendants’ arguments. No. 06-2326 Bennett v. Kemper Nat’l Servs., Inc. et al. Page 7 We have similar concerns in the case at bar. Although the policy gave the defendants the right to conduct a physical examination, the defendants opted to rely only on peer reviews of Bennett’s files. J.A. at 135 (Plan). Our first concern is that, although both Cohan and Rose had access to the SSA’s determination that Bennett was disabled and could not perform any job in the national economy, neither doctor made any mention of this fact in his file review, much less attempted to explain why he disagreed with the SSA’s determination. This raises serious questions about the thoroughness and accuracy of these file reviews. Second, as in Calvert, Cohan implies in his file review that Bennett is not credible, despite the fact that he had never physically examined her. J.A. at 346 (describing Bennett as “exaggerati[ng]” and “embellish[ing]” in her test performance). Cohan based this determination on notes from Bennett’s treating physicians, but none of those physicians ever cited any concerns that Bennett was malingering. In fact Keenan’s examination notes state quite the opposite: that Bennett’s “profile is more suggestive of depression than frank malingering, which was corroborated by objective personality test results. Rather than a conscious attempt to feign cognitive symptoms for monetary secondary gain, [] Bennett presented as having difficulties adjusting to and accepting the limitations associated with MS.” J.A. at 265 (Keenan Rpt.) (emphasis supplied). Although all of the file reviews key in on Keenan’s finding that the neuropsychological test results demonstrated inconsistent effort, none of the file reviews explain that Bennett’s inconsistent efforts on the tests were related to her difficulty in accepting and adjusting to MS. Third, the final determination that Bennett was not disabled was based, in part, on inconsistent findings from Goldberg’s file review. In 2001, Goldberg originally found that Bennett was not able to perform her own job. In his 2003 file review, he noted that Lisak indicated that Bennett had a Class 4 impairment, cannot stand or walk, can sit for only two hours a day, and cannot work, but Goldberg then concluded that Bennett does not have “a functional impairment that would preclude [her] from either doing her own job or working at any job, particularly in a sedentary capacity.” J.A. at 321 (Goldberg Review at 4). Goldberg reached this conclusion without any explanation as to why he did not agree with Lisak’s assessment.4 To the extent that Goldberg agreed with Lisak’s assessment, we fail to understand how a person who can sit for only two hours in an eight-hour work day and cannot stand or walk for any appreciable period of time could, nonetheless, work. We conclude that the file reviews used in this case do not adequately explain why the reviewers reach decisions contrary to both the SSA and the medical evidence presented through the reports of Bennett’s treating physicians. Instead, the file reviews summarize Bennett’s medical records and then conclusorily assert that Bennett can work. Further, we will not credit a file review to the extent that it relies on adverse credibility findings when the files do not state that there is reason to doubt the applicant’s credibility. Our concerns with the file reviews in this case weigh significantly in favor of a finding that the final decision was arbitrary or capricious. E. Broadspire’s Determination Was Both Arbitrary and Capricious. Our review of the record leads us to conclude that Broadspire’s decision was not made as the result of “a deliberate, principled reasoning process.” Glenn, 461 F.3d at 666. As we have discussed earlier in this opinion, the defendants assisted Bennett in obtaining disability benefits from the SSA, reaped financial benefits from this decision, and then Broadspire failed to explain why it reached a disability conclusion at odds with the SSA’s findings. Similarly, the file reviews which 4 The only indication we have that Goldberg discredits Lisak’s conclusion is when Goldberg points out that although Lisak indicates that Bennett should never drive, Lisak also noted that Bennett had driven to her examination in June 2003. However, Goldberg, himself, states that a no-driving restriction would be a reasonable limitation to place on Bennett. No. 06-2326 Bennett v. Kemper Nat’l Servs., Inc. et al. Page 8 Broadspire relied upon in denying Bennett’s claim offer no discussion about the SSA’s disability determination. We are also troubled by Broadspire’s reliance on file reviews that imply that Bennett is not credible, when in fact, no one who actually examined Bennett reached that conclusion. Further, Broadspire’s reliance on a file report that acknowledges that Bennett cannot walk or stand and can only sit for two hours and that conclusorily asserts that she can work in a sedentary capacity demonstrates a lack of principled reasoning. We finally register our serious concern that the final denial letter fails to explain the reasons for its decision. The three-page letter uses approximately one page to explain the standard for ownoccupation disability. The next page simply lists the approximately ninety documents which were included in the review of Bennett’s claim. The actual explanation of the decision-making process employed simply states that Broadspire did not believe that the submitted documents contained “sufficient medical evidence . . . to substantiate a significant functional impairment that would prevent[] [] Bennett from performing the essential functions of any occupation.” J.A. at 313 (Final Decision). This reads like a conclusion, not a “deliberate, principled reasoning process . . . supported by substantial evidence.” Glenn, 461 F.3d at 666. Accordingly, we hold that Broadspire’s determination cannot withstand scrutiny under the “arbitrary or capricious” standard of review.