Opinion ID: 3062257
Heading Depth: 2
Heading Rank: 3

Heading: deference owed to aetna decision

Text: When, as here, a benefit plan “confers upon the administrator discretionary authority to determine eligibility for benefits or to interpret plan terms, ‘a deferential standard of review is appropriate.’” Foster v. PPG Indus., Inc., 693 F.3d 1226, 1231 (10th Cir. 2012) (quoting Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 111 (2008)). “In such cases, we review the administrator’s decision for abuse of discretion,” which we treat “as interchangeable in this context” with “the-arbitrary-and-capricious standard.” Id. (internal quotation marks omitted). When unaffected by other considerations, this is a very deferential standard: When reviewing under the arbitrary and capricious standard, the Administrator’s decision need not be the only logical one nor even the best one. It need only be sufficiently supported by facts within his knowledge to counter a claim that it was arbitrary or capricious. The decision will be upheld unless it is not grounded in any reasonable basis. The reviewing court need only assure itself that the administrator’s decision falls somewhere on a continuum of reasonableness—even if on the low end. Nance v. Sun Life Assur. Co. of Can., 294 F.3d 1263, 1269 (10th Cir. 2002) (brackets and internal quotation marks omitted). - 13 - But there is a tempering consideration here. “Where the plan administrator is operating under a conflict of interest, that conflict may be weighed as a factor in determining whether the plan administrator’s actions were arbitrary and capricious.” Foster, 693 F.3d at 1232 (brackets, ellipses, and internal quotation marks omitted). “A plan administrator [such as Aetna] acting in a dual role, i.e., both evaluating and paying claims, has such a conflict of interest.” Id. “In such cases, we apply a combination-of-factors method of review that allows judges to take account of several different, often case-specific factors, reaching a result by weighing all together.” Id. (internal quotation marks omitted). In this regard, a conflict “‘should prove less important (perhaps to the vanishing point) where the administrator has taken active steps to reduce potential bias and to promote accuracy.’” Holcomb, 578 F.3d at 1193 (quoting Glenn, 554 U.S. at 117). Of particular relevance here, we give a conflict “limited weight in evaluating whether [a plan administrator] abused its discretion” when it “did not rely solely on . . . its own on-site physicians and nurses” but “took steps to reduce its inherent bias by hiring . . . independent physicians” to assess the claimant’s alleged disability. Id. The district court properly invoked this consideration in according diminished weight to Aetna’s dual-role conflict here. We do so as well. 11 11 In particular, we note Aetna’s use of the IME by Dr. Carl. The district court also cited Aetna’s use of Dr. Swotinsky and Dr. VanderPutten to review Ms. Liebel’s medical records and engage in peer-to-peer consultations, but we do not rely on their participation as part of our conflict analysis. In direct contrast with a reference to (continued) - 14 - That is not the end of the matter, however. The Supreme Court held in Glenn that encouraging and assisting a claimant to apply for social security benefits, while denying benefits under a plan using a similar disability standard, would justify a “court in giving more weight to [a dual-role] conflict,” because the “seemingly inconsistent positions” are “both financially advantageous” to the administrator (who gets to apply social security benefits as an offset against benefit obligations under the plan). 554 U.S. at 118. Thus, the deference needle, properly “dialed back” in light of Aetna’s use of an IME, may be nudged forward again in response to Aetna’s conduct in connection with Ms. Liebel’s social security benefit application.12 Because the SSA disability determination is also a stand-alone factor in Ms. Liebel’s challenge to Aetna’s contrary decision, we pursue this point further in the section below dealing specifically with that factor. Our analysis there leads us to conclude that Aetna’s conduct in connection with the SSA award should have little effect on our deferential standard of review. Dr. Carl as an “independent” examiner, Aetna called Dr. VanderPutten “our physician,” App. at 486, and we note that “Dr. Robert Swotinsky” was pointedly characterized as an “Aetna employee[]” in a recent ERISA case, McDonough v. Aetna Life Ins. Co., 2014 WL 690319, at ,  n.12 (D. Mass. Feb. 19, 2014). While we do not reach any definitive conclusions regarding their status vis a vis Aetna, we hesitate to rely on their unsubstantiated independence here. But even as to physicians who may not qualify as independent, we note Aetna made an effort to provide Ms. Liebel’s independent doctors their reports for review and comment. 12 We clarified the nature of this “dialing” deference process in light of Glenn in Murphy v. Deloitte & Touche Group Insurance Plan, 619 F.3d 1151, 1157 n.1 (10th Cir. 2010). - 15 -